Pennsylvania Department of Health
ABBEYVILLE SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ABBEYVILLE SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 215 surveys for this facility. Please select a date to view the survey results.

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ABBEYVILLE SKILLED NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance survey and an Abbreviated Survey for one complaint completed on March 8, 2024, at Abbeyville Skilled Nursing and Rehabilitation Center, it was determined the facility was not in compliance under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:

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.

§483.15(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 ensure that written notices of emergency transfers to the hospital were provided to the Office of the State Long Term Care Ombudsman for 6 of 24 residents reviewed (Resident 78, 111, 112, 119, 126 and 146).

Findings include:

Review of Resident 78's clinical record revealed Resident 78 was hospitalized on February 5, 2024 and was readmitted to the facility on February 9, 2024. No documentation was provided indicating the Office of the State Long Term Care Ombudsman was notified.

Review of Resident 111's clinical record revealed Resident 111 was hospitalized on December 27, 2023 and was readmitted to the facility on January 8, 2024. No documentation was provided indicating the Office of the State Long Term Care Ombudsman was notified.

Review of Resident 112's progress note of October 28, 2023, revealed that the resident wanted to go to the hospital. The on-call physician was notified and ordered that the resident be sent to the hospital.

Review of Resident 119's progress note of January 8, 2024, revealed that the CRNP ordered the resident to be sent to the hospital secondary to wound/drainage and elevated temperature. Resident was admitted with early stage osteomyelitis (bone infection).

Review of Resident 126's clinical record revealed a progress note indicating that the resident was sent to the hospital on January 20, 2024, for seizure like activity. No further documentation stating that the Office of the State Long Term Care Ombudsmans was notified.

Review of Resident 146's progress note of January 13, 2024, revealed resident was unresponsive and was transported to the hospital.

Interview with Nursing Home Administrator on March 3, 2024, at 1:00 p.m. confirmed that the facility did not send notifications to the Office of the State Long Term Care Ombudsman's office when residents were transferred to the hospital.

28 Pa. Code 201.14(a) Responsibility of Licensee

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

Plan of Correction - To be completed: 04/26/2024

1.Notice was sent to the Office of the State Long Term Care Ombudsman Office for Residents 78, 111, 112, 119, 126, and 146.
2.A Comprehensive review to be completed of all discharges in the last two weeks to ensure that documentation was sent to the Office of the State Long Term Care Ombudsman's Office as required.
3.The facility will take the further steps to ensure that the problem does not recur by in-servicing the IDT Team on FTAG 623 with a focus on notification of the State Long Term Care Ombudsman upon discharge.
4.Compliance will be monitored by the NHA/Designee through 4 audits weekly x 2 weeks to ensure residents who have been discharged have the State Ombudsman Notifications completed, with audit results being reported to the QAA committee to determine the need for further follow up/monitoring.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.80 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 observations, and staff interview, it was determined that the facility failed to follow acceptable infection control practices related to proper ice handling on 3 of 4 units (Buchanan, Stevens, and Roosevelt).

Findings include:

Observation on March 5, 2024, at 11:25 a.m. on Buchanan unit revealed that the ice scoop was in a covered plastic container. The container had a washcloth placed in the bottom with the ice scoop resting directly on the washcloth which was wet.

Observations on March 8, 2024 between 10:05 a.m. and 10:07 a.m on the Stevens unit and Roosevelt unit, respectively, revealed that the ice scoops were in covered plastic containers. The containers had a washcloth in the bottom with the ice scoop resting directly on the washcloth in approximately one inch of water.

Interview with the DON and Employee E4, Infection Preventionist, on March 8, 2024, at 1:30 p.m., confirmed that the washcloth should not be in the container with the ice scoop.

28 Pa Code 201.18(b)(3) Management

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

Plan of Correction - To be completed: 04/26/2024

1. No residents were harmed from failure to follow acceptable practices related to proper ice handling on 3 of 4 units (i.e., washcloth in ice scoop containers).
2. House sweep of Ice chest completed to ensure no washcloths were present inside of ice bins.
3. The facility will take further steps to ensure the problem does not reoccur by in-servicing all staff on ice chest hygiene as well as F Tag 880.
4. .Compliance will be monitored by the Director of Nursing/designee through 5 ice chest audits weekly x 4 weeks to ensure no washcloths are inside of ice scoop containers, with audit results being reported to the QAA committee to determine the need for further follow up / monitoring.

483.20(g) REQUIREMENT Accuracy of Assessments:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:

Based on a review of clinical records and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for one of 32 residents reviewed (Resident 79).

Findings include:

Review of Resident 79's clinical record revealed a quarterly Minimmal Data Set (MDS- a tool used to identify plan of care) dated December 1, 2023, identified a new pressure ulcer.

Further review of Resident 79's clinical record revealed no further documentation of the pressure ulcer.

An interview with the licensed employee E3, on March 8, 2024, at 9:49 a.m., revealed that the resident did not have a pressure ulcer during the review for the MDS, and it was incorrectly coded.

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.12(c) Nursing services

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

Plan of Correction - To be completed: 04/26/2024

1.Resident 79's MDS in regards to Pressure Ulcers has been corrected and submitted
2.A Comprehensive review of current residents with pressure ulcers to be completed to ensure that they are coded correctly on the MDS.
3.The facility will take the further steps to ensure the problem does not recur by in-servicing the CRC on FTAG 641 with a focus on Pressure Ulcers
4.Compliance will be monitored by the Director of Nursing/Designee using the MDS Accuracy Audit through 4 audits weekly x 2 weeks to validate that the MDS is coded correctly, with audit results being reported to the QAA committee to determine the need for further follow up/monitoring.

483.25 REQUIREMENT Quality of Care:

§ 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 observations, clinical records review, and staff interviews, it was determined that the facility failed to ensure residents with an order for fluids restrictions were monitored for their fluid intake for three of the 32 residents reviewed (Residents 76, 108, and 124).

Findings include:

Review of Resident 76's physician orders revealed an order for "Fluid restriction 1800 ml daily [milliliters]"

Further review of Resident 76's clinical records failed to reveal documented evidence that Resident 76's fluid restrictions were monitored according to physician's orders.

Clinical records review revealed Resident 108 was readmitted from the hospital on January 16, 2024, with a diagnosis of Hyponatremia (low sodium level).

Review of the physician order dated January 18, 2024, revealed an order for Fluid restriction 1800/24 hrs.

Review of Resident 108's clinical records failed to reveal Resident 108's fluid intake was monitored from January 18, 2024, until February 1, 2024.

Review of Resident 124's physician orders revealed an order for "Fluid restriction 2000 ml [milliliters] daily".

Further review of Resident 124's clinical records failed to reveal any documented evidence that Resident 124's fluid restrictions were monitored according to physician's orders.

Review of the progress notes dated January 17, 2024, revealed blood works were reviewed by NP (nurse practitioner), a new order for fluid restriction of 1800 ml/24 hr., and repeat blood work was ordered.

Interview with the NHA conducted on March 8, 2024, at 11:30 a.m., confirmed that there was no documentation indicating Residents fluid intake was monitored.

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.12(c) Nursing services

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

Plan of Correction - To be completed: 04/26/2024

Residents 76, 108, 124 order for fluid restrictions was updated to include supplementary documentation to include the amount consumed each shift. All residents with fluid restriction orders were updated.
A Comprehensive Review of current residents with order for fluid restrictions will be completed by the Director of Nursing/Designee to ensure appropriate consumption of fluid documentation is in place.
The facility will take further steps to ensure the problem does not reoccur by in-servicing Licensed Nurses on fluid restriction documentation as well as FTag 684.
Compliance will be monitored by the Director of Nursing/Designee through 5 random audits weekly x 4 weeks to ensure fluid consumption documentation is being completed on residents with fluid restriction orders , with audits being reported to the QAA committee to determine the need for further follow up/ monitoring.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 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 records review and staff interview it was determined that the facility failed to provide respiratory service and treatment for one of the 32 residents reviewed (Resident 42).

Findings include:

Review of Resident 42's diagnosis list includes Obstructive sleep apnea (Which means breathing stops for short periods during sleep due to a blocked/partially blocked airway).

Observation conducted on March 6, 2024, revealed a CPAP (Continuous positive airway pressure - A machine that uses mild air pressure to keep breathing airways open while you sleep) machine on Resident 42's bedside table.

Review of Resident 42's physician's order sheet dated November 21, 2022, revealed an order for CPAP @ pressure 15cm H2O every night shift for Sleep Apnea.

Review of Resident 42's clinical records revealed Resident 42 was hospitalized on December 31, 2023, due to Acute Encephalopathy (An acute/subacute functional alteration of mental status due to systemic factors) and returned to the facility on January 4, 2024.

Review of Resident 42's hospital discharge summary dated January 4, 2024, revealed an order for CPAP pressure of 15 cm H2O.

Review of Resident 42's admission physician order failed to reveal an order for the CPAP.

An interview with the Director of Nursing on March 8, 2024, at 10:30 a.m., was conducted. The DON confirmed Resident 42 had an order for the CPAP before the hospitalization but nursing staff failed to place the CPAP order when the resident was readmitted to the facility on January 4, 2024. The physician was not notified of the missed CPAP order from readmission to the facility until questioned by the surveyor.

The above information was conveyed to the Nursing Home Director on March 8, 2024, at 11:19 a.m.

The facility failed to ensure CPAP order for Resident 42 was followed.

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.12(c) Nursing services

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

Plan of Correction - To be completed: 04/26/2024

Resident 42 order for CPAP was discontinued due to non use. Resident 42 had no ill effects from CPAP order being omitted.
A Comprehensive review of current residents who have returned from the hospital in the last 30 days to be completed by the Director of Nursing/Designee to ensure CPAP orders were transcribed into the EMAR.
The facility will take further steps to ensure the problem does not reoccur by Inservicing Licensed Nurses on the Medication Reconciliation Process as well as FTag 695.
Compliance will be monitored by the Director of Nursing/Designee through 5 new admission audits weekly x 4 weeks to ensure CPAP orders are transcribed into the EMAR, with audit results being reported to the QAA committee to determine the need for further follow up / monitoring.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§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, pharmacy record review, and staff interview it was determined the facility failed to ensure medications were available for residents for two of the 32 residents reviewed (Resident 42, and 85).

Findings include:

Review of Resident 42's physician order dated September 3, 2023, revealed an order for Linezolid Oral Tablet (antibiotic) 600mg one tablet by mouth every 12 hours for UTI (Urinary Tract Infection).

Review of Resident 42's September 2023 Medication Administration Record (MAR) revealed Linezolid ordered on September 3, 2023, was not administered to the resident until the evening of September 5, 2023.

Review of the pharmacy delivery report revealed Resident 42's Linezolid medication ordered on September 3, 2023, was not delivered to the facility until September 5, 2023.

Review of Resident 85's nursing progress notes dated January 19, 2024, revealed resident was observed with redness and swelling to the left eye, the NP (nurse practitioner) was notified and ordered Erythromycin ointment (eye antibiotic) to the left eye and Prednisone tablet.

Review of Resident 85's physician order dated January 19, 2024, revealed an order for Erythromycin Ophthalmic Ointment 5 mg/gm. Instill 5 mg in the left eye two times daily for red rash around the left eye for five days.

Review of Resident 85's January 2024 MAR revealed Erythromycin eye ointment ordered on January 19, 2024, was not administered to the resident until January 23, 2024.

Review of the nursing progress notes dated January 20, 2024, at 8:51 p.m., revealed waiting for delivery from the pharmacy (for Erythromycin eye ointment).

Review of the nursing progress notes dated January 22, 2024, at 8:56 a.m., revealed awaiting (Erythromycin eye ointment medication) arrival from a pharmacy, call was placed to the pharmacy.

Review of the pharmacy delivery record revealed Erythromycin eye ointment ordered on January 19, 2024, was delivered to the facility on January 22, 2024.

Interview with the Director of Nursing conducted on March 8, 2024, at 10:30 a.m., confirmed that the above medications were not timely administered to the residents due to the unavailability of the medications from the pharmacy.

The facility failed to ensure medications ordered for Residents 42 and 85 were available.

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.12(c) Nursing services

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

Plan of Correction - To be completed: 04/26/2024

No resident was harmed from failure to administer medications timely.
A Comprehensive review of new orders in the last 30 days to be completed to ensure all medications were available and given timely.
The facility will take further steps to ensure the problem does not reoccur by in-servicing Licensed nurses on notification of MD if medications are not available, Omnicell Emergency Medication Supply, as well as FTag 755.
Compliance will be monitored by the Director of Nursing/Designee through 5 random audits x 4 weeks to ensure medications are available and given timely, with audit results being reported to the QAA committee to determine the need for additional follow up/ monitoring.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

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

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

Observations:

Based on observations, a review of medication manufacturer's guidelines, and staff interviews, it was determined that the facility failed to ensure medications were properly stored and labeled for two of the three units observed (Stevens and Fulton).

Findings include:

Review of the facility's policy titled "Storage and Expiration Dating of Medications, Biologicals", dated January 2022, revealed that once a medication or biological package is opened, the facility should follow manufacturer/supplier guidelines concerning the expiration date for opened medication. Facility staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened. The same policy also revealed that the facility should ensure that the medications are stored in the containers in which they were originally received.

Review of the manufacturer's storage guidelines for Insulin Lispro (Humalog-fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening.

Review of manufacturers' storage guidelines for Lantus Insulin Pen (long-acting insulin) revealed that the medication may be stored at room temperature and must be discarded within 28 days after opening.

Review of the manufacturer's guidelines for Latanoprost (used to treat high pressure in the eye), revealed that once a bottle is opened for use it may be stored at room temperature for six weeks.

Review of the Olopatadine manufacturer's storage guidelines revealed to discard each bottle four weeks after it has been opened.

Review of the Tobramycin Eye Solution (A medication to treat eye infection) manufacturer's guidelines revealed not to use the medication stored at room temperature for more than 28 days.

Review of same guidelines indicated Loteprednol Etabonate Ophthalmic Solution (used to treat eye inflammation). Discard any unused contents 28 days after first opening the bottle.

Observation on Steven Nursing unit, front medication cart was conducted on March 6, 2024, at 8:57 a.m., in the presence of licensed nurse Employee E5. The following were observed: One Insulin Lispro pen, opened and undated; One Lantus vial opened and undated; One bottle of Latanoprost eye drop, opened and undated; One bottle of Olopatadine eye drop, opened and undated; One bottle of Tobramycin eye drops, opened and undated; and One bottle of Loteprednol Etabonate eye drops, opened and undated.

Interview with Employee E5 on March 6, 2024, at 9:00 a.m., was conducted. Employee E5 was unable to determine when the medications listed above were opened. Employee E5 confirmed that the medications listed should have been dated once opened.

Observation of the Fulton front medication cart conducted on March 6, 2024, at 9:05 a.m., revealed 12 Omeprazole (medication that treats certain conditions where there is too much acid in the stomach) lying on the top-drawer cart without its original container.

Interview with Employee E6 was conducted on March 6, 2024, at 9:07 a.m. Employee E6 was unable to say who the medication belonged to. Employee E6 confirmed that medications should be in their original container.

Observation of the Fulton back medication cart conducted on March 6, 2024, at 9:15 a.m., revealed 18 scattered medications of different sizes, shapes, and colors.

The above information was conveyed to the Director of Nursing on March 8, 2024, at 1:30 p.m.

The facility failed to ensure medications on Stevens and Fulton Units were property stored and labeled.

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.12(c) Nursing services

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

Plan of Correction - To be completed: 04/26/2024

1. No residents were harmed from failure to ensure medications on Stevens and Fulton Units were property stored and labeled.
2. A Comprehensive review of medication carts on Stevens and Fulton Units to be conducted to ensure Insulin pens and eye drops are appropriately labeled and OTC medications are in original containers.
3. The facility will take further steps to ensure the problem does not reoccur by in-servicing licensed nurses on FTag 761 and the importance of maintaining proper packaging for OTC medications.
4. Compliance will be monitored by the Director of Nursing / Designee through 5 audits weekly x 4 weeks to ensure Insulin pens and eye drops are dated, and OTC medications are in original containers, with audit results being reported to the QAA committee to determine the need for further follow up / monitoring.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(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 upon review of staffing records and schedules, it was determined the facility failed to meet the State required minimum ratio for nurse aides for three out of three weeks reviewed.

Findings include:

Review of staffing records and schedules for the week of January 14, 2024, through January 20, 2024, revealed the facility was below the State minimum ratio for nurse aides on the following dates: January 15, 2024, 11-7 shift; January 16, 2024, 7-3 shift and January 19, 2024, 11-7 shift.

Review of staffing records and schedules for the week of February 18, 2024, through February 24, 2024, revealed the facility was below the State minimum ratio for nurse aides on the following dates: February 19, 2024, 11-7 shift; February 20, 2024, 11-7 shift; February 23, 2024, 3-11 shift and February 24, 2024, 3-11 and 11-7 shifts.

Review of staffing records and schedules for the week of March 1, 2024, through March 7, 2024, revealed the facility was below the State minimum ratio for nurse aides on the following dates: March 3, 2024 7-3 and 3-11 shifts; March 4, 2024, 7-3 and 3-11 shifts and March 6, 2024, 3-11 and 11-7 shifts.

The above information was conveyed to the Nursing Home Administrator on March 8, 2024, at 11:00 a.m.

Plan of Correction - To be completed: 04/26/2024

1. No residents or staff harmed by not meeting CNA ratio.
2. The DON/designee will review 10 random deployment sheets to ensure the facility is meeting CNA ratio requirements per PA State Regulations.
3. The facility will take the further steps to ensure the problem does not reoccur by in-servicing the DON, Unit Managers and HRD on the PA State Regulation 5510.
4. Compliance will be monitored by the Director of Nursing/designee through audits of 5 deployment sheets a week x4 weeks to ensure the facility is meeting the CNA ratio requirement, with audit results being reported to the QAA committee to determine the need for further additional follow up / monitoring.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:
Based upon review of staffing records and schedules, it was determined the facility failed to meet the State required minimum ratio for Licensed Practical Nurses for three out of three weeks reviewed.

Findings include:

Review of staffing records and schedules for the week of January 14, 2024, through January 20, 2024, revealed the facility was below the State minimum ratio for Licensed Practical Nurses on the following dates: January 14, 2024, 7-3 and 3-11 shifts; January 15, 2024, 11-7 shift; January 16, 2024, 7-3 shift; January 19, 2024, 11-7 shift and January 20, 2024, 7-3 shift.

Review of staffing records and schedules for the week of February 18, 2024, through February 24, 2024, revealed the facility was below the State minimum ratio for Licensed Practical Nurses on the following dates: February 19, 2024, 7-3 shift; February 20, 2024, 11-7 shift and February 24, 2024, 11-7 shift.

Review of staffing records and schedules for the week of March 1, 2024, through March 7, 2024, revealed the facility was below the State minimum ratio for Licensed Practical Nurses on the following dates: March 1, 2024, 11-7 shift; March 2, 2024, 11-7 shift; March 3, 2024, 7-3 shift; March 5, 2024, 7-3 and 11-7 shifts; March 6, 2024, 11-7 shifts and March 7, 2024, 11-7 shift.

The above information was conveyed to the Nursing Home Administrator on March 8, 2024, at 11:00 a.m.

Plan of Correction - To be completed: 04/26/2024

1. No residents or staff harmed by not meeting LPN ratio.
2. The DON/designee will review 10 random deployment sheets to ensure the facility is meeting LPN ratio requirements per PA State Regulations .
3.The facility will take the further steps to ensure the problem does not reoccur by in-servicing the DON, Unit Managers, HRD and Scheduler on the PA State Regulation 5530.
4. Compliance will be monitored by the Director of Nursing/designee through audits of 5 deployment sheets a week x4 weeks to ensure the facility is meeting the LPN Ratio Requirement, with audit results being reported to the QAA committee to determine the need for further additional follow up/ monitoring.

§ 211.12(i)(1) LICENSURE Nursing services.:

(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 upon review of staffing schedules, it was determined the facility did not meet the State minimum PPD hours on multiple date for three out of three weeks reviewed.

Findings include:

Review of staffing records and schedules for the week of January 14, 2024, through January 20, 2024, revealed the facility was below the State minimum PPD for the following dates:

January 14, 2024 - 2.71 PPD
January 15, 2024 - 2.83 PPD
January 16, 2024 - 2.60 PPD
January 19, 2024 - 2.86 PPD

Review of staffing records and schedules for the week of February 18, 2024, through February 24, 2024, revealed the facility was below the State minimum PPD for the following dates:

February 20, 2024 - 2.82 PPD
February 21, 2024 - 2.77 PPD
February 23, 2024 - 2.84 PPD
February 24, 2024 - 2.69 PPD

Review of staffing records and schedules for the week of March 1, 2024, through March 7, 2024, revealed the facility was below the State minimum PPD for the following dates:

March 1, 2024 - 2.83 PPD
March 2, 2024 - 2.81 PPD
March 3, 2024 - 2.59 PPD
March 4, 2024 - 2.67 PPD
March 5, 2024 - 2.66 PPD
March 6, 2024 - 2.70 PPD

The above information was conveyed to the Nursing Home Administrator on March 8, 2024, at 11:00 a.m.

Plan of Correction - To be completed: 04/26/2024

1. No residents or staff were harmed by not meeting the minimum HPPD.
2. The DON/designee will review 10 random deployment sheets to ensure the facility is meeting the minimum of 2.87 HPPD requirements.
3. The facility will take the further steps to ensure the problem does not reoccur by in-servicing the DON, Unit Managers,HRD, and scheduler on the PA State Regulation 5630.
4.Compliance will be monitored by the Director of Nursing/designee through audits of 5 deployment sheets a week x4 weeks to ensure the facility is meeting the minimum HPPD requirement of 2.87, with audit results being reported to the QAA committee to determine the need for further additional follow up / monitoring.

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