Pennsylvania Department of Health
HANOVER HALL FOR NURSING AND REHABILITATION
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

HANOVER HALL FOR NURSING AND REHABILITATION
Inspection Results For:

There are 98 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.


HANOVER HALL FOR NURSING AND REHABILITATION - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights survey and a complaint survey completed on March 14, 2024, it was determined that Hanover Hall for Nursing and Rehabilitation 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:

483.20(g) REQUIREMENT Accuracy of Assessments:

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.

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

Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that resident assessments accurately reflected the resident's status for three of 25 residents reviewed (Residents 53, 107, and 358).

Finding include:

Review of Resident 53's clinical record on March 12, 2024, at 11:47 AM, revealed diagnoses that included vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain) and heart failure (condition where the heart can't pump enough blood to meet the body's needs).

Review of Resident 53's physician orders revealed Resident 53 was admitted to hospice services on February 27, 2023.

Review of Resident 53's minimum data set (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial needs), section O0110 special treatments, procedures, and programs, subsection K1 hospice, revealed the facility failed to indicate that Resident 53 was receiving hospice services while a Resident for three quarterly MDS assessments with the dates of May 31, 2023; August 30, 2023; and November 23, 2023.

During an interview on March 13, 2024, at 9:50 AM, with the NHA, it was revealed that Resident 53's quarterly MDS assessments where coded incorrectly and corrections had been completed. The NHA stated it is the facility's expectation that MDS assessments would be completed accurately.

Review of Resident 107's clinical record revealed she was admitted to the facility from the hospital on December 20, 2023, following a total knee replacement, and was discharged from the facility on December 26, 2023.

Review of Resident 107's progress notes revealed a physician discharge note and summary on December 26, 2023, that stated, "She progressed well with physical therapy and is comfortable to return home where she lives with her husband who helps provide care for her. On exam today patient is awake, alert and sitting in her wheelchair. She denies pain at present."

Further review of Resident 107's progress notes revealed a note on December 26, 2023, at 4:54 PM, that stated, "Discharge home."

Review of Resident 107's Discharge Return Not Anticipated MDS with ARD (assessment reference date- last day of the assessment period) of December 26, 2023, revealed under "Section A - Identification Information" subsection "A2105. Discharge Status" Resident 107 was coded as being discharged to a Short-Term General Hospital.

During an interview with Employee 5 (Nurse Assessment Coordinator) on March 14, 2024, at 12:26 PM, she revealed Resident 107 discharged home and not to a hospital, and her assessment was coded inaccurately.

During an interview with the NHA on March 14, 2024, at 1:02 PM, she revealed she would expect resident 107's Discharge Return Not Anticipated MDS with ARD of December 26, 2023, to be coded accurately.

Review of Resident 358's clinical record on March 12, 2024, at 12:33 PM, revealed diagnoses that included neuroleptic induced parkinsonism (condition caused by use of antipsychotic medication that causes slowed movements, stiffness, and tremors) and dysphagia (difficulty swallowing).

Review of Resident 358's physician orders revealed Resident 358 was admitted to hospice services November 13, 2023.

Review of Resident 358's significant change MDS dated November 13, 2023, section O0110 special treatments, procedures, and programs, subsection K1 hospice, revealed the facility failed to indicate that Resident 358 was receiving hospice services while a Resident.

During an interview with the NHA on March 13, 2024, at 9:50 AM, it was revealed Resident 358's significant change MDS assessment was incorrect, and that corrections had been completed. The NHA stated it is the facility's expectation that MDS assessments would be completed accurately.

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

Plan of Correction - To be completed: 04/24/2024

1. R53, R107, and R358s MDS' were modified to reflect accuracy of hospice and discharge locations.
2. Residents discharged in last 60 days and residents on hospice will have their MDS' audited to ensure accuracy of those sections.
3. Education will be provided to MDS staff regarding accuracy of documentation on assessments.
4. MDS Coordinator/designee will audit 5 residents weekly x4 weeks, 10 residents monthly x2 months to ensure accuracy of MDS. Results will be reviewed at QAPI to ensure compliance and quality improvement.

483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides:

§483.95(g) Required in-service training for nurse aides.
In-service training must-

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

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

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

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

Observations:

Based on review of nurse aide in-service records and staff interview, it was determined that the facility failed to ensure that all nurse aide staff received a minimum of 12 hours of in-service education training each year for five of five direct care staff members reviewed (Employees 8, 9, 10, 11, and 12).

Findings include:

Review of the facility's yearly mandatory in-service training failed to reveal documented evidence that Employees 8, 9, 10, 11, and 12 (Nurse Aides) met the yearly regulatory minimum training requirements. The following were documented hours of training for each employee: Employee 8 had 7 hours; Employee 9 had 6 hours; Employee 10 had 7 hours; Employee 11 had 7 hours; and Employee 12 had 7 hours.

During an interview with the Nursing Home Administrator (NHA) on March 14, 2024, at 10:55 AM, it was revealed that the facility scheduled in-person training lasting one hour in duration each month and covered a different topic. It was further revealed that all staff are expected to attend one of the two training sessions offered each month; no "make-up" sessions were scheduled. The NHA acknowledged that training scheduled for August 2023 and December 2023 were canceled due to a COVID-19 outbreak, and the training schedule was revamped for the mandatory topics to be covered; however, the two missed hours weren't rescheduled.

28 Pa. Code 201.18(b)(3) Management.
28 Pa. Code 201.19(7) Personnel policies.
28 Pa. Code 201.20(a)(d) Staff development.

Plan of Correction - To be completed: 04/24/2024

1. Employees 8, 9, 10, 11, and 12 will receive their required missing trainings.
2. Facility audit revealed some direct care failed to attend required monthly trainings.
3. The facility will provide re-education on the regulatory requirement for required in-servicing, and how it directly affects their certification. The facility will provide an opportunity for staff to receive 1:1 training if they are unable to attend mandatory in-servicing. Staff will be removed from the schedule if they fail to meet the monthly in-servicing requirements.
4. HR/designee will complete audits monthly after required in-services to ensure required staff are in attendance. Audits will be reviewed at QAPI to ensure compliance and quality improvement.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§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.

Plan of Correction - To be completed: 04/24/2024

1.Items identified as unlabeled or outdated in all pantries, kitchen and waLk-in refrigerator were discarded per policy
2. Facility completed audit of resident pantries for labeling/dated/outdated items and discarded items appropriately. The facility's walk-in refrigerators were also audited to ensure all items were labeled and wrapped appropriately, and outdated items discarded.
3. Re-education will be provided to dietary staff on Labeling/storing policy. Facility will utilize closing checklist nightly which will include auditing refrigerators and walk-in refrigerator to ensure all open food it dated, expired food is discarded per policy, and items are properly wrapped. Will also educate on adding thaw dates for frozen supplements. Education will be provided to nursing staff regarding ensuring residents items in pantry refrigerators are labeled with name, date, and room number when received. Facility policy will also be reviewed with the residents at the next food committee.
4. DSM/designee will complete audits of kitchen refrigerators, and pantries 3x week, then 10x monthly x2 months to ensure facility is adhering to policy. Audits will be reviewed at QAPI to ensure compliance and quality improvement.

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed:

§483.60(c) Menus and nutritional adequacy.
Menus must-

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

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

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

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

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

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

Observations:

Based on review of select facility documentation, observations, and staff interview, it was determined that the facility failed to follow appropriate portion sizes for residents prescribed double portions for three of five residents observed (Residents 5, 7, and 32); and failed to provide therapeutic diet restrictions (a meal plan that controls the intake of certain foods or nutrients) for five of five residents observed on the carbohydrate controlled diet restriction (Residents 28, 58, 70, 83, and 409) during one of one tray line meal service observed.

Findings include:

Review of Document titled "Carbohydrate Controlled Diet" not dated, read, in part, "Food Group: Desserts ...Foods Allowed: Half portion of regular desserts."

Review of the meal extension sheets revealed that residents on the carbohydrate controlled diet restriction should be served half of a 2 x 3 inch square of the chocolate chip brownie bar.

Observation of lunch meal tray line service on March 13, 2024, between 11:10 AM and 12:07 PM, revealed Residents 28, 58, 70, 83, and 409's, tray tickets had notation that they were on the carbohydrate controlled diet restriction, and were served a whole square of the chocolate chip brownie bar.

Review of Document titled "Portion Sizes" last revised July 2023, read, in part, "Meal Category: Meat (Lunch), Double Portion: 6 oz (2svg-serving)"

Observation of lunch meal tray line service on March 13, 2024, between 11:10 AM and 12:07 PM, revealed Residents 5, 7, and 32's, tray tickets had notation that they should be provided double protein portions, and were served a single breaded chicken sandwich with one patty.

Observation on the units on March 13, 2024, between 11:59 AM and 12:37 PM, confirmed Residents 5, 7, and 32, were not served double protein portions.

During a staff interview on March 14, 2024, at 10:47 AM, the observations of the lunch meal tray line service from March 13, 2024, were discussed with the Nursing Home Administrator (NHA). The NHA revealed she would expect therapeutic diets and double protein portions to be followed.

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

Plan of Correction - To be completed: 04/24/2024

1. Facility cannot retroactively correct this concern. R28, R58, R70, R83, and R409 had no adverse effects from receiving full portion size of dessert rather than half. R5, R7, and R32 had no adverse effects from not receiving double protein portions.
2. The facility will complete an audit of current residents with double protein portions and carb consistent diets to ensure these diets remain appropriate.
3. Education will be provided to dietary staff regarding Carb consistent diets, and ensuring double protein portions are served according to diet orders.
4. DSM/designee will audit 10 residents weekly x4 weeks, and 10 monthly x2 weeks to ensure residents diets are being served appropriately. Audits will be reviewed at QAPI to ensure compliance and quality improvement.

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, facility policy review, and staff interview, it was determined that the facility failed to ensure controlled substances were contained in a permanently affixed locked compartment for two of two medication rooms observed (A1/B1 hall and C2/D2 hall); failed to ensure adherence to medication expiration dates for one of two medication storage rooms observed (A1/B1 hall); and failed to ensure appropriate labeling of medication when opened for one of two medication storage rooms observed (A1/B1 hall).

Findings include:

Review of facility policy, titled "Medication Storage in the Facility", last reviewed August 24, 2023, stated, "Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications."

Further review of the policy revealed a section titled "Procedures" subsection I stated, "Controlled medications are stored separately from other medications in a locked drawer or compartment designated for that purpose."

Subsection M stated, "Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy, if a current order exists."

Review of facility policy, titled "Administering Medication", last reviewed August 24, 2023, section titled "Policy Interpretation and Implementation", number 8 stated, in part, " ...When opening a multi-dose container, the date opened shall be recorded on the container."

Further review of the policy revealed a section titled "Injection Practices and Sharps Safety (Medications and Infusates)" stated, "Multi-dose vials which have been opened or accessed (e.g. needle-punctured) are dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for the opened vial."

Observation of the A1/B1 hall medication room on March 13, 2024, at 9:40 AM, revealed an unlocked medication refrigerator.

Further observation of the medication refrigerator revealed one box of lorazepam (a schedule IV-controlled substance) containing a bottle with 30 milliliters (mL - Metric unit of measure) of lorazepam lying on a shelf in the refrigerator; one opened, partially used multi-dose vial of Aplisol (substance that's used to detect exposure to tuberculosis) with no open date documented on the vial; and one opened, partially used multi-dose vial of Energix-B (vaccine for immunization against Hepatitis B virus), with no open dated documented on the vial. Further review of the medication room revealed one house stock tube of Glutose 15 gel (used to treat low blood sugar) with a do not use after date of October 2022.

Observation of the C2/D2 hall medication room on March 13, 2024, at 11:57 AM, revealed an unlocked medication refrigerator.

Further review of the medication refrigerator revealed two boxes of lorazepam (a schedule IV-controlled substance) containing a total of 59 mL of lorazepam lying on a shelf in the refrigerator.

During an interview on March 14, 2024, at 11:06 AM, with the Nursing Home Administrator (NHA) and Director of Nursing, after notifying them of the observations made in the medication rooms, the NHA stated it is the expectation of the facility that medication refrigerators are to be locked, multi-dose vials of medications are to be dated when opened, and expired medications are to be disposed of.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.9(a)(1) Pharmacy services
28 Pa. Code 211.12 (d)(2)(5) Nursing services

Plan of Correction - To be completed: 04/24/2024

1. Medication refrigerator on A1/B1 hall and C2/D2 hall were locked immediately with no concerns noted. The expired glucose gel was disposed of immediately. The opened medications that were undated were disposed of per policy.
2. The facility will complete an audit of all medication rooms to ensure all refrigerators are locked, opened medications are dated, and there are no expired medications.
3. Education will be provided to licensed nursing staff regarding policy on Medication Storage, to include controlled substances, outdated/expired medication and disposal, and dating multi-dose medications.
4. DON/designee will complete audit of all medication rooms weekly x4 weeks, then twice monthly x2 months to ensure facility maintains compliance with medication storage policy. Audits will be reviewed at QAPI to ensure compliance and quality improvement.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

§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 facility policy review, clinical record review, and staff interviews, it was determined the facility failed to ensure the monthly pharmacy medication regimen review recommendations were acted upon in a timely manner for two of 25 residents reviewed (Residents 37 and 49).

Findings include:

Review of facility policy, titled "Medication Monitoring and Management", not dated, read, in part "The consultant pharmacist reviews written record to determine that: 'Stop order' policies, where utilized, are observed ...'Standing orders,' where utilized, are implemented appropriately."

Review of Resident 37's clinical record revealed diagnoses that included pain in left knee, hypertension (high blood pressure), and osteoarthritis (a type of arthritis that affects the joints in your body).

Review of Resident 37's monthly pharmacy medication regimen review recommendations revealed a recommendation from July 9, 2023, that stated "Please add 'Do not exceed 3 grams in 24 hours from all sources' to the PRN [PRN- as needed] Acetaminophen order(s). Thank you."

Review of Resident 37's monthly pharmacy medication regimen review recommendations revealed a recommendation from August 11, 2023, that stated "Please add a specific temperature to the PRN Acetaminophen order. It should state a specific numerical level, not simply for fever/elevated temperature. Thank you."

Review of Resident 37's physician orders revealed an order for "Tylenol Extra Strength Oral Tablet (Acetaminophen) Give 1000 mg by mouth at bedtime for chronic pain", with a start date of June 26, 2023.

The order failed to reflect the July 2023 pharmacy recommendation.

Further review of Resident 37's physician orders revealed an order for "Tylenol Oral Tablet (Acetaminophen) Give 650 mg by mouth every 6 hours as needed for elevated temp or mild pain may give suppository if unable to take orally", with a start date of June 26, 2023.

The order failed to reflect the July 2023 and August 2023 pharmacy recommendations.

An interview with the Director of Nursing (DON) on March 14, 2024, at 1:18 PM, revealed the pharmacy recommendations should have gone to nursing to get the orders updated, and the recommendations should be looked at and responded to timely.

Review of Resident 49's clinical record revealed diagnoses that included Post-Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being) and diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).

Review of Resident 49's monthly pharmacy medication regimen review recommendations revealed pharmacy recommendations from July 9, 2023, that stated "Please add 'Do not exceed 3 grams in 24 hours from all sources' to the PRN Acetaminophen order(s). Thank you ... Please add a specific temperature to the PRN Acetaminophen order. It should state a specific numerical level, not simply for fever/elevated temperature. Thank you."

Review of Resident 49's physician orders revealed an order for "Tylenol Tablet (Acetaminophen) Give 650 mg by mouth every 6 hours as needed for fever", with a start date of August 26, 2022.

The order failed to reflect the July 2023 pharmacy recommendations.

Further review of Resident 49's physician orders revealed an order for "Tylenol Tablet (Acetaminophen) Give 650 mg by mouth every 6 hours as needed for pain", with a start date of August 26, 2022.

The order failed to reflect the July 2023 pharmacy recommendations.

Review of Resident 49's monthly pharmacy medication regimen recommendations revealed a recommendation from November 4, 2023, that stated "The resident has orders for Triamcinolone Compound. Please add a stop/reassess date, as topical corticosteroids are not intended for ongoing therapy. Thank you."

Further review of Resident 49's monthly pharmacy medication regimen review recommendation from November 4, 2023, revealed it was signed by a nurse practitioner on January 31, 2024, with a notation of agreement and "D/c [discontinue] Triamcinolone."

Review of Resident 49's progress notes revealed a note on February 1, 2024, that stated "[Employee 7] CRNP [Certified Registered Nurse Practitioner], agrees with consultant pharmacy recommendations to D/C Triamcinolone."

Review of Resident 49's active physician orders revealed an order for "4:1 Cream (Zinc Oxide 20%oint.//Nystatin 1000U/gm//Triamcinolone 0.1 %//Lidocaine 3%) 60/30/30/30 GM, Apply to affected areas topically every day and evening shift for yeast; rash", with a start date of April 4, 2023.

Review of Resident 49's monthly pharmacy medication regimen review recommendations revealed a recommendation from December 4, 2023, "Please include the level of pain at which the PRN Tramadol is to be administered. Thank you."

Review of Resident 49's physician orders revealed an order for "Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) give 50 mg", with a start date of March 8, 2023, and an end date of March 4, 2024". Further review of the order failed to reveal a level of pain at which the medication should be administered.

During an interview with the DON on March 14, 2024, at 1:18 PM, she revealed the pharmacy recommendations should have gone to nursing to get the orders updated, and that recommendations should be looked at and responded to timely.

During a follow-up interview with the DON on March 14, 2024, at 2:47 PM, she revealed there was a triamcinolone cream that was discontinued on March 4, 2024, but that was due to a wound that had resolved. The triamcinolone compound that was recommended to be discontinued appeared to be the one that was still an active order, with a start date of April 4, 2023.

28 Pa. Code 211.9(k) Pharmacy Services.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 04/24/2024

1. R37 and R49s pharmacy recommendations have been reviewed and revised accordingly.
2. The facility will complete an audit of most recent pharmacy recommendations to ensure there are no outstanding recommendations.
3. Facility will provide education to licensed nursing staff as well as attending physicians on facility process and expectations for follow up with pharmacy recommendations.
4. DON/designee will audit 10 residents' pharmacy recommendations weekly x4 weeks, then 15 residents x 2 months to ensure recommendations have been provided to MD and follow up has been completed. Audits will be reviewed at QAPI to ensure compliance and quality improvement.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§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 facility policy review, clinical record review, and staff interviews, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to attain or maintain the highest practicable level of physical and mental well-being for one of 25 residents reviewed (Resident 49).

Findings include:

Review of facility policy, titled "Care Plans, Comprehensive Person-Centered", last revised September 2022, read, in part, "A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial, and functional needs, is developed and implemented for each resident. The services provided or arranged by the facility, as per the comprehensive care plan, must be culturally-competent and trauma-informed ...Trauma-informed Care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures, and practices to avoid re-traumatization."

Review of Resident 49's clinical record revealed diagnoses that included Post-Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being) and Type 2 Diabetes Mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).

Review of Resident 49's clinical record revealed a Nurse Practitioner Note on February 22, 2023, that stated "Resident is a veteran of the Marine Corps and served in the Vietnam War. 2 Purple hearts and a bronze star."

Review of Resident 49's care plan revealed a focus area of "Richard has a mood problem related to history of PTSD and self-reported signs and symptoms of depression: history of feeling down/depressed, like a failure and has thoughts he would be better off dead (no plan to harm self)", initiated August 13, 2020, and last revised December 6, 2022. The care plan failed to reveal what caused his PTSD or triggers related to PTSD.

During an interview with Employee 4 (Director of Social Services) on March 12, 2024, at 2:33 PM, the surveyor inquired about Resident 49's diagnosis of PTSD. Employee 4 stated that Resident 49 has PTSD due to being a Vietnam Veteran, he has interventions in place for this, including that he follows with geri-psychiatric for talk therapy, and he goes out of the facility to the VFW (Veterans of Foreign Wars - war veterans service organization) to meet with other veterans and attend events such as flag burning ceremonies. Employee 4 further stated he used to sleep in a recliner, but stopped due sliding out of the recliner when he was having night terrors and flashbacks. She stated that those have gotten much better since he has been receiving geri-psychiatric services.

Further review of Resident 49's care plan on March 12, 2024, failed to reveal his interventions of going out to the VFW, or him experiencing night terrors and flashbacks.

Review of Resident 49's care plan on March 13, 2024, at 1:00 PM, revealed his focus area of his PTSD had been updated to state "history of PTSD (Vietnam Vet)" with interventions for "be sure to approach from the front, calling out name", initiated on March 13, 2024, and "does go out to VFW with friends on a regular basis", initiated on March 13, 2024.

Further review of Resident 49's care plan on March 13, 2024, at 1:00 PM, revealed his activities care plan was updated to state "He is a Vietnam Veteran with PTSD" with interventions for "Friends occasionally take him to the VFW with them", initiated on March 13, 2024, and "monitor/record/report any changes in feeling down or behavior or depression (PTSD- Vietnam Veteran)".

An interview with the Nursing Home Administrator on March 13, 2024 at 1:32 PM, revealed she would expect Resident 49's care plan to be comprehensive to include the source of his PTSD as well as his triggers and interventions.

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Plan of Correction - To be completed: 04/24/2024

1. R49s care plan was revised to include PTSD triggers and additional interventions.
2. Facility will complete audit of current residents with PTSD to ensure care plan includes triggers and all interventions for treatment of PTSD.
3. Education will be provided to the nursing and care plan team regarding ensuring appropriate and accurate interventions are in place, in addition to revising and updating care plans regularly as changes occur.
4. MDS coordinator/designee will audit care plans of 5 residents weekly x4 weeks, and 10 monthly x2 months to ensure care plans are updated and accurately reflect current conditions and interventions. Results will be reviewed at QAPI to ensure compliance and quality improvement.

483.25(a)(1)(2) REQUIREMENT Treatment/Devices to Maintain Hearing/Vision:

§483.25(a) Vision and hearing
To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-

§483.25(a)(1) In making appointments, and

§483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

Observations:

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure each resident received proper treatment to maintain vision for one of 25 residents reviewed (Resident 90).

Findings include:

Review of Resident 90's clinical record revealed diagnoses that included adult failure to thrive (syndrome of weight loss, decreased appetite, depressive symptoms, and impaired immune function), hemiplegia (paralysis of one side of the body) following stroke effecting left dominant side, diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), chronic kidney disease (CKD - the kidneys don't function as they should), and depressed mood.

During an interview with Resident 90 on March 11, 2024, at 11:31 AM, it was revealed that he hasn't seen an eye doctor to get shots in his right eye for at least two months and that, according to the facility, this was due to the eye doctor not accepting his insurance. He also revealed that he is almost blind in his left eye.

Review of Resident 90's physician orders revealed orders for Resident 90 to have routine ophthalmic consult and treatment as needed, effective March 1, 2024.

Review of Resident 90's clinical record revealed that he was seen by a retinal specialist on August 25, 2023, and the next appointment was scheduled for November 10, 2023, at 10:30 AM.

Review of progress note dated November 10, 2023, revealed that Resident 90 returned to the facility at 11:30 AM, but was not see by the retinal specialist due to them not accepting his new medical insurance.

Progress notes dated November 11, 2023, documented Resident 90 was complaining of blurred vision in his right eye, and not being able to see out of his left eye. Resident was transferred to the hospital for evaluation due to history of stroke.

Hospital discharge instructions dated November 12, 2023, read, in part, Resident presents to the emergency department for evaluation of left-sided vision loss. Resident also reported that the vision in his right eye is blurry. Resident 90 had a normal neurological exam and was evaluated multiple times over the past 6 months for acute stroke; stroke noted April 2023. Resident had minimally reactive left pupil and reports still can't see out of that eye, right pupil is normal with normal pupillary reflex. Recommendations included "it is imperative for resident to follow up with your ophthalmologist upon discharge from the emergency department."

Review of email communication between Employee 4 (Social Services Director) and the scheduling coordinator for in-house optometry services revealed on December 10, 2023, it was requested for Resident 90 to be seen for a vision evaluation the next time they are scheduled to be onsite which was to be January 15, 2024.

On January 10, 2024, Employee 4 canceled Resident 90's vision appointment with the in-house optometry service due to Resident 90's vision requiring an evaluation at a doctor's office.

Further review of Resident 90's clinical record revealed a consult report from an out-of-facility optometrist, dated February 8, 2024, for routine eye care and evaluation. Recommendations were made for Resident 90 to follow-up with a retinal specialist as soon as possible, and to follow-up with an out-of-facility doctor for ongoing treatment for glaucoma.

A progress note dated February 9, 2024, documented that an appointment was scheduled with a retinal specialist for March 1, 2024, at 1:45 PM.

A progress note dated February 12, 2024, documented that an appointment was scheduled with an out-of-facility doctor for glaucoma treatment.

During an interview with the Nursing Home administrator on March 13, 2024, at 2:00 PM, it was revealed that the facility had made two appointments at different ophthalmology offices for Resident 90 to seen, and the resident was transported to both offices only to find out they didn't take his new insurance. When asked if the facility should've checked to see if the ophthalmology offices accepted the resident's insurance, it was revealed that the facility forwards that information at the time the appointment is made and, therefore, would expect the office to inform the facility if they don't accept the resident's insurance. It was revealed that the facility had asked the ophthalmologist's office to bill the facility; however, they wanted payment at time of service. It was revealed that the facility could provide payment at time of service if they are aware of that ahead of time.

The facility failed to effectively managing routine eye appointments/treatments for Resident 90, resulting in a delay in required vision services and treatments from November 2023 through March 2024.

28 Pa. code 211.12(d)(5) Nursing Services

Plan of Correction - To be completed: 04/24/2024

1. R90 has two eye appointments for retina and ophthalmology appointments scheduled.
2. Facility will audit current residents with any current visual concerns to ensure appropriate recommendations are followed and any necessary appointments are scheduled.
3. Facility will educate social worker and appointment scheduler that at the time of appointment scheduling a discussion regarding insurance coverage is held to ensure resident is able to be seen by provider.
4. Social Worker will audit 3 residents weekly x4 weeks, and then 5 monthly x2 months to ensure the visual needs of residents are being met. Audits will be reviewed monthly at QAPI to ensure compliance and quality improvement.

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 facility policy review, observations, record review, and staff interviews, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for one of 25 residents reviewed (Resident 49).

Findings include:

Review of facility policy, titled "Equipment Management", last revised February 27, 2019, read, in part, "All equipment must be wiped down between patient use with a disinfectant cleaning solution/wipe that is rated: bactericidal, fungicidal, virucidal, tuberculocidal or as per manufacturer instructions ...CPAP Machine filters: Non disposable filters should be washed monthly. Disposable filters should be changed out monthly ...Humidifier chambers: Recommend to use distilled water only. Water should be changed daily."

Review of Resident 49's clinical record revealed diagnoses that included Obstructive Sleep Apnea (a common disorder that causes repeated breathing interruptions during sleep), Post-Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being), and Type 2 Diabetes Mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).

Review of Resident 49's physician orders revealed an order for "AutoCpap 10 min, 20 max every evening and night shift", with a start date of August 27, 2022.

Further review of Resident 49's physician orders on March 12, 2024, failed to reveal orders for cleaning his mask or changing the filter or humidifier water.

Observation in Resident 49's room on March 12, 2024, at 10:55 AM, revealed his CPAP mask was laying out on his bedside table.

Observation in Resident 49's room on March 13, 2024, at 9:45 AM, revealed his CPAP mask was laying out on his bedside table.

During an interview with the Director of Nursing (DON) on March 13, 2024, at 1:33 PM, the surveyor inquired what the facility's process is for managing residents' CPAP. The DON revealed the Resident should have orders for cleaning the mask every morning, that they have bags for sanitary storage of equipment, and he should also have orders for changing the filter and humidifier water.

A follow-up interview with the DON on March 14, 2024, at 10:07 AM, revealed Resident 49 now has orders for cleaning his mask and changing the filter and humidifier water, and she would have expected those to be in place.

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Plan of Correction - To be completed: 04/24/2024

1. R49s orders were obtained for cleaning of mask and changing filter and humidifier water per policy.
2. Current residents with CPAP machines had their orders reviewed to ensure they had orders for cleaning of mask, changing filter, and humidifier water per policy.
3. Education will be provided to nursing staff on Respiratory care policy, to include orders for cleaning and storing of mask, and changing filters and water.
4. DON/designee will randomly audit 3 residents with CPAP orders weekly x4 weeks, then up to 5 monthly x2 months with ensure accurate orders are in place, and masks are being properly stored. Audits will be reviewed at QAPI to ensure compliance and quality improvement.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Observations:

Based on completion of a test tray and resident and staff interviews, it was determined that the facility failed to provide foods that were at an appetizing temperature for one of one meals tested.

Findings include:

An interview with Resident 408 on March 11, 2024, at 11:17 AM, revealed his food is not always served hot during meals.

During the resident group interview completed on March 12, 2024, at 10:00 AM, multiple residents voiced concerns with the temperature of the food served during meal service.

During an interview with Employee 3 on March 13, 2024, at 12:20 PM, he revealed that he conducts test trays monthly, and hot foods should be served at or above 135 degrees and chilled foods should be served at or below 40 degrees.

A test tray was completed on March 13, 2024, at 12:26 PM, utilizing a lunch tray served from tray line in the main kitchen. A test tray was served and placed in a closed food cart for approximately two minutes prior to being delivered to the C1 unit (other trays for room service were being delivered here also at this time). The test tray included: a breaded chicken sandwich, chilled diced pears, a chocolate chip brownie bar, apple juice, and coffee. Temperatures taken by Employee 3 revealed the breaded chicken sandwich was 129 degrees and the chilled pears were 70 degrees, not palatable.

An interview with the Nursing Home Administrator on March 13, 2024, at 1:45 PM, revealed she would expect food and beverages to be served at palatable temperatures.

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

Plan of Correction - To be completed: 04/24/2024

1. No residents had adverse effects related to food temps.
2. The facility will conduct an interview with residents at the next Food Committee to determine if other residents have concerns with food temps.
3. Re-education will be completed with dietary services staff to ensure they are educated on appropriate food temperatures for both hot and cold foods. Nursing staff will also be re-educated on passing of trays to ensure timeliness and how this may affect food temps. Dining services will refrigerate canned items in advance to ensure appropriate cold temperatures. Temperature will be increased in food warmer and served in smaller batches to steam table to ensure hot temperatures are maintained.
4. DSM/designee will conduct test tray audits for 5 meals weekly x4 weeks; then 10 monthly x2 months to ensure appropriate temperatures. Audits will be reviewed at QAPI to ensure compliance and quality improvement.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations:

§483.80(d) Influenza and pneumococcal immunizations
§483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

§483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.

Observations:

Based on facility record review, facility policy review, and staff interviews, it was determined that the facility failed to provide education regarding the benefits and risks of the influenza and pneumococcal vaccines for three of five residents reviewed for vaccination status (Residents 61, 90, and 92).

Findings include:

Review of facility policy, titled "Influenza Vaccine", last reviewed August, 2023, revealed the policy statement included, "The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (or residents' legal representatives); for example, risk factors that have been identified for specific age groups or individuals with risk factors such as allergies or pregnancy."

Review of subsection 4 of the policy revealed it stated, "Prior to the vaccination, the resident (or residents' legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. (See current vaccine information statements at [Centers for Disease Control's website] for educational materials.) Provisions of such education shall be documented in the resident's/employee's medical record."

Review of subsection 3 of the facility's policy, titled "Pneumococcal Vaccine", last reviewed August, 2024, revealed it stated, "Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. (See current vaccine information statements at [Centers for Disease Control's website] for educational materials.) Provision of such education shall be documented in the resident's medical record."

Review of the facility's infection control's vaccination tracking data revealed that Residents 61, 90, and 92 had refused the 2023/2024 influenza vaccination. Further review revealed Resident 92's Resident Representative had refused the pneumococcal immunization.

During a staff interview on March 14, 2024, at approximately 10:40 AM, Employee 2 (Facility Infection Control Nurse) was asked if Residents 61, 90, and 92 were provided education and risks and benefits of the vaccines via the identified Centers for Disease Control education material. Employee 2 stated that the Residents/Resident Representatives were not provided with the educational material at the time of refusal.

During a staff interview on March 14, 2024, at approximately 1:00 PM, Nursing Home Administrator revealed it was the facility's expectation that Residents/Resident Representatives would be provided the Centers for Disease Control's educational information sheet on the influenza and pneumococcal vaccinations at the time of refusal of the vaccine.

28 Pa code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 04/24/2024

1. R61, R90, and R92 were provided with flu and pneumonia education.
2. Facility provided written education to current residents on flu and pneumonia vaccine.
3. Education will be provided to Infection Control nurse to on requirements of provided written education to residents and families on flu/pneumonia vaccines.
4. ADON/designee will audit up to 5 new residents admitted weekly x4 weeks, then 10 monthly x2 months to ensure education on flu/pneumonia vaccines was provided. Audits will be reviewed at QAPI to ensure compliance and quality improvement.

483.95(b) REQUIREMENT Resident Rights Training:

§483.95(b) Resident's rights and facility responsibilities.
A facility must ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents as set forth at §483.10, respectively.

Observations:

Based on review of facility documentation, and interviews it was determined that the facility failed to ensure that direct care nursing staff completed training/demonstrated competency upon hire and annually thereafter related to resident rights for two of five direct care staff members reviewed (Employees 8 and 9).

Findings include:

Review of the annual Staff Education Reports for five direct care staff members revealed that Employees 8 and 9 (Nurse Aides) failed to complete annual training for resident rights in the past year.

During an interview with the Nursing Home Administrator (NHA) on March 14, 2024, at 10:55 AM it was revealed that the facility scheduled in-person training lasting one hour in duration each month and covered a different topic. It was further revealed that all staff were expected to attend one of the two training sessions offered each month. The NHA acknowledged that at times a staff member doesn't attend the required monthly training, and the facility doesn't provide "make-up" sessions.

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

28 Pa. Code 201.20(a)(d) Staff development.

Plan of Correction - To be completed: 04/24/2024

1. Employee 8 and 9 will receive education on residents rights.
2. Facility audit revealed some direct care failed to attend required monthly trainings.
3. The facility will provide re-education on the regulatory requirement for required in-servicing, and how it directly affects their certification. The facility will provide an opportunity for staff to receive 1:1 training if they are unable to attend mandatory in-servicing. Staff will be removed from the schedule if they fail to meet the monthly in-servicing requirements.
4. HR/designee will complete audits monthly after required in-services to ensure required staff are in attendance. Audits will be reviewed at QAPI to ensure compliance and quality improvement.

§ 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.

Plan of Correction - To be completed: 04/24/2024

1. Facility cannot retroactively correct the staffing concern.
2. Facility reviews of grievances did not reveal any residents' concerns related to the days licensed staffing did not meet regulatory requirements (3/6 night shift, and 3/9 and 3/10 day shift).
3. Re-education will be provided to staff regarding Act 102, mandated staffing, in the event of unanticipated call outs or no call, no shows at the start of the shift and staffing ratios. Re-education will be provided to scheduler and nursing supervisors regarding making additional calls to staff to cover call outs. The facility will continue to utilize recruiting services for hiring new staff and hold weekly meetings for ongoing recruitment/retention efforts. Monetary incentives are offered to staff on days when anticipated ratios are below minimum. DON/Administrator will monitor PPD and staffing ratios via daily meeting with scheduler to ensure compliance with regulations.
4. NHA/designee will audit LPN ratios daily to ensure compliance. Audits will be reviewed at QAPI to ensure compliance and quality improvement.

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