Pennsylvania Department of Health
RIDGEVIEW HEALTHCARE & REHAB CENTER
Patient Care Inspection Results

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RIDGEVIEW HEALTHCARE & REHAB CENTER
Inspection Results For:

There are  157 surveys for this facility. Please select a date to view the survey results.

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

Based on Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and Abreviated Complaint Survey, completed on January 26, 2024, it was determined that Ridgeview Healthcare and Rehab 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(a)(1)(2) REQUIREMENT Qualified Dietary Staff: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(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e)

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.
Observations:

Based on staff interview and a review of employee time sheets, it was determined that the facility failed to employ a full-time qualified director of food and nutrition services manager in the absence of a full-time qualified dietitian.

Findings include:

An interview with the food service director (FSD) on January 24, 2024, at 9:30 AM revealed that she was currently enrolled in an online course to become a certified dietary manager as she was presently not qualified for the position according to regulatory criteria.

Further interview with the FSD revealed that the facility has two consultant part-time dietitians who worked both onsite hours and remotely. The FSD stated that the consultant dietitians performed clinical nutrition duties and provided no direct oversight in the dietary department and food service operations.

Review of time schedules for each consultant dietitian dated November 1, 2023, through January 25, 2024, failed to provide documented evidence that the consultant dietitians worked a combined total at least 35 hours per week to meet the requirement of having a full-time qualified dietitian. The U.S. Department of Labor, Bureau of Statistics defines 34 or fewer hours a week as part-time work.

Interview with the nursing home administrator (NHA) on January 26, 2024, at 10:30 AM, failed to provide documented evidence that the facility's consultant dietitians provided direct oversight to the current food service director or that the facility employed a full-time qualified director of food service in the absence of a full-time qualified dietitian.


Refer F812, F806, F803

28 Pa Code 201.18 (e)(1)(6) Management.












 Plan of Correction - To be completed: 02/27/2024

In coordination with Nutraco, our consultant dietary company, there is a Registered Dietician performing oversight of our dietary department on a fulltime basis primarily in facility with remote work as needed. The RD will provide consultant services to the food service manager and assist with daily kitchen operations to ensure compliance.
Education has been provided to dietary director and dietician on the necessary oversight functions for the dietary department.
Administrator or designee will conduct weekly audits x 4 weeks then monthly x 4 months of consultant dietician timecards to ensure fulltime status as well as oversight and sign off of facility menus with results reported to QAPI as needed.

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed: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(c) Menus and nutritional adequacy.
Menus must-

§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

§483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

§483.60(c)(5) Be updated periodically;

§483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

§483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.
Observations:

Based on review of the facility's planned written menu and menu extensions, and staff interviews, it was determined that the facility failed to ensure the planned menu was sufficiently reviewed for variety and periodically updated by the facility's consultant registered dietitian to ensure nutritional adequacy and variety to meet the nutritional needs and preferences of the residents.

Findings included:

Review of the facility's 4 week planned cycle menu planned written menu revealed that the planned lunch menu for Thursday January 25, 2024, was chicken Alfredo, steamed broccoli, dinner roll, and a brownie.

However, observation of the lunch meal on January 25, 2024, at 11:45 AM revealed that the meal served was creamy chicken, mashed potatoes, broccoli, and rice pudding.

Interview with the foodservice director (FSD) on January 25, 2024, at 12:30 PM confirmed that she changed the menu because the residents did not like the facility's chicken Alfredo. The FSD stated that the menus were planned offsite through an agreement with the food supplier and that the facility's menu has not been changed in two years. The FSD confirmed that several residents have complained about the menu not being changed. The FSD provided an altered menu for the week of January 21, 2024, through January 27, 2024, which she had planned based on resident input and stated that the consultant registered dietitian signed off on the changes. The altered menu did not include menu extensions for residents prescribed therapeutic and mechanically altered diets to ensure nutritional adequacy.

Interview with the consultant dietitian on January 25, 2024, at 1:00 PM confirmed that she did approve the menu changes for the week of January 21 through January 27, 2024, but that the menu changes were completed by the food service director and she was unable to confirm that the menu/recipes were reviewed for nutritional adequacy, portion sizes, variety, and appropriate combinations for each therapeutic and mechanically altered diet provided to residents at the facility.

Interview with the administrator on January 26, 2024, at 12:00 PM failed to provide documented evidence that the facility's menu was sufficiently reviewed and periodically updated by the facility's consultant registered dietitian to ensure nutritional adequacy, meet the nutritional needs of the residents, and ensure menu variety.

28 Pa. Code 211.6 (a) Dietary services.

28 Pa. Code 201.29(a) Resident rights.












 Plan of Correction - To be completed: 02/27/2024

In coordination with Nutraco, our consultant dietary company, there is a Registered Dietician performing oversight of our dietary department on a fulltime basis primarily in facility with remote work as needed. The RD will provide consultant services to the food service manager and assist with daily kitchen operations to ensure compliance.
The facility has also reached out to our food supplier, Bertram, and they will be implementing rotating, seasonal menus in coordination with our consultant dietician. These menus will also be modified to match resident needs as necessary.
Education has been provided to dietary director and dietician on the necessary oversight of facility menus as well as the necessity to keep the menus updated and varied.
Administrator or designee will conduct weekly audits x 4 weeks then monthly x 4 months to ensure dietician sign off of facility menus with results reported to QAPI as needed.

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 clinical record review, a review of grievances lodged with the facility and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance as evidenced by two residents out of 21 sampled (Residents 19 and CR2).

Findings include:

A clinical record review revealed that Resident 19 had diagnoses which included cerebral infarction (ischemic stroke caused by disrupted blood flow to the brain) with right side hemiplegia (paralysis one side of the body).

A review of a quarterly comprehensive Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 20, 2023, revealed that Resident 19 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

During an interview with Resident 19 on January 24, 2024, at 11:30 AM the resident stated that staff do not timely answer call bells. Resident 19 stated that he can use a urinal but is unable to use a bed pan, is mostly incontinent of bowel, and wears a disposable brief. Resident 19 stated that on January 23, 2023, after lunch he waited 90 minutes to be changed after a bowel movement. Resident 19 stated that a staff member came into his room (he could not recall which staff member), asked if he could wait until resident lunch trays were picked up, turned off the call bell, and never returned. Resident 19 noted that staff often turn off the call bell and never return to provide the care requested.

Clinical record review revealed that Resident CR2 was admitted to the facility on October 31, 2023 with diagnosis to include morbid obesity and chronic kidney disease.

An admission MDS assessment dated November 6, 2023 revealed her to be cognitively intact and was dependant on staff for toileting and was frequently incontinent of urine.

A review of a care plan for bladder incontinence initiated November 7, 2023 revealed interventions to include, assist with toileting as needed.

A review of a facility grievance dated November 27, 2023 (no time indicated) the resident stated on Saturday night, November 25, 2023 she was put on the bedpan. I rang the call bell and no staff came. I waited 75 minutes till someone came in. That day, on the 3 P.M. to 7 A.M. shift it was not the usual staff who were caring for me.

The written resolution to the grievance dated November 27, 2023 was noted as, written education provided to staff about placing someone on the bed pan and notifying the nurse aide, and to answer the call bell in an appropriate manner.

There was no evidence at the time of the survey of any education provided to staff in regards to appropriate call bell response time as noted in the grievance resolution.

During an interview on January 26, 2024, at approximately 10:00 AM, the Nursing Home Administrator (NHA) verified that all residents at the facility should be treated with dignity and respect. The NHA was unable to explain why residents are reporting untimely staff responses to residents' requests for assistance, which is negatively affecting their quality of life in the facility. The NHA confirmed that call bells should not be turned off by staff until the resident's need is met.

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

28 Pa. Code 201.29 (a) Resident Rights

28 Pa. Code 211.12 (c)(d)(4)(5) Nursing Services.
















 Plan of Correction - To be completed: 02/27/2024

1. RESIDENT CR2 IS NO LONGER A RESIDENT IN THE FACILITY.
RESIDENT 19 IS PROVIDED CARE AND SERVICES IN A TIMELY MANNER, NEEDS ARE BEING MET.
2. THE FACILITY WILL AUDIT CALL BELL RESPONSE TO ENSURE RESIDENT NEEDS ARE MET IN A TIMELY MANNER AND RESIDENTS ARE TREATED WITH DIGNITY AND RESPECT.
3. ALL DEPARTMENTS WILL BE EDUCATED ON APPROPRIATE CALL BELL RESPONSE TO PROMOTE EACH RESIDENTS QUALITY OF LIFE.
4. DEPARTMENT MANAGERS/DESIGNEE WILL CONDUCT AUDITS ENSURING ALL NEEDS ARE MET AND RESIDENTS ARE TREATED WITH DIGNITY AND RESPECT WEEKLY x 4, MONTHLY X 2, THEN AS DEEMED NECESSARY BY QA. ALL RESULTS WILL BE REPORTED TO QA COMMITTEE.
5. FEBRUARY 27, 2024

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.75(g) Quality assessment and assurance.
§483.75(g) 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; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.
Observations:



Based on review of facility documents and staff interviews, it was determined that the facility failed to ensure that the Medical Director or designee was in attendance at quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for two of four quarters (June 2023 through December 2023)

Findings include:

A review of QAPI Committee meeting sign-in sheets for the period of June 2023 through December 2023, revealed that the Medical Director or other physician was not in attendance, virtually or in-person, at the QA meetings held from June 2023 through December 2023, missing 6 monthly meetings (June 2023 through December 2023).

Interview with the administrator on January 26, 2024, at 12:00 PM confirmed that the a physician failed to attend the facility's QAPI meetings on a quarterly basis.



28 Pa. Code 211.2 (d)(3)(4)(5)(6) Medical Director

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
















 Plan of Correction - To be completed: 02/27/2024

Facility medical director was present for January quarterly QAPI and signed off.
Facility will be scheduling regularly quarterly QAPI meetings with the Medical Director to ensure his attendance.
Education has been provided to the Administrator and Medical Director about the need for Medical Director involvement with the QAPI process.
Administrator or designee will conduct monthly audits with QAPI to ensure that Medical Director participation occurs at least quarterly.

483.70(e)(1)-(3) REQUIREMENT Facility Assessment: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.
§483.70(e) Facility assessment.
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include:

§483.70(e)(1) The facility's resident population, including, but not limited to,
(i) Both the number of residents and the facility's resident capacity;
(ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population;
(iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population;
(iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and
(v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

§483.70(e)(2) The facility's resources, including but not limited to,
(i) All buildings and/or other physical structures and vehicles;
(ii) Equipment (medical and non- medical);
(iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies;
(iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;
(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
(vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

§483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.
Observations:

Based on staff interviews and a review of the facility's assessment and the medical, psychiatric, and mental health conditions of the resident census it was determined that the facility failed to conduct and document a facility wide assessment, which identified the specific resources necessary to care for its specific resident population.

Findings include:

At the time of the survey ending January 26, 2024, the facility had completed a facility assessment to determine the specific and unique needs of its resident population.

Following surveyor inquiry, the facility provided a "Facility Assessment" document, which failed to identify the mental health, addiction and substance abuse issues of the current population in the facility. The assessment also failed to identify the needs and services offered for the under 67 year old population at the facility.

A review of facility documentation as of the date of the survey ending January 26, 2024, revealed that there were 77 of the 95 residents in the facility with a mental health diagnosis and 22 residents with an alcohol or substance abuse diagnosis.

A review of facility's monthly activity calendars for the last quarter revealed no activities specifically designated for younger residents and residents with mental health diagnoses as diversional activities for behavior management.

Interview with the facility activity director on January 25, 2024, at 11 a.m., confirmed that there were no activities specifically geared towards the mental health diagnosed, younger residents or residents with substance abuse issues in the facility.

The facility assessment presented to the survey team did not include comprehensive data and corresponding resources in order to competently care for the residents in the facility.

Refer F740, F741, F744


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

































 Plan of Correction - To be completed: 02/27/2024

Facility assessment has been updated to better reflect the resident population.
Education has been provided to the administrator by facility QA specialist on the facility assessment process.
Administrator or designee will conduct ongoing, monthly reviews with QAPI to ensure the facility assessment continues to reflect the resident population's needs.

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

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

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

Based on observation and staff interview and review of select facility policy, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and two of three resident pantries.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

During the initial tour of the food and nutrition services department conducted with the facility's food service director on January 24, 2024, at 9:10 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness:

The perimeter of the floor throughout the kitchen was visibly soiled with an accumulation of dirt and debris.

There was an approximate three inch by five inch missing floor tile along the wall across from the ice machine.

There was a ceiling tile with a large stain above the prep table in the kitchen.

A ceiling pipe located above the two-compartment sink in the dishroom was dripping.

There was an approximate three-inch hole and 2 inch hole in the wall located across from the dishwasher.

Observation of the second floor resident pantry on January 24, 2024, at 11:00 AM revealed a pitcher which contained lemonade which was dated but not labeled as to whether it was regular or diet lemonade.

The top interior surface of the microwave oven contained a build-up of food splatter and needed cleaning.

Observation of the third floor resident pantry on January 26, 2024, at 9:30 AM revealed 2 pitchers with fruit punch which were dated but labeled as to whether it was regular or diet fruit punch.

The top interior surface of the microwave oven contained a build-up of food splatter and needed cleaning.

Interview with the Nursing Home Administrator on January 25, 2024, at 1:00 PM, confirmed that the food and nutrition services department and resident pantries were to be maintained and food is to be stored in a sanitary manner.

28 Pa. Code 201.18(e)(2.1) Management








 Plan of Correction - To be completed: 02/27/2024

Kitchen was cleaned and all necessary repairs were made at the time of the survey.
Education has been provided to dietary staff by facility QA specialist on kitchen sanitation and the need to timely report maintenance needs.
Nightly post service cleaning schedule for dietary staff and weekly sanitation rounds implemented. Administrator or designee will conduct kitchen sanitation audits weekly x 4 then monthly x 4 with results reported to QAPI as needed

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes: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(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 observation, a review of facility's planned menus and resident and staff interview it was determined that the facility failed to accommodate individual food preferences, to the extent possible, to increase resident satisfaction with meals for residents which included three residents of 21 residents reviewed (Residents 19, 69, and 74).

Findings include:

An interview with Resident 19 on January 24, 2024, at 11:30 AM revealed that he is often not satisfied with the menu served and the alternates offered at the facility. Resident 19 stated that in the past hamburgers were offered on the alternate menu. Resident 19 stated that currently the facility very rarely offers hamburgers on the menu or as an alternate.

An interview with Resident 69 on January 24, 2024, at 12:00 PM revealed that he would like to have a hamburger on occasion since there are many meals on the menu which he does not like.

An interview with Resident 74 on January 26, 2024, at approximately 9:00 AM the resident stated that he did not like the food at the facility and that it "tasted terrible." He also mentioned that they do not provide him with his preferences being hamburgers, cheesesteaks, and cookies.

An interview with Employee 1, on January 26, 2024, at approximately 9:10 AM, revealed that Resident 74's family brings him in food regularly due to him not liking the food served at the facility.

Review of the planned menu revealed that hamburger and cheesesteak sub were each offered for one meal out of the four-week cycle menu.

Interview with the food services director (FSD) on January 26, 2024, at approximately 10:00 AM confirmed that hamburgers are a favorite food preference for many residents at the facility including Residents 19, 69, and 74. The FSD confirmed that hamburgers were removed from the alternate menu due to the number of hamburgers being requested at meal time by residents.

Interview with the nursing home administrator on January 26, 2024, at 12:30 PM failed to provide documented evidence that individual food preferences were being provided to the extent possible to increase resident satisfaction with meals.


28 Pa. Code 211.6 (a) Dietary services

28 Pa. Code 201.18 (a) Resident rights













 Plan of Correction - To be completed: 02/27/2024

Facility food committee minutes have been reviewed to update resident food preferences.
The facility will reinstitute hamburgers as part of the regular substitution menu. The facility will continue to assess resident preferences and update menus as needed with Dietician oversight.
Education has been provided to dietary director and dietician on the need to honor resident food preferences.
Administrator or designee will continue to review food committee minutes to ensure resident food preferences are being met with results reported to QAPI as needed.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

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

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

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

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

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

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

Based on a review of clinical records and staff interview, it was determined that the facility failed to provide medical justification for the continued use of an antipsychotic medication and/or attempt a gradual dose reduction of the drug for three residents out of five (Resident 15, 68 and 74) sampled receiving psychoactive drugs and failed to ensure the presence of clinical rationale for the continued use of an psychotropic medication prescribed on an as needed basis for one of five residents (Resident 83).

Findings include:

A review of the clinical record revealed that Resident 74 had diagnoses that included schizoaffective disorder (A mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior) and brief psychotic disorder and bipolar disorder.

A current physician order dated November 17, 2021, was noted for Seroquel (antipsychotic medication) 50 milligrams (mg) one tablet daily related to psychosis, with administration time at 6:00 AM.

A physician order was noted January 18, 2022, for the resident to receive Seroquel 50 mg one tablet daily related to bipolar disorder, with administration time at 9:00 PM.

A physician order was noted January 13, 2023, for the resident to receive Nuplazid (antipsychotic medication) 34 mg one tablet daily related to Parkinson's Disease induced hallucinations and delusions, with administration time at 9:00 AM.

A physician order was noted February 14, 2023, to increase the resident's Seroquel 50 mg one tablet, to twice daily, related to bipolar disorder and schizoaffective disorder

A review of the facility's behavioral monitoring and behavioral symptom tracking documented from October 2023 through January 2024, revealed that the resident did not display any psychotic behavioral symptoms of hallucinations or delusions. During that time the only mood and behavior issues noted were non-compliance with care, and frustration.

A review of a pharmacy consultation dated July 23, 2023, revealed the pharmacist recommended a GDR of the multiple physician prescribed psychoactive drugs, Seroquel (Quetiapine), Nuplazid, Duloxetine and Clonazepam. The record noted that the physician disagreed with the recommendation stating that the resident has a history of psychosis, bipolar disorder, and schizoaffective disorder, in addition to anxiety and any changes to her medications may have an adverse outcome on her health, no changes were made at this time. The physician did not identify the potential adverse outcomes to the resident's health if a GDR for any of the psychoactive drugs was attempted and the potential effects on the resident's functional abilities.

The facility was unable to provide documented evidence the resident was experiencing increased behaviors to warrant the continued use of the current dose of both Seroquel and Nuplazid or evidence that a gradual dose reduction of the antipsychotic medications for Resident 74 was conducted in the past year.

A review of the resident's clinical record, including interdisciplinary progress notes and behavioral monitoring, failed to reveal that the resident was displaying any psychotic behaviors or behaviors to clinical justify the dose increases of this antipsychotic medication.

A review of the clinical record revealed that Resident 15 had diagnoses that included unspecified dementia and psychotic disorder with hallucinations due to known physiological condition.

A quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated November 5, 2023, revealed Resident 15 was 93 years old and severely cognitively impaired.

The resident had a current physician order dated January 20, 2023, for Olanzapine (antipsychotic medication) 2.5 mg one tablet daily related to psychotic disorder with hallucinations due to known physiological condition, with administration time at 8:00 PM.

A review of the resident's clinical record, including progress notes and behavioral monitoring, failed to reveal that the resident was displaying any psychotic behaviors or behaviors to clinical justify the dose of this antipsychotic medication.

A review of a pharmacy consultation dated August 29, 2023, revealed the pharmacist recommended GDR of the physician prescribed medication Olanzapine. The record noted that the physician disagreed with the recommendation stating that the resident has a history of psychotic disorder with hallucinations, and any changes to her medications may have an adverse outcome on her health, no changes were made at this time. The physician did not identify the potential adverse outcomes to the resident's health if a GDR for any of the psychoactive drugs was attempted and the potential effects on the resident's functional abilities.

An interview with Employee 1, RN Unit Manager on January 25, 2024, at approximately 9:00 AM revealed that the resident is non-verbal and fully dependent on staff. She stated that she has been working at the facility for approximately three months and has not ever heard the resident speak. She may moan during repositioning, but that is the extent. The resident is currently under palliative care (end of life care).

The facility was unable to provide documented evidence the resident was experiencing behaviors to warrant the continued use of the current dose of Olanzapine or evidence that a GDR of the antipsychotic medication for Resident 15 was conducted in the past year.

A review of the clinical record revealed that Resident 68 had diagnoses that included major depressive disorder and unspecified psychosis not due to a substance or known physiological condition.

A physician order was dated February 9, 2023, for Abilify (antipsychotic medication) 2 mg one tablet daily related to unspecified psychosis not due to a substance or known physiological condition, with administration time at 9:00 AM.

A review of a pharmacy consultation dated October 29, 2023, revealed the pharmacist recommended a GDR of the physician prescribed medication Abilify. The record noted that the physician disagreed with the recommendation stated that she was currently undergoing a trial GDR of Venlafaxine (anti-depressant medication) no other changes would be made with this review.

The facility was unable to provide documented evidence the resident was experiencing behaviors to warrant the continued use of the current dose of Abilify or evidence that a GDR of the antipsychotic medication for Resident 68 was conducted in the past year.

A review of the resident's clinical record, including interdisciplinary progress notes or behavioral monitoring, failed to reveal that the resident was displaying any psychotic behaviors or behaviors to clinical justify the dose of this antipsychotic medication.

Review of Resident 83's clinical record revealed that the resident was admitted to the facility on November 8, 2022, with diagnoses including dementia.

Review of Resident 83's clinical record revealed a physician's order for Lorazepam (used to treat anxiety) tablet 0.5 MG give 1 tablet by mouth every 8 hours, as needed, for agitation related to Generalized Anxiety Disorder with a start date of February 9, 2023, and no end date.

Review of the January 2024 Medication Administration Records (MAR) revealed that the medication (Lorazepam) was administered three times to the resident during the month of January 2024.

Review of the physician's notes for the months of February 2023 through end of survey January 25, 2024 revealed that the physician failed to document the clinical rationale for the continued use or identify the need for the extended duration for the prn (as needed) order for the psychoactive drug without re-evaluation of its necessity.

An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 26, 2024, at 1:30 PM revealed that there was no documented evidence of a GDR or of any documented justification for the administration of the antipsychotic medications.


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

28 Pa. Code 211.2 (d)(3) Medical Director

28 Pa. Code 211.5 (f) Medical records





 Plan of Correction - To be completed: 02/27/2024

1. RESIDENTS 15,68, AND 74 HAVE BEEN PROVIDED WITH A MEDICAL JUSTIFICATION FOR CONTINUED USE OF ANTIPSYCHOTIC MEDICATIONS/GDR AS DETERMINED BY THE PROVIDER.
RESIDENT 83 END DATE FOR PRN MEDICATION IS 2/21/2024.
A MONTHLY IDT MEETING WITH THE PRESCRIBING PRACTITIONER WILL BE HELD MONTHLY TO REVIEW CONTINUED USE OF ANTIPSYCHOTIC MEDICATIONS AND GRADUAL DOSE REDUCTIONS, AND REVIEW POC FINDINGS.
2. NURSING WILL AUDIT RESIDENTS FOR CONTINUED USE OF ANTIPSYCHOTIC MEDICATION IN ATTEMPT TO PROVIDE GRADUAL DOSE REDUCTIONS FOR CONTINUED USE OF PSYCHOACTIVE MEDICATIONS AS PRESCRIBED.
3. NURSING STAFF/SOCIAL SERVICE WILL BE EDUCATED ON GRADUAL DOSE REDUCTIONS AND THE NEED FOR DOCUMENTED JUSTIFICATION FOR THE ADMINISTRATION OF PSYCHOACTIVE MEDICATIONS.
4. NURSING MANAGEMENT/DESIGNEE WILL AUDIT GRADUAL DOSE REDUCTIONS OF ANTIPSYCHOTIC MEDICATIONS AND THE DOCUMENTATION FOR JUSTIFICATION OF CONTINUED USE OF ANTIPSYCHOTIC MEDICATION WEEKLY X 4, MONTHLY X 2, AND AS DEEMED NECESSARY BY QA. RESULTS WILL BE REPORTED TO QA COMMITTEE.
5. FEBRUARY 27, 2024

483.40(a)(1)(2) REQUIREMENT Sufficient/Competent Staff-Behav Health Needs:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.40(a) The facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with §483.70(e). These competencies and skills sets include, but are not limited to, knowledge of and appropriate training and supervision for:

§483.40(a)(1) Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, that have been identified in the facility assessment conducted pursuant to §483.70(e), and
[as linked to history of trauma and/or post-traumatic stress disorder, will be implemented beginning November 28, 2019 (Phase 3)].

§483.40(a)(2) Implementing non-pharmacological interventions.
Observations:

Based on a review of the facility's assessment and clinical record and staff interviews it was determined that the facility failed to ensure staff possess the necessary competencies and skills to care for residents with mental and psychosocial disorders, which included two residents (Residents 92 and 49) out of 21 sampled.

Findings include:

A review of the facility census at the time of survey ending January 26, 2024, revealed a census of 95 residents. Review of information provided by the facility revealed 77 of 95 residents had some mental health diagnosis and 22 of 95 residents had a history of alcohol or substance abuse.

A review of the clinical record revealed that Resident 92 was admitted to the facility on July 11, 2023, with diagnoses that included opioid dependency, depression, and anxiety.

The resident's clinical record, when reviewed during the survey ending January 26, 2024, contained psychiatric consults indicating that Resident 92 continued to struggle with the desire to do drugs, anxiety and depression.

A review of the clinical record revealed that Resident 49 was admitted to the facility on April 20, 2022, with diagnoses to have included alcohol abuse, and schizoaffective disorder.

When reviewed during the survey ending January 26, 2024, the resident's clinical record revealed documentation that the resident had gained a significant amount of weight since admission to the facility. Review of psychiatric consults completed during the admission, as of the time of the survey ending January 26, 2024, revealed that the consults indicated that Resident 49 had likely replaced his addiction to alcohol with food.

Interview with the Director of Nursing on January 25, 2024, confirmed that the facility does not provide training to its staff on providing care and services to residents with substance abuse disorders, addiction problems or designing and implementing behavior management or modification programs.

The facility failed to provide sufficient direct care staff (nurse aides and licensed nurses) with knowledge of behavioral health care and services in accordance with the care plans for all residents, including those with mental or psychosocial disorders, including implementing non-pharmacological interventions.

Interview with the Nursing Home Administrator on January 25, 2024, at approximately 1:10 PM confirmed that the facility failed to employ sufficient staff with the necessary competencies and skills sets to develop and implement interdisciplinary person-centered approaches to resident care and provide related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of these residents.

Refer F740, F744

28 Pa Code 211.12 (d)(3)(4)(5) Nursing services

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










 Plan of Correction - To be completed: 02/27/2024

1. STAFF HAVE BEEN PROVIDED WITH THE NECESSARY COMPETENCIES AND SKILLS TO CARE FOR RESIDENTS 92 AND 49.
A FACILITY EDUCATION WILL BE COMPLETED BY BEHAVIORAL HEALTH PROFESSIONALS TO ENSURE STAFF COMPETENCIES AND SKILLS COMPLETED, AND EVALUATED WITH THE ASSISTANCE OF SOCIAL SERVICE AND NURSING.
2. THE FACILITY WILL AUDIT COMPETENCIES AND SKILLS TO CARE FOR RESIDENTS WITH MENTAL/PSYCHOSOCIAL DISORDERS.
3. NURSING/SOCIAL SERVICE DIRECTOR WILL PROVIDE EDUCATION REGARDING CARE AND SERVICES TO RESIDENTS WITH SUBSTANCE ABUSE DISORDER AND ADDICTION PROBLEMS ALONG WITH DESIGNING/IMPLEMENTING BEHAVIOR MANAGEMENT.
4. NURSING MANAGEMENT/DESIGNEE WILL COMPLETE AN INITIAL AUDIT ON COMPETENCIES/SKILL SETS FOR PSYCHOSOCIAL DISORDERS, INCLUDING SUBSTANCE ABUSE AND ADDICTION PROBLEMS, THEN MONITOR MONTHLY X 2, AND AS DEEMED NECESSARY BY QA. ALL RESULTS WILL BE REPORTED OT QA COMMITTEE.
5. FEBRUARY 27, 2024

483.40 REQUIREMENT Behavioral Health Services:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations:


Based on review of clinical records and select investigative reports and staff interview it was determined that the facility failed to provide the necessary behavioral health care and services to meet the needs of two residents out of 21 sampled (Residents 80 and 77) to maintain the residents' highest practicable physical, mental and psychosocial well-being).

Findings include:

Review of the clinical record revealed that Resident 80 was admitted to the facility on August 30, 2021, and had diagnoses, which included cerebral vascular accident with hemiparesis, cerebral palsy, profound intellectual disabilities and a history of falls.

The resident's care plan initially dated December 10, 2021, indicated that the resident had impaired cognitive function/dementia or impaired thought processes related to developmentally delayed and health diagnoses. The planned interventions, initiated September 10, 2021, were to keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion.

A nurses note dated March 14, 2023, at 11:50 A.M. revealed that "\ more vocal, calling out, banging right fist on side of geri-lounger. Squirming around in geri-chair, unable to console with touch, snacks or music. Call placed to the nurse practitioner; new order noted. discontinue Sertraline (an antidepressant medication) 25 mg PO qd; start Sertraline 50 mg PO every day."

A nurse's note dated March 22, 2023 at 2:29 P.M. revealed "\ very restless this am. Continually calling out with loud sounds. Hitting his hand off the wall and his gerichair in dining room. Repositioned by staff. Unable to make needs known. Tylenol given as ordered with negative results. Resident continued with same and biting at Right arm. Fluids provided. Assisted back to bed. Resident calmed down and no further behaviors noted since resident was assisted back to bed. Nurse practitioner made aware of same and new orders noted. Currently in bed resting with eyes closed. No distress noted."

A review of a nurses note dated July 12, 2023, at 08:15 AM revealed that staff observed Resident 80 seated in a geri-lounger in TV dining room. An LPN reported to the nurse that "He \ banged his head against the wall a couple of times." A nursing assessment of resident found a hematoma to center of his forehead. Nursing noted that the resident was alert to self, with confusion, and at baseline at present. Vital signs stable. Neuro checks initiated per facility protocol and within normal limits at present. Staff were educated on positioning resident away from wall; for safety while in Broda chair, due to involuntary movements.

A review of Resident 80's initial psychiatric/psychological services consult, dated August 24, 2023, revealed that the provider noted that "\ is a 61 year old male with history of generalized anxiety disorder and bipolar disorder. He recently has been prescribed Citalopram (an antidepressant medication) for agitation and anxiety. Today he was found relaxed without banging on his chair or moaning. He was more verbal than typically but does not appear in distress, his verbalizations were not loud enough to bother residents around him as all residents ignored his noises in day room. No behavior suggesting hallucinations."

A review of a facility investigation report dated November 18, 2023, at 8:20 AM revealed that staff were pushing Resident 80 in his wheelchair into the dining room for breakfast. Resident 80 intentionally struck his forehead against the wall during the transport. According to the report the immediate intervention initiated at the time of the incident was noted as "staff education to keep the resident positioned away from the wall while in the dining room for his safety."

The interventions did not address the potential root cause of the resident's behavior with approaches developed to address the resident's behavioral symptoms.

The resident's care plan was updated on November 18, 2023, to address a self-inflicted bruise to the head with the planned response for staff education to keep resident positioned away from wall while in dining room for his safety, initiated November 18, 2023, in response to the self-inflicted bruise to the head.

A review of a nurses note dated November 19, 2023 at 11:32 A.M. revealed, Resident 80 was assessed status post incident to have a hematoma to his forehead. Vital signs stable. Pupils equal. The resident was unable to follow verbal commands, as is his baseline. Red/slightly raised bruise to forehead. Being monitored for resolution. Resident positioned away from walls of dining room at present for his safety.

There was no documented evidence that Resident 80 was provided follow-up psych services treatment between August 24, 2023, thru the time of the survey ending January 26, 2024.

There was no documented evidence that the facility demonstrated an interdisciplinary approach to the resident's care, with qualified staff that demonstrate the competencies and skills necessary to provide appropriate services to the resident, including individualized approaches to care, including direct care and activities, provided to support the resident's physical, mental, and psychosocial environment.

During an interview with the Director of Nursing (DON), on January 26, 2024, at approximately 11:00 a.m., the NHA confirmed that Resident 80 had not received psychological/psychiatric services as recommended for follow-up during the period of August 24, 2023 and January 26, 2024.

Clinical record revealed that Resident 77 was admitted to the facility on September 9, 2023, with diagnoses of cerebral infarction (stroke), alcoholic hepatitis, alcohol dependence and anxiety.

The resident had a physician order dated September 9, 2023 that the resident "May be seen by Psychiatric Services for evaluation/ treatment."

A quarterly MDS assessment dated December 4, 2023, revealed that Resident 77 was severely cognitively impaired and required assistance of staff for activities of daily living.

The resident's care plan, initiated September 11, 2023 for alterations in behavior
manifested by socially inappropriate behavior impulsive behaviors. The care plan was updated January 15, 2024, related to exit seeking behavior, updated on January 9, 2024, when the resident hit a staff member in the stomach. Planned interventions were to allow the resident time to calm down, ensure resident safety and approach at a later time, monitor for exit seeking behavior.

A certified registered nurse practitioner note dated November 9, 2023, at 11:46 AM revealed, "This is a 69 year old male patient who was seen by psych related to anxiety and a history of alcohol dependence. The patient is alert but randomly oriented to self. The patient exhibits behaviors which range from withdrawn to yelling and screaming to physical aggression. There do not appear to be triggers for his random behaviors. No new recommendations were made with this visit. He is noted to be withdrawn and nursing requested this examination related to increased anxiety and/or behaviors." The noted recommendations were to provide the resident with redirection with increased behaviors and/or confusion.

Individualized designed methods to redirect the resident were not identified.

Resident 77 was seen by the facility contracted psychiatric nurse practitioner in October 2923 and November 2023 for his behaviors.

A review if a psychiatric physician assistant progress note dated December 7, 2023, the last documented psych service entry in the resident's clinical record, as of the time of the survey, revealed that the resident " is a 69 year old male with history of alcohol dependence, tobacco use, and has unspecified cognition and social deficits with altered mental status and generalized anxiety disorder. Started Citalopram ( an antidepressant medication) 10 mg on October 15, 2023. Continues to display agitation and aggression weekly. Aggression is monitored per shift, noncompliant with medications at times. Resident resists conversation and stares at this writer blankly with confused demeanor.

A review of nursing documentation dated January 10, 2024, at 08:15 AM revealed "\ alarm sounding resident coming out of his room, nurse aide's at doorway with breakfast trays. Nurse aide attempted to ask resident if he wanted breakfast and resident hit the nurse aide in the stomach and is cursing at staff threatening to hurt staff. Resident walking around and not answering anyone when spoken to. Nurse Practitioner made aware and Crisis (immediate mental health intervention) called. Nursing spoke to the crisis personnel and she said they won't come to evaluate resident unless he is willing. I asked resident and he won't answer "yes" or "no." The crisis personnel said they won't come out since he won't answer and will call back around lunch time to see how he is doing. She is going to fax over paperwork if we want to fill it out and fax back over. Resident presently is still walking around in unit won't answer anyone and is being followed by a nurse aide with his wheelchair."

A nurse practitioner note January 10, 2024, at 09:49 AM revealed that "This is a 69 year old male patient who was noted to hit a nurse aide. The patient has exhibited similar behavior in the past. The Unit Manager Nurse was instructed to contact Crisis related to the patient's behavior. The psych nurse practioner is in the building today and will see the patient related to increased behaviors. Will continue to monitor. Assessment & Plan, Agitation; Follow up with nursing related to increased agitation or aggression; Provide redirection with increased behaviors; and contact Crisis related to behaviors.

There was no documented evidence that the facility had developed individualized interventions related to the resident's diagnosed conditions, including community substance use services, had reviewed and revised behavioral health care plans that have not been effective.

A review of a nursing note dated January 15, 2024, at 2 PM revealed "Resident ambulating in hallway and attempting to open exit doors; nurse aide with him and able to redirect but still ambulating in unit. Nurse practitioner made aware, new order noted, 1:1 safety measures."

A nurses note dated January 15, 2024, at 06:20 AM revealed that the resident displayed "Increased behaviors noted throughout this shift, resident agitated with bed alarm sounding, took bed alarm off bed and threw it into the hallway breaking it. Bed alarm replaced, resident states if alarm goes off again he 'will smash it, now leave me alone or I will hit you in the face', resident safe in bed with alarm intact, call bell within reach."

A review of a nurses note dated January 25, 2024, at 09:00 AM revealed "Resident walking in unit walked down to long hall window and threatened to throw himself out \ and banging on window. Redirected away from the window and walking in unit with NA following with wheelchair for safety, Nurse Practitioner made aware new order, 1:1, crisis called. Crisis worker attempted to talk to resident and he threw the phone at this writer. Crisis is coming out to see resident."

A review of a nurses note dated January 25, 2024, at 09:28 AM rvealed that that Director of Social Services (DSS) was called to floor due to resident threatening self-harm and harm to others. DSS was able to create a safe environment for resident and calm him down. Resident went to his room to rest sitting on his bed. Crisis was called by nursing. Awaiting crisis to evaluate need for hospitalization.

A nurses note dated January 25, 2024 at 10:41 AM., revealed that the resident seen by psych services nurse practitioner for increased behaviors. New recommendations noted to administer Depakote ( an antiseizure medication used for bipolar disorder) 125 mg PO BID for altered mental status and labs ordered.

A nurses note dated January 25, 2024, at 11:10 A.M., revealed that staff from crisis intervention called the facility regarding the resident and nursing informed her that the resident was walking in the unit and walked down to our window at the end of the hallway and yelled he is going to throw himself out the window and began violently banging on the window to try to break it and jump. We were able to redirect him away from the window but resident having outbursts in the unit yelling how he is going to throw himself out the window. The nurse practitioner was called and order for 1:1 safety measures. Resident declined to speak with crisis staff by phone and threw the phone at the nurse. Crisis informed the facility that they wouldn't be coming onsite to the facility because of RSV infections in the building, stating their supervisor said they are "to keep their employees safe." Crisis intervention worker declined to physically see the resident inside the facility, but would review the nurses's statement, after meeting the nurse outside the facility, and decide if he meets criteria or not to 302 him.

Nursing noted on January 25, 2024 at 12:59 P.M., revealed that a representative from crisis called back and they issued a warrant, 302 ( an involuntary commitment to a psychiatric facility for evaluation and treatment) and the ambulance was coming to get him.

A nurses note dated January 25, 2024 at 3:43P.M. revealed "Health Status the State police arrived at the facility and resident taken to the hospital. The hospital called and spoke to facility staff and report given."

A nurses note dated January 30, 2024 at 11:06 AM, revealed that the "Resident remains at the hospital Behavioral Health for further treatment. A 302 hearing was held today with staff of the facility (DON and petitioner) participating via phone. According to the psychiatrist who is treating Resident 77 at the behavioral unit, they will uphold the 302 and the resident will remain there at this time for medication management and group meetings, RP aware.

The facility failed to timely review and revise behavioral health care plans that have not been effective, show awareness of the resident's history and prior level of functioning in order to identify appropriate goals and interventions and attempt to identify individual resident responses to stressors and utilize person-centered interventions developed by the interdisciplinary team. The facility staff repeatedly required the crisis intervention in response to the resident's behaviors, which were not consistently readily available or present onsite to diffuse, modify or manage the resident's escalating behaviors.


Refer F741


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






























 Plan of Correction - To be completed: 02/27/2024

1. RESIDENTS 77 AND 80 HAVE BEEN PROVIDED THE NECESSARY BEHAVIORAL HEALTHCARE AND SERVICES TO MEET THEIR NEEDS.
SOCIAL SERVICE WILL DEVELOP BEHAVIORAL HEALTH CAREPLANS AS NECESSARY, IN COORDINATION WITH THE BEHAVIORAL HEALTH SERVICES PSYCHIATRIC NURSE PRACTITIONER.
2. THE FACILITY WILL AUDIT THE BEHAVIORAL HEALTH OF RESIDENTS TO ENSURE AN IDT APPROACH IS USED IN PROVIDING CARE AND SERVICES, WITH REVIEWING CARE PLANS AND GOALS/INTERVENTIONS.
3. SOCIAL SERVICE WILL BE EDUCATED ON TIMELY REVIEW AND REVISION OF BEHAVIORAL CAREPLANS THAT ARE NOT EFFECTIVE IN PROVIDING NECESSARY BEHAVIORAL HEALTHCARE AND SERVICES WTH IDENTIFICATION OF APPROPRIATE GOALS AND INTERVENTIONS.
4. SOCIAL SERVICE DIRECTOR WILL AUDIT BEHAVIORAL CAREPLANS FOR EFFECTIVE INTERVENTIONS TO PROVIDE NECESSARY CARE AND SERVICES WEEKLY X 4, MONTHLY X 4, THEN AS DEEMED NECESSARY BY QA. ALL RESULTS WILL BE REPORTED TO QA COMMITTEE.
5. FEBRUARY 27, 2024

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 interview with administrative staff and a review of employee personnel records and facility provided documentation, it was determined that facility failed to show that annual performance evaluation of nurse aides were conducted at least once every 12 months for those nurse aides employed by the facility for longer than one year.

Findings include:

On January 25, 2024, at 1:05 PM the surveyors requested the facility provide evidence of the completed performance evaluations for nurse aides who have been employed by the facility for longer than one year.

As of the conclusion of the survey ending January 26, 2024, the facility was unable to locate any performance evaluations for nurse aides employed by the facility for longer than one year.

During an interview on January 25, 2024 at 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to complete annual performance evaluations for nurse aides at least once every 12 months


28 Pa. Code 201.19 (2) Personnel records









 Plan of Correction - To be completed: 02/27/2024

1. PERFORMANCE EVALUATIONS ARE COMPLETED FOR NURSES AIDES WHO HAVE BEEN EMPLOYED BY THE FACILITY FOR LONGER THAN 1 YEAR.
2. THE FACILITY WILL AUDIT CURRENT NURSE AIDE PERFORMANCE EVALUATIONS FOR COMPLETION AT LEAST ONE TIME EVERY 12 MONTHS.
3. NURSING MANAGEMENT WILL BE EDUCATED ON THE COMPLETION OF ANNUAL PERFORMANCE EVALUATIONS AT LEAST ONCE EVERY 12 MONTHS.
4. NURSING MGT/DESIGNEE WILL CONDUCT AN INITIAL AUDIT OF THE CURRENT NURSE AIDE PERFORMANCE EVALUATIONS, THEN MONTHLY X 2, AND AS DEEMED NECESSARY BY QA. ALL RESULTS WILL BE REPORTED TO QA COMMITTEE.
5. FEBRUARY 27, 2024

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on clinical record review and staff interview it was determined that the facility failed to provide respiratory care, oxygen, as ordered by the physician for one resident out of 21 sampled (Resident 60).

Findings included:

A review of Resident 60's clinical record revealed she was admitted to the facility on June 2, 2020, with diagnoses schizoaffective disorder, major depression and difficulty walking.

A quarterly MDS (minimum data set- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 12, 2023, indicated that the resident was independent for transfers, bed mobility, ambulation and activities of daily living (ADLs) and uses a manual wheelchair. The resident was cognitively intact with a BIMS score of 15 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact).

Documentation in the resident's clinical record revealed that the resident had a history of nightmares. A sleep study was completed on December 4, 2023, which noted decreased nocturnal oxygenation. The resident agreed to utilize oxygen at night.

A physician order dated December 8, 2023, was noted for Oxygen 2 liters at bedtime.

A review of the resident's December 2023 TAR (treatment administration record) revealed no documented evidence that nursing staff provided the oxygen to the resident at bedtime.

The resident's January 2024 TAR indicated that the resident's oxygen saturation levels were obtained at bedtime but no documented evidence that oxygen was provided as ordered.

Interview with the NHA on January 25, 2024, confirmed that there was no documented evidence that the facility consistently provided the oxygen at bedtime as ordered by the physician on December 8, 2023.


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

28 Pa. Code 211.5 (f) Medical records




 Plan of Correction - To be completed: 02/27/2024

1. RESIDENT 60 IS UTILIZING OXYGEN AS PER PHYSICIAN ORDER.
2. THE FACILITY WILL AUDIT CURRENT OXYGEN ORDERS TO ENSURE ADMINISTRATION AS ORDERED BY THE PHYSICIAN.
3. NURSING STAFF WILL BE EDUCATED ON PROVIDING OXYGEN AS ORDERED BY THE PHYSICIAN.
4. NURSING ADMINISTRATION/DESIGNEE WILL CONDUCT AUDITS OF CURRENT OXYGEN ORDERS AND ENSURE ADMINISTRATION AS PER PHYSICIAN ORDER WEEKLY X 4, MONTHLY X 2, THEN AS DEEMED NECESSARY BY QA. ALL RESULTS WILL BE REPORTED TO QA COMMITTEE.
5. FEBRUARY 27, 2024

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:


Based on clinical record review, observation and staff and resident interview, it was determined that the facility failed to monitor the fluid intake of two residents out of 21 sampled prescribed a fluid restriction related to a clinical condition to assure sufficient fluid intake to maintain proper hydration and manage their clinical condition (Residents 5 and 25).

Findings include:

Clinical record review revealed that Resident 5 was moderately cognitively impaired and was admitted to the facility on May 31, 2023 with diagnoses of dementia, diabetes and chronic kidney disease.

A physician order was noted November 21, 2023, for a 1500 cc/24 hours fluid restriction. The distribution was noted as: nursing allowance - 420 ccs in 24 hours; 200 ccs on 7 AM to 3 PM shift; 120 ccs on 3 PM to 11 PM shift and 110 ccs on 11 PM to 7 AM shift; dietary allowance, 1080 ccs in 24 hours, 480 ccs breakfast, 240 ccs lunch and 360 ccs dinner.

An observation January 25, 2024 at 9:15 A.M. in Resident 5's room revealed three (3) - 16 oz ounce styrofoam cups of water (a total of approximately 1440 ccs) along with two (2) plastic cups each containing an additional 180 cc of water (360 ccs).

Resident 5 was drinking from the large cup of water during the observation. She stated that she drinks water from these cups all day long and that nursing staff gives her water every shift and when she asks for it.

A review of the resident's January 2024 Treatment administration record revealed that licensed nurses documented the provision of fluids to the resident as follows:

January 19, 2024--520 ccs
January 20, 2024--360 ccs
January 21, 2024--480 ccs
January 22, 2024--440 ccs
January 23, 2024--360 ccs
January 24, 2024--360 ccs
January 25, 2024--500 ccs

A review of nursing activity of daily living "tasks" documentation revealed nurse aide documentation of fluids consumed by the resident:

January 19, 2024-960 ccs (no documentation for the 7 A.M. to 3 P.M. shift)
January 20, 2024--1200 ccs
January 21, 1014--1160 ccs
January 22, 2024--1060 ccs
January 23, 2024--640 ccs
January 24, 2024--1040 ccs
January 25, 2024--870 ccs

There was no documented evidence at the time of the survey that any staff, nursing or dietary, calculated Resident 5's total daily fluid intake to ensure compliance with the physician ordered 1500 cc fluid restriction.

Based on the fluid intake documented by the facility the resident's fluid intake was totaled as:

January 19, 2024--1480 ccs
January 20, 2024--1560 ccs
January 21, 2024--1640 ccs
January 22, 2024--1500 ccs
January 23, 2024--1000 ccs
January 24, 2024--1400 cc's
January 25, 2024--1370 cc's

However, there was no evidence that the above included the observation of the fluids observed at the resident's bedside, and being consumed by the resident, on January 25, 2024. The resident reported that her fluids were not restricted.

Clinical record revealed that Resident 25 had diagnoses of end stage renal disease with dialysis and diabetes.

A quarterly MDS assessment dated November 26, 2023, revealed the resident was severely cognitively impaired, required staff assistance for activities of daily living and was receiving dialysis treatments.

A physician order was noted November 21, 2023, for a fluid Restriction: 1500 ml Total in 24 hours. The daily distribution was noted as: Nursing: 420 ml/24 hr, (200 ml on 7 AM to 3 PM, 120 ml on 3 PM to 11 PM, 100 ml on 11 PM to 7 AM). Dietary: 1080 ml/24 hr (480 ml - Breakfast, 240 ml - Lunch, 360 ml - Dinner).

An observation January 25, 2024 at 12:10 PM in Resident 25's room there were a 16 ounce (480 ccs) styrofoam cup with water.

Observation of Resident 25's lunch tray revealed 120 ccs fruit juice, 120 ccs milk and 240 ccs coffee for a total of 480 ccs (vs the 360 ml planned). Interview with the nurse aide delivering lunch trays at the time of the observation revealed that the aide stated that Resident 25 receives ice water every shift, and more as the resident requests. The aide also stated that the resident receives juice from the pantry as he requests also.

A review of January 2024 Treatment administration record revealed that licensed nurses documented the following fluids provided to the resident:

January 19, 2024-- 360 ccs
January 20, 2024-- 360 ccs
January 21, 2024-- 600 ccs
January 22, 2024-- 680 ccs
January 23, 2024-- 500 ccs
January 24, 2024-- 460 ccs
January 25, 2024-- 400 ccs

A review of nursing activity of daily living "tasks" documentation revealed nurse aide documentation of fluids consumed by the resident:

January 19, 2024--960 ccs
January 20, 2024--1200 ccs
January 21, 1014--1160 ccs
January 22, 2024--720 ccs
January 23, 2024--1160 ccs
January 24, 2024--600 ccs
January 25, 2024--1560 ccs

There was no evidence at the time of the survey that facility staff, nursing or dietary, calculated Resident 25's total daily fluid intake to ensure compliance with the physician ordered 1500 cc fluid restriction.

Based on the fluid intake documented by the facility the resident's fluid intake was totaled as:

January 19, 2024--1320 ccs
January 20, 2024--1560 ccs
January 21, 2024--1760 ccs
January 22, 2024--1400 ccs
January 23, 2024--1660 ccs
January 24, 2024--1060 ccs
January 25, 2024--1960 ccs

However, based on observations of the fluids provided to the resident and interview with staff, confirming that the resident has access to fluids as desired, there was no evidence that the facility was adhering to the physician ordered fluid restriction prescribed for treatment of the resident's clinical condition.

During an interview January 25, 2024 at approximately 2 PM the Director of Nursing confirmed that the facility was not following the physician prescribed fluid restrictions and had failed to accurately monitor the residents' actual fluid consumption.



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

28 Pa. Code 211.5 (f) Medical records








 Plan of Correction - To be completed: 02/27/2024

1. RESIDENTS 5 AND 25 ARE ACCURATELY BEING MONITORED FOR THE PRESCRIBED FLUID RESTRICTION AND ACTUAL FLUID CONSUMPTION. TOTAL FLUID INTAKE WILL BE DOCUMENTED EVERY 24 HOURS.
2. THE FACILITY WILL AUDIT RESIDENTS ON FLUID RESTRICTIONS TO ENSURE FLUID INTAKE WHILE ON FLUID RESTRICTION IS MONITORED ACCURATELY FOR PROPER HYDRATION.
3. NURSING STAFF WILL BE EDUCATED ON PROPER HYDRATION ON PRESCRIBED FLUID RESTRICTIONS AND MONITORING OF ACTUAL FLUID CONSUMPTION. RESIDENTS ON FLUID RESTRICTION WILL BE EDUCATED TO ENSURE UNDERSTANDING OF FLUID RESTRICTIONS AND THE IMPORTANCE OF FOLLOWING THE FLUID RESTRICTION AS ORDERED.
4. NURSING ADMINISTRATION/DESIGNEE WILL CONDUCT AUDITS OF FLUID INTAKE/FLUID RESTRICTION AND THE ACCURATE MONITORING OF FLUID INTAKE WEEKLY X 4, MONTHLY X 2, AND AS DEEMED NECESSARY BY QA. RESULTS WILL BE REPORTED TO QA COMMITTEE.
5. FEBRUARY 27, 2024

483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident: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.
§483.24(c) Activities.
§483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
Observations:

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide an ongoing program of activities designed to meet the needs, interests, preferences, and functional abilities of at least three residents out of 21 sampled residents (Residents 92, 49, and 19).

Findings include:

A review of the facility census at the time of survey ending January 26, 2024, revealed a census of 95 residents. Review of the average age of residents indicated that 18 residents were under the age of 60. Further review of resident indicators revealed that 77 of 95 residents had some mental health diagnoses and 22 of 95 residents had a history of alcohol or substance abuse.

A review of the clinical record revealed that Resident 92 was admitted to the facility on July 11, 2023, with diagnoses that included opioid dependency, depression, and anxiety.

A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated November 9, 2023, indicated that the resident was mildly cognitively impaired with a BIMS [Brief Interview of Mental Status-a tool to assess cognitive function] score of 12 (a score of 8-12 indicates mild cognitive impairment).

Further review conducted during the survey ending January 26, 2024, revealed that the resident's activity preferences had not been reviewed since her admission to the facility in July of 2023.

A review of psychiatric consultation note dated January 10, 2024, revealed that resident continued to struggle with depression and anxiety and stated that she was "bored" in the facility.

A review of the clinical record revealed that Resident 49 was admitted to the facility on April 20, 2022, with diagnoses to have included alcohol abuse, and schizoaffective disorder.

Review of Resident 49's quarterly MDS assessment dated November 3, 2023, indicated that the resident was cognitively intact with a BIMS score of 14.

Interview with Resident 49 during the survey ending January 26, 2024, revealed the resident stated that the activities provided in the facility, did not interest her and that she is often "bored."

Review of Resident 49's clinical record revealed the resident's activity preferences had not been reviewed since October 2022.

A review of the clinical record revealed that Resident 19 was admitted to the facility on June 18, 2022, and has diagnoses, which include depression.

Review of Resident 19's quarterly MDS assessment dated December 20, 2023, indicated that the resident was cognitively intact with a BIMS score of 15.

Review of Resident 19's Annual Activities Assessment dated June 26, 2023, revealed that the resident depended on activities for cognitive and social interaction. The resident's preferred activities included watching television, music, trivia, handout sheets, and bingo.

Further review of the resident's clinical record revealed no documented evidence that the resident's preferred activities were consistently being offered to Resident 19 on an ongoing basis.

Interview with Resident 19 on January 24, 2024, at 11:30 AM revealed that he was not happy with the current activities in the facility. Resident 19 stated that he does enjoy bingo but that instead of prizes they are given "bingo bucks" which then can be redeemed for prizes. However, Resident 19 stated there have not been many prizes to redeem with the "bonus bucks" and that facility offers to redeem the "bonus bucks" are not always completed.

Review of the facility's Activity Calendars for October 2023, November 2023 and December 2023, and through survey ending January 26, 2024, indicated that the scheduled activities provided did not offer variety and not including programming designed for the younger residents.

Interview with the activity director on January 25, 2024, at 11:35 AM, revealed that there are no specific activities for the younger population and no activities directed towards the mental health needs of residents. The director stated that he recently began employment and had not been able to assess all of the residents' activity preferences.

The facility failed to develop and implement a program of activities to meet the varied preferences, interests and cognitive and functional abilities and needs of the resident population, including offering activities designed for higher functioning younger residents.




28 Pa. Code 201.29 (a) Resident rights

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







 Plan of Correction - To be completed: 02/27/2024

The Activities Director shall complete an activity preference for residents 92, 49 and 19.
The Activity Director shall complete an activity preference for residents along with their quarterly care plan review.
The Activity Director and staff shall be educated on completion of activity preferences, and to provide an ongoing program of activities designed to meet the needs, interest, preferences, and functional abilities.
The Activity Director shall complete an audit to verify that resident preferences are obtained and are utilized to provide appropriate programs for the residents.
The audits shall be completed weekly x4, then monthly x2. The audits shall be sent to the QA meeting for a review of trends.

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

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

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

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

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

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

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

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


Based on observation and resident and staff interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a clean, sanitary, and orderly environment on the second and third floor nursing units.

Findings include:

Observation of Resident Room 318 located on the Third Floor Nursing Unit on January 24, 2024, at 9:32 AM revealed several brown and reddish colored stains on resident's beds (A and B). There was also residents clothing and belongings on the floor, and multiple empty cups and dirty dishes on resident's bedside tables.

Observation of Resident Room 214 located on the Second Floor Nursing Unit on January 24, 2024, at 11:15 AM revealed a stained ceiling tile above the bed located near the window. There were also two stained ceiling tiles in the corner of the room near the bathroom.

Observation of Resident Room 315 located on the Third Floor Nursing Unit on January 25, 2024, at 9:10 AM revealed the floor to be sticky, food on the floor, dirty dishes on resident's bedside table.

Interview with the Nursing Home Administrator on January 25, 2024, at 1:00 PM confirmed that the resident environment should be maintained in a clean, sanitary, and orderly manner.


28 Pa Code 201.18(e)(2.1) Management








 Plan of Correction - To be completed: 02/27/2024

Rooms 315, 318, and 214 were cleaned and had necessary repairs made at the time of survey.
All resident rooms inspected for cleanliness and repair needs.
Housekeeping staff will be educated on proper room cleaning and reporting of maintenance needs.
Room audits will be conducted weekly x 4 weeks then monthly x 4 months by administrator or designee with results reported to QAPI as needed.

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 controlled drug records and select facility policy and staff interview, it was determined that the facility failed to implement procedures to promote accurate administration, and accounting of controlled drugs to one of 21 residents sampled (Resident CR1) .

Finding include:

A review of the clinical record revealed that Resident CR1 was admitted to the facility on October 23, 2023, with diagnoses to include chronic obstructive pulmonary disease, diabetes and anxiety.

The resident had a physician order, dated October 24, 2023, for Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen, a combination narcotic/non narcotic pain medication)
Give 1 tablet by mouth every 6 hours as needed for moderate pain (4-6). The Physicians order was discontinued October 27, 2023.

A review of a controlled substance record for the resident's supply of Hydrocodone/APAP 5/325 mg tablets, take 1 tablet by mouth every 6 hours as needed for pain indicated that on November 2, 2023 at 08:37 A.M., Employee 2, RN, documented the administration of one Hydrocodone/APAP tablet to Resident CR1. This dose of the narcotic pain medication was not documented on the November 2023 Medication administration Record. The medication order had been discontinued October 27, 2023.

During an interview, January 25, 2024, at approximately 1 PM the Director of Nursing confirmed that the facility failed to implement procedures to promote accurate administration and accounting of controlled drugs.


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

28 Pa. Code 211.9 (k) Pharmacy Services













































































 Plan of Correction - To be completed: 02/27/2024

1. RESIDENT CR1 IS NO LONGER A RESIDENT AT THE FACILITY.
2. THE FACILITY WILL AUDIT CONTROLLED MEDICATIONS TO ENSURE ACCURATE ADMINISTRATION AND ACCOUNTING OF CONTROLLED MEDICATIONS.
3. NURSING STAFF WILL BE EDUCATED ON ACCURATE ADMINISTRATION AND ACCOUNTING OF CONTROLLED MEDICATIONS.
4. NURSING ADMINISTRATION/DESIGNEE WILL AUDIT THE ADMINISTRATION AND ACCOUNTING OF CONTROLLED MEDICATIONS WEEKLY X 4, MONTHLY X 2, AND AS DEEMED NECESSARY BY QA. ALL RESULTS WILL BE REPORTED TO QA COMMITTEE.
5. FEBRUARY 27, 2024

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:


Based on a review of select facility policy and clinical records, observations, and staff interview it was determined that the facility failed to develop and implement effective person-centered plans to address dementia-related behavioral symptoms displayed one resident out of 21 sampled (Resident 5).

Findings included

A review of the clinical record revealed that Resident 5 was moderately, cognitively impaired and was admitted to the facility on May 31, 2023, with diagnosis to include, dementia, diabetes and chronic kidney disease.

A quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 2, 2023, indicated that the resident was moderately cognitively impaired with a BIMS (brief interview for mental status, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 8-12 equates to being moderate cognitively impaired) score of 9 and required staff assistance for activities of daily living.

A review of Resident 5's plan of care, initiated June 6, 2023, for depression and feeling down at times revealed that the resident had a history of depression. The resident's goal was to have no suicidal ideation during her review period, The care plan, was revised December 19, 2023, that the resident will remain free from signs and symptoms of depression through next review. Planned interventions were to converse with the resident while providing care, do not belittle my feelings, encourage the resident to continue with personal interests and to participate in activites that she enjoys, encourage the resident to voice her feelings and concerns as a way to vent same in healthy/productive manner, identify to the residents physical signs of depression i.e. increased pain, change in sleep pattern, change in usual appetite, lethargy, poor judgement and irritability and assist them with acceptance of same, medications as ordered, monitor for effectiveness or adverse reaction and report, monitor for and report changes in sleep pattern to nurse, monitor for decreased appetite, poor po intake, weight loss and report same to nurse, observe for target behaviors ( no target behaviors identified in the plan)of resident and document same, provide emotional support to the resident in times of depression, spend time merely talking to them and providing care and support and psych consult as needed.

The resident's care plan for Cognitive Loss, initiated June 6, 2023, revealed that Resident 5 has cognitive losses, was moderately cognitively impaired with a BIMS score of 9, with interventions to explain care to the resident and give her a moment to process the information, offer her choices regarding care and activities; include choices that will enhance cognitive stimulation, provide her with frequent verbal reminders to reinforce information, provide her with simple, clear instructions, and provide praise and support when the resident follows through with care instructions or make independent choices

A review of a social services note dated October 10, 2023, at 2:28 PM revealed that social services spoke to resident. The resident stated that she was depressed. She stated that she does not have a phone number for her son in Germany. If her son calls, nursing is to get his number and put it in the electronic clinical record. The resident agreed to participate in activities and socialize with others. The resident went into the community room to participate in social interaction with other residents. The nurse practitioner was notified of social services's conversation with the resident.

A review of a nurse's note dated October 10, 2023, at 6:53 PM revealed that the resident was alert and able to make her needs known. The resident was out of bed ambulating within facility without difficulty. She voices concerns of recent feelings of sadness, denies thoughts of self- harm. Stated she wishes to speak to her son, however she does not have his contact information. 1:1 provided periodically through this shift. The resident was resting comfortably at this time.

A social services note dated October 19, 2023, at 2:17 P.M. revealed that social services staff met with resident and she stated her son is going to come to get her in the next few weeks and take her to Germany. Social services informed that the resident that her son needs to contact social services.

A nurse practitioner note dated November 3, 2023 at 12:36 PM revealed that the resident's
"Chief Complaint : Anxiety, Depression Follow-Up. This is a 77 Year old female patient who was seen by psych related to anxiety and depression. The patient exhibits intermittent depression, however, the patient states that this is normal for her and that she is able to manage her depression without the use of medications. No new recommendations were made with this visit. Will continue to monitor for increased depression."

A social service note dated November 14, 2023 at 12:06 PM revealed that social services met with the resident for socialization and to allow adequate time to voice feelings and thoughts. The resident stated that she would like to get in contact with her family in Germany but has no phone numbers to provide to the department of social services.

A nurses note dated November 19, 2023, at 08:33 AM revealed that "At around 01:30 AM resident heard screaming and staff immediately went to Resident 5's room. Noted resident laying on her bed with a washcloth covering her head. Resident continued to scream, staff offered her comfort and reassurance until she was able to talk, she stated 'my head is exploding.' Resident asked to describe pain and location, unable to describe, offered resident prompting words such as throbbing, pressure, still unable to describe pain. When asked location resident stated that the pain was all over her head, rated the pain score a 6. Upon further investigation, resident stated that her head was hurting because of the roommate's television, which was on. Asked resident if she was really hurting, she stated she did not know but the TV was keeping her from sleep. Roommate agreeable to turning TV off, resident offered Tylenol and she accepted and went back to sleep. Approximately an hour later, yelling heard from the room, resident and roommate where both coming out of the room yelling at each other. Resident was yelling at her roommate, 'you need to go away, you have no common sense why, you stay on the phone all night.' Spoke with both residents they apologized to each other; resident went back to bed. When room mate returned 40 minutes later, yelling heard, and resident was threatening roommate not to come in the room, to get out before 'get out of here before something bad happens to you.' Resident was immediately taken out of the room, to another room."

A review of a nurses note dated December 1, 2023 at 2 PM revealed "(I was) approached by another resident during bingo this resident stated, "the only way I'm getting out of here is to kill myself." The assistant director of nursing (ADON) was made aware. The ADON went to talk to the resident privately. When asked, if she \ wants to kill herself, she stated,'yes I need to get out of here and go to airport to go back to Germany with my aunt that I last seen 9 years ago.' The resident placed on every 15 checks along with suicide watch, kitchen made aware. CRISIS (emergency psychiatric services to evaluate resident) called by RN supervisor will be in to see resident today."

A nurses note dated December 1, 2023 at 2:50 PM, revealed that nursing noted "Spoke with resident at this time with fellow LPN as witness. Resident stated "I am going to kill myself if I don't get out of here and back to Germany." Asked resident if she had a plan, she stated "I'll do whatever I have to do." Resident also stated "I'm going to live with my cousin." Asked resident the last time she spoke with her cousin, she stated "About 8 or 9 years ago." Crisis called. every 15 min checks initiated. Suicide precautions initiated. Does not have a specific plan."

A nurses note dated December 1, 2023, at 6:24 P.M. revealed Resident 5 noted to have made suicide threats, stating "I will kill myself if I don't get back to Germany", statements were made to ADON and LPN. Resident was placed on 15-minute checks and suicide precautions. Crisis intervention called and came to speak with and assess resident. Resident did make statements to crisis worker that she did want to harm self and others, but crisis worker and her supervisor felt since resident is in a facility where she is being monitored that she did not need to go for a mental health evaluation. The crisis worker, resident and myself did go over a safety plan. Resident also assessed by nurse practioner. New orders to place resident on 1:1 supervision until Monday December 4, 2023 then reassess if resident still needs to be on 1:1 supervision. Start sertraline (an antidepressant medication) 25 mg daily and Ativan, an antianxiety medication, 50 mg, 1/2 tab at bedtime x 3 days. Resident own RP and aware of new orders and in agreement with same.

A social services note dated December 4, 2023, revealed "Social Service: followed up with resident and she stated she is feeling well today. She would like to move to Germany with her family. She is not having any thoughts of self harm at this time."

An interview conducted on January 24, 2024, at approximately 11 AM with the Social services director confirmed that Resident 5 was born in Germany. She stated that she did not contact the resident's son because there was no contact information in the resident's clinical record. However, a review of the resident's clinical record revealed contact information for other family members.

There was no indication that the facility had developed and implemented an individualized plan, including identifying and attempting purposeful and meaningful activities based on the resident's interests, past history or customary routines related to her German heritage, and preferences, and evaluate if the resident's dementia was exacerbating her depression to promote the resident's quality of life and assist the resident in maintaining her highest practical level of psychosocial well-being and safety.

Interview with the Director of Nursing (DON) on January 25, 2024, at approximately 11 AM confirmed the facility had not updated the resident's care plan since June 6, 2023, to address the resident's behaviors and confirmed the facility failed to develop and implement effective individualized person-center interventions to minimize, modify or manage Resident 29's dementia-related behaviors.



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
































 Plan of Correction - To be completed: 02/27/2024

1. RESIDENT 5 HAS A PERSON - CENTERED CARE PLAN TO ADDRESS DEMENTIA RELATED BEHAVIORAL SYMPTOMS.
SOCIAL SERVICE DIRECTOR WILL ENSURE CARE PLANS FOR RESIDENTS WITH DEMENTIA ARE COMPLETED WITH APPROACHES FOR BEHAVIORAL SYMPTOM MANAGEMENT.
2. SOCIAL SERVICE WILL AUDIT CURRENT RESIDENTS WITH DEMENTIA RELATED BEHAVIORAL SYMPTOMS TO ENSURE CARE PLANS ARE UPDATED AND ADDRESS DEMENTIA RELATED BEHAVIORS AND PERSON - CENTERED INTERVENTIONS.
3. SOCIAL SERVICE WILL EDUCATE NURSING/IDT STAFF ON THE IMPORTANCE OF UPDATING THE RESIDENT CARE PLANS TO ADDRESS RESIDENT BEHAVIORS AND ENSURE PERSON CENTERED INTERVENTIONS ARE IN PLACE TO MINIMIZE, MODIFY, OR MANAGE DEMENTIA RELATED BEHAVIORS.
4. SOCIAL SERVICE/DESIGNEE WILL AUDIT DEMENTIA RELATED BEHAVIORAL SYMPTOMS TO ENSURE CARE PLANS ARE UPDATED TO ADDRESS BEHAVIORS AND PROVIDE PERSON CENTERED INTERVENTIONS WEEKLY X 4 AND MONTHLY X 2, THEN AS DEEMED NECESSARY BY QA. ALL RESULTS WILL BE REPORTED TO QA COMMITTEE.
5. FEBRUARY 27, 2024

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 a review of clinical records and select facility reports, and staff interviews, it was determined that the facility failed to consistently implement planned individualized safety measures designed to prevent falls and injury and ensure that planned fall prevention approaches do not create a potential accident hazard for one resident identified at high risk for falls (Resident 60) out of 21 residents reviewed.

Findings include:

A review of Resident 60's clinical record revealed she was admitted to the facility on June 2, 2020, with diagnoses schizoaffective disorder, major depression and difficulty walking.

A quarterly MDS (minimum data set- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 12, 2023, indicated that the resident was independent for transfers, bed mobility, ambulation and activities of daily living (ADLs) and uses a manual wheelchair. The resident was cognitively intact with a BIMS score of 15 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact).

Documentation in the resident's clinical record revealed that the resident had a history of nightmares. A sleep study was completed on December 4, 2023, which noted decreased nocturnal oxygenation. The resident agreed to utilize oxygen at night.

A physician order dated December 8, 2023, was noted for Oxygen 2 liters at bedtime.

A review of the resident's December 2023 TAR (treatment administration record) revealed no documented evidence that nursing staff provided the oxygen to the resident at bedtime.

The resident's January 2024 TAR indicated that the resident's oxygen saturation levels were obtained at bedtime but no documented evidence that oxygen was provided as ordered.

A review of fall risk assessments dated June 22, 2023 and September 20, 2023, revealed that the resident was at high risk for falls.

The resident's care plan, dated June 4, 2020, revealed that the resident had the potential for falls with interventions for the call light in reach and encourage use, educate resident/family/caregivers about safety reminders and what to do if fall occurs, ensure proper footwear, non skid footwear wen ambulating or mobilizing. Since resident was non- compliant with using the call bell on August 10, 20202 call bell education was provided according to the care plan.

Nursing noted on December 13, 2023 at 7:50 AM that the resident was found on the floor on the right side of her bed. She had non skid socks on her feet. The resident reported that she was attempting to transfer from her bed to her wheelchair and she slipped on the floor. The resident complained of right leg pain. X-rays were completed and they resulted in no injury just moderate arthritis. As a result of this fall the facility put non-skid floor strips to both sides of her bed to prevent her from slipping. There were no witnesses to this fall, however, it was determined by the facility that she was "walking without proper assistive device."

Nursing documentation dated January 31, 2024 at 2:25 AM revealed the resident's roommate rang the call bell to alert staff that the resident was on the floor. The resident was observed sitting on her buttocks. She did not have non-skid socks on her feet. She stated she was dreaming and requested to be seen by psychiatric services. It could not be determined if the resident was receiving oxygen at this time. The resident sustained a 3 cm bruise on her right cheek. Facial X-rays determined there was no fractures. The facility did not determine the cause of the resident's cheek bruise. Interventions after this fall revealed the facility placed a defined perimeter mattress with bilateral enablers (side rails) to prevent any additional falls.

The facility failed to demonstrate the consistent use of the planned and prescribed measures to prevent this fall on January 31, 2024. The resident was not wearing non-skid footwear as planned. The facility was aware of the resident's history of nightmares, which resulted in a order for oxygen at bedtime, after a sleep study. There was no indication that the resident was receiving the oxygen at the time of the fall on January 31, 2024, at which time she stated she was experiencing another nightmare. In response to the resident's fall, the facility implemented measures that may increase the resident's risk for injuries as the result of a future attempt to transfer from bed and fall from bed, a defined perimeter mattress and bilateral side rails, which may pose a potential accident hazard to the resident.

Interview with the NHA on January 25, 2024, failed to provide evidence of consisent implementation of the resident's planned safety measures and that the resident's environment was free of potential accident hazards.

Refer F695

28 Pa. Code 201.18 (e)(2.1) Management

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













 Plan of Correction - To be completed: 02/27/2024

1. RESIDENT 60 HAS INDIVIDUALIZED SAFETY MEASURES IN PLACE TO PREVENT FALLS AND INJURY, ENSURING FALL PREVENTION MEASURES DO NOT CREATE A POTENTIAL ACCIDENT/HAZARD.
2. THE FACILITY WILL AUDIT INDIVIDUALIZED PLANNED SAFETY MEASURES TO PREVENT FALLS, ENSURING THE PLANNED APPROACHES DO NOT CREATE POTENTIAL HAZARDS.
3. NURSING STAFF/IDT TEAM WILL BE EDUCATED ON ENSURING PLANNED SAFETY MEASURES ARE IN PLACE AND THE ENVIRONMENT IS FREE OF POTENTIAL ACCIDENT/HAZARDS.
4. NURSING ADMINISTRATION/DESIGNEE WILL CONDUCT AUDITS OF FALL INTERVENTIONS TO ENSURE PLANNED SAFETY MEASURES ARE IN PLACE AND DO NOT CREATE POTENTIAL HAZARDS WEEKLY X 4, MONTHLY X 2, THEN AS DEEMED NECESSARY BY QA. RESULTS WILL BE REPORTED TO THE QA COMMITTEE.
5. FEBRUARY 27, 2024

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

Based on a review of grievances lodged with the facility, clinical records and select reports, and staff interview, it was determined that the facility failed to provide person centered care in accordance with professional standards of practice, the resident's care plan and choices as evidenced by two residents out of 21 sampled (Resident 90 and 45).


Findings include:

Clinical record review revealed that Resident 90 was admitted to the facility on June 23, 2023 with diagnoses to include, pneumonia, and adjustment disorder with anxiety.

A review of a quarterly Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 11, 2024, revealed that the resident was moderately cognitively impaired, required staff assistance for activities of daily living and was at risk for pressure sore development.

The resident's care plan, initiated June 23, 2023, revealed that the resident had the potential for pressure ulcer development, with planned interventions to educate the resident /family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, Follow facility policies/protocols for the prevention/treatment of more often as needed or requested.

A review of a facility investigation report and nursing documentation dated January 24, 2024, at 2:30 P.M. revealed, Resident 90 was at the nurses station and bilateral lower leg blood blisters were noted. A left lower shin blood blister had opened and was bleeding. The resident had just been in the shower and rubbed his legs with a washcloth. The report noted "other info" for the causes were frail skin and vascular disease in bilateral lower extremities. The physician and resident's responsible party were notified. The noted intervention was for nursing to reinforce with the resident to be careful when washing his legs with blood blisters.
A review of an employee witness statement dated January 24, 2024, revealed that Employee 3 (LPN) stated "walked by Resident 90 sitting in his wheelchair in the hallway. His pant legs were pulled up to his knees. Multiple areas were noted to his bilateral shins that appeared to be scabbed blood blisters. Employee 3 that the resident was brought to the RN supervisor.

There was no documented evidence at the time of the survey ending January 26, 2024, that licensed and professional nursing staff had documented an assessment of the blood blisters, to include a description of the areas and surrounding skin and the measurements upon discovery of the areas. Additionally there was no documented evidence of the treatment provided and the measures planned to prevent recurrence, aside from educating the resident to be careful washing his legs due to the presence of the blood blisters.

During an interview January 25, 2024 at 1 P.M., the Director of Nursing confirmed that nursing staff did not document a complete assessment of Resident 90's blood blisters and the care and services provided.

Clinical record review revealed that Resident 54 was admitted to the facility on September 16, 2021, with diagnoses of Bipolar disorder, Borderline personality disorder, schizoaffective disorder (psychiatric diagnosis) and heart failure.

A review of a quarterly MDS Assessment dated November 10, 2023, revealed that Resident 45 was cognitively intact and required minimal staff assistance for activities of daily living.

A review of a nurses note dated December 29, 2023, at 1:45 P.M. revealed that the resident had complaints of non-radiating, midsternal chest pain rated 5 out of 10 (on a scale of 0-10), shortness of breath, and dizziness. The resident's vital signs were stable. The Certified Registered Nurse Practitioner was made aware, who ordered that the resident be sent to the hospital for evaluation. Emergency transport services were contacted and the resident was sent to the hospital.

Regulatory guidance under indicates that arranging for physician services may include assuring resident transportation to a hospital emergency room or other medical facility if the facility is unable to meet the particular medical need at the facility.

A nurses note dated December 29, 2023 at 9:08 PM, revealed that the hospital called the facility to inform nursing staff that Resident 45 was ready to return to the facility. The hospital emergency room nursing staff verbally informed the facility that Resident 45 had a diagnosis of chest congestion and viral syndrome, and the papers/orders were to return with the resident and the hospital was awaiting for the resident's transport the resident's return transport back to the facility.

A day later, nurse's notes dated December 30, 2023 at 11:30 AM revealed that Resident 45 returned from the hospital with transport provided by her brother. The resident's brother accompanied her back into the facility.

A review of a facility grievance form dated December 31, 2023, written by Resident 45, revealed that "At around 2 P.M (on December 29, 2023) in the afternoon, I was leaving an administration office (on the first floor). By the time I reached the elevator, I was having sharp chest pains in the center of my chest. I have congestive heart failure. When I arrived on the third floor, I went directly to the head nurse and told her I was out of breath, had chest pain and was dizzy. 911 was called and I was transported to the hospital. At the hospital, after I was declared all clear I signed the discharge papers around 4:30 P.M. (on December 29th) and every person (at the hospital) I asked about getting back to the facility and said, "no transit-out of our control." The hours got later, 5 PM, 7 PM, 10 PM. still no answer, no transport. I ended up sleeping in a hospital bed in the hallway. I was not given my evening meds. At 7 AM, I called the facility to find out if someone was coming to get me. I spoke to the charge nurse who did not know what was going on and said that it was Saturday and there were no vehicles available at the facility. At 9 AM my brother called me and said he was driving from Harrisburg Pa. to pick me up from the hospital and take me back to the facility. This letter describes pure and unadulterated negligence on the part of the facility. A patient with a cardiac problem, transported by ambulance and then being given no means to get back is just wrong and abusive."

The facility's noted resolution to the resident's grievance dated January 2, 2024 revealed, "Transportation from the hospital to the facility is the responsibility of the hospital to arrange based on ambulance availability."

However, during an interview with the NHA on January 26, 2024, at 11 AM it was confirmed that the facility does have its own transportation services options and transport vehicle that could have been used to pick up the resident to allow a timely return to the facility or could have assisted the resident in arranging more timely transport back to the facility.

During an interview January 26, 2024 at approximately 11 A.M., the Nursing Home Administrator confirmed that the facility could have arranged timely transportation for this resident after discharge from the ER to prevent the overnight stay, long delay awaiting return and the resident having to sleep in a hallway in the hospital and miss his scheduled medication administration.


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














 Plan of Correction - To be completed: 02/27/2024

1. RESIDENT 90 BILATERAL SHIN AREAS (BLOOD BLISTERS) ARE HEALED.
RESIDENT 45 HAD NO FURTHER TRANSPORTATION CONCERNS.
2. THE FACILITY WILL AUDIT SKIN ASSESSMENTS TO ENSURE DOCUMENTATION IS COMPLETE AND IN ACCORDANCE WITH PROFESSIONAL STANDARDS OF PRACTICE.
THE FACILITY WILL AUDIT TRANSPORTATION NEEDS UPON RETURN FROM THE EMERGENCY ROOM TO ENSURE TIMELY TRANSPORTATION.
3. NURSING STAFF WILL BE EDUCATED ON ENSURING DOCUMENTATION OF COMPLETE ASSESSMENTS.
NURSING STAFF/TRANSPORTATION DEPT WILL BE EDUCATED ON TIMELY TRANSPORTATION UPON HOSPITAL DISCHARGE.
4. NURSING ADMIN/DESIGNEE WILL CONDUCT AUDITS OF SKIN ASSESSMENTS TO ENSURE COMPLETE ASSESSMENTS ALONG WITH CARE AND SERVICES ARE PROVIDED, AND TRANPORTATION WILL AUDIT RESIDENTS RETURNING FROM THE EMERGENCY ROOM WEEKLY X 4, MONTHLY X 2, THEN AS DEEMED NECESSARY BY QA. ALL RESULTS WILL BE REPORTED TO QA COMMITTEE.
5. FEBRUARY 27, 2024

483.21(c)(1)(i)-(ix) REQUIREMENT Discharge Planning Process: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)(1) Discharge Planning Process
The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and-
(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident.
(ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
(iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan.
(iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.
(v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.
(vi) Address the resident's goals of care and treatment preferences.
(vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community.
(A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose.
(B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities.
(C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.
(viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences.
(ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.
Observations:


Based on a review of clinical records and staff and resident interview it was determined that the facility failed to develop and implement an individualized discharge plan for one of 21 sampled residents (Resident 69).

Findings Include:

A review of the clinical record revealed that Resident 69 was admitted to the facility on November 24, 2022, with diagnoses which included COPD (chronic obstructive pulmonary disease- group of lung diseases that block airflow and make it difficult to breathe).

Interview with Resident 69 on January 24, 2024, revealed that the resident expressed concern that the facility's social worker was not keeping him updated about his desire to return to the community and the progress being made to help him with getting an apartment.

Review of Resident 69's comprehensive care plan revealed a focus area dated April 17, 2023, which indicated that the facility was working with waiver and NHT (nursing home transition waiver provides home and community-based services to seniors who require nursing facility care but elect to live and receive care in their own homes or other community living arrangements) for community placement. There was no planned goal or interventions noted on the care plan based on the resident's desire for community placement. This discharge plan was not revised or updated as of the time of the survey on January 24, 2024.

During an interview on January 24, 2024, at 12:30 PM the social services director (SSD) confirmed that Resident 69 was interested in returning to the community. The SSD confirmed she was assisting Resident 69 with the Waiver Progam to return to the community. However, the SSD confirmed that there was no documented evidence that an individualized discharge care plan to reflect discharge planning for Resident 69 was developed and updated to reflect Resident 69's goal to return to the community.




28 Pa. Code 201.29 (a) Resident rights.






 Plan of Correction - To be completed: 02/27/2024

Resident # 69 has had their Care Plan reviewed/revised by the Social Service Director on their discharge to the community. The Social Service Director has spoken with the resident and updated them on what progress has been made to help them obtain placement in the community.
The Social Service Director shall review the Care plans for residents waiting for community housing to ensure they have an individualized discharge plan. The care plan shall be updated/revised as needed. The Social Service Director shall update those residents on the progress of their community placement.
The Social Service Director shall be educated by the DON/Designee on the regulation as it relates to Discharge planning.
The Social Service Director shall complete an audit to verify compliance. The audits shall be completed weekly x 4 weeks then monthly x2 or longer if issues are identified.
The audits shall be sent to the QA meeting for a review of trends.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.15(d) Notice of bed-hold policy and return-

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

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


Based on a review of clinical records and staff interview it was determined the facility failed to provide evidence of written information of the facility's bed hold policy provided upon transfer to the hospital for four of 21 residents sampled (Residents 27, 75, 4, 50).

Findings include:

A review of Resident 27's clinical record revealed the resident was transferred to the hospital on June 17, 2023, and returned to the facility on June 17, 2023.

A review of Resident 75's clinical record revealed the resident was transferred and admitted to the hospital on October 20, 2023, and returned to the facility on October 21, 2023.

A review of Resident 4's clinical record revealed that the resident was transferred to the hospital on the following dates: September 4, 2023, and returned to the facility on September 7, 2023; November 9, 2023, and returned on November 14, 2023; and December 13, 2023, and returned on December 20, 2023.

A review of Resident 50's clinical record revealed that the resident was transferred to the hospital on December 16, 2023, and returned to the facility on December 24, 2023.

The facility was unable to provide documented evidence, by the end of the survey on January 26, 2024, that the facility had provided the residents and the residents' representatives written information, at the time of transfer, of the specifics of the facility's bed hold policies, including notice of the duration of the bed-hold policy.

Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 26, 2024, at 1:40 PM, confirmed that the facility did not provide the resident or resident representative with a written notice, which specifies the duration of the bed hold upon the residents' transfer to the hospital.



28 Pa Code 201.18 (e)(1) Management

28 Pa Code 201.29 (b) Resident rights












 Plan of Correction - To be completed: 02/27/2024

The facility cannot correct the deficiency as cited for residents 27, 75, 4, and 50 as they occurred in the past.
Social Services has been educated about the need to forward the facility bed hold policy to the resident, as well as the resident's responsible party when a resident is transferred to the hospital.
Administrator or designee will audit 100% of resident transfers x 4 months to ensure that the bed hold policy has been forwarded appropriately with results reported to QAPI as needed.

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

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

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

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

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


Based on a review of clinical records and written transfer notices, and staff interview, it was determined that the facility failed to ensure that a written notice of a facility initiated resident's hospital transfer was provided to the resident and the resident's representative for four residents out of 21 residents sampled (Residents 27, 75, 4 and 50).

The findings include:

Regulatory requirements indicate that before a facility transfers or discharges a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand.

A review of Resident 27's clinical record revealed that the resident was transferred to the hospital on June 17, 2023, and returned to the facility on June 17, 2023.

A review of Resident 75 's clinical record revealed that the resident was transferred to the hospital on October 20, 2023, and returned to the facility on October 21, 2023.

A review of Resident 4's clinical record revealed that the resident was transferred to the hospital on the following dates: September 4, 2023, and returned to the facility on September 7, 2023; November 9, 2023, and returned on November 14, 2023; and December 13, 2023, and returned on December 20, 2023.

A review of Resident 50's clinical record revealed that the resident was transferred to the hospital on December 16, 2023, and returned to the facility on December 24, 2023.

Clinical record review revealed no evidence that a written notice was provided to the above residents and their representatives regarding the transfer that included the required contents: reason for the transfer, contact and address information for the Office of the State Long-Term Care Ombudsman, and if applicable, information for the agency responsible for the protection and advocacy of individuals with developmental disabilities.

Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 26, 2024, at approximately 1:40 PM, confirmed that there was no documented evidence that written notifications of transfer were provided to the residents and/or the residents' representatives.



28 Pa. Code 201.29 (c) Resident rights














 Plan of Correction - To be completed: 02/27/2024

The facility cannot correct the deficiency as cited for residents 27, 75, 4, and 50 as they occurred in the past.
Social Services has been educated about the need to forward notice of hospital transfer to the resident, as well as the resident's responsible party when a resident is transferred to the hospital.
Administrator or designee will audit 100% of resident transfers x 4 months to ensure that transfer notice has been forwarded appropriately with results reported to QAPI as needed.

§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on review of nursing time schedules and staff interviews, it was determined that the facility failed to provide a minimum of one nurse aide per 12 residents during the evening shifts, and one nurse aide per 20 residents during the night shift on 12 of 21 days reviewed(December 19, 2023, December 20, 2023, December 30, 2023, December 31, 2023, January 19, 2024, January 22, 2024, January 23, 2024, January 24, 2024 and January 25, 2024).

Findings include:

Review of facility census data indicated that on December 19, 2023, the facility census was 90, which required 4.5 nurse aides during the night shift.

Review of the nursing time schedules and time punch documentation revealed 4.25 nurse aides provided care on the night shift on December 19, 2023. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on December 20, 2023, the facility census was 93, which required 4.65 nurse aides during the night shift.

Review of the nursing time schedules and time punch documentation revealed that 3.84 nurse aides worked on the night shift on December 20, 2023. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on December 30, 2023, the facility census was 93, which required 7.75 nurse aides during the evening shift.

Review of the nursing time schedules and time punch documentation revealed 7.44 nurse aides worked on the evening shift on December 30, 2023. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on December 31, 2023, the facility census was 94, which required 7.83 nurse aides during the evening shift.

Review of the nursing time schedules and time punch documentation revealed 7.44 nurse aides worked on the evening shift on December 31, 2023. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on December 31, 2023, the facility census was 94, which required 4.70 nurse aides during the night shift.

Review of the nursing time schedules and time punch documentation revealed 4.69 nurse aides worked on the night shift on December 31, 2023. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 19, 2024, the facility census was 96, which required 8 nurse aides during the evening shift.

Review of the nursing time schedules and time punch documentation revealed 7.25 nurse aides worked on the evening shift on January 19, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 19, 2024, the facility census was 96, which required 4.80 nurse aides during the night shift.

Review of the nursing time schedules and time punch documentation revealed 4.72 nurse aides worked on the night shift on January 19, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 22, 2024, the facility census was 96, which required 4.8 nurse aides during the night shift.

Review of the nursing time schedules and time punch documentation revealed 4.78 nurse aides worked on the night shift on January 22, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 23, 2024, the facility census was 96, which required 8 nurse aides during the evening shift.

Review of the nursing time schedules and time punch documentation revealed 7.75 nurse aides worked on the evening shift on January 23, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 23, 2024, the facility census was 96, which required 4.8 nurse aides during the night shift.

Review of the nursing time schedules and time punch documentation revealed 3.84 nurse aides worked on the night shift on January 23, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 24, 2024, the facility census was 96, which required 4.80 nurse aides during the night shift.

Review of the nursing time schedules and time punch documentation revealed 4.13 nurse aides worked on the night shift on January 24, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 25, 2024, the facility census was 94, which required 2.35 nurse aides during the night shift.

Review of the nursing time schedules and time punch documentation revealed 1.94 nurse aides worked on the night shift on January 25, 2024. No additional excess higher-level staff were available to compensate this deficiency.

An interview January 26, 2024, at 2 P.M., the Director of Nursing confirmed that the facility did not meet minimum staffing ratios for nurse aides.







 Plan of Correction - To be completed: 02/27/2024

Facility will schedule CNAs to meet the current, required staffing ratios.
The facility is currently utilizing agency to bolster facility staffing. The facility is also using multiple outside resources such as partnerships with local high school and trade schools to recruit more staff. The facility is also utilizing a number of employee appreciation efforts to retain current staff.
Nursing Admin team will be re-educated on current staffing ratios and protocol for replacing call offs.
Nursing Admin team will review schedules to ensure proper staffing has been scheduled. When call offs occur the DON will be notified and DON or designee will utilize staff call list as well as agency support to fill the opening created.
IDT designee will conduct an audit on scheduled staffing levels to ensure minimum staffing levels are maintained. Audit will be conducted weekly with results reported to the QAPI as necessary.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on review of nursing time schedules and staff interviews, it was determined that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift, 1 LPN per 30 residents on the evening shifts on 21 of 21 days (December 19 2023, December 20, 2023, December 21, 2023, December 22, 2023, December 23, 2023, December 24, 2023, December 25, 2023, December 26, 2023, December 27, 2023, December 28, 2023, December 29, 2023, December 30, 2023, December 31, 2023, January 19, 2024, January 20, 2024, January 21, 2024, January 22, 2024, January 23, 2024, January 24, 2024, January 25, 2024 ).

Findings include:

Review of facility census data indicated that on December 19, 2023, the facility census was 90, which required 2.25 LPNs during the night shift.

Review of the nursing time schedules and time punch card documentation revealed 1.02 LPNs provided care on the night shift on December 19, 2023.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on December 20, 2023, the facility census was 93, which required 2.33 LPNs during night shift.

Review of the nursing time schedules and time punch documentation revealed 1.97 LPNs worked the night shift on December 20,2024.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on December 21, 2023, the facility census was 93, which required 2.33 LPNs during the night shift.

Review of the nursing time schedules and time punch card documentation revealed 1.91 LPNs provided care on the night shift on December 21, 2023.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on December 22, 2023, the facility census was 93, which required 2.33 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 1.97 LPNs worked the evening shift on December 22,2023.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on December 23, 2023, the facility census was 93, which required 2.33 LPNs during the night shift.

Review of the nursing time schedules and time punch card documentation revealed 1.97 LPNs provided care on the night shift on December 23, 2023.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on December 24, 2023, the facility census was 94, which required 2.35 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 2 LPNs worked the night shift on December 24,2023.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on December 25, 2023, the facility census was 94, which required 2.35 LPNs during the night shift.

Review of the nursing time schedules and time punch card documentation revealed 2 LPNs provided care on the night shift on December 25, 2023.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on December 26, 2023, the facility census was 93, which required 2.33 LPNs during night shift.

Review of the nursing time schedules and time punch documentation revealed 1.97 LPNs worked the night shift on December 26,2024.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on December 27, 2023, the facility census was 93, which required 2.33 LPNs during the night shift.

Review of the nursing time schedules and time punch card documentation revealed 1.78 LPNs provided care on the night shift on December 27, 2023.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on December 28, 2023, the facility census was 94, which required 2.35 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 1.97 LPNs worked the evening shift on December 28,2023.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on December 29, 2023, the facility census was 94, which required 2.35 LPNs during the night shift.

Review of the nursing time schedules and time punch card documentation revealed 2 LPNs provided care on the night shift on December 29, 2023.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on December 30, 2023, the facility census was 93, which required 2.33 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 1.97 LPNs worked the night shift on December 30,2023.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on December 31, 2023, the facility census was 94, which required 2.35 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 1.97 LPNs worked the night shift on December 31,2023.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 1, 2024, the facility census was 94, which required 2.35 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 2 LPNs worked the night shift on January 1,2024.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 19, 2024, the facility census was 96, which required 2.40 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 1.94 LPNs worked the night shift on January 19 ,2024.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 20, 2024, the facility census was 96, which required 2.4 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 1.94 LPNs worked the night shift on January 20,2024.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 21, 2024, the facility census was 96, which required 2.40 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 2 LPNs worked the night shift on January 21 ,2024.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 22, 2024, the facility census was 96, which required 2.4 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 1.97 LPNs worked the night shift on January 22,2024.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 23, 2024, the facility census was 96, which required 2.40 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 1.94 LPNs worked the night shift on January 23 ,2024.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 24, 2024, the facility census was 96, which required 2.4 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 2 LPNs worked the night shift on January 24,2024.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 25, 2024, the facility census was 94, which required 2.36 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 1.94 LPNs worked the night shift on January 25 ,2024.

No additional excess higher-level staff were available to compensate this deficiency.

An interview January 26, 2024, at 1 PM the Director of Nursing confirmed that the facility did not meet the minimum nursing staff ratios for LPNs














 Plan of Correction - To be completed: 02/27/2024

Facility will schedule LPNs to meet the current, required staffing ratios.
The facility is currently utilizing agency to bolster facility staffing. The facility is also using multiple outside resources such as partnerships with local high school and trade schools to recruit more staff. The facility is also utilizing a number of employee appreciation efforts to retain current staff.
Nursing Admin team will be re-educated on current staffing ratios and protocol for replacing call offs.
Nursing Admin team will review schedules to ensure proper staffing has been scheduled. When call offs occur the DON will be notified and DON or designee will utilize staff call list as well as agency support to fill the opening created.
IDT designee will conduct an audit on scheduled staffing levels to ensure minimum staffing levels are maintained. Audit will be conducted weekly with results reported to the QAPI as necessary.



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