Pennsylvania Department of Health
MAPLE HEIGHTS HEALTH & REHAB CENTER
Patient Care Inspection Results

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MAPLE HEIGHTS HEALTH & REHAB CENTER
Inspection Results For:

There are  254 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.
MAPLE HEIGHTS HEALTH & REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a complaint survey completed on February 14, 2024, it was determined that Maple Heights Health and Rehab 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:


483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.
Observations:


Based on review of facility policies and personnel records, as well as staff interviews, it was determined that the facility failed to ensure that reference checks were obtained prior to hire for four of five new employees reviewed (Nurse Aides 3 and 4, Licensed Practical Nurse 5, Registered Nurse 6).

Findings include:

The facility's policy regarding abuse, dated December 12, 2023, indicated that prior to hiring a new employee the facility would generally attempt to obtain references from two prior employers for an applicant.

The personnel file for Nurse Aide 3 revealed that she was hired on October 22, 2023, and there was no documented evidence that reference checks from previous employers were obtained prior to the staff's start date.

The personnel file for Nurse Aide 4 revealed that she was hired on December 7, 2023, and there was no documented evidence that reference checks from previous employers were obtained prior to the staff's start date.

The personnel file for Licensed Practical Nurse 5 revealed that she was hired on December 18, 2023, and there was no documented evidence that reference checks from previous employers were obtained prior to the staff's start date.

The personnel file for Registered Nurse 6 revealed that she was hired on January 8, 2024, and there was no documented evidence that reference checks from previous employers were obtained prior to the staff's start date.

Interview with the Human Resource Director on February 13, 2024, at 3:23 p.m. confirmed that there was no documented evidence of reference checks for Nurse Aides 3 and 4, Licensed Practical Nurse 5, and Registered Nurse 6 prior to their start date.

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





 Plan of Correction - To be completed: 03/07/2024

1. Reference checks for Nurse Aides 3 and 4, Licensed Practical Nurse 5 and Registered Nurse 6 were completed.
2. Look back of everyone hired since January 1, 2024 to verify their background checks were completed by Human Resources Director or designee.
3. To prevent a reoccurrence, Human Resource Director will educate all department managers on obtaining reference checks as part of the hiring process.
4. Human Resource Director or designee will audit all new hires for reference checks weekly for 4 weeks then monthly for 2 months. Results will be tracked and trended and reported to the Quality Assurance Committee for recommendations and Follow Up by Human Resources or designee.

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 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.
§483.75(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) surveys ending February 16, 2023; March 9, 2023; March 29, 2023; June 6, 2023; July 13, 2023; August 23, 2023; September 15, 2023; October 18, 2023; and November 6, 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 February 14, 2024, identified repeated deficiencies related to a failure to notify residents' physician/responsible parties regarding changes in condition, to provide a clean and homelike environment, to ensure that Minimum Data Sets (MDS, a mandated assessment of a resident's abilities and care needs) assessments were accurate upon submission, develop individualized care plans, to prevent accident hazards, to prevent issues with oxygen therapy, to prevent issues with the accountability of controlled medications (drugs with the potential to be abused), properly store and label medications, to serve palatable food at appropriate temperatures, store and prepare food under sanitary conditions, and to ensure proper infection control practices were followed.

The facility's plan of correction for a deficiency regarding notifying the physician/responsible party about changes in condition, cited during the survey ending February 16 and August 25, 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 F580, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding physician/responsible party notification.

The facility's plans of correction for deficiencies regarding providing a clean and homelike environment, cited during the surveys ending February 16, 2023 revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F584, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to maintaining a clean and homelike environment.

The facility's plan of correction for a deficiency regarding a failure to ensure that MDS's were accurate upon submission, cited during the survey ending February 16, 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 F641, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to accurate MDS assessments.

The facility's plan of correction for a deficiency regarding the development of a comprehensive person-centered care plan, cited during a survey ending February 16, 2023, revealed that audits would be completed. The results of the current survey, cited under F656, revealed that the QAPI committee was ineffective in correcting deficient practices related to the development of a comprehensive person-centered care plan.

The facility's plans of correction for deficiencies regarding providing a safe environment free of accident hazards, cited during the surveys ending February 16, March 9, and October 18, 2023, revealed that the facility developed plans 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 F689, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to safety and accident-free enviornment's.

The facility's plan of correction for a deficiency regarding failure to provide respiratory care and treatment as ordered by the physician, cited during the survey ending July 13, 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 F695, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to administering oxygen as ordered.

The facility's plans of correction for deficiencies regarding the failure to account for controlled medications, cited during the surveys ending February 16 and October 18, 2023, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications.

The facility's plan of correction for a deficiency regarding storing/labeling medications properly, cited during the survey ending February 16, 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 facility's QAPI committee was ineffective in correcting deficient practices related to storing/labeling medications properly.

The facility's plan of correction for a deficiency regarding food palatability, cited during the survey ending March 29 and September 15, 2023, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F804, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding food palatability.

The facility's plan of correction for a deficiency regarding food storage and labeling, cited during the survey ending February 16 and November 6, 2023, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F812, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding food storage and labeling.

The facility's plans of correction for deficiencies regarding infection control practices, cited during the surveys ending February 16 and June 6, 2023, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F880, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to infection control.

Refer to F580, F584, F641, F656, F689, F695, F755, F761, F804, F812, F880.

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

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




 Plan of Correction - To be completed: 03/07/2024

1. Facility is unable to fix the Quality Assurance audits at the time of the survey.
2. No other issues identified.
3. Nursing Home Administrator will educate the all department managers on the quality assurance process improvement policy.
Nursing Home Administrator or designee will audit the Quality Assurance Process Improvement meeting monthly to verify all audits are reported, analyzed and a process improvement plan implemented if needed.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
§483.60(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 ensure that food was stored and served under sanitary conditions, in accordance with professional standards for food service safety, and failed to ensure that food items were stored in accordance with professional standards for food service safety in three of three nursing unit pantry refrigerators (first, third, fourth floor pantries).

Findings include:

The facility's policy regarding food storage, dated December 12, 2023, indicated that dented cans shall be stored separately or immediately returned to the food supplier. If dented cans are stored in the storeroom, they are to be clearly marked to prevent usage.

Observations in the main kitchen in the dishwashing area on February 11, 2024, at 8:51 a.m. and February 13, 2024, at 11:55 a.m. revealed that the ceiling and wall by the door exiting the dish room into the hallway had large areas where the paint was cracked, peeling, and hanging down. The ceiling that leads from the dish room to the tray line area and the food prep area had multiple areas where the paint was cracked, peeling, and hanging down. Over the prep area there was a ceiling tile that was broken and missing exposing the area above the ceiling tiles.

Observations in the corner of the prep area near walk-in cooler 10 on February 11, 2024, at 8:58 a.m. revealed that there were three metal racks that had two-gallon cans of baked beans and one-gallon can of spaghetti sauce that were dented.

Interview with Cook 10 on February 11, 2024, at 9:09 a.m. confirmed that the cans were dented and that they should not have been stored on metal racks.

Interview with the Dietary Manager on February 13, 2024, at 11:59 a.m. confirmed that the ceilings needed repair and indicated that it was not that long ago that those areas were painted. He confirmed that the ceiling tile was broken exposing the area above the ceiling tile. He confirmed that the dented cans should have been removed to the area that they have for them to go back to the food supplier.

The facility's policy regarding storage of refrigerated foods, dated December 12, 2023, indicated that refrigerators will be maintained at temperatures of 41 degrees Fahrenheit (F) or below. Thermometers should be checked at least two times each day. Staff was to report unacceptable temperatures to the food and nutrition services manager or designee immediately. Maintenance staff must also be notified of unacceptable temperatures. All refrigerated and frozen items must be appropriately dated to ensure proper rotation by expiration dates. "Use by" dates will be completed with expiration dates on all prepared food in refrigerators.

Observations in the first-floor pantry on February 14, 2024, at 11:18 a.m. revealed that the refrigerator contained two glasses of Almond milk that was prepared by the dietary department with a use by date of February 13, 2024.

Interview with Licensed Practical Nurse 9 on February 14, 2024, at 11:30 a.m. confirmed that the two glasses of Almond milk should have been discarded.

Review of the first floor, third floor, and fourth floor's temperature logs, dated December 2023, January 2024, and February 2024, revealed that the refrigerator temperatures were only obtained once a day January 1 through 31, 2024, and February 1 through 13, 2024. There was no documented evidence that the freezer temperatures were obtained twice a day December 1 through 31, 2023; January 1 through 31, 2024; and February 1 through 13, 2024.

Interview with the Nursing Home Administrator on February 14, 2024, at 2:05 p.m. confirmed that the refrigerator temperatures were not completed twice a day as per the facility's policy on the dates listed above and that there was no documented evidence that the freezer temperatures were obtained on the above listed dates.

28 Pa. Code 211.6(f) Dietary Services.





 Plan of Correction - To be completed: 03/07/2024

1. Dented cans were thrown away at the time they were found. The hole in the ceiling was fixed and the peeling paint was scraped and fixed, the two glasses of Almond Milk were discarded at the time of survey, temperature in the refrigerator and freezer were checked and were within acceptable range.
2. All cans were audited for dents the same day. Ceiling was audited for any additional holes and peeling paint; refrigerators were checked for outdated food and beverages and all refrigerators were checked for appropriate temperatures and were within normal range.
3. In order to prevent a reoccurrence, dietary staff will be educated on not putting dented cans on the can racks and reporting holes in the ceiling and peeling paint on the walls, discarding food and beverage prior to expiration date and documenting refrigerator and freezer temperature twice per day Dietary Manager or designee.
4. Dietary manager or designee will do audits weekly for four weeks and then monthly for two months to verify the cans are not dented, there are no holes in the ceiling or peeling paints on the walls, there is no outdated food or beverage in the refrigerator and the temperatures were taken twice per day. Results will be tracked and trended and reported to Quality Assurance committee for recommendations and Follow Up by Dietary Manager or designee.

483.60(d)(6) REQUIREMENT Drinks Avail to Meet Needs/Prefs/Hydration: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.
§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(6) Drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration.
Observations:


Based on clinical record reviews and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents' drink preferences were honored for 16 of 65 residents reviewed (Residents 3, 10, 25, 38, 41, 45, 51, 65, 67, 87, 98, 102, 105, 106, 112, 117).

Findings include:

Interview with a group of residents on February 12, 2024, at 3:00 p.m. revealed that they wanted to have soda as a drink choice, either for meals or for a snack. They stated that there was no soda available for them at all. The residents stated that they were told that they could purchase their own soda from the vending machines in the building, or they could have someone bring in soda for them, but it would no longer be supplied for them by the facility.

Interview with the Dietary Manager on February 13, 2024, at 11:59 a.m. revealed that the facility has some soda that he will use for special occasions; however, he is not permitted to order soda for the residents on a regular basis. He indicated that the decision came from his corporate office that they could no longer order soda.

Interview with the Dietician and Nursing Home Administrator on Feburary 13, 2024, at 2:41 p.m. revealed that the facility prefers to give the residents drinks with nutritional value and not soda. They stated that the residents may purchase their own soda, but that they would not provide it for them because it was not a good choice for them. They were aware that the residents continue to request soda as a drink choice for some meals and for their snacks.

28 Pa. Code 201.29(j) Resident Rights.







 Plan of Correction - To be completed: 03/07/2024

1. Resident identified during survey was informed sodas are available in vending machines in facility and Activities will assist them in purchasing in bulk to keep on hand in their room.
2. No other issues were identified with availability of sodas.
3. Dining Director or designee will educate dining staff on resident's preferences and availability of drinks available. Activity Director will assist residents in purchasing soda in bulk to keep on hand if they have soda as a preference and place them on a routine schedule to make sure their supply is stocked.
4. Dining director or designee will audit five residents per week for four weeks and then five residents monthly for two months to verify their preferences were followed.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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.
§483.60(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 review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures.

Findings include:

The facility's policy regarding food temperatures, dated December 12, 2023, revealed that hot food items may not fall below 135 degrees Fahrenheit (F) while holding after cooking. Hot food should be at least 135 degrees F when plated. Hot food should be palatable at point of delivery.

Interview with Resident 41 on February 11, 2024, at 10:00 a.m. revealed that she does not like the taste of the food.

Interview with Resident 143 on February 11, 2024, at 10:08 a.m. revealed that the meat is dry, there is no flavor, and the meals are sometimes cold when she gets her tray.

Interview with Resident 26 on February 11, 2024, at 10:20 a.m. revealed that the food is awful, never tastes good, and is not warm when he gets his tray.

Observations in the main kitchen on February 13, 2024, revealed that the Third Floor South Shoe cart left the main kitchen at 12:37 p.m. and arrived on the Third Floor at 12:39 p.m. Trays were passed to the residents in their rooms at 12:40 p.m. and the last resident was served at 12:46 p.m. At 12:47 p.m. the temperature of the Ravioli was 131.5 degrees F, the temperature of the Cauliflower was 147 degrees F, the temperature of the soup was 154 degrees F, the temperature of the coffee was 152 degrees F, and the temperature of the milk was 33.3 degrees F. The Ravioli was lukewarm and not appetizing. The Cauliflower was mushy and not appetizing. Interview with the Dietary Manager at the time of observation revealed that he would like to see his hot foods to be at a minimum of 140 degrees F.




 Plan of Correction - To be completed: 03/07/2024

1. Facility is unable to fix the food temperatures at the time of the survey.
2. No other identified issues at the time of the survey.
3. Dining manager or designee will educate Dining staff on the appropriate food temperatures.
4. Dining manager or designee will audit 5 resident trays per week for four weeks and then 5 trays monthly for two months for appropriate food temperatures. Results will be tracked and trended and reported to Quality Assurance committee for recommendations and Follow Up by Dietary Manager or designee.

483.30(b)(1)-(3) REQUIREMENT Physician Visits - Review Care/Notes/Order: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.
§483.30(b) Physician Visits
The physician must-

§483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section;

§483.30(b)(2) Write, sign, and date progress notes at each visit; and

§483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the Certified Registered Nurse Practitioner/physician wrote, signed, and dated progress notes with each visit for one of 65 residents reviewed (Resident 8).

Findings include:

Nursing notes for Resident 8, dated July 21 and 28, 2023; August 2, 7, and 29, 2023; September 18, 2023; October 9, 2023; November 1, 2023; December 13, and 28, 2023; and February 5, 2024, revealed that the resident was seen by Certified Registered Nurse Practitioner 8 (CRNP - a registered nurse with advanced training).

As of February 13, 2024, there was no documented evidence in Resident 8's clinical record that CRNP 8 had completed a progress note for her visits to the resident on the above dates.

A nursing note for Resident 8, dated December 14, 2023, revealed that the resident was seen by the physician for a regulatory visit.

As of February 13, 2024, there was no documented evidence in Resident 8's clinical record that the physician had completed a progress note for his visit to the resident on December 14, 2023.

Interview with the Director of Nursing on February 13, 2024, at 1:00 p.m. confirmed that she could not find any documented evidence of the notes from CRNP 8 and the physician that matched the nursing notes on the above dates for Resident 8.

28 Pa. Code 211.5(f) Clinical Records.



 Plan of Correction - To be completed: 03/07/2024

1. Facility is not able to obtain previous physician or Registered Nurse Practitioner notes for resident 8.
2. Facility looked back two weeks to audit that physician and Registered Nurse Practitioner notes were present for their visits by Director of Nursing or designee.
3. In order to prevent a reoccurrence, Physician and Registered Nurse Practitioner will be educated on writing a note for each resident they visit by Director of Nursing or designee.
4. Director of Nursing or designee will audit Physician and Registered Nurse Practitioner visits weekly for four weeks, and then monthly for two months to verify a note is present for each resident they visit. Results will be tracked and trended and reported to Quality Assurance committee for recommendations and Follow Up by Director of Nursing or designee.

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 a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for five of 65 residents reviewed (Residents 21, 41, 51, 90, 113).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2023, revealed that Section N0415E1 Anticoagulant (medicines that help prevent blood clots) Medications was to be coded if an anticoagulant medication was taken by the resident at any time during the seven-day look-back period.

Physician's orders for Resident 21, dated January 9, 2024, included an order for the resident to receive one 3 milligram (mg) tablet of Warfarin (an anticoagulant) at bedtime.

Review of the Medication Administration Record (MAR) for Resident 21, dated January 2024, revealed that staff had administered the 3 mg tablet of Warfarin to the resident on January 9 through 23, 2024.

A quarterly MDS assessment for Resident 21, dated, January 17, 2024, revealed that Section NO415E1 was not coded, indicating that the resident to did not receive an anticoagulant medication during the seven-day look-back assessment period.

Interview with a Licensed Practical Nurse Assessment Coordinator on February 14, 2024, at 9:10 a.m. confirmed that Resident 21 received an anticoagulant medication during the seven-day look-back period and should have been coded for an anticoagulant medication.

The RAI User's Manual, dated October 2023, revealed that Section N0415F Antibiotic Medications was to be coded if the resident took the medication during the seven-day look-back period.

Physician's orders for Resident 41, dated January 25, 2024, included an order for the resident to receive 2 percent of Bactroban (an antibiotic) one application to right thumb nail every eight hours for five days.

Review of the MAR for Resident 41, dated January 2024, revealed that staff had administered the 2 percent Bactroban ointment to the resident on January 26 through January 29, 2024.

A quarterly MDS for Resident 41, dated January 29, 2024, revealed that section N0415F was not coded, indicating that the resident to did not receive antibiotic medication during the seven-day look-back assessment period.

Physician's orders for Resident 51, dated September 30, 2023, included an order for the resident to receive 0.5 percent of Moxifloxacin (an antibiotic) one drop to bilateral eye twice a day.

Review of the MAR for Resident 51, dated November 2023, revealed that staff had administered the 0.5 percent Moxifloxacin eye drops to the resident on November 4 through November 9, 2023.

An annual MDS for Resident 51, dated November 10, 2023, revealed that section N0415F was not coded, indicating that the resident did not receive antibiotic medication during the seven-day look-back assessment period.

Interview with a Licensed Practical Nurse Assessment Coordinator on February 13, 2024, at 12:15 p.m. confirmed that Resident 41 and 51 received antibiotics during the seven-day look-back period and should have been coded for antibiotics.

The RAI User's Manual, dated October 2023, revealed that Section N0415G Diuretic Medications (medication used to remove excess fluid) was to be coded if the resident took the medication during the seven-day look-back period.

Physician's orders for Resident 90, dated June 22, 2023, included an order for the resident to receive 20 mg of Furosemide (diuretic medication) daily.

Review of the MAR for Resident 90, dated January 2024, revealed that staff had administered 20 mg Furosemide to the resident on January 19 through January 25, 2024.

A quarterly MDS for Resident 90, dated January 25, 2024, revealed that section N0415G was not coded, indicating that the resident did not receive diuretic medication during the seven-day look-back assessment period.

Interview with a Licensed Practical Nurse Assessment Coordinator on February 13, 2024, at 12:15 p.m. confirmed that Resident 90 received diuretic medication during the seven-day look-back period and should have been coded for diuretic medication.

The RAI User's Manual, dated October 2023, revealed that Section N0415F Antibiotic Medications was to be coded if the resident took the medication during the seven-day lookback period, Section N0415G Diuretic Medications was to be coded if the resident took the medication during the seven-day lookback period, and Section N0415I Antiplatelet Medications was to be coded if the resident took the medication during the seven-day look-back period.

Physician's orders for Resident 113, dated October 6, 2023, included orders for the resident to receive 800/160 mg of Bactrim DS (antibiotic) daily on Monday, Wednesday, and Friday, and 81 mg of aspirin (antiplatelet) once a day. Physician's orders, dated December 30, 2023, included an order for the resident to receive 40 mg of Lasix (diuretic) once a day.

The resident's MAR's for December 2023 and January 2024 revealed that the resident received Bactrim DS on December 29, 2023, and January 1 and 3, 2024; Lasix on December 30 and 31, 2023, and January 1 and 2, 2024; and aspirin on December 28 to 31, 2023, and January 1 and 2, 2024.

A quarterly MDS for Resident 113, dated January 3, 2024, revealed that sections N0415F, N0415G, and N0415I were not coded, indicating that the resident to did not receive antibiotic, diuretic, and antiplatelet medications during the seven-day look-back assessment period.

Interview with the Director of Nursing on February 14, 2024, at 3:50 p.m. confirmed the resident's MDS assessments listed above were coded incorrectly.

28 Pa. Code 211.5(f) Clinical Records.



 Plan of Correction - To be completed: 03/07/2024


1. Resident # 21 Minimum Data Set (MDS) assessment with an ARD of 1/17/24 was modified to include Anti-coagulant
Resident # 41 Did not have an MDS with an ARD of 1/25/24
Resident # 41 MDS with an ARD of 1/29/24 was modified to include Antibiotics
Resident # 51 MDS with ARD of 11/10/23 was modified to include Antibiotic
Resident # 90 Did not have an MDS with ARD of 1/25/24, however the MDS with ARD of 1/24/24 was modified to include Diuretic
Resident # 113 MDS with ARD of 1/3/24 was modified to include Antibiotic, Diuretic and Anti-Platelet

2.Current residents and new admissions have the opportunity to be affected. The MDS Nurse, nurse and/or Regional Clinical Reimbursement Specialist will complete an audit of the most recent MDS assessments to ensure they are coded correct. Modification will be made as needed.

3.To prevent this from reoccurring the Regional Clinical Reimbursement Specialist provided education with the MDSs nurse and IDT team members on proper coding of the MDS items. This education was completed on 2/22/24.

4. To monitor and maintain ongoing compliance the MDS nurse or designee will complete audits weekly for 4 weeks then weekly for 2 months to ensure MDS assessments are being completed within acceptable time frames.
The results of the audits will be forwarded to the facility Quality Assurance committee for further review and recommendations by Director of Nursing or designee.

483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing: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 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

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

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


Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission and annual Minimum Data Set assessments were completed in the required time frame for six of 65 residents reviewed (Residents 16, 55, 118, 123, 129, 130).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that an admission MDS assessment was to be completed no later than 14 days following admission, that the Assessment Reference Date (ARD - the last day of an assessment's look-back period) must be set within 366 days after the ARD of the previous comprehensive assessment, and that the assessment was to be completed no later than the ARD plus 14 calendar days.

An admission MDS assessment for Resident 16 revealed that the resident was admitted to the facility on January 10, 2024, and the resident's admission MDS assessment was dated as completed on January 30, 2024, which was 21 days after admission.

An admission MDS assessment for Resident 55 revealed that the resident was admitted to the facility on December 28, 2023, and the resident's admission MDS assessment was dated as completed on January 19, 2024, which was 23 days after admission.

An admission MDS assessment for Resident 123 revealed that the resident was admitted to the facility on January 18, 2024, and the resident's admission MDS assessment was dated as completed on February 6, 2024, which was 20 days after admission.

An admission MDS assessment for Resident 129 revealed that the resident was admitted to the facility on January 11, 2024, and the resident's admission MDS assessment was dated as completed on January 30, 2024, which was 20 days after admission.

An admission MDS assessment for Resident 130 revealed that the resident was admitted to the facility on January 17, 2024, and the resident's admission MDS assessment was dated as completed on February 6, 2024, which was 21 days after admission.

An annual comprehensive MDS assessment for Resident 118, with an ARD of January 15, 2024, was due to be completed by January 29, 2024, but was not signed as completed until February 2, 2024, which was four days from the ARD until completion.

Interview with the Nursing Home Administrator on February 14, 2024, at 11:50 a.m. confirmed that the admission MDS assessments for Residents 16, 55, 123, 129, and 130, and the annual MDS assessment for Resident 118 were completed late.

28 Pa. Code 211.5(f) Clinical records.






 Plan of Correction - To be completed: 03/07/2024

1. Resident # 16 had a timely completed Minimum Data Set (MDS) assessment with an ARD 2/1/24
Resident # 55 Will have a timely MDS completed by: 4/16/24
Resident # 118 Will have a timely MDS completed by: 4/16/24
Resident # 123 Discharge the facility on 2/24/24
Resident # 129 Expired on 2/23/24
Resident # 130 Will have a timely MDS completed by: 4/25/24


2. Current residents and new admissions have the opportunity to be affected. The MDS Nurse or Regional Clinical Reimbursement Specialist will complete an audit of MDS assessments to ensure they are not past due.

3. To prevent this from reoccurring the Regional Clinical Reimbursement Specialist provided education with the MDSs nurse and IDT team members on completion of MDS assessments to include acceptable time frames of completion. This education was completed on 2/22/24.

4. To monitor and maintain ongoing compliance the Regional Clinical Reimbursement Specialist or MDS nurse will complete audits weekly for 4 weeks then weekly for 2 months to ensure MDS assessments are being completed within acceptable time frames.
The results of the audits will be forwarded to the facility Quality Assurance Committee for further review and recommendations by Director of Nursing or Designee.

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

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


Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's physician was notified about the need to alter treatment for one of 65 residents reviewed (Resident 51).

Findings include:

The facility's policy regarding Diabetic Protocol, dated December 12, 2023, indicated that the provider and staff will work together give appropriate treatments to manage diabetes.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated November 10, 2023, indicated that the resident was cognitively intact, required assistance with daily care needs, and had diagnoses that included diabetes (a disease that interferes with blood sugar control).

Physician's orders for Resident 51, dated January 22, 2024, included an order to check the resident's blood sugar before meals and at bedtime and notify the physician if the blood sugar was greater than 400 milligrams per deciliter (mg/dL).

A review of Resident 51's Medication Administration Record (MAR) for January and February 2024 revealed that the resident's blood sugar on January 24, 2024, at 11:00 a.m. was 530 mg/dl and at 4:00 p.m. it was 438 mg/dl; on January 31, 2024, at 7:00 a.m. it was 460 mg/dl; on February 1, 2024, at 11:00 a.m. it was 478 mg/dl; on February 2, 2024, at 4:00 p.m. it was 418 mg/dl; and on February 4, 2024, at 7:00 a.m. it was 471 mg/dl. There was no documented evidence that the physician was notified of these elevated blood sugars as ordered.

An interview with the Director of Nursing on February 12, 2024, at 3:19 p.m. confirmed there was no documented evidence that the physician was notified of Resident 51's elevated blood sugars and that he should have been.

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




 Plan of Correction - To be completed: 03/07/2024

1. Resident 51's blood sugar was reported to the physician with no negative outcome or additional orders.
2. Two-week look back on all resident's blood sugars to verify they were reported to the physician to be done by the Director of Nursing or Designee
3. To prevent a reoccurrence, Director of Nursing or designee will educate all licensed nursing staff on physician notification with elevated blood sugars.
4. Director of Nursing or Designee will monitor blood sugars weekly for four weeks and then monthly for two months. Results will be tracked and trended and reported to Quality Assurance committee by Director of Nursing or designee for recommendations and follow up.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:


Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment for one of 65 residents reviewed (Resident 33).

Findings include:

The facility's policy regarding cleaning and disinfecting, dated December 12, 2023, indicated that housekeeping was to remove visible debris from surfaces and that proper cleaning was necessary to reduce infection.

A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated January 17, 2024, revealed that the resident was cognitively impaired and had diagnoses that included acute respiratory disease (a serious blood condition that causes low blood oxygen) and a history of atrial fibrillation (irregular heart rhythm). The resident was receiving continuous oxygen via nasal cannula (tubes that deliver oxygen into the nostrils).

Observations on February 11, 2024, at 12:20 p.m. and 2:27 p.m. revealed that the resident was lying in her bed with a stand-up fan blowing directly on her. The fan was noted to have a large amount of visible dirt and debris accumulated on the blade cover.

Interviews with Housekeeper 1 and Registered Nurse Supervisor 2 on February 11, 2024, at 2:30 p.m. revealed that the fan belonged to the resident. They confirmed that the fan was blowing directly on the resident with a large amount of dirt and debris accumulated on the blade cover, and that it should have been clean and it was not.

Interview with Director of Nursing on February 12, 2024, at 4:10 p.m. confirmed that Resident 33's fan cover should be clean, and it was not.





 Plan of Correction - To be completed: 03/07/2024

1. Resident 33's fan was cleaned the same day.
2. Housekeeping Supervisor audited all fans in resident rooms to make sure they were clean.
3. To prevent a reoccurrence, housekeeping staff will be educated to monitor cleanliness of fans by housekeeping supervisor or designee.
4. Housekeeping supervisor will audit all fans for cleanliness weekly for four weeks and then monthly for two months. Results will be tracked and trended and reported to Quality Assurance committee for recommendations by Director of Nursing or designee.

483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.
Observations:


Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required timeframe for three of 65 residents reviewed (Residents 45, 47, 77).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to be completed no later than the ARD plus 14 calendar days.

A quarterly MDS assessment for Resident 45, with an ARD of January 16, 2024, was due to be completed by January 30, 2024, but was not signed as completed until February 8, 2024, which was 23 days from the ARD until completion.

A quarterly MDS assessment for Resident 47, with an ARD of January 17, 2024, was due to be completed by January 31, 2024, but was not signed as completed until February 8, 2024, which was 22 days from the ARD until completion.

A quarterly MDS assessment for Resident 77, with an ARD of November 8, 2023, was due to be completed by November 22, 2023, but was not signed as completed until February 1, 2024, which was 85 days from the ARD until completion.

An interview with Director of Nursing on February 14, 2024, at 11:50 a.m. confirmed that Resident 45, 47, and 77's quarterly MDS assessments were completed late.

28 Pa. Code 211.5(f) Clinical Records.




 Plan of Correction - To be completed: 03/07/2024

1. Resident # 45 Will have an Minimum Data Set (MDS) assessment timely completed by: 4/16/24
Resident # 47 Will have an MDS timely completed by: 4/18/24
Resident # 77 had a timely Quarterly MDS completed with an ARD of 2/7/24

2. Current residents and new admissions have the opportunity to be affected. The MDS Nurse or Regional Clinical Reimbursement Specialist will complete an audit of MDS assessments to ensure they are not past due.

3. To prevent this from reoccurring the Regional Clinical Reimbursement Specialist provided education with the MDSs nurse and IDT team members on completion of MDS assessments to include acceptable time frames of completion. This education was completed on 2/22/24.

4. To monitor and maintain ongoing compliance the Regional Clinical Reimbursement Specialist or MDS nurse will complete audits weekly for 4 weeks then monthly for 2 months to ensure MDS assessments are being completed within acceptable time frames.
The results of the audits will be forwarded to the facility Quality Assurance committee for further review and recommendations by Director of Nursing or designee.

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


Based on review of facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of two of 65 residents reviewed (Residents 57, 109).

Findings include:

A policy regarding care plans, dated December 12, 2023, indicated that the facility was to develop a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessments.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 57, dated November 13, 2023, revealed that the resident was cognitively intact, and was receiving an anti-depressant and an anti-psychotic medication.

Physician's orders for Resident 57, dated November 7, 2023, included an order for the resident to receive 40 milligrams (mg) of Celexa (anti-depressant) once a day, and an order, dated November 6, 2023, for the resident to receive 1 mg of Haldol (anti-psychotic) twice a day.

There was no documented evidence that a care plan was developed to address Resident 57's care needs related to the use of an anti-depressant or an anti-psychotic medication.

Interview with Nursing Home Administrator on February 14, 2024, at 10:41 a.m. confirmed that Resident 57 did not have a care plan to address his anti-depressant or anti-psychotic medication use and that he should.


An annual MDS assessment for Resident 109, dated December 30, 2023, revealed that the resident received an anticoagulant medication (a medication that thins the blood to prevent clots). Physician's orders, dated December 14, 2023, included orders for the resident to receive 5 milligrams (mg) of Eliquis (an anticoagulant medication) twice a day, and the resident's Medication Administration Records for January 2024 revealed that the resident received Eliquis on January 1 through 14, 2024.

There was no documented evidence that a care plan was developed to address Resident 109's specific and individualized care needs related to receiving an anticoagulant medication.

Interview with the Director of Nursing on February 13, 2024, at 1:14 p.m. confirmed that an individualized care plan and interventions were not developed related to Resident 109 receiving anticoagulant medication.

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



 Plan of Correction - To be completed: 03/07/2024

1. Resident # 57 Had an Anti-depressant and Anti-psychotropic care plan created
Resident # 109 Had an Anti-coagulant care plan created.

2. Current residents and new admissions have the opportunity to be affected. The Nursing team will complete an audit of residents with the same medications to ensure they have appropriate care plans in place.

3. To prevent this from reoccurring the Regional Clinical Reimbursement Specialist provided education with the Minimum Data Set assessment nurses and Interdisciplinary team members on creating comprehensive care plans. This education was completed on 2/22/24.

4. To monitor and maintain ongoing compliance the MDS nurse or designee will complete audits weekly for 4 weeks then weekly for 2 months to ensure Comprehensive care plans are in place.
The results of the audits will be forwarded to the facility Quality Assurance committee for further review and recommendations by the Director of Nursing or designee.

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 clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards by failing to follow physician's orders and care-planned interventions for one of 65 residents reviewed (Resident 119) who was at risk for skin breakdown.

Findings include:

A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 119, dated November 10, 2023, revealed that the resident was cognitively impaired and had diagnoses that included Alzheimer's disease. A care plan, dated November 14, 2023, revealed that the resident was at risk for skin breakdown.

Physician's orders for Resident 119, dated June 30, 2023, included orders for the resident to have a wedge seat cushion on her wheelchair, a red foam cover on the right brake handle, palm guards (guards worn on the hands to protect the fingers from injuring the palms) around both leg rest brackets of the wheelchair frame, and geri-sleeves (material sleeves that provide protection for sensitive skin) on both lower legs.

Observations of Resident 119 on February 12, 2024, at 1:24 p.m. and February 13, 2024, at 10:03 a.m. revealed that the resident was sitting in her wheelchair on a wedge seat cushion and palm guards were noted around both leg rest brackets and geri-sleeves were on both lower legs. However, there was no red foam cover on the right brake handle.

Interview with Occupational Therapist 7 on February 13, 2024, at 11:09 p.m. revealed that, due to resident's history of bumping her leg on the metal wheelchair brake handle, a red foam cover was ordered to be placed over the metal handle. She confirmed that the foam cover was there to protect her skin from injury, and it should have been in place per the physician's order, and it was not.

Interview with the Director of Nursing on February 13, 2024, at 12:21 p. m. confirmed that Resident 119's metal wheelchair brake handle should have had a protective foam cover as per physician's order, and it did not.

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



 Plan of Correction - To be completed: 03/07/2024

1. Wheelchair was provided with foam padding the same day.
2. All wheelchairs were audited by the director of nursing or designee to make sure they had the foam padding as ordered.
3. To prevent a reoccurrence, nursing staff will be educated on making sure the foam padding is provided as ordered by Director of nursing or designee.
4. Director of Nursing or designee will audit wheelchairs to verify they have foam padding as ordered weekly for four weeks and then monthly for two months and report findings to the monthly Quality Assurance Committee for recommendation and follow up by Director of nursing and designee.

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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received oxygen as ordered by the physician for one of 65 residents reviewed (Resident 33).

Findings include:

The facility's policy regarding oxygen therapy, dated December 12, 2023, indicated that oxygen was to be administered by licensed staff and in accordance with physician's orders.

A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated January 17, 2024, revealed that the resident was cognitively impaired and had diagnoses that included acute respiratory disease (a serious condition that causes low blood oxygen) and a history of atrial fibrillation (irregular heart rhythm). A care plan, dated January 25, 2022, indicated that Resident 33 was to receive continuous oxygen at 2 liters per minute via nasal cannula (tube that delivers oxygen into the nostrils).

Physician's orders for Resident 33, dated June 19, 2023, included an order for the resident to receive continuous oxygen at a flow rate of 2 liters per minute via nasal cannula.

Observations of Resident 33 in her room on February 11, 2024, at 1:10 p.m. and February 12, 2023, at 12:28 p.m. and 3:35 p.m. revealed that she was receiving oxygen at 3 liters per minute.

Interview with Registered Nurse Supervisor 2 on February 12, 2024, at 3:35 p.m. confirmed that Resident 33's oxygen flow rate was set at 3 liters per minute, not 2 liters per minute as ordered by the physician.

Interview with the Director of Nursing on February 12, 2024, at 4:10 p. m. confirmed that Resident 33's oxygen flow rate should be set at 2 liters continuously as per physician order, and it was not.

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




 Plan of Correction - To be completed: 03/07/2024

1. The respiratory oxygen rate for Resident 33 was fixed the same day.
2. Residents with O2 orders were audited to make sure their oxygen rates were set correctly by Director of Nursing or designee.
3. To prevent a reoccurrence, all nursing staff will be educated on the oxygen policy by Director of nursing or designee.
4. Director of nursing or designee will audit Residents on oxygen to verify their rates are correct weekly for four weeks and then monthly for two months. Results will be tracked and trended and reported to the Quality Assurance committee for recommendation and follow up by Director of Nursing or designee.

483.30(c)(1)-(4) REQUIREMENT Physician Visits-Frequency/Timeliness/Alt NPP: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.
§483.30(c) Frequency of physician visits
§483.30(c)(1) The residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter.

§483.30(c)(2) A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required.

§483.30(c)(3) Except as provided in paragraphs (c)(4) and (f) of this section, all required physician visits must be made by the physician personally.

§483.30(c)(4) At the option of the physician, required visits in SNFs, after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist in accordance with paragraph (e) of this section.
Observations:


Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a physician performed the initial comprehensive visit with the resident for one of 65 residents reviewed (Resident 96).

Findings include:

Resident 96's clinical record revealed that the resident was admitted to the facility on September 17, 2023.

A Certified Registered Nurse Practitioner's (CRNP, a registered nurse who has advanced education and clinical training in a health care specialty area) note for Resident 96, dated September 18, 2023, revealed that the resident was seen by the CRNP. Additional CRNP notes, dated October 26, 2023; November 8, 2023; and November 20, 2023, revealed that all visits were completed by the CRNP and not the attending physician.

There was no documented evidence in Resident 96's clinical record to indicate that the physician saw the resident until January 9, 2024, which was four months after the resident was admitted to the facility.

Interview with the Director of Nursing on February 14, 2024, at 3:34 p.m. confirmed that the physician did not complete the initial physician's visit for Resident 96 and had not seen Resident 96 from his initial admission on September 17, 2023, until January 9, 2024.

28 Pa. Code 211.2(a) Physician Services.



 Plan of Correction - To be completed: 03/07/2024

1. Facility is unable to obtain a physician admission note for resident 96.
2. Facility audited all admission in a two-week look back period to verify that a physician admission note was present by Director of Nursing or designee
3. In order to prevent a reoccurrence, the Physician will be educated on seeing new residents within 30 days of admission by Director of Nursing or designee.
4. The Director of Nursing or designee will audit new admissions to verify the physician has seen them within thirty days of admission, weekly for four weeks and then monthly for two months. Results will be tracked and trended and reported to the Quality Committee for recommendations and follow up by Director of Nursing or designee.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications for one of 65 residents reviewed (Resident 113).

Findings include:

The facility's policy regarding medication administration, dated December 12, 2023, indicated that during medication administration, facility staff should take all measures required by facility policy and applicable law, document the administration of controlled substances in accordance with applicable law and observe the resident's consumption of the medication(s), and document necessary medication administration/treatment information on appropriate forms.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 113, dated January 3, 2024, revealed that the resident was alert and oriented, received an antianxiety medication, and had diagnoses that included anxiety (a feeling of fear, dread, and uneasiness).

Physician's orders for Resident 113, dated November 16, 2023, and January 9 and 12, 2024, included an order for the resident to receive 1 milligram (mg)/0.5 milliliters (mL) of Ativan intensol (schedule IV-controlled anti-anxiety medication) every eight hours for anxiety.

Controlled drug records and Medication Administration Records (MAR's) for Resident 113 for December 2023 and January 2024 indicated that a dose of 0.5 mL of Ativan was signed out for administration to the resident on December 8, 2023, at 4:00 p.m.; however, the amount documented prior to the administration on December 8 at 4:00 p.m. was 24.0 mL and after the dose was administered, the remaining amount was documented as 24.5 mL. A 0.5 mL dose of Ativan was signed out for administration to the resident on January 4, 2024, at 5:00 p.m.; however, the amount documented prior to the administration on January 4 at 5:00 p.m. was 12.0 mL and after the dose was administered, the remaining amount was documented as 11.0 mL. A 0.5 mL dose of Ativan was signed out for administration to the resident on January 19, 2024, at 10:00 a.m.; however, the amount documented prior to the administration on January 4 at 5:00 p.m. was 22.5 mL and after the dose was administered, the remaining count was documented as 21.5 mL. Staff continued to sign out Ativan from the inaccurate remaining amounts without question.

Interview with the Director of Nursing on February 14, 2024, at 12:39 p.m. confirmed that the signed-out doses of Ativan were administered to Resident 113, but the staff counted the remaining amounts inaccurately and continued to sign out Ativan doses without question.

28 Pa. Code 211.9(a)(h) Pharmacy Services.

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



 Plan of Correction - To be completed: 03/07/2024

1. Facility was unable to go back and verify that specific Ativan count for resident 113.
2. Facility looked back two weeks to verify the narcotic count was correct by Director of Nursing or designee
3. In order to prevent a reoccurrence, licensed staff will be educated on the medication count policy by Director of Nursing or designee
4. The director of nursing or designee will audit the medication counts weekly for four weeks and then monthly for two months. Results will be tracked and trended and reported to the Quality Assurance committee for recommendations and Follow Up by Director of Nursing or designee.

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 review of manufacturer's instructions and facility policy, as well as observations and staff interviews, it was determined that the facility failed to label medication when opened for one of two medication storage rooms reviewed.

Findings include:

The manufacturer's instructions for Aplisol (an injectable medication used to detect exposure to the bacteria that causes tuberculosis), dated March 2016, indicated that opened and in-use vials of Aplisol were to be discarded in 30 days.

The facility policy regarding storage and expiration dating of medications, biologicals, dated December 12, 2023, indicated that if a multi-dose vial of an injectable medication had been opened or accessed, the vial should be dated and discarded within 28 days unless the manufacturer specifies a different date for that opened vial.

Observations in the first floor medication refrigerator on February 14, 2024, at 9:57 a.m. revealed that there were two 1.0 milliliter (ml) vials of Aplisol, each in its own box. The safety cap (a plastic cap put on by the manufacturer and that is removed prior to withdrawing the medication) was missing on both vials, and neither of the vials of Aplisol, nor the boxes they were stored in, were labeled with the date they were opened, or with a "use by" date.

Interview with Licensed Practical Nurse 9 on February 14, 2024, at 9:57 a.m. confirmed that neither vial of Aplisol had a plastic safety cap, and neither of the vials nor the boxes were labeled with a "date opened" or a "use by" date.

Interview with the Director of Nursing on February 14, 2024, at 2:55 p.m. confirmed that at the time they were opened, vials of Aplisol were to labeled with the month, day and year, and were only good for 30 days once opened.

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



 Plan of Correction - To be completed: 03/07/2024

1. The vial of Aplisol was thrown away.
2. All vails of Aplisol were audited to verify they were dated by Director of Nursing or designee.
3. In order to prevent a reoccurrence, licensed nursing staff will be educated on dating all multi dose vials by Director of Nursing or designee
4. Director of Nursing or designee will audit the Dating of all multi dose vials weekly for four weeks and then monthly for two months. Results will be tracked and trended and reported to Quality Assurance committee by Director of Nursing or designee.

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 and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices and techniques were followed during the administration of medications.

Findings include:

The facility's policy regarding medication and administration through certain routes, dated December 12, 2023, indicated that staff were to cleanse their hands and wear gloves, draw up the medication dose, and select the appropriate injection site. After the injection, staff were to dispose of equipment according to facility policy and cleanse hands.

Physician's orders for Resident 82, dated November 29, 2023, included an order for the resident to receive 32 units of Lantus Insulin (a long-acting Insulin) once a day in the a.m.

Physician's orders for Resident 82, dated July 6, 2023, included an order for the resident to receive Humulin R regular insulin (a fast-acting Insulin) via a sliding scale (varies the dose of insulin based on blood glucose level). If the blood sugar is less than 60 milligram/deciliter (mg/dL), call the physician. 0 to 150 mg/dL = 0 units, 151 to 200 mg/dL = 2 units, 201 to 250 mg/dL = 4 units, 251 to 300 mg/dL = 6 units, 301 to 350 mg/dL = 8 units, 351 to 400 mg/dL = 10 units, 401 to 450 mg/dL = 12 units, and if greater than 450 mg/dL call the physician.

Observations during medication administration on February 13, 2024, at 8:47 a.m. revealed that Registered Nurse 11 prepared Resident 82's 32 units of Lantus insulin and 2 units of Humulin R insulin, then entered the resident's room and administered the 32 units of Lantus insulin and the 2 units of Humulin R in the resident's right arm without wearing gloves. Then without performing hand hygiene she administered the resident his medications.

Interview with Registered Nurse 11 on February 13, 2024, at 8:50 a.m. confirmed that she should have been wearing gloves when administering Resident 82 his insulin and should have performed hand hygiene prior to administering his medications.

Interview with the Director of Nursing on February 13, 2024, at 10:48 a.m. confirmed that Registered Nurse 11 should have been wearing gloves when administering insulin to Resident 82.

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




 Plan of Correction - To be completed: 03/07/2024

1. Registered nurse 11 was educated on wearing gloves while administering insulin at the time of this occurrence.
2. No other like residents identified.
3. Licensed nurses were educated on wearing gloves while administering insulin by Director of Nursing designee
4. Director of nursing or designee will audit the administration of insulin weekly for four weeks and then monthly for two months to verify nurses are wearing gloves. Results will be tracked and trended and reported to the Quality Assurance committee for recommendations and Follow up by Director of Nursing or designee

§ 211.9(j.1) (1) - (5) LICENSURE Pharmacy services.:State only Deficiency.
(j.1) The facility shall have written policies and procedures for the disposition of medications that address all of the following:
(1) Timely and safe identification and removal of medications for disposition.
(2) Identification of storage methods for medications awaiting final disposition.
(3) Control and accountability of medications awaiting final disposition consistent with standards of practice.
(4) Documentation of actual disposition of medications to include the name of the individual disposing of the medication, the name of the resident, the name of the medication, the strength of the medication, the prescription number if applicable, the quantity of medication and the date of disposition.
(5) A method of disposition to prevent diversion or accidental exposure consistent with applicable Federal and State requirements, local ordinances and standards of practice.

Observations:


Based on a review of facility policies and closed records, as well as interviews with staff, it was determined that the facility failed to document the disposition of medications and/or the quantity of drugs disposed for one of three closed clinical records reviewed (Resident 132).

Findings include:

The facility's policy for discharge medications, dated December 12, 2023, indicated that the nurse was to complete a medication disposition record, which included the amount or quantity of each medication and the nurse releasing the medication.

A nursing note for Resident 132, dated November 20, 2023, indicated that the resident was discharged to another long-term care facility. There was no documented evidence in the clinical record of the disposition of medications and/or the quantity upon discharge from the facility.

Interview with the Director of Nursing on February 14, 2024, at 1:45 p.m. confirmed that there was no documented evidence of the disposition of medications for Resident 132, and that there should have been.





 Plan of Correction - To be completed: 03/07/2024

1. Facility could not reconcile the medication disposition record for resident 132
2. No other issues identified
3. In order to prevent a reoccurrence, the director of nursing or designee will educate licensed nursing staff on the medication disposition policy.
4. Medical records or designee will audit medication disposition records for completion weekly for four weeks and then monthly for two months. Results will be tracked and trended and taken to Quality Assurance committee for Follow Up by Director of Nursing or designee.

§ 211.10(d) LICENSURE Resident care policies.:State only Deficiency.
(d) The policies shall be designed and implemented to ensure that the resident receives proper care to prevent pressure sores and deformities; that the resident is kept comfortable, clean and well-groomed; that the resident is protected from accident, injury and infection; and that the resident is encouraged, assisted and trained in self-care and group activities.

Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to develop care polices related to the treatment of weight loss.

Finding include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 109, dated December 20, 2023, indicated that the resident had a weight loss not on a physcian-prescribed weight-loss regimen.

A weight record for Resident 109 revealed that on October 24, 2023, the resident's weight was 186.7 pounds.

A nursing noted, dated November 6, 2023, at 12:36 a.m., revealed that Resident 109 arrived from the hospital and his weight was 156.5 pounds. There was no documented evidence that the physician or dietitian were notified of the resident's weight loss.

A nursing noted dated November 8, 2023, at 4:44 p.m. revealed that Resident 109 was admitted to the hospital with a diagnosis of coffee ground emesis. A nursing note, dated November 12, 2023, at 8:40 p.m. revealed the resident returned from the hospital and his weight record revealed that he weighed 153.7 pounds. There was no documented evidence that the dietitian or physician were notified of the resident's weight loss.

A dietary progress note, dated November 16, 2023, revealed that the resident's weight on November 14 was 151.7 pounds (significant loss of 33.5 pounds (18 percent) for one month). The resident's Mighty Shakes (supplement) were re-ordered for three times a day and Boost Glucose Control (supplement) was added twice day.

There was no documented evidence that the facility had a policy and procedure regarding the treatment of weight loss.

Interview with the Director of Nursing on February 14, 2024, at 2:26 p.m. confirmed that the resident was in and out of the hospital and had a weight loss, and that the facility did not have a policy regarding the treatment of weight loss or when the physician/dietitian should be notified of a resident's weight loss.



 Plan of Correction - To be completed: 03/07/2024

1. Facility provided a weight best practice guideline at the time of the survey, along with weight policy.
2. No other issues identified.
3. Dietician will be re-educated on the weight loss policy
4. Audit of weight loss policy will be reviewed monthly and discussed at Quality Assurance committee for recommendations and Follow Up by Dietician or designee.

§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:


Based on a review of nursing schedules, staffing information provided by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents on the day shift for one of 21 days.

Findings Include:

Review of facility census data indicated that on January 19, 2024, the facility census was 135, which required 11.25 (135 residents divided by 12) nurse aides (NA's) during the day shift. Review of the nursing time schedules revealed 10.46 NA's provided care on the day shift on January 19, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Interview with the Director of Nursing on February 14, 2024, at 3:50 p.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the day listed above.



 Plan of Correction - To be completed: 03/07/2024

1. Facility was unable to fix the NA ratio at the time of the survey as it was a previous day.
2. Facility audited the schedule that was submitted to the department of health during the survey. The day that we did not meet ratio was due to a call off, moving forward we have certified nurse aides that work in different departments that we will use to cover call offs as available, we will also use Nurses to cover certified nurse aid call offs as available.
3. In order to prevent a reoccurrence, Administrator, Director of Nursing and scheduler will be educated on meeting Certified Nursing Aide ratios by Regional Director of Nursing or designee.
4. Administrator or designee will audit daily schedules weekly for four weeks and then monthly for two months to verify Certified Nursing Aide ratio were met. Results will be tracked and trended and reported to Quality Assurance committee for recommendations and follow up by Director of Nursing or designee.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:


Based on a review of nursing schedules, staffing information provided by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 40 residents on the overnight shift for one of 21 days (24-hour periods) reviewed.

Findings Include:

Review of facility census data indicated that on indicated that on January 16, 2024, the facility census was 133, which required 3.33 licensed practical nurses (LPN's) during the overnight shift. Review of the nursing time schedules revealed 3.06 LPN's provided care on the overnight shift on January 16, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Interview with the Director of Nursing on February 14, 2024, at 3:50 p.m. confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the day listed above.




 Plan of Correction - To be completed: 03/07/2024

1. Facility was unable to fix the Licensed Practical Nurse ratio at the time of the survey as it was a previous day.
2. Facility audited the schedule that was submitted to the department of health during the survey.
3. In order to prevent a reoccurrence, Administrator, Director of Nursing and scheduler will be educated on meeting Licensed Practical Nurse ratios by Regional Director of Clinical Services.
4. Administrator or designee will audit daily schedules weekly for four weeks and then monthly for two months to verify Licensed Practical Nurse ratios were met. Results will be tracked and trended and reported to Quality Assurance committee for recommendations and follow up.


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