Pennsylvania Department of Health
 WECARE AT SYCAMORE REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WECARE AT SYCAMORE REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  140 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.
WECARE AT SYCAMORE REHABILITATION AND NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, Civil Rights Compliance Survey, and two Complaint Investigations, completed on March 15, 2024, it was determined that Wecare At Sycamore Rehabilitation And Nursing Centerr was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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.
§483.35(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 staff interviews and review of facility documentation, it was determined that the facility failed to ensure that nurse aides received an annual performance review for three of three nurse aides reviewed (Employees 3, 4, and 5).

Findings Include:

Review of the facility's list of active nurse aide staff revealed Employee 3 had a hire date of November 15, 2022. Employee 3 should have had an annual performance review by November 15, 2023.

Employee 4 had a hire date of November 15, 2022. Employee 4 should have had an annual performance review by November 15, 2023.

Employee 5 had a hire date of November 15, 2022. Employee 5 should have had an annual performance review by November 15, 2023.

Requests to review Employees 3, 4, and 5's performance reviews revealed no documented evidence that the facility completed the reviews at least once every 12 months.

Interview with the Nursing Home Administrator on March 14, 2023, at 10:50 AM confirmed that performance evaluations were not completed.

28 Pa. Code 201.19(2) Personnel policies and procedures












 Plan of Correction - To be completed: 05/07/2024

1.Employees #3, #4, and #5 have had a completed performance evaluation.
2.A plan has been developed to ensure that performance evaluations are completed based upon hire date. Annual evaluations will be completed within the next 90 days to ensure competent staff.
3.The NHA/Designee will educate the IDT Team on F-Tag726, F-Tag 730, "Nurse Aide Performance" to ensure staff are competent to perform job duties.
4.An audit will be completed by the HRD/Designee weekly x5 weeks to ensure competent staff have a completed annual evaluation. All findings will be reported to the Quality Assurance Committee Meeting.

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 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.
§483.15(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 clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility's bed hold policy at the time of transfer for six of 10 residents reviewed for hospitalizations (Residents 3, 10, 44, 45, 62, and 69).

Findings include:

Clinical record review for Resident 10 revealed that she was transferred to the hospital on December 13, 2023, for respiratory distress. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or the resident's responsible party upon transfer out of the facility.

Clinical record review for Resident 45 revealed that she was transferred to the hospital on December 27, 2023, related to pneumonia. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or the resident's responsible party upon transfer out of the facility.

Clinical record review for Resident 62 revealed that he was transferred to the hospital on October 31, 2023, related to concerns with swelling around his dialysis (a process that helps your body remove extra fluid and waste when your kidneys are not able to) fistula (a surgical connection that is made between and artery and a vein for dialysis access). There was no documentation available that the facility provided written notice regarding a bed hold to Resident 62 and/or his responsible party upon transfer out of the facility.

Clinical record review for Resident 3 revealed that she was transferred to the hospital on November 11 to 13, 2023, for a change in mental status. There was no documentation available that the facility provided written notice regarding a bed hold to Resident 3 and/or Resident 3's responsible party upon transfer out of the facility.

Clinical record review for Resident 44 revealed that she was transferred to the hospital on December 18 to 21, 2023, for a change in his mental status. There was no documentation available that the facility provided written notice regarding a bed hold to Resident 44 and/or the Resident 44's responsible party upon transfer out of the facility.

Clinical record review for Resident 69 revealed that she was transferred to the hospital on December 28, 2023, to January 2, 2024. There was no documentation available that the facility provided written notice regarding a bed hold to Resident 69 and/or Resident 69's responsible party upon transfer out of the facility.

The facility failed to provide written notice of their bed hold policy at the time of transfer for Residents 3, 10, 44, 45, 62, and 69. The Nursing Home administrator confirmed the above-noted findings related to bed hold notices during a meeting on March 14, 2024, at 2:40 PM.

28 Pa. Code 201.14(a) Responsibility of licensee

















 Plan of Correction - To be completed: 05/07/2024

1.Residents #3, #10, #44, #45, #62, and #69 have no ill effect; all have returned to the facility. The facility cannot retroactively issue a bed hold notice.
2.The Business Office Manager/designee will review all hospital transfers to ensure a written copy of the bed hold notice is provided to all residents and/ representatives.
3.The NHA/designee will re-educate the Social Services Department, Business Office Manager, and all licensed staff on F-Tag 625, "Notice of Bed Hold Policy" to ensure a written notification of the bed hold policy has been provided.
4.An audit will be completed by the BOM/designee of all transfers to the hospital 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week times a month to ensure a written notification is provided regarding bed hold notification. All findings will be reported to the Quality Assurance Committee Meeting.

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 clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for three of five residents reviewed (Residents 2, 8, and 64).

Findings include:

Clinical record review for Resident 8 revealed current physician orders for Seroquel (for bipolar disorder) 75 milligrams (mg) by mouth (PO) at bedtime (HS), Seroquel 50 mg PO twice daily (BID), Depakote sprinkles (for bipolar disorder) 125 mg two capsules PO daily (QD) and one capsule PO BID, and Duloxetine (for Depression) 60 mg PO QD.

Resident 8's physician ordered the every shift staff to monitor her for dry mouth, constipation blurred vision, disorientation/confusion, difficulty urinating, hypotension (low blood pressure), dark urine, yellow skin, nausea and/or vomiting, lethargy drooling, tremors, disturbed gait, increased agitation, restlessness, and/or involuntary movement of the mouth or tongue. Staff were to document "Y" if monitored and none of the above were observed or "N" if monitored and any of the above was observed, select chart code "other/see nurses notes and progress note findings related to bipolar disorder and Depression.

Review of Resident 8's January, February, and March 2024 MAR (medication administration record, a form to document medication administration) and clinical record revealed that there was no documentation that staff were monitoring Resident 8 for the above noted physician ordered signs and symptoms or behaviors.

The surveyor reviewed the above for Resident 8 during an interview with the Nursing Home Administrator on March 15, 2024, at 8:58 AM.

Review of Resident 2's clinical record revealed a current physician order for nursing staff to administer Ativan (helps with anxiety) .5 mg three times a day for anxiety, Remeron (an anti-depressant) 45 mg at bedtime for depression, and Risperdal (used to treat mental disorders) 2mg three times a day for psychosis.

A physician order dated December 3, 2023, indicated that nursing staff were to monitor Resident 2's behaviors such as crying, wringing of her hands, outbursts, and physical aggression. Review of Resident 2's MAR dated March 2024 revealed that there was no documented evidence that the facility was tracking Resident 2's behaviors to determine what behavior she was exhibiting, how many episodes, or what interventions nursing staff were using to help alleviate the behavior.

Review of Resident 64's clinical record revealed a current physician order for nursing staff to administer Seroquel (treats depression) 12.5 mg every morning and 25 mg every evening, and Zoloft (treats depression) 100 mg every day, both to treat her depression.

A physician order dated December 28, 2023, indicated that nursing staff were to monitor Resident 64's behaviors such as agitation, restlessness, anger, fear, hallucinations, sadness, crying, and fatigue. Review of Resident 64's MAR dated March 2024 revealed that there was no documented evidence that the facility was tracking Resident 64's behaviors to determine what behavior she was exhibiting, how many episodes, or what interventions nursing staff were using to help alleviate the behavior.

The above findings for Resident 2 and 64 were reviewed with the Administrator and Director of Nursing on March 14, 2023, at 2:00 PM.

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

28 Pa. Code 211.10(a) Resident care policies

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


 Plan of Correction - To be completed: 05/07/2024

1.Residents #2, #8, and #64 have had no ill effect related this cited deficiency.
2.Residents receiving psychotropic medications will have the appropriate behavior monitoring placed in the MAR in PCC.
3.The Staff Development/Designee will educate licensed nurses on F-Tag 758, "Free from Unnecessary Psychotropic Medications," to ensure accurate behavior monitoring.
4.An audit will be completed by the DON/Designee 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week times a month to ensure behavior monitoring is appropriately documented in the MAR. All findings will be reported to the Quality Assurance Committee Meeting.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:
Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed and responded appropriately to pharmacy recommendations for four of six residents reviewed (Resident 64, 33, 50, and 75) and failed to ensure that the consulting pharmacy identified potential appropriateness for psychoactive medications for one of six residents reviewed (Resident 64).

Findings include:

Review of Resident 64's clinical record revealed a physician order dated September 22, 2022, for nursing staff to administer Zoloft (used to treat depression) 150 mg (milligrams) every day for schizoaffective disorder (a combination of symptoms of schizophrenia and bipolar disorder).

A consultant pharmacy review dated September 1, 2023, indicated that Resident 64 has been on the current dose of Zoloft since "September 2022" and that her physician review the current dose and should consider a gradual dose reduction. There was no documented evidence that Resident 64's physician addressed the consultant pharmacist's recommendation. Resident 64 continued to get the 150 mg of Zoloft for an additional two months before a gradual dose reduction was attempted.

Review of Resident 64's clinical record revealed a nursing progress noted dated November 13, 2023, that indicated her attending physician was going to write an order for nursing staff to decrease her dose of Seroquel (a medication that treats mental disorders) to 12.5 mg in the morning and 25 mg in the evening. Review of the order dated November 13, 2023, indicated the above changes.

Review of Resident 64's Medication Administration Record (MAR, a form used to document the administration of medications) dated November 2023 revealed that in addition to the above orders changes for Resident 64's Seroquel, the nurse transcribing the order also entered an order for an additional 50 mg of Seroquel to be given in the morning. There was no documented evidence to indicate that Resident 64's attending physician authorized the extra 50 mg of Seroquel.

A consultant pharmacy review was conducted on November 17, 2023, with no recommendations for Resident 64's attending physician. The consultant pharmacist did not identify that Resident 64 was receiving an extra 50 mg of Seroquel that her physician did not order.

Interview with the Director of Nursing on March 15, 2024, at 9:32AM confirmed the above findings for Resident 64.

A consultant pharmacy review dated December 19, 2023, requested Resident 33's physician consider ordering a Lipid Panel (a blood test that can measure the amount of cholesterol in your blood), CBC (complete blood count, is a blood test used to look at overall health), BMP (basic metabolic panel, a test that measures eight different substances in your blood), and Vitamin D level. There was no documented evidence that Resident 33's physician addressed the consultant pharmacist's recommendation from December 19, 2023.

A consultant pharmacy review dated January 22, 2024, indicated Resident 33 has an order for Seroquel with an indication of dementia. The consultant pharmacist requested Resident 33's physician change the indication for Resident 33's Seroquel to depression. There was no documented evidence that Resident 33's physician addressed the consultant pharmacist recommendations from January 22, 2024.

A consultant pharmacy review dated December 19, 2023, noted Resident 50 has four psychotropic medication orders for at least three to 12 months that are now potentially due for a gradual dose reduction based on CMS guidelines. The consultant pharmacist requested Resident 50's physician evaluate if Resident 50 is a candidate for gradual dose reduction and consider a reduction in the total daily dose of any of the four psychotropic medication orders. There was no documented evidence that Resident 50's physician addressed the consultant pharmacist's recommendation from December 19, 2023.

Interview with Employee 9 (assistant director of nursing) on March 14, 2024, at 1:02 PM confirmed the above findings for Residents 33 and 50.

A consultant pharmacy review dated November 22, 2023, noted that Resident 75 had an order for Olanzapine (a medication used to treat schizophrenia, bipolar disorder, and depression). The consulting pharmacist requested that the physician change the indication for use to depression. Resident 75's physician addressed the recommendation on November 28, 2023. He declined to change the indication for use marked the box that indicated to continue the zyprexa order with the current indication and that he was aware that olanzapine is not FDA approved for agitation/hallucination but the benefits to the resident outweights any potential adverse side effect risks. He also documented under the physician reponse area that the resident is on hospice with metastatic cancer. The physician failed to provide an appropriate indication for use of the medication Olanzapine for Resident 75.

Interview with Employee 9, on March 15, 2024, at 11:00 AM confirmed the above noted finding related to Resident 75.

28 Pa. Code 211.9 (d)(k) Pharmacy services

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



 Plan of Correction - To be completed: 05/07/2024

1.Residents #64, #33, #50, and #75 did not have any ill effects from the physician not addressing the pharmacy recommendations. Resident #64 had no ill effects from the consulting pharmacist not identifying potential appropriateness for psychoactive medications. Resident #75 has the appropriate diagnosis for the use of Olanzapine.
2.All medication reviews will be reviewed and addressed in timely manner by the Physician or Physician Assistant. The facility will look back 30 days to ensure all medication reviews have been addressed timely by the Physician or Physician Assistant. A collaborative approach with be established to ensure the reviewing pharmacist and facility identify any potential discrepancies.
3.The Staff Development/Designee will educate on F-Tag 756, "Drug Regimen Review," to practicing clinicians and licensed staff regarding addressing pharmacy recommendations in timely manner.
4.An audit will be completed by the ADON/Designee of pharmacy recommendations monthly x3 months to ensure timely responses and discrepancies related to medication reviews. All findings will be reported to the Quality Assurance Committee Meeting.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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(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 clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by four of five residents reviewed (Residents 33, 50, 8, and 75).

Findings include:

Clinical record review for Resident 33 revealed the facility admitted her on October 22, 2023, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) with other behavior disturbances. A review of Resident 33's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated September 1, 2023, indicated that the facility assessed Resident 33 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 33's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.

Clinical record review for Resident 50 revealed the facility admitted her on October 1, 2020, with diagnosis including Dementia. A review of Resident 50's most recent MDS dated November 14, 2023, indicated that the facility assessed Resident 50 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

The findings were reviewed with the Nursing Home Administrator and Director of Nursing on March 13, 2024, at 2:35 PM. The facility had no further documentation that the facility developed and implemented individualized person-centered care plans to address Resident 33 and 55's dementia and cognitive loss.

Clinical record review for Resident 8 revealed that she was admitted to the facility on December 2, 2015. Resident 8's physician diagnosed her with Dementia on November 2, 2016. An annual MDS completed on January 8, 2024, revealed that the facility indicated that she had Dementia and determined that a care plan for dementia and cognitive loss would be developed.

Review of Resident 8's care plan revealed that there was no documentation of an individualized Dementia care plan.

Clinical record review for Resident 75 revealed that she was admitted to the facility on November 2, 2023, with diagnosis including dementia.

Review of Resident 75's most recent comprehensive MDS dated November 8, 2023, revealed that the facility determined that a care plan for cognitive loss and dementia would be developed.

Review of Resident 75's current care plan revealed that there was no evidence of an individualized dementia care plan.

The surveyor reviewed the above information regarding Resident 75, during an interview on March 15, 2024, at 8:46 AM with the Nursing Home Administrator.

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












 Plan of Correction - To be completed: 05/07/2024

1.Resident #33 and #50 has an updated care plan specific to address dementia and cognitive loss with personalized interventions. Resident #8 and #75's care plan has been updated with a personalized care plan for dementia.
2.All residents with cognitive loss and dementia will be reviewed and updated as appropriate with personalized interventions.
3.An education to the Social Services Department, Licensed Staff and IDT team will be completed by the Staff Development/Designee related to F-Tag 744, "Treatment/Services for Dementia" related to cognitive loss and dementia.
4.An audit will be completed by the NHA/Designee 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week times a month to ensure any new residents or changes to current residents for cognition loss or dementia are captured. All findings will be reported to the Quality Assurance Committee Meeting.

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 the review of facility documentation, four employee files and staff interviews, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of resident tracheostomy, peg tube, and catheter care.

Findings include:

A review of the facility documentation revealed that the facility had six residents with urinary catheters (insertion of a tube into the bladder to remove urine), one resident with a tracheostomy (a surgical airway management procedure that consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea), and two residents with peg tubes (medical procedure in which a tube is passed into resident's stomach through the abdominal wall, most commonly to provide a means of feeding).

A request for nursing staff competencies for tracheostomy, peg tube, and catheter care revealed the facility was unable to provide any.

The findings were reviewed with the Nursing Home Administrator and Director of Nursing on March 14, 2024, at 2:55 PM confirmed the facility could provide no documentation that ensured nurses have specific competencies and skill sets to care for the residents' needs listed above.

28 Pa Code 201.20(a) Staff development

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







 Plan of Correction - To be completed: 05/07/2024

1.No ill effects have been related to any resident related to this deficient practice.
2.Nursing staff will have competencies completed on urinary catheters, tracheostomy, peg tubes, or any new skill sets needed to care for the residents to ensure competency.
3.The NHA/designee will educate the Nursing Administration Team on F-Tag 726, "Competent Nursing Staff," to ensure that competencies are completed in accordance with our resident population to care for our resident's needs.
4.An audit will be completed by the Staff Development/Designee monthly x3 months to ensure nursing staff have completed annual competencies based on hire date. All findings will be reported to the Quality Assurance Committee Meeting.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a less serious (but not lowest level) deficiency and 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(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to assess and implement treatment and services to prevent development and promote healing of pressure ulcers for four of six residents reviewed for pressure ulcer concerns (Residents 15, 22, 34 and 260).

Findings include:

Clinical record review for Resident 15 revealed wound clinic documentation date of March 14, 2024, which indicated that he had a chronic pressure ulcer on his left buttock measuring 2 centimeters by 2 centimeter by 3 centimeters.

Resident 15's current physician order revealed that staff was to place an air mattress to his bed, ensure that it was set at 150 pounds, and provided alternating pressure.

Observation of Resident 15 on March 12, 2024, at 10:01 AM revealed that he was in bed and his air mattress was set at 660-750 pounds.

Clinical record review for Resident 22 revealed that the facility admitted her on September 25, 2023, with diagnoses of paraplegia (paralyzed lower extremities), a non-pressure chronic ulcer to her back, osteomyelitis, and extradural and subdural abscess. An admission assessment dated September 25, 2023, revealed that Resident 22 had an unstageable pressure ulcer on her left buttock measuring 14.5 centimeters by 9 centimeters with eschar (blackened dead tissue).

On March 8, 2024, staff documented that Resident 22 weighed 220.8 pounds.

Resident 22's current physician orders indicated that staff was to place a pressure relieving mattress to her bed and monitor that it was functioning every night shift.

Observation of Resident 22 on March 13, 2024, at 9:44 AM, March 14, 2024, at 1:10 PM revealed that she was in bed and her air mattress was set at 100 pounds.

Clinical record review for Resident 260 revealed that the facility admitted her on February 22, 2024, with diagnoses of rhabdomyolysis (damaged tissue releases protein and electrolytes into the blood resulting in potentially permanent disability). An admission assessment dated February 22, 2024, revealed that Resident 260 had an open wound on her right hip measuring 8 centimeters by 2 centimeters with slough (yellow/white dead tissue).

On March 12, 2024, staff documented that Resident 260 weighed 159.4 pounds.

Resident 260's current physician orders indicated that staff was to place an air mattress to her bed and check inflation and patency every shift.

Observation of Resident 260 on March 12, 2024, at 9:53 AM and March 13, 2024, at 9:50 AM revealed that she was in bed and her air mattress was set at 620 pounds.

This surveyor reviewed the above information with the Nursing Home Administrator and the Director of Nursing on March 14, 2024, at 1:10 PM.

Clinical record review for Resident 34 revealed the facility admitted him on May 22, 2023. Review of Resident 34's nursing skin evaluation on August 30, 2023, revealed no skin impairments were observed. The nursing skin evaluation dated September 6, 2023, noted Resident 34's current skin condition changed and a pressure sore was noted on Resident 34's right heel. There was no further assessment, or interventions implemented related to the identified pressure ulcer on Resident 34's heel until September 11, 2023.

Nursing documentation dated September 11, 2023, at 10:24 AM, noted a nurse was in to assess Resident 34's heels for potential deep tissue injuries. The nurse assessed Resident 34's left heel measuring 1 by 1.5 centimeters, and the left heel was not blanchable, or open. The nurse assessed Resident 34's right heel measuring 4 by 6 centimeters, and the right heel was open with serosanguinous drainage.

The facility did not assess and implement interventions timely to address the pressure area identified on Resident 34's right heel on September 6, 2023.

Interview with Employee 9 (assistant director of nursing) on March 15, 2024, at 8:51 AM confirmed these findings. She could provide no further documentation that the facility assessed and implemented interventions to address Resident 34's identified pressure ulcer when identified on September 6, 2023.

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

28 Pa. Code 211.5(f)(ii)(iv)(ix) Medical records

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

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


 Plan of Correction - To be completed: 05/07/2024

1.Resident #15, #22, and #260's air mattress pressure settings have been corrected according to physician orders.
Resident #34 has a current and accurate skin assessment.
2.All air mattress settings have been assessed and adjusted per the physician order.
During weekly skin assessments, any residents with an observed changes in skin integrity, the nurses will notify the MD and ADON and document.
3.Maintenance Staff and nursing staff will be educated on F-Tag 684, "Quality of life," by the Staff Development/designated to ensure accurate and appropriate air pressure settings to the physician's orders.
All nursing staff will be educated on F-Tag 684, "Quality of life," by the Staff Development/designated to ensure observed skin integrity issues are reported and documented.
4.An audit will be completed 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week times a month to ensure appropriate air mattress setting and correlating physician orders.
An audit will be completed by the ADON/Designee 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week times a month to ensure skin integrity changes have been documented. All findings will be reported to the Quality Assurance Committee Meeting.

483.25 REQUIREMENT Quality of Care: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 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 clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician-ordered vital signs, medications, and interventions for two of 22 residents (Residents 8 and 52) and integrated hospice care and services for two of four residents reviewed (Residents 34 and 75).

Findings include:

Clinical record review for Resident 8 revealed a current physician order for staff to place an air mattress on her bed and monitor the air mattress every shift to ensure the pump setting was 220 (pounds) alternating pressure for skin protection.

Observation of Resident 8's air mattress on March 12, 2023, at 9:54 AM, March 13, 2024, at 11:21 AM, and March 14, 2024, at 8:28 AM and 10:45 AM revealed that her air mattress pump setting was 380 pounds.

Further clinical record review for Resident 8 revealed a physician order for staff to administer Detemir insulin 100 unit/milliliter 37 units subcutaneously (just under the skin) daily for diabetes. Staff were to hold the insulin if Resident 8's blood sugar was less then 100 mg/dl (milligrams/deciliter).

Review of Resident 8's January, February, and March 2024 MAR (medication administration record, a form to document medication administration) revealed that there was no documentation that staff were monitoring Resident 8's blood sugars as ordered.

Clinical record review for Resident 52 revealed a current physician order place a wide air mattress on his bed and monitor the air mattress every shift to ensure the pump setting was 450 (pounds) alternating pressure.

Observation of Resident 52's air mattress on March 12, 2023, at 9:37 AM and 3:05 PM revealed that his air mattress pump setting was 540 pounds.

The surveyor reviewed the above information during an interview on March 14, 2024, at 10:45 AM and 1:21 PM and March 15, 2024, 10:20 AM with the Nursing Home Administrator and Director of Nursing.

Clinical record review for Resident 75 revealed that she was on Hospice related to a terminal diagnosis of malignant neoplasm of the endometrium (a disease in which cancer cells form in the tissues of the lining of the uterus).

Review of Resident 75's current care plan revealed that the facility failed to implement an integrated plan of care with hospice services. The plan of care did not include evidence of all services that hospice will provide for the management of Resident 75's terminal illness.

Resident 75's current care plan failed to identify the hospice entity providing services, the hospice disciplines that would provide her care and services, and how often.

Interview with Employee 7 (social services) confirmed the above-noted finding related to Resident 75's hospice services and plan of care during an interview on March 15, 2024, at 10:30 AM and confirmed that she updated Resident 75's care plan with hospice information after the surveyor brought this to her attention at 8:30 AM on March 15, 2024.

Clinical record review revealed the facility admitted Resident 34 to hospice on December 30, 2023, due to a terminal diagnosis of end-stage dementia with a poor prognosis.

Review of Resident 34's current care plan revealed that the facility failed to implement an integrated plan of care with hospice services. The plan of care did not include evidence of all services that hospice will provide for the management of Resident 34's terminal illness.

Interview with Employee 7 on March 15, 2024, at 10:32 AM confirmed the above-noted findings for Resident 34. Resident 34's plan of care failed to delineate who was to provide for the physical, psychosocial, spiritual, and emotional needs of Resident 34.

483.25 Quality of Care
Previously cited 11/2/23 and 3/3/23

28 Pa. Code 211.10(c) Resident care policies

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



 Plan of Correction - To be completed: 05/07/2024

1.Resident #8's air mattress pressure settings was corrected immediately when discovered by the Department of Health. Resident #8's blood sugar parameter has been added to the MAR to ensure that the documentation/monitoring is completed.
Resident #52's air mattress pressure settings was corrected immediately when discovered by the Department of Health.
Resident #75's care plan has been edited to ensure collaboration with Hospice Services.
Resident #34's care plan has been edited to ensure collaboration with Hospice Services.
2.All air mattress settings have been assessed and adjusted per the physician order. All residents with insulin parameter orders will be audited for accuracy. All residents with Hospice Services will have a collaborative care plan.
3.Maintenance Staff and licensed staff will be educated on F-Tag 684, "Quality of life," by the Staff Development/designated to ensure accurate and appropriate air pressure settings to the physician's orders.
Licensed Staff will be educated on F-Tag 684, "Quality of life," by the Staff Development/designee to ensure insulin parameters are accurate.
Social Services will be educated on F-Tag 684, "Quality of life," by the Staff Development/designee to ensure collaborative Hospice Care plans are in place.
4.An audit will be completed 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week times a month to ensure appropriate air mattress setting and correlating physician orders.
An audit will be completed by the DON/Designee 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week times a month to ensure parameters are placed related to insulin orders and collaborative Hospice Care Plans are in place. All findings will be reported to the Quality Assurance Committee Meeting.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan regarding cognitive loss and psychotropic medication use with behaviors for two of 22 residents reviewed (Resident 64 and 75).

Findings Include:

Review of Resident 64's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment done at specific intervals to determine care needs) dated May 12, 2023, revealed that the facility assessed Resident 64 as having cognitive loss and determined that a plan of care would be developed to address her cognitive loss.

Review of Resident 64's current plan of care revealed that the facility did not develop a plan of care to address her cognitive loss until March 12, 2024.

Interview with the Director of Nursing on March 15, 2024, at 9:32 AM, confirmed the above findings for Resident 64.

Clinical record review for Resident 75, revealed her current physician orders to include the following psychoactive (medications that affects how the brain works and causes changes in mood, awareness, thoughts, feelings or behavior) medications: Xanax (a medication used to treat anxiety) 0.5 milligrams three times a day, Olanzapine (a medication used to treat schizophrenia), and Bupropion HCI (a medication used to treat depression).

Review of Resident 75's current plan of care revealed that the facility did develop a personalized care plan for Resident 75 that identified her targeted behaviors and individualized interventions related to her mood and behaviors.

Interview with Employee 7, Social Services, on March 15, 2024, at 10:31 AM, confirmed the above findings related to Resident 75.

The Nursing Home Administrator was made aware of the concerns related to Resident 75's care plan on March 15, 2024, at 12:30 PM.

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






 Plan of Correction - To be completed: 05/07/2024

1.Facility cannot retroactively correct the care plan from May 12, 2023. However, Resident #64 has an updated care plan specific to address cognitive loss with personalized interventions. Resident #75's care plan has been updated with a personalized care plan for mood and behavior.
2.All residents with cognitive loss and/or use of psychotropic medications for mood and behaviors will be reviewed and updated as appropriate with personalized interventions.
3.An education to the Social Services Department, Licensed Staff and IDT team will be completed by the Staff Development/Designee related to F-Tag 656, "Development / Implement Comprehensive Care Plans" related to cognitive loss and mood and behaviors.
4.An audit will be completed by the NHA/Designee 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week times a month to ensure any new residents or changes to current residents for cognition loss or changes to mood and behaviors are captured. All findings will be reported to the Quality Assurance Committee Meeting.

483.90(d)(3) REQUIREMENT Resident Bed: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.
§483.90(d)(3) Conduct Regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment. When bed rails and mattresses are used and purchased separately from the bed frame, the facility must ensure that the bed rails, mattress, and bed frame are compatible.
Observations:

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to perform an assessment for possible entrapment after installation of enabler bars and/or side rails for two of two residents reviewed (Residents 22 and 66).

Findings include:

Observation of Resident 22 on March 13, 2024, at 9:41 AM revealed that she was in bed sleeping. There was an enabler bar on the left side of her bed.

Clinical record review for Resident 22 revealed that she requested the use of enabler(s) on November 10, 2023.

There is no documentation indicating that the facility assessed Resident 22's bed to ensure that that the enabler bar placed on Resident 22's bed was compatible with the mattress and/or bed frame utilized and there was no documentation that the facility completed an assessment to ensure that there was not the potential for entrapment while utilizing an enabler bar on Resident 22's bed.

Observation of Resident 66 on March 12, 2024, at 11:14 AM revealed that there were bilateral enabler bars on her bed.

Clinical record review for Resident 66 revealed that the facility completed an assessment for the use of enabler bars to promote independence on October 5, 2023.

There is no documentation indicating that the facility assessed Resident 66's bed to ensure that that the enabler bars placed on Resident 66's bed was compatible with the mattress and/or bed frame utilized and there was no documentation that the facility completed an assessment to ensure that there was not the potential for entrapment while utilizing enabler bars on Resident 66's bed.

The surveyor reviewed the above information during an interview with the Nursing Home Administrator on March 14, 2024, at 1:25 PM.

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



 Plan of Correction - To be completed: 05/07/2024

1.Residents #22 and #66 have current entrapment zone assessments. Residents #22 and #66 have no ill effect related to this deficient practice.
2.All residents with enabler bars will have a current entrapment zone assessment.
3.The Staff Development/Designee will educate nursing and maintenance staff on F-Tag 909, "Resident Bed," to ensure the entrapment zones are in place for all enabler bars.
4.An audit will be completed by the Maintenance Director/Designee 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week times a month to ensure all new admissions and current residents with enabler has a current entrapment zone assessment in place. All findings will be reported to the Quality Assurance Committee Meeting.

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

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

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

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

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

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

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

Based on observation and staff interviews, it was determined that the facility failed to prevent the potential spread of infection to one of five residents reviewed for infection control. (Residents 10).

Findings include:

Observation of Resident 10's door to her room revealed a sign indicating that she was on enhanced barrier precautions. (EBPs, precautions used to prevent the spread of multi-drug resistant organisms). The sign indicated to use gloves and to wear a gown with device care, and listed one example of device care as a tracheostomy ( An opening in the front of the neck with a tube inserted directly into the airway that allows a person to breath).

Observation of Resident 10's tracheostomy care on March 14, 2024, at 8:20 AM with Employee 2, LPN (Licensed Practical Nurse), revealed that she performed the care without putting a gown on.

Interview with the Director of Nursing on March 14, 2024, at 2:51 PM revealed that Employee 2 should have worn a gown to perform Resident 10's tracheostomy care.

The facility failed to prevent the potential spread of a multi-drug resistant infection to Resident 10.

483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control
Previously cited 03/03/2023

28 Pa. Code 201.18 (d) Management

28 Pa. Code 211.10(d) Resident care policies

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





 Plan of Correction - To be completed: 05/07/2024

1.Resident #10 had no ill effect related this this deficient practice. Employee #2 has been educated on Enhanced Barrier Precautions related to gowning appropriately.
2.All residents on Enhanced Barrier Precautions will receive care with staff wearing the appropriate PPE.
3.The Staff Development/Designee will educate nursing and therapy staff an on F-Tag 880, "Infection Prevention & Control," to ensure the prevention of the potential spread of infection.
4.An audit will be completed by the Infection Preventionist/Designee 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week times a month to ensure proper PPE is being utilized for Enhanced Barrier Precautions. All findings will be reported to the Quality Assurance Committee Meeting.

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 clinical record review, review of select policies and procedures, and resident and staff interview, it was determined that the facility failed to ensure accurate acquiring and dispensing of medications for one of 22 residents reviewed (Resident 103).

Findings include:

The policy entitled "Remedi, Pharmacy Contact Info," last reviewed on December 4, 2023, indicates that for any new admissions, facility staff "must" call the pharmacy for any new admissions orders. The pharmacy will not automatically send medications from a facsimile.

The policy entitled "Medications brought to the facility by the resident" last reviewed on December 4, 2023, indicates that if a medication is not available and have been determined to be essential to the resident's life, the Director of Nursing and nursing staff along with the support of the attending physician to ensure that the medication has been ordered by the resident's physician.

Review of Resident 103's medication admission orders revealed that she was transferred from the hospital with an order for nursing staff to administer Norco (a combination drug containing acetaminophen and a narcotic pain reliever) 5 mg/325mg (milligrams) one tablet every six hours for moderate to severe pain. A nursing note dated January 30, 2024, at 3:22 PM, indicated that Resident 103 was admitted and oriented to the facility.

Interview on March 12, 2024, at 11:53 AM, with Resident 103 revealed that "none of her pills were here" when she was admitted. Resident 103 also indicated that she had to wait for one of her pain pills because the facility didn't have it on hand, and that she took one of her own pills that she brought to the facility.

A nursing note dated January 30, 2024, at 10:22 PM, indicated that Resident 103's medications were not available to administer and that she was having severe pain to her left foot. The note indicated that "she was medicated with her own pain medication." There was no documented evidence to indicate that Resident 103's physician was made aware that she brought her own medication, nor if nursing staff ensured it was a medication ordered by her physician.

Review of Resident 103's Medication Administration Record (MAR, a form used to document the administration of medications) dated January 2024, revealed that her physician ordered Allegra (for allergies), Combigan (treats eye diseases), and Mirapex (treats restless leg syndrome) were not administered for the 8:00 PM dose. There was no documented evidence in Resident 103's clinical record to indicate if nursing staff called the pharmacy as required or why the medications were not administered.

Interview with the Administrator and Director of Nursing on March 14, 2024, at 2:00 PM, confirmed the above findings for Resident 103, and could not provide further documented evidence to indicate why her medications were not administered as ordered.

28 Pa. Code 211.9 (a)(1)(d)(e)(4)(k) Pharmacy services

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





 Plan of Correction - To be completed: 05/07/2024

1.Resident #103 has discharged from our facility. Employee #1 received 1:1 education from the DON regarding the appropriate process for receiving medications after hours.
2.Licensed staff will be educated on F-Tag 755, "Pharmacy Services Procedure / Pharmacist," by the Staff Development/Designee on acquisition of medications after hours from the pharmacy post normal business hours.
3.Licensed staff will be educated on F-Tag 755, "Pharmacy Services Procedure / Pharmacist," by the Staff Development/Designee on acquisition of medications after hours from the pharmacy post normal business hours.
4.An audit will be completed by the DON/Designee 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week times a month to ensure all nursing, including new staff are aware of the after-hour process to obtain medications after pharmacy hours. All findings will be reported to the Quality Assurance Committee Meeting.

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 clinical record review, resident and staff interview, it was determined that the facility failed to ensure the highest practicable pain management for one of six residents reviewed (Resident 103).

Findings include:

Clinical record review for Resident 103 revealed that the facility admitted her on January 30, 2024. An admission note dated January 30, 2024, at 3:22 PM, indicated that nursing staff oriented her to the facility and the key locations. There was no documented evidence in the admission note to indicate Resident 103 was experiencing any pain.

Review of Resident 103's medication admission orders revealed that she was transferred from the hospital with an order for nursing staff to administer Norco (a combination drug containing acetaminophen and a narcotic pain reliever) 5 mg/325mg (milligrams) one tablet every six hours for moderate to severe pain.

Interview on March 12, 2024, at 11:53 AM, with Resident 103 revealed that she had to wait for "59 minutes" for a pain pill upon her admission and was in "excruciating" pain. There was no documented evidence in Resident 103 clinical record to indicate Resident 103 verbalized her pain level to nursing staff upon her admission to the facility.

A nursing note dated January 30, 2024, at 10:22 PM, indicated that Resident 103's medications were not available to administer and that she was having severe pain to her left foot. The note indicated that "she was medicated with her own pain medication." The note did not indicate Resident 103's level of pain, nor did it indicate how long she was in pain. There was no documented evidence to indicate what medication was administered, by whom, or its effectiveness for Resident 103's pain level.

Review of the facility's list of medications available to use in their Cubex (a medication storage system for use when medications are not available by pharmacy) revealed that Norco 5mg/325mg was available for use. There was no documented evidence to indicate that nursing staff used the available Norco in the facility's Cubex system.

Interview with Employee 1, registered nurse, on March 14, 2024, at 3:18 PM, revealed that she was the supervisor during the shift of Resident 103's admission. Employee 1 indicated that she "misread" the Cubex list of available medications and didn't realize that Resident 103's prescribe pain medication of Norco was available to administer.

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





 Plan of Correction - To be completed: 05/07/2024

1.Resident #103 has discharged from the facility. Employee #1 received 1:1 education from the DON regarding the appropriate process for receiving medications after hours and re-education regarding the available medications in the Cubex.
2.All resident pain medications will be administered per the physicians' orders with supporting documentation regarding effectiveness.
3.Licensed staff will be educated on F-Tag 697, "Pain Management," by the Staff Development/Designee on acquisition of medications after hours from the pharmacy post normal business hours. A re-education will be completed on the availability of medications in the Cubex.
4.An audit will be completed by the DON/Designee3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week times a month to ensure pain management to include documentation of administration and effectiveness of medication of new admissions. All findings will be reported to the Quality Assurance Committee Meeting.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(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 observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of two residents reviewed (Resident 8).

Findings include:

According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer) equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag.

Clinical record review for Resident 8 revealed a current physician order for staff to change their oxygen tubing and bag for their CPAP (continuous positive airway pressure, a device to help treat sleep apnea) tubing weekly on Friday during night shift.

Observation of Resident 8's Oxygen concentrator on March 12, 2024, at 9:56 AM and March 13, 2024, at 1:51 PM, revealed that their oxygen tubing was dated March 1, 2024 (12 days prior) and her CPAP mask was lying on top of the bedside stand unbagged. Concurrent interview with Employee 10, licensed practical nurse, during the March 13, 2024, at 1:51 PM observation it was identified that an additional oxygen tubing with the date March 8, 2024, and a clean bag was located inside another bag hanging on Resident 8's bedside stand. Employee 10 confirmed that the March 1, 2024, dated oxygen tubing continued to be in use for Resident 8 at the time of the observation.

The surveyor reviewed the above information for Resident 8 during observation and interview with the Director of Nursing and the Nursing Home Administrator on March 14, 2023, at 2:17 PM.

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

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



 Plan of Correction - To be completed: 05/07/2024

1.Resident #8's CPAP was placed in a clean bag and the oxygen tubing was immediately replaced with the correct date and bag. There was no ill effect on resident #8.
2.All oxygen tubing will be replaced per the facility policy related to respiratory care. All CPAP masks will be kept in a clean bag when not in use.
3.Licensed staff will be educated on F-Tag 695, "Respiratory/Tracheostomy Care and Suctioning," by the Staff Development/Designee on ensuring appropriate respiratory care.
4.An audit will be completed by the DON/Designee 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week times a month to ensure appropriate equipment and storage regarding respiratory supplies. All findings will be reported to the Quality Assurance Committee Meeting.

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 clinical record review, and staff interview it was determined that the facility failed to thoroughly investigate a resident elopement for one of 22 residents sampled (Resident 44)

Findings include:

Clinical record review revealed the facility admitted Resident 44 on September 1, 2023. Review of Resident 44's care plan initiated on September 2, 2023, revealed that Resident 44 is a high risk for elopement.

Nursing documentation dated December 11, 2023, at 10:59 AM revealed Resident 44 followed a staff member off the locked dementia unit. Documentation revealed staff were alerted by the physical therapist that Resident 44 was on another hall. The physical therapist attempted to get Resident 44 back into the dementia unit when Resident 44 grabbed the handrail in the hallway and would not let go. Documentation revealed that it took three staff members to get Resident 44 back to the dementia unit. The documentation further revealed that Resident 44 was having delusions and was noted to be sitting by the locked door to the unit.

Interview with the Nursing Home Administrator, Director of Nursing, and Employee 9 (assistant director of nursing) on March 15, 2024, at 8:27 AM, revealed that the facility did not have an investigation into Resident 44's elopement off the locked dementia unit. Further interviews revealed they do not know how Resident 44 got out of the locked dementia unit. The Nursing Home Administrator confirmed the facility could not provide any further documentation that facility staff was interviewed, and educated, or that maintenance checked that the door lock was functioning properly.

The facility failed to thoroughly investigate Resident 44's elopement.

483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices
Previously cited 03/03/2023.

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

28 Pa. Code 211.10(d) Resident care policies











 Plan of Correction - To be completed: 05/07/2024

1.Resident #44 remains safe on the locked dementia unit.
2.Any noted exit from a resident from a secured unit will be investigated as a potential elopement.
3.Staff will be educated on F-Tag 689, "Free of Accident / Supervision," to ensure that any noted exits from the secure unit need to be investigated.
4.An audit will be completed by the DON/Designee 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week times a month to ensure any noted exits from a secure unit will be investigated. All findings will be reported to the Quality Assurance Committee Meeting.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

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

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion (ROM, movement of the body to maintain a resident's ability) for three of 10 residents reviewed (Residents 69, 66, and 20).

Findings include:

Interview with Resident 69 on March 12, 2024, at 10:24 AM revealed that he wants to go home. He stated that the staff tell him he needs to be able to walk to be discharged home. Resident 69 indicated that staff do not help him improve his walking.

Clinical record review revealed that Resident 69 was discharged from physical therapy on January 5, 2024. Review of the physical therapy discharge summary revealed Resident 69's prognosis was good with consistent staff follow-through. Physical therapy's discharge recommendations included a restorative nursing program to facilitate Resident 69 maintaining his current level of performance and to prevent a decline in his ambulation and transfers.

Review of Resident 69's clinical record revealed he was not currently on a restorative nursing program. Review of Resident 69's Documentation Survey Report dated February 2024, documented an intervention for staff to ambulate with Resident 69 to Sycamore Nursing Station with his walker and limited assistance of one staff following with his wheelchair. There was no documentation of the restorative nursing program after February 2, 2024.

Interview with Employee 8 (physical therapy assistant, director of therapy) on March 15, 2024, at 10:58 AM confirmed the above findings. Employee 8 could provide no further documentation as to why Resident 69's restorative nursing program was discontinued.

Clinical record review for Resident 20 revealed a current care plan for staff to provide ROM (range of motion) to her BLLE (bilateral lower extremities) and BLUE (bilateral upper extremities) twice daily (BID).

Review of task documentation for Resident 20 for January and February 2024, revealed that staff did not document completion of the restorative task on the following dates:

January 13 and 26, 2024, day shift
January 24, 2024, evening shift
February 8, 15, and 20, 2024, day shift
February 10, 13, and 18, 2024, evening shift

Clinical record review for Resident 66 revealed a current care plan for staff to provide a restorative nursing program for her activities daily of living (ADLs, daily resident care and services) with limited assistance for her upper body and extensive assistive for her lower body BID, restorative nursing to ambulate from the foot of her bed to the central bathroom with a front wheel walker with extensive assist of one staff member and the wheelchair to follow BID, AROM (active range of motions) to BLLE BID, and restorative nursing for transfers with extensive assistance of one staff member BID.

Review of task documentation for Resident 66 for January, February, and March 2024, revealed that staff did not document completion of the restorative task on the following dates:

ADL's-

January 5 and 6, 2024
February 10, 2024, day shift
February 2, 10, and 13, 2024, evening shift
March 1 and 8, 2024, day shift

Ambulation-

January 5 and 6, 2024, day shift
February 10, 2024, day shift
February 2, 10, and 13, 2024, evening shift
March 1 and 8, 2024, day shift

AROM-

January 5 and 6, 2024, day shift
February 10, 2024, day shift
February 2, 10, and 13, 2024, evening shift
March 1 and 8, 2024, day shift

Transfers-

January 5 and 6, 2024, day shift
February 10, 2024, day shift
February 2, 10, and 13, 2024, evening shift
March 1 and 8, 2024, day shift

The surveyor reviewed the above information on March 14, 2024, at 2:30 PM with the Nursing Home Administrator and Director of Nursing.

CFR 483.25(c)(2) Mobility
Previously cited 3/3/23

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



 Plan of Correction - To be completed: 05/07/2024

1.Resident #69, #66, #20 have been evaluated by therapy with no ill effects.
2.All residents will continue to be evaluated for post therapy exercises following therapy discharge if deemed necessary. All PTE will be reviewed after 4 weeks to ensure the continued need to post-therapy exercises remains appropriate versus receiving this through ADL care.
3.Nursing and therapy staff will be educated on F-Tag 688, "Increase/Prevent Decrease in ROM," by the Staff Development/designated to ensure accurate documentation.
4.An audit will be completed by the PT Director/Designee 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week times a month to ensure any PTE program has accurate documentation. All findings will be reported to the Quality Assurance Committee Meeting.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on review of select facility policies, clinical record review, and staff and resident interview, it was determined that the facility failed to invite and ensure resident and responsible party attendance and to hold care plan conferences for three of 22 residents reviewed (Resident 8, 62, and 66).

Findings include:

Clinical record review for Resident 8 revealed that the facility documented a care plan note on February 15, 2023, to review and revise her plan of care. There was no documentation after February 15, 2023, that the facility completed a care plan meeting or invited Resident 8 and/or her responsible party to care plan meetings.

Clinical record review for Resident 66 revealed that the facility completed a quarterly MDS MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) on January 16, 2024, and indicated that she was capable. The facility indicated that she was her own responsible party. On October 17, 2023, the facility documented a care plan meeting to review and revise her plan of care with Resident 66 and her sister attending. There was no documentation after October 17, 2023, that the facility completed a care plan meeting or invited Resident 8 and/or her responsible party to care plan meetings.

During an interview with Resident 62, and his wife, on March 12, 2024, at 10:50 AM, the wife indicated that they were to attend a meeting at 11:00 the same day. She presented an invitation and it was noted that the meeting was a care plan meeting. She indicated that the facility holds care plan meetings once a year. There was no clinical documentation prior to the scheduled meeting of March 12, 2024, at 11:00 AM to indicate that the facility completed a care plan meeting or invited Resident 62 and/or her responsible party to care plan meetings within the past year.

Interview with Employee 7, Social Services on March 15, 2024, at 12:45 PM, confirmed that she did not invite or hold any other care plan meetings over the past year with Resident 62.

Interview with the Nursing Home Administrator on March 15, 2024, at 8:43 AM and 11:25 AM confirmed the above findings.

28 Pa. Code 211.10(c) Resident care policies

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



 Plan of Correction - To be completed: 05/07/2024

1.Resident #8 and #66 and RP's will be offered the opportunity to join in a care plan meeting. Resident #66 has had a care plan meeting on 3/12/2024 and documented in the resident's chart.
2.All residents and/or RP's will be offered the opportunity to attend care plan meetings.
3.An education will be completed by the NHA/designee to the Social Services Department and IDT Team regarding F-Tag 657, "Care Plan Timing & Revision," to ensure all residents and/or RP's are invited accordingly.
4.An audit will be completed by the NHA/Designee 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week times a month to ensure invites and attendance by resident and/or representative. All findings will be reported to the Quality Assurance Committee Meeting.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

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

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

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

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

Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or the resident's responsible party in writing of a transfer to the hospital for seven of 10 residents reviewed (Residents 3, 34, 69, 44, 62, 45, and 10). The facility also failed to notify the Office of the State Long-Term Care Ombudsman of a transfer to the hospital for 3 of 10 residents reviewed (Residents 34, 44, and 69).

Findings include:

A review of Resident 3's clinical record revealed that the facility transferred her to the hospital from November 11 to 13, 2023. There was no documented evidence to indicate that the facility provided a written notice to Resident 3's responsible party regarding her transfer to the hospital that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred to, contact and address (mailing and email) information for the Office of the State Long-Term Care Ombudsman, and information (mailing and email address and telephone number) for the agency responsible for the protection and advocacy of individuals with developmental disabilities, and a statement of resident's appeal rights, including name, address (mailing and email) and telephone number of entity which receives requests.

A clinical record review for Resident 34 revealed he was transferred to the hospital from December 16 to 21, 2023, for a change in condition and was admitted. There was no evidence to indicate that Resident 34's responsible party was provided written notification to include the above-required contents. Further review of facility documentation revealed there was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 34's transfer to the hospital.

A clinical record review for Resident 44 revealed he was transferred to the hospital from December 18 to 21, 2023, for a change in condition and was admitted. There was no evidence to indicate that Resident 44's responsible party was provided written notification to include the above-required contents. Further review of facility documentation revealed there was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 44's transfer to the hospital.

A clinical record review for Resident 69 revealed he was transferred to the hospital from December 28, 2023, to January 2, 2024. There was no evidence to indicate that Resident 69's responsible party was provided written notification to include the above-required contents. Further review of facility documentation revealed there was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 69's transfer to the hospital.

The surveyor reviewed the above information for Residents 3, 34, 44, and 69 during an interview with the Nursing Home Administrator Director of Nursing on March 14, 2024, at 2:20 PM.

Clinical record review for Resident 10 revealed that she was transferred to the hospital on December 13, 2023, for respiratory distress. There was no evidence to indicate that Resident 10's responsible party was provided written notification to include the above-required contents.

Clinical record review for Resident 45 revealed that she was transferred to the hospital on December 27, 2023, related to pneumonia. There was no evidence to indicate that Resident 45's responsible party was provided written notification to include the above-required contents.

Clinical record review for Resident 62 revealed that he was transferred to the hospital on October 31, 2023, related to concerns with swelling around his dialysis (a process that helps your body remove extra fluid and waste when your kidneys are not able to) fistula (a surgical connection that is made between and artery and a vein for dialysis access).
There was no evidence to indicate that Resident 62's responsible party was provided written notification to include the above-required contents.

The Nursing Home administrator confirmed the above noted findings regarding transfer notices during a meeting on March 14, 2024, at 2:40 PM.

The surveyor reviewed the above noted findings for Residents 10, 45, and 62, during a meeting with the Nursing Home Administrator and Director of Nursing on March 14, 2024, at 2:45 PM.

28 Pa. Code 201.14(a) Responsibility of license

28 Pa. Code 201.29(a) Resident rights












 Plan of Correction - To be completed: 05/07/2024

1.Residents #3, #34, #69, #44, #62, #45, and #10 have had no ill effect; all have returned to the facility. The facility cannot retroactively issue a transfer notice. There were no ill effects for the inaccurate reporting to the State Long-Term Care Ombudsman.
2.The Business Office Manager/designee will review all hospital transfers to ensure a written copy of the transfer notice is provided to all residents and/ representatives. The Social Services Director/designee will audit, correct, and resubmit the prior (3) months of notifications to the State Long-Term Care Ombudsman
3.The NHA/designee will re-educate the Social Services Department, Business Office Manager, and all licensed staff on F-Tag 623, "Notice of Transfer/Discharge" to ensure a written notification of the transfer has been provided. The NHA/designee will re-educate the Social Services Department on the requirements that are needed to be sent monthly the State Long-Term Care Ombudsman.
4.An audit will be completed by the BOM/designee of all transfers/discharges 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week times a month to ensure a written notification is provided and reported to the State Long-Term Care Ombudsman. All findings will be reported to the Quality Assurance Committee Meeting.

§ 211.9(j) LICENSURE Pharmacy services.:State only Deficiency.
(j) [Reserved].
Observations:

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure the disposition of medications for one of three closed records reviewed (Resident 104).

Findings include:

Review of the facility policy labeled "Discharge Medications," revealed medications shall be sent with the resident upon discharge. The nurse shall complete the disposition record including the quantity or amount of each medication. The nursing staff shall forward completed drug disposition records to medical records. The complete list of the resident's medications shall also be provided to the resident upon discharge.

Review of Resident 104's clinical record revealed that the resident was admitted to the facility on February 5, 2024, and was discharged home on February 23, 2024.

Review of Resident 104's nursing documentation dated February 23, 2024, at 11:31 AM, revealed medication supply was sent with the resident. There was no documentation in the record to reflect the disposition of the medications.

Interview with the Director of Nursing and Nursing Home Administrator on March 15, 2024, at 8:33 AM confirmed these findings.









 Plan of Correction - To be completed: 05/07/2024

1.The facility cannot retroactively correct medication disposition of resident #104. There was no ill effect to the resident.
2.All residents upon discharge will have a completed medication disposition record.
3.The Staff Development/Designee will educate licensed nurses on State Tag, P5270, "Pharmacy Services," to ensure accurate medication dispositions upon discharge.
4.An audit will be completed by Medical Records/Designee 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week times a month to ensure documented medication disposition. All findings will be reported to the Quality Assurance Committee Meeting.

§ 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 a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 20 residents during the night shift for four of the 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following nurse aides (NA) scheduled for the resident census:

Night shift:

February 18, 2024, 5 nurse aides for a census of 108, requires 5.40 NAs
February 20, 2024, 5 nurse aides for a census of 106, requires 5.30 NAs
February 21, 2024, 5 nurse aides for a census of 107, requires 5.35 NAs
March 11/ 2024, 5 nurse aides for a census of 106, requires 5.30 NAs

Interview with the Nursing Home Administrator on March 14, 2024, at 2:30 PM confirmed the above findings.




 Plan of Correction - To be completed: 05/07/2024

1.Facility cannot retroactively correct.
2.Facility will conduct audit of 2 week look back period of nursing staffing ratios.
3.The facility shall make reasonable attempts to acquire new staff, including offering competitive pay rates, shift differential, partnering with local community schools, and offering employee benefits.
4.The NHA/Designee will educate the scheduler/designee on the requirements or meeting the minimum staffing ratio as per regulation. The Scheduling Manager/Designee will randomly audit weekly x3 weeks to ensure ratio compliance. Any concerns/issued will be reviewed monthly to the Quality Assurance Committee.

§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure the total of nursing care hours provided in each 24-hour period was a minimum of 2.87 hours per patient day (PPD), effective July 1, 2023, on one of 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following nursing care hours for each 24-hour period of concern:

February 18, 2024, PPD was 2.82.

Interview with the Nursing Home Administrator on March 14, 2024, at 2:38 PM, confirmed that the facility failed to meet the required nursing staffing PPD as listed above.




 Plan of Correction - To be completed: 05/07/2024

1.Facility cannot retroactively correct.
2.Facility will conduct audit of 2 week look back period of nursing staffing hppd's.
3.The facility shall make reasonable attempts to acquire new staff, including offering competitive pay rates, shift differential, partnering with local community schools, and offering employee benefits.
4.The NHA/Designee will educate the scheduler/designee on the requirements or meeting the minimum HPPD as per regulation. The Scheduling Manager/Designee will randomly audit weekly x3 weeks to ensure HPPD compliance. Any concerns/issued will be reviewed monthly to the Quality Assurance Committee.


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