Pennsylvania Department of Health
 SILVER STREAM NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SILVER STREAM NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  138 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.
SILVER STREAM NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey, and an Abbreviated Survey in response to three complaints completed on February 27, 2024, it was determined that Silver Stream Nursing and Rehabilitation Center was not in compliance with the 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 related to the health portion of the survey process.



 Plan of Correction:


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

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

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

Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Findings include:

The undated Policy: "Food Storage Policy", states, "he Food Service Director and/or Cook(s) will insure that all food items are stored properly, covered containers must be airtight, labeled and dated using a two date system (prepared date and use by date)."

An initial tour of the Food Service Department was conducted on February 21, 2024, at 9:15 a.m. with Employee E5, AM Cook, which revealed the following:

Observation in the food preparation area revealed a 5-pound tub of peanut butter with no date of when it was opened or a use by date and it had peanut butter smeared on the outside of the container.

Observation in the walk-in freezer revealed a brown cardboard box of fish cakes with the inner plastic liner open to the circulating air.

Interview with the AM Cook at 9:30 a.m. on February 21, 2024, confirmed the above findings.

Observation during a follow up visit to the kitchen on February 22, 2024, at 12:05 p.m. with the Food Service Director (FSD) revealed the tray line area steam table containing the hot food above which was a black electric cord coming from the ceiling that was covered with dust, grease, dirt and cobwebs which were hanging above the hot food being served.

Interview with FSD at 12:30 a.m. on February 22, 2024, confirmed the above findings.

28 PA Code: 201.14(a) Responsibility of licensee.

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





 Plan of Correction - To be completed: 04/01/2024

Identified food was discarded.

All residents have the potential to be affected. An initial audit will be conducted to identify any labeling and dating issues in the kitchen and dry storage areas.

Dietary staff will be re-educated on the facility's policy for food storage and kitchen sanitation.

Food Service Director / designee will conduct audits of kitchen and dry storage area to identify any labeling and dating issues in the kitchen and dry storage areas. Audits will be done daily x 4 weeks, then weekly x3 months. Findings will be presented at QAPI committee.
483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:

Based on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly.

Findings include:

An initial tour of the Food Service Department was conducted on February 21, 2024, at 9:15 a.m. with Employee E5, AM Cook, which revealed the following:

Observation in the receiving area revealed three green dumpsters, the middle dumpster had the one of the lids on the top open. Around the dumpster on the right was a lot of debris including used latex gloves, paper, straws, cups, lids, empty pudding cup, empty yogurt cup and a plastic bag sticking out from underneath the dumpster.

Interview with the AM Cook at 9:30 a.m. on February 21, 2024, confirmed the above findings.


28 PA Code: 201.14(a) Responsibility of licensee.

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








 Plan of Correction - To be completed: 04/01/2024

Garbage dumpster lids were properly placed to cover. Outdoor garbage area was cleaned.

An initial audit will be conducted to determine cleanliness of outside garbage area.

An education of all dietary, housekeeping and maintenance staff will be completed on facility's policy relating to proper trash disposal.

Food Service Director / designee will conduct audits of trash area to identify any trash, refuse and open containers. Audits will be done daily x3 weeks then weekly x3 months. Findings will be presented at QAPI committee.
483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

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

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

Based on the review of clinical records and interview with staff, it was determined that the facility failed to ensure that there was sufficient nursing staff to complete residents' comprehensive and quarterly assessments in a timely manner. for eight of eight residents reviewed. (Resident R79, R59, R15, R3, R38, 6, R1 and R50)

Findings Include:

Refer to citation: 636, 638.

Based on the review of clinical records and interview with staff, it was determined that the facility failed to ensure that a comprehensive assessment was completed every 12 months as required.

Based on the review of clinical records and interview with staff, it was determined that the facility failed to ensure that a quarterly assessment was completed not less frequency than once every 3 months as required.

Interview with MDS coordinator, Employee E7 on February 23, 2024, at 10:44 a.m., confirmed that the MDS's were completed late. She stated she was busy with case management responsibilities and there were over 17 short term residents that required case management services. She did not have enough time to complete MDS responsibilities as she was the only RNAC in the facility.

Interview with the facility COO (Chief Operating Officer), Employee E3, on February 26, 2024, at 11:04 a.m., stated facility only had one staff, Employee E7 who was responsible and trained for completing resident comprehensive assessment. Employee E3 also stated Employee E7 was also responsible for case management responsibilities of facility short term residents.

28 Pa Code: 211.12 (d)(4) Nursing services

28 Pa Code: 201.14(a) Responsibility of licensee




 Plan of Correction - To be completed: 04/01/2024

Assessments have been completed, submitted and transmitted by RNAC for residents R79, R59, R15, R3, R38, R6, R1 and R50.

All residents are at risk of deficient practice. RNAC will review all MDS assessments due in the last 15 days to verify timely completion and transmission of assessments.

A PRN RNAC will be recruited to assist as needed. Duties other than MDS-related will be reassigned to other departments including case management duties.

Director of Nursing / designee will conduct weekly review of MDS to monitor timely completions and submissions.
Audits will be completed weekly x4 weeks then monthly x3 months. Findings will be reported to QAPI committee.
483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program: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.
§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:

Based on the review of facility policy, review of facility documentation and interview with staff, it was determined that the facility failed to establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor and track the antibiotic use for seven of nine months of antibiotic data requested for review (June, July, August, September, October, November and December, 2023).

Finding Include:

Review of facility policy Antibiotic Stewardship- Review and Surveillance of Antibiotic use and outcome" dated December 2016, revealed that "Antibiotic usage and outcome data will b collected and documented using a facility-approved antibiotic surveillance racking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship.

Policy Interpretation and Implementation
1.As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee.
2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics.
a. Therapy may require further review and possible changes if:
(1) The organism is not susceptible to antibiotic chosen;
(2) The organism is susceptible to narrower spectrum antibiotic;
(3) Therapy was ordered for prolonged surgical prophylaxis; or
(4) Therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics.
3. At the conclusion of the review, the provider will be notified of the review findings:
4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include:
a. Resident name and medical record number.
b. Unit and room number.
c. Date symptoms appeared.
d. Name of antibiotic (see approved surveillance list);
e. Start date of antibiotic.
f. Pathogen identified (see approved surveillance list);
g. Site of infection.
h. Date of culture.
i. Stop date.
j. Total days of therapy.
k. outcome; and
l. Adverse events."

A request for documentation related to facility antibiotic stewardship data was requested to facility administration at the entrance conference on February 21, 2024, at 11:00 a.m.

Review of facility antibiotic stewardship data revealed that there was no documented evidence that the facility established and implemented antibiotic stewardship program from June 2023 to December 2024.

A request was made to Director of Nursing, Employee E2, on February 23, 2024, at 2:00 p.m. for evidence of facility antibiotic stewardship data.

Facility did not submit any data related to facility antibiotic stewardship, tracking the use of antibiotics, tracking of symptoms and review of appropriateness of antibiotics prescribed in the facility from June 2023 to December 2023.

Interview with Director of Nursing, Employee E2, on February 26, 2024, at 12:30 p.m. stated antibiotic stewardship and infection surveillance data was not available from June 2023 to December 2023.

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

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





 Plan of Correction - To be completed: 04/01/2024

Facility audit of antibiotics stewardship including all new and current antibiotic usage for the last 15-days will be completed by the Infection Prevention Nurse to be tracked and investigated.

All residents on antibiotics have the potential to be affected. Residents that are receiving or have received antibiotics in the last 30 days will be audited by the Infection Prevention Nurse, reviewed and tracked for proper diagnosis, prescription and usage.

New infections and antibiotics stewardship will be discussed at weekday morning meetings. Licensed staff will be reeducated on facility policy for Antibiotic Stewardship program.

Director of Nursing / designee will conduct audits of antibiotic stewardship and surveillance program to comply with proper tracking, investigation and follow up. Audits will be completed of all new antibiotic orders and of the follow up tracking out facility infection preventionist. Audits will be completed weekly x4 weeks then monthly x3 months. Findings will be presented to the QAPI committee.
483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:

Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that licensed nursing staff had the proper competencies including intravenous (IV) catheter care, trach care and total parenteral nutrition (TPN) administration care for six of six licensed nurse training records reviewed (E11, E13, E14, E15, E21 & E22).

Findings include:

Review of the provided facility policies did not reveal any policy related to nursing competencies.

Review of training records provided did not reveal any competencies requested including IV (Intravenous) catheter care, trach care and TPN (Total Parental Nutrition) administration care for Employees E13, E14 and E21.

A review of training records for Employees E11, E15 and E22 revealed incomplete competencies as follows:
-Employees E11 & E22 had TPN partially completed (no skill assessment) and no competencies for IV or Trach care.
-Employee E15 had no competency for TPN.

Interview with the Director of Nursing on February 26, 2024, at 1:45 p.m. confirmed the above findings.

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

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





 Plan of Correction - To be completed: 04/01/2024

Identified nursing staff competencies will be completed.

Any residents that are provided with care by nursing staff that lack competency are at risk for the deficient practice.

Nursing staff competencies will be completed for nursing staff. Nursing staff's competencies will be audited 90-days after their initial employment. Nursing staff's competencies will be audited upon their annual hire date.

Director of Nursing / designee will conducts audits of employee education files to monitor completion of competencies. 4 employees will be audited weekly. Audits will be done weekly x4 weeks then monthly x6 months.
Findings will be presented to QAPI Committee.
483.10(c)(2)(3) REQUIREMENT Right to Participate in Planning 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.
§483.10(c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:
(i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.
(ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
(iii) The right to be informed, in advance, of changes to the plan of care.
(iv) The right to receive the services and/or items included in the plan of care.
(v) The right to see the care plan, including the right to sign after significant changes to the plan of care.

§483.10(c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-
(i) Facilitate the inclusion of the resident and/or resident representative.
(ii) Include an assessment of the resident's strengths and needs.
(iii) Incorporate the resident's personal and cultural preferences in developing goals of care.
Observations:

Based on interviews with residents and staff, and review of clinical records, it was determined that the facility failed to ensure a resident had the right to be informed of their care plan meeting for one out of 21 residents reviewed (Resident R59).

Findings include:

Review of the facility policy, "Care Planning-Interdisciplinary Team," with a revision date of September 2013, indicated that the resident, the resident's family and/or the resident's legal representative/guardians or surrogate are encouraged to participate in the development of and revisions to the resident's care plan.

Review of the February 2024 physician orders for Resident R59 included the diagnoses of morbid obesity, post-traumatic stress disorder (a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it); atrial fibrillation (an irregular heart rhythm that can cause fatigue, palpitations, stroke, and other complications); depression (a mental health condition that causes a persistent feeling of sadness and loss of interest) ; muscle weakness, and hypertension (high blood pressure).

During an interview with the resident on February 21, 2024 at 11:12 a.m. the resident reported that she was not notified of care plan meetings in advanced. Resident reported, "you don't know you have one until that day. I am supposed to be notified in advance. I also have the right to have a family or friend attend." Resident reported that the last care plan meeting she had this month, "the social worker, and somebody else came in here and said we're here for your care plan meeting today."

Review of the resident's clinical record from May 2023 to February 2024 did not show evidence that resident received verbal notification or written notification of her care plan meetings, so that she can participate in them when they are scheduled.

During an interview with the social worker (Employee E8) on February 26, 2024 at 1:45 p.m. the social worker confirmed that there was no documented evidence that Resident R58 received notification regarding when her care plan meetings occur.

28 Pa. 211.5(f) Clinical records

28 Pa. Code 211.12(c) Nursing services

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





 Plan of Correction - To be completed: 04/01/2024

Resident #59 was notified of facility policy and given updated notification form.
Care conference will be offered to resident #59 based on resident's availability.

The Director of Social Services will conduct an audit of missing resident or resident rep invitation for the care conferences conducted in the last 15 days with an option to reconvene the meeting based on their availability or update plan of care in-person or over the phone.

A system of written notification form was initiated.
An education with the IDT will be conducted on care conference policy including advanced notification and the new form in use.

Social Worker / designee will conduct audits of 4 residents with care conference reviews to be conducted weekly x4 weeks, monthly x3 months to monitor compliance.
Findings will be reported to QAPI Committee x3 months.
483.10(e)(2) REQUIREMENT Respect, Dignity/Right to have Prsnl Property: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(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.
Observations:

Based on observations and resident interviews, it was determined that the facility failed to ensure that personal belongings were accounted for three of 21 residents reviewed (Resident R83, R58 and R60).

Findings include:

Review of the facility policy, "Admissions, Transfers and Discharge," with a revision date of September 2013 indicated that when taking inventory of a resident's personal effects, staff should inventory all clothing, equipment, valuables, etc. and record the quantity of each item, a discreption of each item and other identifying factors as necessary or appropriate. The policy also indicated that when all items have been inventoried and recorded on the "Inventory of Personal Effects" form, staff is to sign their name, and instruct the resident and/or his/her family member who witnessed the inventory to also sign the form. Continued review of the policy also indicated that staff is to provide the reident and/or family member with a copy of the completed and signed inventory form.

Review of the resident's February 2024 physician orders indicated that the resident was admitted into the facility in December 2023 with diagnoses of substance abuse; bipolar (a mental health condition that causes extreme mood swings that include emotional highs and lows); respiratory failure (a serious condition that affects your breathing and oxygen levels in the blood), and muscle weakness.

During an interview with the resident on February 22, 2024 at 11:40 a.m. the resident reported that he has clothing that has been missing for 18 days. He reported that he sent them to be washed by laundry and never received them back.

Review of the resident's electronic clinical record and the resident's paper record did not produce evidence of the resident's inventory sheet upon his admission to the facility where resident's clothing and personal properly was recorded and accounted for upon admission (e.g. clothing, dentures, cell phone, shoes)

During an interview with the housekeeping director (Employee E12) and the Regional Housekeeping Director (Employee E25) on February 26, 2024, at 10:00 a.m. it was confirmed that there was no inventory sheet completed on the resident when he was admitted into the facility. It was also confirmed that there was no record of what clothes were taken from the resident's room for washing and drying.

Review of the February 2024 physician orders for Resident R58 included the diagnoses of cerebral infarction (a stroke); lymphedema (a condition that results in swelling of the leg or arm); hypertension (high blood pressure); morbid obesity; lack of coordination and need for assistance with personal care.

During an interview with the resident on February 22, 2024 at 11:12 a.m. the resident was observed lying in bed. The resident reported that he does not get dressed because he had no clothes and no shoes. Resident provided consent and upon opening up his closet and drawers, there was no evidence of any clothing or shoes.

During an interview with Resident R60 at 11:16 a.m. the resident was observed wearing a tan short jacket that was dirty and with approximately 4 white strips of tape on the right side of the jacket. Resident reported that he burned his jacket prior to his admission into the facility, so he taped that burned sections of the jacket. During the interview the resident reported that he only had 2 pairs of paints to wear and 2 tops to wear. Resident was dressed in checkered black and red flannel pair of paints that he had on during the interview, and a red shirt with print shirt on the front of it. The resident showed a black pair of jeans, and a tan colored sweat shirt.

Resident provided consent and upon opening up his closet and drawers, there was no evidence of any clothing other clothing for the resident to wear.

During an observation in the room that Resident R58 and Resident R60 shared with the Regional Administrator (Employee E3) on February 26, 2024 at 12:45 p.m. a discussion was held regarding both residents not having clothes to wear, in addition to Resident R58 reporting not having any clothes and not having any shoes to wear.

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

28 Pa. Code 211.10(d) Resident care policies

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





 Plan of Correction - To be completed: 04/01/2024

The personal inventory sheets for resident R83, R58 and R60 will be completed reflecting accurate information about their personal belongings. Needs for additional clothing and shoes will be evaluated and followed up as needed.

Unit Manager / designee will conduct an audit of all new / re-admissions for the last 15 days to verify personnel inventory sheets are completed accurately.

An education on our new personal inventory system with Department Heads will be completed. Inventory sheets will be placed at the front desk reception area and on both units.

Admissions Director / designee will conduct audits of new admissions. Audits will be done weekly x4 weeks, monthly x3 months to monitor compliance. Findings will be reported to QAPI committee x3 months.
483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

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


Based on staff interviews and review of the clinical record, it was determined that the facility failed to ensure that the physician was notified of a fall incident sustained by a resident for one out of 21 residents reviewed (Resident R89).

Findings include:

Review the February 2024 physician orders for Resident R89 indicated that the resident was admitted into the facility from the hospital on January 5, 2024 with the diagnoses of seizures (a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness); cerebral infarction (a stroke); chronic obstructive pulmonary disorder (COPD- a condition involving constriction of the airways and difficulty or discomfort in breathing); alcohol abuse; substance abuse; anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome); depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), in addition to a right below the knee amputation.

Review of a nursing noted date January 10, 2024 at 6:29 a.m. indicated that the resident was found on his floor in his bedroom by nursing staff. The note also documented that the resident fell on the bathroom floor from out of his wheelchair and crawled from the bathroom to his bed to try and get up on his own. Continued review of the nursing note documented that nursing made an attempt to notify the physician's office of the fall, and that they were unable reached the physician. Per the nursing note, "MD [name of Dr.] office unable to be reached."

Review of the resident's clinical record regarding referenced incident did not show evidence that the facility made any additional attempts to contact the resident's physician after not being able to reach the resident's physican during the initial contact in order to ensure appropiate care and services.

During an interview with the Director of Nursing (DON) on February 27, 2024 at 10:10 a.m. it was discussed that there was no documentation in the clinical record that the physician was notified after the resident's fall on January 10, 2024.

28 Pa. 211.5(f) Clinical records

28 Pa. Code 211.12(c) Nursing services

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





 Plan of Correction - To be completed: 04/01/2024

Resident R89's physician was notified about the fall reported on 1/10/2024. An educational counseling was issued to the nurse who failed to notify the physician.

All residents are at risk of the deficient practice. Director of Nursing / designee will conduct an audit of incidents occurring over the last 15 days to ensure physician notification.

Licensed nursing staff will be educated on the importance of timely physician notification after each incident / accident. Director of Nursing / designee will conduct audits to monitor compliance with physician notification as per state and federal regulations. Audits will be done of 4 residents weekly x4 weeks then monthly x3 months. Findings will be reported to QAPI committee.
483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

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

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


Based on the review of clinical records and interview with staff, it was determined that the facility failed to ensure that a comprehensive assessment was completed every 12 months as required for two of eight residents reviewed. (Resident R1 and R50)

Findings Include:

Review of clinical record for Resident R50 revealed that the resident had an admission MDS (Assessment of Resident Care Needs) assessment completed on January 27, 2023. Further review of the clinical record the revealed that the annual assessment was scheduled with an assessment reference date (ARD) of January 10, 2024. Continued review of the clinical record revealed that the assessment was not completed until February 19, 2024.

Review of clinical record for Resident R1 revealed that the resident had a modification admission MDS assessment completed on January 18, 2023. Further review of the clinical record the revealed that the annual assessment was scheduled with an assessment reference date (ARD) of January 10, 2024. Continued review of the clinical record revealed that the assessment was not completed until oon February 19, 2024.

Interview with MDS coordinator on February 23, 2024, at 10:44 a.m., confirmed that the MDS's were completed late. She stated she was busy with case management responsibilities and there were over 17 short term residents that required case management services. She did not have enough time to complete MDS responsibilities as she was the only RNAC in the facility.

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

28 Pa. Code 211.14(fResponsibility of the licensee.




 Plan of Correction - To be completed: 04/01/2024

Assessments have been completed and transmitted for residents R1 and R50.

All residents are at risk for this deficient practice. RNAC will review all comprehensive assessments that were due in the last 15 days to ensure timely completion of annual assessments.

RNAC was re-educated on facility policy. Case management duties will be transferred to a different department.

RNAC / designee will conduct audits to monitor timely completion and transmission of comprehensive assessments. Audits will be done weekly x4 weeks then monthly x3 months. Findings will be reported to the QAPI committee.
483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.
Observations:

Based on the review of clinical records and interview with staff, it was determined that the facility failed to ensure that a quarterly assessment was completed not less frequency than once every 3 months as required for six of eight residents reviewed. (Resident R79, R59, R15, R3, R38, R6)

Findings Include:

Review of clinical record for Resident R79 revealed that the resident had an admission MDS (Assessment of Resident Care Needs) assessment completed on October 13, 2023. Further review of the clinical record the revealed that the quarterly assessment was scheduled with an assessment reference date (ARD) of January 10, 2024. Continued review of the clinical record revealed that the assessment was not completed until February 19, 2024.

Review of clinical record for Resident R59 revealed that the resident had a quarterly MDS assessment completed on October 18, 2023. Further review of the clinical record the revealed that the quarterly assessment was scheduled with an assessment reference date (ARD) of January 17, 2024. Continued review of the clinical record revealed that the assessment was not completed until February 23, 2024.

Review of clinical record for Resident R15 revealed that the resident had a annual MDS assessment completed on October 17, 2023. Further review of the clinical record the revealed that the quarterly assessment was scheduled with an assessment reference date (ARD) of January 17, 2024. Continued review of the clinical record revealed that the assessment was onot completed until February 23, 2024.

Review of clinical record for Resident R3 revealed that the resident had a quarterly MDS assessment completed on October 6, 2023. Further review of the clinical record the revealed that the quarterly assessment was scheduled with an assessment reference date (ARD) of January 5, 2024. Continued review of the clinical record revealed that the assessment was not completed until February 19, 2024.

Review of clinical record for Resident R38 revealed that the resident had a quarterly MDS assessment completed on October 13, 2023. Further review of the clinical record the revealed that the quarterly assessment was scheduled with an assessment reference date (ARD) of January 12, 2024. Continued review of the clinical record revealed that the assessment was not completed until February 22, 2024.

Review of clinical record for Resident R6 revealed that the resident had a quarterly MDS assessment completed on October 11, 2023. Further review of the clinical record the revealed that the quarterly assessment was scheduled with an assessment reference date (ARD) of January 10, 2024. Continued review of the clinical record revealed that the assessment was not completed until February 19, 2024.

Interview with MDS coordinator on February 23, 2024, at 10:44 a.m., confirmed that the MDS's were completed late. She stated she was busy with case management responsibilities and there were over 17 short term residents that required case management services. She did not have enough time to complete MDS responsibilities as she was the only RNAC in the facility.

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

28 Pa. Code 211.14(fResponsibility of the licensee.




 Plan of Correction - To be completed: 04/01/2024

Assessments have been completed and transmitted for residents R79, R59, R15, R3, R38 and R6.

All residents are at risk for this deficient practice. The RNAC will review all assessments due within the last 15 days to monitor timely completion of assessments.

RNAC was re-educated on facility policy. Case management duties will be transferred to a different department.

RNAC / designee will conduct audits to monitor timely completion of quarterly assessments. Audits will be done weekly x4 weeks then monthly x3 months. Findings will be reported to the QAPI committee.
483.20(k)(4) REQUIREMENT MD/ID Significant Change Notification:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(k)(4) A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review.
Observations:

Based on staff interviews and the review of clinical records, it was determined that the facility failed to ensure that the State mental health authority and/or the State intellectual disability authority was notified of a significant change in resident's mental health status which required admission into a psychiatric facility for one out of 21 residents reviewed (Resident R48).

Findings include:

Review of the February 2024 physician orders for Resident R48 included the diagnoses of anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome); cognitive communication deficit (a group of disorders that affect a person's ability to communicate); depression (a mood disorder that causes a persistent feeling of sadness and loss of interest); schizophrenia (a mental disorder characterized by fixed false convictions in something that is not real of shared by other people, seeing, hearing, feeling or smelling something that does not exist, disorganized thoughts, speech and behavior; heart failure (a progressive heart disease that affects pumping action of the heart muscles that causes fatigue, shortness of breath; and peripheral vascular disease ( a common condition in which narrowed arteries reduce blood flow to the arms or legs).

Review of a nursing note dated Augst 8, 2023 at 9:41 a.m. indicated that the resident was sent out to a psychiatric hospital for evaluation. Review of a nursing note dated September 8, 2023 at 3:30 p.m. documented that the resident was readmitted into the facility from the psychiatric hospital.

Continued review of the clinical record did not show evidence of documentation that the facility notified that State mental health authority and/or the State intellectual disability authority regarding the resident's change in mental status and her admission into a psychiatric treatment facility.

During an interview with the Social Worker (Employee E8) on February 26, 2024 at 1:45 p.m it was confirmed by the Social Worker that there was no information to produce to show evidence that the facility notified that State mental health authority and/or the State intellectual disability authority regarding the resident's change in mental status and her admission into a psychiatric treatment facility.

28 Pa. Code 211.12(c) Nursing services

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





 Plan of Correction - To be completed: 04/01/2024

Relevant state agencies have been notified of change in status for resident R48.

All residents with a PASRR Level II (ID/DD or MI) are at risk of the deficient practice.

The Director of Social Services will review all residents with a PASRR Level 2 for all incidents over the last 2 weeks to verify notification of relevant state agencies.

Re-education of Director of Social Services will be re-educated on facility's PASSR policy.

The Director of Social Services will conduct audits of PASSR Level 2 and appropriate state agency notifications. Audits will be done weekly x4 weeks, monthly x3 months to monitor compliance. Findings will be reported to QAPI committee x3 months.
483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on observations, interviews, and the review of clinical records, it was determined that the facility failed to ensure that resident received activities of daily living care related to shaving and haircuts for 2 out of 21 residents reviewed (Resident R58 and R60).

Findings include:

Review of the facility policy, "Activities of Daily Living (ADLs), Supporting," with a revised date of October 2021, indicated that resident will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living.

The policy also stated that appropriate care and services will be provided for resident who are unable to carry out activities of daily living independently with the consent of the resident in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care); toileting mobility and eating.

Review of the February, 2024 physician orders for Resident R58 included the following diagnoses: cerebral infarction (a stroke); lymphedema (a condition that results in swelling of the leg or arm); hypertension (high blood pressure); morbid obesity; lack of coordination and need for assistance with personal care.

Review of the Quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated December 20, 2023 indicated that the resident was awake, alert and oriented.

Review of the resident's person-centered plan of care, included a plan of care dated June 30, 2023 for the resident related to deficits of his activities of daily living related to weakness, cerebral infarction, and monoplegia of the resident's lower limb (paralysis of a limb), and obesity. Care plan interventions to address this care concern included assistance with activities of daily living, as needed.

During an interview with the resident on February 22, 2024 at 11:12 a.m. the resident reported that "this is too long," referring to his hair. Resident's hair was observed to be unkempt, long, and straggly. The length of the hair extended to the end of his neck. Resident reported that he needs a haircut and had not had one in a while.

Review of the resident's clinical record provided no documentation as to the last time resident was offered and/or received a haircut.

Review of the February 2024 physician orders for Resident R60 indicated that the resident was admitted into the facility on December 19, 2023 with the following diagnoses: kidney failure (a gradual loss of kidney function); diabetes (a condition that happens when your blood sugar is too high); chronic obstructive pulmonary disease (COPD- a condition involving constriction of the airways and difficulty or discomfort in breathing); cerebral infarction (a stroke); muscle weakness; lack of coordination, and the need for assistance with personal care.

Review of the Admission Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated December 26, 2023 indicated that the resident was awake, alert and oriented and required staff supervision with his activities of daily living (e.g. combing hair, shaving, applying makeup, washing/drying face and hands). Continued review of the resident's Quarterly MDS indicated that the resident was awake, alert and oriented.

During an interview with the resident on February 22, 2024 at 11:16 a.m. the resident reported that he had not had a haircut or his beard trimmed since he was admitted to the facility in December 2023. The resident was observed sitting in his wheelchair with long hair and a long beard that looked unkempt and straggly.

Review of the resident's clinical record provided no documentation as to the last time resident was offered and/or received a haircut and a shave.

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

28 Pa. Code 211.10(d) Resident care policies

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

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





 Plan of Correction - To be completed: 04/01/2024

Haircuts and grooming were provided to residents R58 and R60.

All residents are at risk of deficient practice. Audit completed of all residents relating to grooming needs.

An education will be provided to Nursing and Recreation staff on facility's ADL policy relating to grooming.
Recreation Director will audit residents in need of haircuts bi-weekly. Recreation Director will monitor consistent visits by beautician / barber. Nursing staff will monitor for resident's grooming care.

Director of Nursing / designee will conduct audits of 8 residents weekly to monitor ADL care was provided as per state and federal regulations. Audits will be done weekly x4 weeks, then x3 months. Findings will be reported to QAPI committee.
483.25(b)(2)(i)(ii) REQUIREMENT Foot 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(b)(2) Foot care.
To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must:
(i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and
(ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments.
Observations:


Based on review of policies and clinical records, observations and resident and staff interviews, it was determined that the facility failed to ensure that foot care needs were provided timely for one of 48 residents reviewed (Resident 73).

Findings include:

Review of a quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 73, dated November 22, 2023, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 3 which indicated that resident's cognitive status was severely impaired.

Review of care plan for Resident R73 dated June 8, 2023, revealed that the resident required assistance for mobility and Activities of Daily Living functions.

Observation of Resident R73 on February 23, 2024, at 12:41 p.m. with Director of Nursing, Employee E2, revealed that the resident had long and thick toenails on both feet. The nail was discolored with yellowish and whitish discoloration which appeared like infected nails. Employee E2 confirmed the finding and stated she would be contacting the physician for treatment.

Review of podiatry consult June 26, 2023, revealed that the resident had mycotic (fungal infection) toenails on all toes on both feet and it was painful with palpation. Nail debridement was completed and follow up exam was ordered in 9 weeks.

Further review of the clinical record revealed no evidence that the resident was seen by podiatry until January 5, 2024.

Review of podiatry consult January 5, 2024, revealed that the resident had onychomycosis (A nail fungus causing thickened, brittle, crumbly, or ragged nails) in 10 nails with pain and pigment discoloration. Further review of the clinical record revealed evidence that a treatment was recommended for the condition observed by the podiatry.

Review of clinical record dated February 24, 2024, revealed that the resident was noted with fungal infection to bilateral foot. Provider made aware. New orders received for Lotrimin AF (antifungal cream) cream and follow up with podiatry during next rounds.

Further review of the clinical records and care plan for Resident R73 revealed documented evidence that the facility staff documented resident's foot concern, notified physician, obtained treatment orders or developed a plan for care for the prevention and management of toenail infection until February 24, 2024.

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

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







 Plan of Correction - To be completed: 04/01/2024

Resident #73 was seen by Podiatrist and notes were uploaded in resident's chart.

All residents that are followed by Podiatry are at risk of deficient practice. A review of the last 3 months of Podiatrist's findings and recommendations were reviewed. Notes were uploaded on the EHR.

An education with the licensed nursing staff will be completed. Unit Managers will review the Podiatrist's findings timely upon receipt and follow up with recommendations, as well as upload notes in the resident's chart.

Director of Nursing / designee will conduct audits of Podiatry visits to monitor for compliance of timely recommendations and follow-up. Audits will be weekly x4 weeks then x3 months. Findings will be reported to QAPI committee.
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 observations, interviews with staff and residents, review of clinical records and facility documentation, it was determined that the facility failed to ensure adequate supervision during medication administration for one out of 21 residents reviewed (Resident R59).

Findings include:

Review of the facility policy, "Administering Medications," with a revised date of December 2012 indicated that medications shall be administered in a safe and timely manner, and as prescribed.The policy also indicated that residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.

Review of the February 2024 physician orders for Resident R59 included the following diagnoses: morbid obesity, post-traumatic stress disorder (a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it); atrial fibrillation (an irregular heart rhythm that can cause fatigue, palpitations, stroke, and other complications); depression (a mental health condition that causes a persistent feeling of sadness and loss of interest) ; muscle weakness, and hypertension (high blood pressure).

During an observation in Resident R59's room on February 21, 2024 at 10:40 a.m. the resident was observed in her room lying in bed with a cup of 6 pills in a clear plastic cup on her bedside table. She reported that the nurse left them there for her to take.

During an interview with Employee E27 on February 21, 2024 10:55 a.m. it was confirmed that Employee E27 gave the resident the medications to take on her own, left the room after providing the medications to the resident, and did not ensure that the resident was supervised during the consumption of the medications.

28 Pa. Code 211.12 (d) Nursing services

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




 Plan of Correction - To be completed: 04/01/2024

Medications that were left at bedside were taken under watch of a licensed nurse once the licensed nurse was notified by the state survey team.

An educational counseling for the identified nurse was completed.

All residents are at risk of deficient practice. An audit of residents with a care plan for self-administering medications will be completed.

All licensed nurses will be re-educated on the facility's policy for Medication Administration.

Director of Nursing / designee will conduct audits of med-pass for 8 residents to monitor compliance with self-administering of medications. Audits will be done weekly x4 weeks then x3 months. Findings will be reported to QAPI committee.
483.25(h) REQUIREMENT Parenteral/IV Fluids: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(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:



Based on observations, review of facility policies, clinical record review and interviews with residents and staff, it was determined that the facility failed to administer intravenous (IV) nutrition in accordance with physician orders and professional standards of practice for one of one resident reviewed on IV therapy (Resident R245).

Findings include:

Review of facility policy "Parenteral Nutrition" (TPN - a method of providing nutrition where a liquid formula is given into a vein through an intravenous catheter), revised July 2017, revealed a physician order is necessary for this treatment. The TPN order should include the formula or a list of all ingredients/nutrients in the base solution, volume, and rate of administration as well as an order for monitoring lab results on a routine basis. The facility must verify with the State Nurse Practice Act the role of the Nurse.

Continued review of section "Safety Precautions" revealed the event that the TPN is stopped or discontinued suddenly, parenteral nutrition will include an order for dextrose 10% IV to run at the same rate as PN.

Continued review of section "Documentation" revealed the following should be documented in the resident's medical record: date and time of administration, signature of nurse(s) checking and hanging PN bag and person monitoring infusion, and additives which are to be documented in the medication administration record.

Resident R245's was admitted to the facility on February 8, 2024. Resident R245's care plan dated February 14, 2024, revealed the resident had diagnoses of protein calorie malnutrition (lack of sufficient protein in the body) as well as a refusal to eat related to dysphasia and dislike of foods. Resident 245 also have a Central Venous Catheter (subclavian access).

Review of Resident R245's clinical record revealed a physician order dated February 10, 2024, "TPN Electrolytes Intravenous Concentrate (Parenteral Electrolytes): Use 127.3 ml/hr intravenously every shift for malnutrition. Multiple Vitamin 5 ml vial 1&2 is to be added to the TPN prior to infusion. Infuse Cyclic TPN at 127.3ml/hr for total volume of 1400ml over 12 hours via central line access device. Infusion start time is 2100"

Review of hospital discharge documentation dated February 8, 2024, revealed TPN order "start rate at 63.6ml/hr for one hour. Increase rate to 127.3ml/hr for 10 hours. Decrease to 63.6ml/hr for one hour, then stop." TPN order also listed these additives: "amino acids 15% 75g, dextrose 70% solution 250g, lipid 20% 40g, sterile water parenteral solution 240.25ml, sodium acetate 2mEq/ml 106 mEq, sodium chloride 4mEq/ml 70 mEq, sodium phosphate 3 mmol/ml 6 mmol, magnesium sulfate 4 mEq (50%) 8mEq, calcium gluconate 100mg/ml (10%) 8mEq, adult MVI 3300unit-150mcg/10ml 10ml, trace elements 1ml."

Observation on February 21, 2024 at 10:28 a.m. revealed TPN running @ 127ml/hr without dextrose 10% at the same rate. Also observed was the bottom section of dressing to central venous catheter (subclavian line) noted to be loose and not adhered to the skin. Follow up observation on February 22, 2024, at 8:28 a.m. noted dressing still loose.

Review of Resident R245's Febraurh 2024 Medication Administration Record (MAR) on February 12, 13, 14, 18 and 19 2024, for 7 a.m. - 3 p.m. shift and 3 p.m. - 11p.m. shift, indicated no documentation of TPN being administered.

Interview on February 22, 2024, at 10:14 a.m. with Director of Nursing, confirmed no documentation in MAR for those dates. Interview also confirmed that the TPN order did not contain the additives or the taper order for the rate of 63.6ml/hr for the first and last hour of the infusion. Director of Nursing also confirmed that residents dressing frequently becomes loose.



28 Pa. Code 211.10(c) Resident care policies

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



 Plan of Correction - To be completed: 04/01/2024

The orders for resident R245 were updated to reflect all ingredients / nutrients and rate of administration as per MD orders. The order was updated to reflect ongoing monitoring of site.
Licensed nurses educated on timely and proper documentation in MAR.
Dressing was replaced and reapplied. Resident's care plan was updated to reflect resident picking on dressing.

An audit was completed to verify if other residents are receiving TPN. No further residents identified at risk for deficient practice of TPN.

Licensed nursing staff will be educated on facility's TPN policy. Competencies will be completed on licensed staff working with TPN. TPN policy will be updated with physician review.

Director of Nursing / designee will conduct audits to monitor compliance with standards of practice and facility's updated TPN policy. Audits will be done weekly x4 weeks then monthly x3 months. Findings will be reported to QAPI committee.
483.25(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on the review of clinical records, and interviews with staff, it was determined that the facility failed to ensure that pain management was provided consistent with physician orders for two of 21 residents reviewed. (Resident R89 and Resident R81)

Findings include:

Interview with Resident R89 on February 21, 2024, at 11:46 a.m. stated he did not receive her pain medications and some other medications ordered by the physician consistently. He stated she was admitted to the facility on January 5, 2024, and staff stated, some of his medications were not available as they were waiting for the pharmacy to deliver the medications. He did not receive the medication for three days after the admission and he was in pain, with pain level ranging from 8 to 10 of a scale of 10. Resident also stated two weeks ago that happened again, his pain medication was not available, and staff told him they were waiting for the pharmacy to deliver.

Review of physician orders for Resident R89 revealed an order dated January 5, 2024, Suboxone 2-8 mg film sublingually in the morning and evening for chronic pain management.

Review of Medication Administration Record for Resident R89 for the month of January 2024 revealed that on the resident did not receive the medication on January 5 evening, January 6 and 7, 2024 morning and evening. The reason for not administering was documented as "Other/See Progress notes."

Further review of the progress notes dated January 5, 6 and 7, 2024 revealed that the medication was not available and waiting to be delivered from pharmacy.

Review of Medication Administration Record for Resident R89 for the month of February 2024 revealed that on the resident did not receive the medication on February 7 and 8, 2024. The reason for not administering was documented as "Other/See Progress notes."

Further review of the progress notes dated February 7 and 8, 2024 revealed no documented reason for the missed doses.

During interview with Resident R81 February 21, 2024, at 10:48 a.m. it was revealed that resident's pain medication of Morphine sulfate 15 milligrams (mg) was discontinued. Resident stated that she was recently diagnosis of lung cancer and that she has periods of pain which reach are 'unbearable'. Resident stated that the medicine was discontinued by the doctor due to accusation of selling the medication to her roommate. Resident went on to say that it was a misunderstanding and that she only stated "well you could have my cancer" when roommate was talking about her own diagnoses. Resident then said that all she has for pain management is Tylenol which "doesn't help at all".

Review of clinical record revealed a recent Pulmonary consult which showed a primary right lung lesion and need for a follow up with an oncologist. It was also revealed that resident had an order for Morphine Sulfate 15mg every 6 hours as needed for pain which was discontinued on February 20, 2024.

Review of physicians note from February 20, 2023 revealed discontinuation of Morphine Sulfate due to possible selling of pills and recording of resident offering the narcotics to another resident.

Interview with Director of Nursing on February 22, 2023 at 10:46 a.m. revealed physician never listened to the recording did not include any instances of resident selling narcotics. It was also revealed that no investigation was performed to substantiate the claims of narcotic sales.

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





 Plan of Correction - To be completed: 04/01/2024

Pain med orders for resident R89 and R81 were updated to reflect appropriate pain management per Physician's orders.

Unit Manager / designee will conduct an audit of all residents followed by Physiatry for the last 15 days to ensure consistency and appropriateness of pain management regimen.

A meeting with physicians will be scheduled and ongoing on a monthly basis.

Director of Nursing / designee will conduct audits of 4 residents followed by Physiatry to monitor for consistent and appropriate pain management regimen. Audits will be completed weekly x4 weeks then monthly x3 months. Findings will be reported to the QAPI committee.
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 the review of facility documentation, clinical records, staff and resident interviews, it was determined that the facility failed to provide necessary pharmaceutical services for one of 21 residents reviewed. (Resident R89)

Findings include:

Review of the facility policy, "Providing Pharmacy Services" with a revision date of January 1, 2021, indicated that the pharmacy will ensure that facility staff has access to medications, emergency services for medications, and drug information on a 24 hour basis.

Interview with Resident R89 on February 21, 2024, at 11:46 a.m. stated he did not receive her pain medications and some other medications ordered by the physician consistently. He stated she was admitted to the facility on January 5, 2024, and staff stated, some of his medications were not available as they were waiting for the pharmacy to deliver the medications. He did not receive the medication for three days after the admission and he was in pain, with pain level ranging from 8 to 10 of a scale of 10. Resident also stated two weeks ago that happened again, his pain medication was not available, and staff told him they were waiting for the pharmacy to deliver.

Review of clinical record for Resident R89, revealed that the resident was admitted to the facility on dated January 5, 2024, with diagnosis including fracture of right tibia, chronic pain and traumatic ischemia (reduced blood flow) of muscles.

Review of physician orders for Resident R89 revealed an order dated January 5, 2024, for Suboxone 2-8 milligrams (mg) film sublingually in the morning and evening for chronic pain management.

Review of physician orders for Resident R89 revealed an order dated January 5, 2024, for Oxycodone 5 mg every 4 hours as needed for pain.

Review of Medication Administration Record for Resident R89 for the month of January 2024 revealed that resident did not receive the medication on January 5, 2024 evening, January 6 and 7, morning and evening. The reason for not administering was documented as "Other/See Progress notes."

Further review of the progress notes dated January 5, 6 and 7, 2024 revealed that the medication was not available and waiting to be delivered from pharmacy.

Review of Medication Administration Record for Resident R89 for the month of February 2024 revealed that on the resident did not receive the medication on February 7 and 8, 2024. The reason for not administering was documented as "Other/See Progress notes."

Further review of the progress notes dated February 7 and 8, 2024 revealed no documented reason for the missed doses.

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

28 Pa. Code: 211.9(a)(1)(f)(2)(4)(g)(h)(k) Pharmacy services.




 Plan of Correction - To be completed: 04/01/2024

Resident R89 received medication of 1/8/2024.

All residents have the potential to be affected. An initial audit will be conducted of the last 7 days of "resident medication administration audit report" to identify if a medication was not given.

Licensed nurses will be reeducated on facility medication policy.

Director of Nursing / designee will conduct daily audits of "resident medication administration audit report" M-F during business day x4 weeks, then weekly x1 month, then monthly x3 months. Findings will be presented to QAPI committee.
483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

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

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

Based on observations and interview with staff, it was determined that the facility failed to store, label, and dispense drugs according to professional standards of practice for one of 28 resident medication observations. (Resident R15)

Findings Include:

During a medication administration observation on February 22, 2024, at 8:54 a.m. with Employee E24, Licensed Practical Nurse, for Resident R15. It was observed that staff took an unlabeled clear 30 ml medication cup from the cart. Inside the cup there were white colored tablets. Staff administered the medication to the resident.

During interview with Licensed staff, Employee E24 at the time of the observation Employee E24 stated that the medication Colace 100mg tablet was not available in the medication cart, and she took few pills from the other cart in a cup and placed it inside the cart to administer to the resident for morning medication administration.

Interview with Director of Nursing, Employee E2, on February 23, 2024, at 12:30 p.m. stated that the staff should not keep the medication in unlabeled containers. Employee E2 confirmed that that staff should verify each medication administered by the physician order and label of medication on the medication container or packet.

28 Pa. Code 211.12(c) Nursing Services

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




 Plan of Correction - To be completed: 04/01/2024

Medication for resident R15 was discarded.

All residents have the potential to be affected. An initial audit will be conducted of med carts by Unit Managers / designee

Licensed nurses will be reeducated on facility's policy for medication storage, labeling and dispensing medication.

Director of Nursing / designee will conduct audits of 1 med cart and 1 med room to verify proper labeling and medication storage and handling. Audits will be completed weekly x4 weeks then monthly x3 months. Findings will be presented to QAPI committee.
483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

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

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

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

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

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

Based on interviews, review of facility's policy and the review of clinical records, it was determined that the facility failed to ensure that complete and accurate documentation for one out of 21 residents reviewed (Resident R89).

Findings include:

Review of the facility policy, "Charting and Documentation," with a revision date of July 2017 indicated that all services provided to the resident progress toward care plan goals, or any change in the resident's medical, physical, function or psychosocial conditions, shall be documented in the resident's medical record. The policy also indicated that the medical record should facilitation communication between the interdisciplinary team regarding the resident's condition and response to care.

Review the February 2024 physician orders for Resident R89 indicated that the resident was admitted into the facility from the hospital on January 5, 2024 with the following diagnosis seizures (a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness); cerebral infarction (a stroke); chronic obstructive pulmonary disorder (COPD- a condition involving constriction of the airways and difficulty or discomfort in breathing); alcohol abuse; substance abuse; anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome); depression(a mood disorder that causes a persistent feeling of sadness and loss of interest), in addition to a right below the knee amputation.

Review of a social services note dated January 17, 2024 at 4:16 p.m. documented that the social worker spoke with the resident regarding suicide ideation. "Social services to [sic] resident about suicidal ideations ....."

Continued review of the resident's clinical notes did show evidence of any other information regarding what events led up to the social worker needing to speak with the resident regarding suicide ideations.

During an interview with the Director of Nursing (DON) on February 27, 2024 at 10:10 a.m. the DON reported that she was told that the previous Nursing Home Administrator (NHA) received a call from the resident's daughter who had a concern that her the resident "did not sound like himself." During this interview it was discussed with the DON that there was no documentation from the previous Nursing Home Administrator in the resident's clinical record regarding the details of the conversation that he had with the resident's daughter regarding the concerns that she had about her father.

During an interview with the Social Worker (Employee E8) on February 27, 2024 at 10:13 a.m. Employee E8 reported that he was told in morning meeting that day to speak with the resident about his mental health needs, and that he did not know any specific details about what the daughter told the previous Nursing Home Administrator.

28 Pa Code 211.12(c) Nursing services

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






 Plan of Correction - To be completed: 04/01/2024

Former NHA was educated on completing and ensuring timely documentation. SW and Psych both saw resident R89 and concluded that resident was not in imminent harm.

All residents have the potential to be affected. An initial audit of the past 10-days 24-hr reports have been reviewed to monitor complete and accurate charting and documentation of any potential suicidal ideation.

IDT and licensed staff will be re-educated on facility's policy on charting and documentation.

Administrator / designee will conduct daily audit of 24hr report for review of any possible suicide ideation documentation and monitor for proper documentation. Audits will be completed for 10 days, then weekly x4 weeks then monthly x3 months. Findings will be presented to the QAPI committee.
483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides: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.
§483.95(g) Required in-service training for nurse aides.
In-service training must-

§483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

§483.95(g)(2) Include dementia management training and resident abuse prevention training.

§483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at § 483.70(e) and may address the special needs of residents as determined by the facility staff.

§483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
Observations:

Based on a review of facility documentation and staff interview, it was determined that the facility failed to ensure its nurse aide staff was receiving in-service training to be proficient and competent and that the training be no less that 12 hours annually for two of six nurse aides reviewed (Employees E19 and E16).

Findings Include:

Review of the nurse aide annual training information provided for nurse aide Employee E19 during the survey revealed that there were only six hours of annual training documentation to review and did not meet the twelve hours of annual training requirement.

Review of the nurse aide annual training information provided during the survey revealed that nurse aide Employee E16 had only eight hours of training documentation to review and did not meet the twelve hours of annual training requirement.

An interview with the Director of Nursing on February 26, 2024, at 1:45 p.m. confirmed that these nurse aides did not meet the minimum required hours of training.

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







 Plan of Correction - To be completed: 04/01/2024

Identified CNAs will be in-serviced and trained for their annual 12 hours of mandatory trainings.

Any residents being provided with care by nursing staff that lack educations are at risk for the deficient practice. An initial audit will be completed of all CNAs to review for compliance with the 12 hour annual in-services / trainings.

All CNAs will have the 12 hour mandatory in-services / trainings completed.

Director of Nursing / designee will conduct audits of employee education files for the CNAs to monitor the 12 hours are being completed. 4 employees will be audited weekly. Audits will be done x4 weeks then monthly x6 months. Findings will be reported to QAPI committee.
§ 204.7 LICENSURE Laundry.:State only Deficiency.
Equipment shall be made available and accessible for residents desiring to do their personal laundry.
Observations:

Based on observations and staff interviews, it was determined that the facility failed to ensure that laundry equipment was in working order for residents to do their personal laundry for 2 out of 21 residents reviewed (Resident R28 and R65).

Findings include:

During an group meeting with alert and oriented residents on February 23,2024 at 10:30 a.m Residents R9, R28 and R65 reported that the laundry dryer has been broken on and off for the past 6 months, and they have not been able to dry their clothes properly. Residents R28 and R65 reported that when they wash their clothes, they have to lay their clothes out in their room to allow them to dry.

During an interview with the Maintenence Director (Employee E28) on February 27, 2024 at 12:30 p.m. Employee E28 reported that a button on the dryer has been broken since December 2023. Employee E28 reported that a piece has been on backorder since December 2023.

During an interview with the Regional Administrator (Employee E3) on February 27, 2024 at 1:00 p.m. it was discussed with him that that residents have reported that laying their clothes out to dry in their room due to the dryer designated for residents to use was broken.





 Plan of Correction - To be completed: 04/01/2024

The facility purchased and installed a new dryer for resident use.

All residents are at risk of deficient practice. A new dryer has been installed.

A working dryer was purchased and installed. Residents will be notified of a new dryer.

Maintenance Director / designee will conduct audits to ensure washer/dryer are in working order. Audits will be completed weekly x4 weeks then monthly x3 months. Findings will be reported to QAPI committee x3 months

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