Pennsylvania Department of Health
RICHLAND HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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RICHLAND HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  120 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.
RICHLAND HEALTHCARE 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, and a complaint survey completed on January 11, 2024, it was determined that Richland Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

















 Plan of Correction:


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


Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to follow physician's orders for two of 29 residents reviewed (Residents 61, 66).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 61, dated August 10, 2023, revealed that the resident was alert and oriented and required extensive assistance with care.

Physician's orders for Resident 61, dated May 4, 2023, included an order for the resident to have a size 18F, 30 cc indwelling foley catheter (a thin, flexible catheter used to drain urine from the bladder).

Observations on January 10, 2024, at 10:08 a.m. revealed that Resident 61 had a size 18F, 10 cc indwelling foley catheter in place.

Interview with the Director of Nursing on January 11, 2024, at 11:29 a.m. confirmed that the foley catheter in place for Resident 61 was not what the physician ordered.

A significant change MDS assessment for Resident 66, dated December 23, 2023, revealed that the resident was cognitively intact, required extensive assistance for daily care needs, and had a diagnosis of Type 2 diabetes.

Physician's orders for Resident 66, dated September 7, 2023, indicated that the resident was to be given Humalog insulin (fast acting insulin) subcutaneously (under the skin) with meals, depending on the resident's blood sugar level. For a blood sugar greater than 500 milligrams per deciliter (mg/dL) the physician was to be notified.

The medication administration record (MAR) for Resident 66 for December 2023 indicated that her blood sugar level on December 8, 2023, at 12:30 p.m. was 530 mg/dL.

There was no documented evidence that the physician was notified of Resident 66's elevated blood sugar levels over 500 mg/dL as ordered.

Interview with the Assistant Director of Nursing on January 10, 2024, at 11:35 a.m. confirmed that there was no documented evidence that the physician was notified of the Resident 66's elevated blood sugar as ordered and there should have been.

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




 Plan of Correction - To be completed: 02/15/2024

Preparation, submission and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with all applicable state and regulatory requirements.

1. Medical director was notified of resident 61's Foley catheter discrepancy between order and inserted size. New order received for Foley catheter size and balloon size. Medical director was notified of resident 66's elevated blood glucose level. No new orders received at that time.
2. Residents with Foley catheter, orders were reviewed and Foley catheters were checked to ensure proper size was inserted. No other discrepancies were identified. Education provided to licensed staff to ensure they are following the physician order when placing or exchanging a Foley catheter. Education provided to licensed staff on the notification to the physician if blood sugar level is outside of parameters.
3. Assistant Director of Nursing or designee will audit Foley catheter order and size to ensure proper Foley is inserted, weekly times two weeks and monthly times two months. Assistant Director of Nursing or designee will audit accuchecks parameters and the notification of the doctor if elevated accucheck is outside of parameter weekly times two weeks and monthly times two months.
4. Results will be reviewed at the Quality Assurance and Performance Improvement 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 is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(b) 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 reviews and staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for one of 29 residents reviewed (Resident 55).

Findings include:

An admission Minimum Data Set (MDS) for Resident 55, dated October 7, 2023, revealed that the resident had diagnoses that included COPD (congestive obstructive pulmonary disease- a lung disease), was cognitively intact, required extensive assistance from staff for personal care needs, had a history of pressure ulcers on the sacrum and behind the ears, and a need for palliative care (focuses on providing relief from pain and other symptoms of a serious illness).

Review of wound consultation notes for Resident 55, dated November 21 and 28, 2023, and December 5, 2023, and January 11, 2024, revealed that pressure from the oxygen tubing was contributing to the resident having continued off and on skin breakdown behind the ears. Wound consultant recommendations included the continued use of foam protectors on the oxygen tubing behind the residents ears.

Physician's orders for Resident 55, dated December 27, 2023, included an order for the resident to receive oxygen from 4 to 8 liters per minute via nasal canula. The resident's pressure ulcer care plan, dated November 30, 2023, included a goal that the skin will remain free of breakdown within the limits of the disease.

Observations of Resident 55 on January 8 and 9, 2024, revealed no foam ear protectors behind his ears. An interview with the resident on January 11, 2024, indicated that he did not mind wearing ear protectors.

Interview with the Director of Nursing on January 11, 2024, at 1:29 p.m. confirmed that staff did not follow through as recommended by the wound consultant and they should have.

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




 Plan of Correction - To be completed: 02/15/2024

Preparation, submission and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with all applicable state and regulatory requirements.

1. Foam ear protectors were immediately placed on resident 55's oxygen tubing. Wound Nurse Practitioner and Medical Director were notified of resident's previous refusals to wear foam ear protectors. Order received to apply foam ear protectors as allowed by resident.
2. Residents being followed by wound nurse practitioner reviewed to ensure recommendations are being followed. Education provided to licensed staff to ensure that recommendations from Wound Nurse Practitioner are in place and being followed.
3. Director of Nursing or designee will audit Wound Nurse Practitioner recommendations to ensure orders are in the computer and licensed staff are carrying them out weekly times two weeks and monthly times two months.
4. Results will be reviewed at the Quality Assurance and Performance Improvement 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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to conduct an air mattress safety assessment for one of 29 residents reviewed (Resident 33) and failed to ensure that the residents' environment remained as free of accident hazards as possible by transporting a resident without leg rests for one of 29 residents reviewed (Resident 139).

Findings include:

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated May 8, 2023, revealed that he was cognitively impaired, required extensive assistance from staff for care, and had an indwelling urinary catheter. A care plan for the resident, dated June 2, 2023, revealed that he was at risk for falls due to balance, and interventions, dated July 13, 2023, included an alternating air mattress.

A nursing note for Resident 33, dated July 10, 2023, at 9:30 p.m., indicated that the nurse was called to resident's room by a nurse aide. The resident was lying on his right side on the floor beside his bed, his pillow was under his head, and his blankets were covering him. He had his soft boots on his feet. The bed was in low position. The resident was unable to say how he got on the floor. He was on a FLOWT mattress and was dependent on staff for repositioning. The call bell was not ringing. The resident had no shortening or rotation of the extremities. The resident had a 3.0 centimeter (cm) by 3.0 cm bruise on forehead and another 3.0 cm x 3.0 cm bruise on top of his head. Neurological check was within normal limits. The doctor was notified.

A nursing note for Resident 33, dated November 3, 2023, at 10:33 a.m., revealed that the registered nurse was notified by nurse aide that the resident was on the floor. Upon entering the room the resident was lying on the right side of the bed on his right side with head towards the dresser. No injuries were noted. The resident was contracted per normal. Nurse aides were last in the room at approximately 7:50 a.m. and sat the resident midline in bed to eat breakfast. The resident stated "oh my" when asked what he was trying to do. The resident denied any pain or discomfort. The resident returned to bed via a mechanical lift. The Certified Registered Nurse Practitioner (CNRP-advanced practice nurse) was notified and an order was received for bilateral fall mats.

A nurse's note for Resident 33, dated November 3, 2023, at 11:03 a.m., revealed that the resident was noted to have a red hematoma to the right side of his head. Neurological checks were within normal limits, and pupils were equal and reactive to light. The physician was updated.

A nursing note for Resident 33, dated November 12, 2023, at 9:45 p.m., revealed that the registered nurse was called to the resident's room by the licensed practical nurse. The resident was lying on his left side between the bed and wall on the floor mat, and his head was slightly off the mat. The bed was in the low position, he had nonskid socks on his feet, and the call bell was in reach but was not ringing. No injuries were noted. The resident did not know how it happened. Neurological checks within normal limits, no complaints of pain with movement of extremities, and no shortening or rotation of extremities were noted. The doctor was notified, and new order for alarms was received.

There was no documented evidence in Resident 33's clinical record to indicate that an air mattress assessment was completed to determine if the resident would be safe while on the mattress.

An interview with the Director of Nursing and Assistant Director of Nursing on January 11, 2024, at 2:47 p.m. confirmed that the facility did not do a bed safety assessment on the resident after he was placed on the air mattress.


The facility's policy for assistive devices and equipment, dated September 21, 2023, indicated that residents being transported by staff will utilize wheelchair leg rests.

Diagnoses for Resident 139 on admission January 10, 2024, included a history of falls at home and degeneration of the nervous system (damage to the nervous system which can result in physical disabilities).

Observations of Resident 139 on January 10, 2024, at 11:40 a.m. revealed that the resident was sitting in a wheelchair in his room when Nurse Aide 1 placed her hands on the wheelchair's handle bars and transported the resident down the hallway to obtain an admission weight. The resident was wearing non-skid socks and he was holding his feet up away from the floor. It was noted that there were no leg rests on the wheelchair.

Interview with Nurse Aide 1 on January 10, 2024, at 11:54 a.m. revealed that she transported Resident 139 down the hall to obtain an admission weight without leg rests on the wheelchair and she should not have.

Interview with Director of Nursing on January 10, 2024, at 12:28 p.m. confirmed that Resident 139 should have had leg rests on his wheelchair while being transported.

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




 Plan of Correction - To be completed: 02/15/2024

Preparation, submission and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with all applicable state and regulatory requirements.

1. Resident 33 had no ill effects from being placed on the air mattress. Air mattress was discontinued 07/28/2023. Resident 139 had no ill effects from being transported in his wheelchair with no leg rests. Nurse Aide 1 was educated on utilizing leg rests for wheelchair transportation.
2. There are no other residents in the facility ordered air mattresses at this time. Education provided to nursing staff that air mattresses are not to be allowed in the facility without notification to the Director of Nursing or Assistant Director of Nursing so that it can be reviewed by the Interdisciplinary Team and an air mattress safety assessment can be completed. Staff educated on utilizing leg rests for wheelchair transportation.
3. Director of Nursing or designee will audit that mattress safety assessment is completed if an air mattress is ordered weekly times two weeks and monthly times two months. Director of Nursing or designee with audit five resident wheelchair transportation weekly times two weeks and monthly times two months.
4. Results will be reviewed at the Quality Assurance and Performance Improvement committee meeting.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills: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(g)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:


Based on review of policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that physician's orders for enteral feedings (feeding through a tube inserted directly into the stomach) were followed for one of 29 residents reviewed (Resident 79).

Findings include:

The facility's policy regarding enteral feeding, dated September 21, 2023, indicated that the enteral nutrition is based on a dietician's nutritional assessment. Physician's orders for enteral nutrition are based off the recommendations from the dietician.

A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 79, dated November 7, 2023, indicated that the resident was cognitively intact and required assistance from staff for care.

Physician's orders for Resident 79, dated November 16, 2023, included an order for the resident to receive a bolus (one meal of formula) of Osmolite (a type of formula) four times a day (9:00 a.m., 1:00 p.m., 6:00 p.m., and 8:00 p.m.) for meal intakes that were less than 50 percent.

Review of Resident 79's meal intake records for November 2023 revealed that the resident ate more than 50 percent of meals on November 23, 28, and 29, 2023; however, the resident's Medication Administration Record (MAR) for November 2023 revealed that staff administered a bolus of Osmolite following meals on those dates.

Interview with the Registered Dietician on November 11, 2023, at 8:27 a.m. confirmed that staff did not follow physician's orders for Resident 79 regarding her tube feeding on the above days.

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




 Plan of Correction - To be completed: 02/15/2024

Preparation, submission and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with all applicable state and regulatory requirements.

1. Resident 79 had no ill effects from receiving tube feed. The parameters had been discontinued previously, and the resident is currently receiving tube feeding routinely with no parameters in place.
2. There are no like residents with tube feedings with parameters currently. License staff educated to ensure that you are reading and following the physician orders and following the parameters when administering a tube feeding.
3. Director of Nursing or Designee will audit to ensure the physician order and parameters are being followed when administering a tube feeding weekly times two weeks and monthly times two months.
4. Results will be reviewed at the Quality Assurance and Performance Improvement committee meeting.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.
Observations:


Based on review of clinical records and staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors for one of 29 residents reviewed (Resident 1).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 28, 2023, revealed that the resident was cognitively intact, received an anticoagulant (blood thinner to prevent blood clots) medication, and had diagnoses that included end-stage renal disease (kidney failure).

Physician's orders for Resident 1, dated April 30, 2023, included an order for the resident to receive 2.5 milligrams (mg) of Eliquis (an anticoagulant) two times a day.

A nursing note for Resident 1, dated December 27, 2023, revealed that the resident's Eliquis orders were put on hold due to surgery on December 29, 2023. Nursing staff were to check when the Eliquis was to be resumed after surgery was completed.

A nursing note for Resident 1, dated December 29, 2023, at 7:30 p.m. revealed that Resident 1 was to resume taking Eliquis on December 30, 2023.

Review of the Medication Administration Record (MAR) for Resident 1 for December 2023 and January 2024 revealed that the resident was not administered Eliquis as ordered between December 30, 2023, and January 8, 2024.

Interview with the Director of Nursing and the Assistant Director of Nursing on January 10, 2024, at 12:27 p.m. confirmed that Eliquis should have been resumed for Resident 1 on December 30, 2023, but as of January 8, 2024, it was not.

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




 Plan of Correction - To be completed: 02/15/2024

Preparation, submission and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with all applicable state and regulatory requirements.

1. Medical Director notified of Eliquis not being restarted. New order received to restart Eliquis at this time. No ill effects noted on resident 1.
2. There are no like residents at this time. Nursing Staff educated that residents going for surgery will be reviewed upon return to ensure any medications held, are resumed as ordered.
3. Admissions Director or designee will audit to ensure that residents going for surgery will be reviewed upon return to ensure any medications held, are resumed as ordered weekly times two weeks and monthly times two months.
4. Results will be reviewed at the Quality Assurance and Performance Improvement committee meeting.

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

§483.45(h) Storage of Drugs and Biologicals

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

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


Based on observations and staff interviews, it was determined that the facility failed to ensure that medications were appropriately secured within the medication carts for one of four medication carts reviewed (Hall B) and failed to ensure that labeling of medication matched physician's orders for one of 29 residents reviewed (Resident 59).

Findings include:

Observations of a medication cart on Hall B on January 10, 2024, at 11:58 a.m. revealed that the first of four large drawers in the medication cart contained four unidentified, loose pills; the second large drawer contained three unidentified, loose pills; and the fourth large drawer contained two unidentified, loose pills that were unsecured and not in the pharmacy's packaging. Interview with Licensed Practical Nurse 2 at that time confirmed that the pills were loose in the bottom of the cart drawers and should not have been.

Interview with the Director of Nursing on January 10, 2024, at 12:28 p.m. confirmed that there were unidentified loose medications in the drawers of the Hall B medication cart.

Physician's orders for Resident 59, dated November 3, 2023, included an order for the resident to receive 5 milligrams (mg) of Reglan (a medicine related to gastroesophageal reflux - a stomach disorder) every six hours (midnight, 6:00 a.m., 12:00 p.m., and 6:00 p.m.). A review of the pill card (a way of packaging medications that are grouped by the time and day of taking them) for Resident 59's Reglan revealed that the pharmacy had placed several additional labels (stickers) on the pill card related to the medication. One label advised that the resident was to receive Reglan 30 minutes prior to meals.

Observations during B hall medication pass on January 9, 2024, revealed that Licensed Practical Nurse 3 administered Resident 59's 12:00 p.m. medications at 1:28 p.m. (which included Reglan). It was observed at this time that Resident 59's lunch meal tray had been picked up by staff. Interview with Licensed Practical Nurse 3 at that time revealed that she was helping in the dining room with lunch and now her noon medication pass was late. In addition, she indicated that she did not notice the pharmacy label (sticker) on the pill card that advised Reglan was to be given 30 minutes prior to meals. She further revealed that the electronic medication administration record did not indicate that Reglan was to be given 30 minutes prior to meals.

A review of facility mealtimes indicated that Resident 59's lunch had been served at approximately 11:40 a.m.

Interview with the Nursing Home Administrator and Assistant Director of Nursing on January 10, 2024, at 10:54 a.m. confirmed that the facility failed to ensure that physicians orders, pharmacy recommendations, and the electronic medication administration record all matched for Resident 59's Reglan order.

28 Pa. Code 211.9(h) Pharmacy services.

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



 Plan of Correction - To be completed: 02/15/2024

Preparation, submission and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with all applicable state and regulatory requirements.

1. Medication carts were checked and any loose medications were discarded properly. Medical Director was notified of Reglan order timing and times adjusted per order. Medication error was completed for resident 59 due to receiving Reglan dose late. No ill effects were noted to resident 59.
2. Education provided to licensed staff regarding that when a medication is dropped in the cart, it should be immediately retrieved and disposed of properly. Residents with Reglan orders were reviewed with Medical Director and times adjusted. Educated provided to licensed staff regarding ensuring Reglan is given as ordered.
3. Director of Nursing or designee will audit that residents receiving Reglan are receiving their dose at the proper time weekly times two weeks and monthly times two months. Assistant Director of Nursing or designee will audit to ensure there are no loose medications in the carts weekly times two weeks and monthly times two months.
4. Results will be reviewed at the Quality Assurance and Performance Improvement committee meeting.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
§483.60(i) Food safety requirements.
The facility must -

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

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


Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to serve food in accordance with professional standards for food service safety by failing to ensure that dietary staff wore beard coverings that completely covered their beard during food handling.

Findings include:

The facility's dietary policy regarding personal hygiene, dated September 21, 2023, revealed that staff were to cover all hair and facial hair with restraint, either with a hairnet, cap, or hat.

Observations in the kitchen on January 10, 2024, at 11:10 a.m. revealed dietary staff at the stove preparing chicken pot pie for the resident's lunch. Dietary Aide 4 was observed with approximately four to five inches of his beard not contained within the beard net.

Interview with the Dietary Director on January 10, 2024, at 11:15 a.m. confirmed that Dietary Aide 4 did not have all of his beard covered with a restraint as he should have.

Interview with Nursing Home Administrator on January 10, 2024, at 3:46 p.m. confirmed that Dietary Aide 4 should have had all of his beard covered.

28 Pa. Code 211.6(f) Dietary services.




 Plan of Correction - To be completed: 02/15/2024

Preparation, submission and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with all applicable state and regulatory requirements.

1. Dietary Aide 4 placed beard cover on at that time. No ill effects noted to meal trays.
2. Education provided to dietary staff regarding ensuring beard covers and hair nets are worn when in dietary completing meal preparation.
3. Dietary Manager or designee will audit to ensure beard covers are being worn during meal preparation weekly times two weeks and monthly times two months.
4. Results will be reviewed at the Quality Assurance and Performance Improvement committee meeting.

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.
Observations:


Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending February 8, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending January 11, 2024, identified repeated deficiencies related to a failure to ensure quality of care and a failure to ensure labeling and storage of medications.

The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending February 8, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to maintain ongoing compliance with the regulations regarding quality of care services.

The facility's plan of correction for a deficiency regarding labeling and storage of medications, cited during the survey ending February 8, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the QAPI committee failed to maintain ongoing compliance with the regulations regarding labeling and storage of medications.

Refer to F684, F761.

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

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





 Plan of Correction - To be completed: 02/15/2024

Preparation, submission and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with all applicable state and regulatory requirements.

1. The Quality Assurance and Performance Improvement committee reviewed current survey deficiencies and plan of correction including audits.
2. The Quality Assurance and Performance Improvement committee reviewed previous survey deficiencies to correct deficiencies and ensure that plans to effectively address recurring deficiencies.
3. The Quality Assurance and Performance Improvement committee was educated on the Quality Assurance and Performance Improvement Plan.
4. The Quality Assurance and Performance Improvement committee will review previous survey deficiencies to ensure compliance.

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 review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand washing techniques were used during medication administration for three of five residents observed (Residents 17, 59, 83).

Findings include:

The facility's policy regarding hand hygiene, dated September 21, 2023, indicated that all employees were to follow the hand washing procedure, which included hand sanitizing, before preparing or handling medications.

Observations during the medication pass in B hall on January 9, 2024, at 1:20 p.m. revealed that Licensed Practical Nurse 3 prepared Resident 83's medications and administered them. Without sanitizing her hands she prepared and administered Resident 59's medications. She then went to Resident 17's room and without sanitizing her hands she prepared and administered her medications. Licensed Practical Nurse 3 then washed her hands in the sink and exited the resident's room.

Interview with Licensed Practical Nurse 3 on January 9, 2024, at 1:20 p.m. confirmed that she should have sanitized her hands between residents while doing the medication pass.

Interview with the Assistant Director of Nursing on January 9, 2024, at 2:10 a.m. confirmed that Licensed Practical Nurse 3 did not properly sanitize her hands during medication administration and she should have.

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



 Plan of Correction - To be completed: 02/15/2024

Preparation, submission and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with all applicable state and regulatory requirements.

1. No ill effects were noted to resident 83 and 59. License Practical Nurse 3 was educated on the importance of performing hand hygiene between preparing and administering medications to separate residents.
2. Education provided to licensed staff on the importance of performing hand hygiene between preparing and administering medications to separate residents.
3. Assistant Director of Nursing or designee will audit to ensure hand hygiene is being completed between residents medication pass weekly times two weeks and monthly times two months.
4. Results will be reviewed at the Quality Assurance and Performance Improvement committee meeting.


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