Pennsylvania Department of Health
GROVE AT LATROBE, THE
Patient Care Inspection Results

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GROVE AT LATROBE, THE
Inspection Results For:

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GROVE AT LATROBE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, and a complaint survey completed on January 25, 2024, it was determined that The Grove at Latrobe 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:


483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.24(c) Activities.
§483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
Observations:


Based on clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to provide adequate, ongoing activities designed to meet the needs of residents for four of 33 residents reviewed (Residents 1, 14, 54, 58).

Findings include:

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 2, 2023, indicated that the resident was cognitively intact and required assistance from staff for daily care needs.

A quarterly MDS assessment for Resident 14, dated November 2, 2023, revealed that the resident was cognitively intact and required staff assistance for her daily care needs.

A quarterly MDS assessment for Resident 54, dated November 6, 2023, revealed that the resident was cognitively intact and required assistance from staff for daily care needs.

A quarterly MDS assessment for Resident 58, dated November 21, 2023, revealed that the resident was cognitively intact and required assistance for his daily care needs.

An interview with a group of residents on January 23, 2024, at 11:00 a.m. revealed that there are not enough activities for them, and they would like more. They stated that there is usually only one before lunch if the activity worker has time for it, then one after lunch. There are no activities on the weekend, and they would like some.

Interview with the Activity Director on January 24, 2024, at 12:57 p.m. revealed that she is the only staff member in her department. She stated she is not able to get the activities on the calendar completed because she does not have enough time but that she knows the residents would like more activities. She further stated that she does not work seven days a week, and therefore there are only activities on the days that she is able to work.

Interview with the Nursing Home Administrator on January 24, 2024, at 3:09 p.m. confirmed that the activities department only has one staff member and that she is not able to do as much as the residents would like her to do.

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





 Plan of Correction - To be completed: 02/29/2024

The facility will ensure that residents are provided adequate, ongoing activities designed to meet the needs of residents.
The concerns identified for residents 1, 14, 54, and 58 cannot be retroactively corrected. Facility is actively recruiting activities aides to assist in the activities department. Management staff will assist with activities until activities assistants can be hired.
Re-Education will be provided for activities director from Nursing Home Administrator. Audits for daily activities will be done 3 times per week for 4 weeks, then weekly for two months, then monthly for one month.
Audits will be reviewed at the Quality Assurance Performance Improvement Committee meeting for further review and recommendations.

483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.95(g) Required in-service training for nurse aides.
In-service training must-

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

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

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

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


Based on a review of employee education records, as well as staff interviews, it was determined that the facility failed to ensure that nurse aides completed the required annual education for one of five nurse aides reviewed (Nurse Aide 9).

Findings include:

The facility's policy for abuse prevention, dated January 2, 2024, indicated that staff were required to have annual trainings.

Review of the employee education file for Nurse Aide 9 revealed that there was no documented evidence of annual abuse, customer service, residents rights, fall/accident, restorative, ethics and QAPI training.

Interview with the Nursing Home Administrator on January 24, 2024, at 12:45 p.m. confirmed that there was no documented evidence that Nurse Aide 9 completed the annual training as required.

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

28 Pa. Code 201.19 Personnel policies and procedures.





 Plan of Correction - To be completed: 02/29/2024

The facility will ensure that all nurse aide staff receive the required 12 hours of in-service training per year.
Nursing Home Administrator/Designee will educate the Director of Human Resources on the requirements of in-service training for the nurse aide staff must be at least once every 12 months.
House audit will be completed by the Director of Human Resources to ensure that all nurse aide staff have had the required training within the past 12 months.
Director of Human Resources (HR) will provide the required training to the nurse aide staff at least yearly and will complete log of in-service training monthly of each staff member.
The results of the house audit will be forwarded to the Quality Assurance and Performance Improvement Committee for review. In-service logs will be brought to the Quality Assurance and Performance Improvement meeting to ensure compliance.

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§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:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.
Observations:


Based on review of attendance records for the facility's Quality Assurance Committee, as well as staff interviews, it was determined that the facility failed to ensure that Quality Assurance meetings were held at least quarterly.

Findings include:

Review of the attendance records for the facility's Quality Assurance Committee meetings revealed that there were no records of a meeting held during the first quarter of 2023 (January, February and March 2023).

Interview with the Nursing Home Administrator on January 24, 2024, at 12:45 p.m. confirmed that there were no records of any Quality Assurance meetings held during the first quarter in 2023.

28 Pa. Code 201.18(e)(1)(2)(3) Management.


 Plan of Correction - To be completed: 02/29/2024

The facility will ensure Quality Assurance Meetings are held quarterly and that all participants will sign in on the roster sheet.
Nursing Home Administrator/Designee will educate the Quality Assurance committee on the process of meeting quarterly and signing the roster sheet when attending.
Nursing Home Administrator/Designee will complete an audit quarterly for 2 quarters to ensure quarterly meeting is held and all in attendance has signed the roster.


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(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 the review of the facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food stored in the residents' refrigerators/freezers were properly dated and labeled and that food storage areas were clean.

Findings include:

The facility's policy for food storage, dated January 2, 2024, indicated that all food brought in for residents will be dated and labeled, and that food storage areas will be clean at all times.

Observations of the residents' refrigerator/freezer in the west nursing station pantry on January 23, 2024, at 12:13 p.m. revealed undated and/or unlabeled items, including two slider sandwiches and a frozen dinner. In addition, there was a large amount of a brown, sticky substance inside and outside the refrigerator/freezer. Observations on January 23, 2024, at 12:23 p.m. of the residents' refrigerator/freezer in the east-two pantry revealed undated and/or unlabeled items including two frozen beef pot pies, a breakfast sandwich, a chicken Florentine frozen dinner, and a 16 ounce container of caramel syrup. Observations of the residents' refrigerator/freezer in the east-one pantry on January 23, 2024, at 12:34 p.m. revealed undated and/or unlabeled items, including two containers of yogurt, a Chobani flip cookies and cream snack, and a 4 oz. container of butterscotch pudding.

Interview with the Dietician on January 23, 2024, at 12:40 p.m. confirmed that all items in the resident refrigerators/freezers should be dated and labeled with the resident's name, and that the resident food storage areas should be clean, and they were not.

28 Pa. Code 211.6(f) Dietary services.



 Plan of Correction - To be completed: 02/29/2024

The facility will ensure that food stored in the residents' refrigerators/freezers are properly dated and labeled and that the food storage areas are clean. The undated/unlabeled food items identified were discarded immediately and the brown sticky substance on west nursing unit refrigerator/freezer was immediately removed and cleaned.
The facility will complete a house audit of resident refrigerators/freezers to validate food items are dated and labeled and that food storage areas are clean.
The Dietary Manager/Designee will re-educate the dietary staff on the facility policy and procedures for food storage, ensuring resident refrigerators/freezers are clean and that food items are labeled and dated.
The dietary manager /Designee will complete an audit weekly for four weeks then monthly for three months to validate resident refrigerators are clean and food items are labeled and dated appropriately.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.24(c)(2)(i)(ii)(A)-(D) REQUIREMENT Qualifications of Activity Professional:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.24(c)(2) The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who-
(i) Is licensed or registered, if applicable, by the State in which practicing; and
(ii) Is:
(A) Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or
(B) Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or
(C) Is a qualified occupational therapist or occupational therapy assistant; or
(D) Has completed a training course approved by the State.
Observations:


Based on review of facility policy and personnel records, and staff interviews, it was determined that the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program.

Findings include:

A review of the Activities Director job description revealed that the primary purpose of the job position was to plan, organize, implement, evaluate, and direct the Activity Program in accordance with current federal, state, and local standards governing the facility, and as directed by the Nursing Home Administrator, to ensure that emotional, recreational, and social needs of the residents were met and maintained on an individual basis.

Interview with the Activities Director on January 24, 2024, at 12:57 p.m. revealed that she did not have the required qualifications for the position and that she was looking into the courses to become certified but currently was not enrolled in the program.

Interview with the Director of Nursing on January 24, 2024, at 3:09 p.m. confirmed that the Activity Director did not have the regulatory qualifications that were required for the position.

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

28 Pa. Code 201.18(b)(3)(e)(6) Management.

28 Pa. Code 201.21(b) Management.






 Plan of Correction - To be completed: 02/29/2024

The activities director will be enrolled in an approved program to become a qualified activities director.

Facilities Certified Occupational Therapy Assistant (COTA) will provide oversight for the department while the Activity Director Completes the state approved activity program.

The Activities Director and Human Resource Director will be educated on the qualifications needed to oversee the activity program by the Nursing Home Administrator/designee.

The Nursing Home Administrator/designee will audit to ensure the activities director completes an approved
training program to become a qualified director to oversee the activity program.

Audits will be reviewed at the Quality Assurance Performance Improvement Committee meeting for further review and recommendations.

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


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that resident-centered care plans were developed and implemented for three of 33 residents reviewed (Residents 9, 37, 46).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated November 17, 2023, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included depression, anxiety, bipolar disorder, schizophrenia, and Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event).

A review of Resident 9's plan of care revealed that there was no documented evidence that a care plan was developed to address Resident 9's triggers related to PTSD.

Interview with the Director of Nursing on January 25, 2024, at 10:35 a.m. confirmed that Resident 9's care plan should have included her triggers related to PTSD.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated November 16, 2023, indicated that the resident was cognitively intact, required extensive assistance from staff for daily care needs, and had diagnoses that included depression and PTSD.

A review of Resident 37's plan of care revealed that there was no documented evidence that a care plan was developed to address Resident 37's triggers related to PTSD.

Interview with the Director of Nursing on January 25, 2024, at 10:35 a.m. confirmed that Resident 37's care plan should have included her triggers related to PTSD.

A quarterly MDS assessment for Resident 46, dated December 7, 2023, indicated that the resident was cognitively impaired, required substantial assistance from staff for his daily care needs, and had a diagnosis of depression, anxiety and PTSD.

Review of Resident 46's clinical records revealed that he was receiving routine psychological services by Psych 360 for his diagnoses of depression, anxiety and PTSD.

There was no documented evidence that a care plan was developed to address Resident 46's PTSD and his triggers.

An interview with the Director of Nursing on January 25, 2024, at 9:11 a.m. confirmed that Resident 46 did not have a care plan for PTSD and his triggers.




 Plan of Correction - To be completed: 02/29/2024

The facility will ensure that a comprehensive care plan is implemented for residents related to post traumatic stress disorder (PTSD) and will be updated to reflect their current status. Care plans have been implemented for residents 9, 37, and 46 and updated to reflect their current status.
House audit has been completed for all residents and care plans have been initiated for all residents and individualized with each resident's care needs.
Registered Nurse Assessment Coordinator (RNAC)/Designee will complete a house audit to monitor that individualized care plans for each resident's care needs have been devised.
Nursing Home Administrator/Designee will educate the Licensed Practical Nurse Assessment Coordinator and the Registered Nurse Assessment Coordinator on the facility policy and procedures for updating care plans, ensuring that care plans have been devised for all resident's to meet their individual care needs.
The RNAC/Designee will complete an audit weekly for four weeks then monthly for three months to validate that care plans have been devised for all resident's to meet their individual care needs.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:


Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications by failing to ensure that non-pharmacological (non-medication) behavioral interventions were attempted prior to the administration of "as needed" antianxiety medications for one of 33 residents reviewed (Resident 2) and failed to ensure that residents were assessed for adverse consequences and "Extrapyramidal symptoms (EPS)" (neurological side effects) from use of antipsychotic medications for one of 33 resident's reviewed (Resident 9).

Findings include:

The facility's policy regarding antipsychotic medication (any medication that affects brain activities associated with mental processes and behavior), dated January 2, 2024, indicated that residents who used antipsychotic medications would receive behavioral interventions (individualized, non-pharmacological approaches to care) and that residents would be monitored for adverse consequences or complications of drug therapy.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 15, 2023, revealed that the resident was cognitively intact, required substantial assistance with daily care needs, and had diagnoses that included dementia, psychosis, anxiety and depression.

Physician's orders for Resident 2, dated December 14, 2023, included an order for the resident to receive 0.5 milligrams (mg) of Ativan (a psychotropic medication to treat anxiety) every 12 hours as needed for anxiety.

Review of the Medication Administration Records (MAR) for Resident 2 for October, November, and December 2023 and January 2024 revealed that the resident was administered 0.5 mg of Ativan on October 1, 2023, at 6:44 p.m.; October 4, 2023, at 12:41 a.m.; October 8, 2023, at 8:44 p.m.; November 7, 2023, at 10:30 p.m.; November 8, 2023, at 9:37 p.m.; December 8, 2023, at 9:15 p.m.; January 10, 2024, at 7:42 p.m.; January 17, 2024, at 4:11 p.m.; and January 20, 2024, at 9:35 p.m. There was no documented evidence that non-pharmacological behavioral interventions were attempted prior to administering Ativan on these dates and times.

An interview with the Director of Nursing on January 24, 2024, at 1:30 p.m. confirmed that there were no non-pharmacological interventions attempted prior to the administration of Ativan on the above mentioned dates and times.

A quarterly MDS assessment for Resident 9, dated November 17, 2023, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included depression, anxiety, bipolar disorder, schizophrenia, and PTSD.

Physician's orders for Resident 9, dated June 13, 2023, included an order for the resident to receive 3 milligrams of Risperidone (an antipsychotic medication) every day.

A review of Resident 9's clinical record revealed no documented evidence that the facility was monitoring for potential side effects of receiving antipsychotic medication. The last documented AIMS (abnormal involuntary movement scale) test (a test used to detect side effects from antipsychotic use) was completed on May 16, 2022.

Interview with the Director of Nursing on January 25, 2024, at 8:16 a.m. confirmed that there was no documentation in Resident 9's electronic health record to monitor for potential side effects of antipsychotic use.

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



 Plan of Correction - To be completed: 02/29/2024

The facility will ensure residents are free from unnecessary psychotropic medications by ensuring that non-pharmacological interventions are attempted prior to administration of medications. The concerns identified for resident R2 cannot be retroactively corrected.
The facility will complete a house audit on residents who receive "as needed" (PRN) antianxiety medications to validate non-pharmacological behavioral interventions were attempted prior to medication administration and that residents were assessed for adverse consequences.
The Director of Nursing or Designee will re-educate licensed nurses, including new hires and agency on the facility policy and procedures for antipsychotic medications, detailing attempting non-pharmacological interventions prior to administration of anti-anxiety medications and assessing for adverse consequences.
The Director of Nursing or Designee will complete an audit weekly for four weeks then monthly for three months to validate non-pharmacological interventions are attempted prior to administering anti-anxiety medications to residents and that residents are assessed for adverse consequences.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).
Observations:


Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for five of five nurse aides reviewed (Nurse Aide 6, Nurse Aide 7, Nurse Aide 8, Nurse Aide 9, Nurse Aide 10).

Findings include:

Review of Nurse Aide 6's personnel file revealed that she was hired August 30, 2013. There was no evidence that Nurse Aide 6 had a performance evaluation completed until November 30, 2023.

Review of Nurse Aide 7's personnel file revealed that she was hired February 10, 2016. There was no evidence that Nurse Aide 7 had a performance evaluation completed until November 30, 2023.

Review of Nurse Aide 8's personnel file revealed that she was hired June 18, 2015. There was no evidence that Nurse Aide 8 had a performance evaluation completed until November 30, 2023.

Review of Nurse Aide 9's personnel file revealed that she was hired May 10, 2012. There was no evidence that Nurse Aide 10 had a performance evaluation completed until November 28, 2023.

Review of Nurse Aide 10's personnel file revealed that she was hired January 3, 2019. There was no evidence that Nurse Aide 10 had a performance evaluation completed until November 28, 2023.

Interview with the Nursing Home Administrator on January 24, 2024, at 12:30 p.m. confirmed that performance evaluations were not completed since 2022 for five of five Nurse Aides reviewed and that they should have been done annually.

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

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



 Plan of Correction - To be completed: 02/29/2024

The facility will ensure that the nurse aide staff will have a performance evaluation completed yearly.
Nurse Aide 6, 7, 8, 9, and 10 had a performance evaluation completed in November of 2023.
Nursing Home Administrator/Designee will educate the Director of Human Resources on the requirements of performance evaluations for the nurse aide staff must be at least once every 12 months.
Audit will be completed by director of human resources/designee to ensure that all nurse aide staff have had a performance evaluation completed within the last 12 months.
Director of Human Resources (HR) will notify Director of Nursing (DON) monthly on the need for any nurse aide staff that is in need of an annual performance evaluation. DON will complete the performance evaluation, review with the staff member, and return completed performance evaluation to the HR to be placed in the employee record.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

483.25(m) REQUIREMENT Trauma Informed Care:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.
Observations:


Based on review of facility policies and clinical records, and staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for three of 33 residents reviewed (Residents 9, 37, 46).

Findings include:

The facility's policy regarding Trauma Informed Care, dated January 2, 2024, revealed that upon admission, screening for trauma will occur by the social worker. This information will be provided to the interdisciplinary team as needed for diagnosis, treatment and care. When information about past trauma becomes available the interdisciplinary team will incorporate this information into the residents care. Attention will be given to the importance of understanding that trauma is different from person to person to ensure that resident-centered care is provided.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated November 17, 2023, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included depression, anxiety, bipolar disorder, schizophrenia, and PTSD.

There was no documented evidence the facility identified Resident 9's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring.

A quarterly MDS assessment for Resident 37, dated November 16, 2023, indicated that the resident was cognitively intact, required extensive assistance from staff for daily care needs, and had diagnoses that included depression and PTSD.

There was no documented evidence that the facility identified Resident 37's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring.

Interview with the Nursing Home Administrator on January 24, 2024, at 12:30 p.m. confirmed that the facility did not complete trauma informed care assessments for Residents 9 and 37 and that they should have.

A quarterly MDS assessment for Resident 46, dated December 7, 2023, indicated that the resident was cognitively impaired, required substantial assistance from staff for his daily care needs, and had a diagnosis of depression, anxiety and PTSD.

Psychological consults for Resident 46, dated October 26, 2023; December 7, 2023; and January 17, 2024, revealed that the resident had a diagnosis of PTSD.

There was no documented evidence the facility identified Resident 46's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring.

Interview with the Director of Nursing on January 25, 2024, at 9:11 a.m. confirmed that the facility did not complete a trauma informed care assessment for Resident 46, and they should have.

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

28 Pa. Code 211.16(a) Social Services.



 Plan of Correction - To be completed: 02/29/2024

The facility will ensure that residents are assessed and receive trauma- informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD). Residents R9, R37 and R46 will be assessed and will receive trauma informed care to eliminate or mitigate triggers of PTSD.
The facility will complete a house audit of residents with the diagnosis of PTSD to validate a trauma informed care assessment has been completed and measures have been implemented to prevent or minimize triggers from occurring.
The Nursing Home Administrator or Designee will re-educate the Social Services Director on the facility policy and procedures for Trauma informed care, detailing completing assessments for residents.
The Nursing Home Administrator or Designee will complete an audit weekly for four weeks then monthly for three months to validate trauma informed care assessments for new and re-admissions.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§ 483.25(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 oxygen therapy was provided as ordered by the physician for one of 33 residents reviewed (Resident 53), and that the facility failed to obtain a physician's order for oxygen therapy for two of 33 residents reviewed (Residents 70, 277).

Findings include:

The facility's policy regarding oxygen administration, dated January 2, 2024, indicated that a physician's order for oxygen was to include the liter flow and method of administration.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated December 13, 2023, revealed that the resident was cognitively impaired, required substantial assistance with care needs, was using supplemental oxygen, and had diagnoses that included cardiomyopathy (a disease that affects the heart muscle that makes it harder for the heart to pump blood) and edema.

Physician's orders for Resident 53, dated January 9, 2024, included an order for the resident to receive continuous oxygen at a flow rate of 5 liters per minute via nasal canula (tubes that deliver oxygen into the nostrils) for hypoxia (low levels of oxygen in body tissues).

Observations of Resident 53 in her room on January 23, 2024, at 8:57 a.m.; January 24, 2024, at 1:09 p.m.; and January 25, 2024, at 11:10 a.m. revealed that the resident was receiving supplemental oxygen continuously at a flow rate of 3 liters per minute via nasal canula.

Interview with Licensed Practical Nurse 5 on January 23, 2024, at 2:44 p.m. confirmed that Resident 53's oxygen was set at a flow rate of 3 liters per minute via nasal canula and the physician's order was for a flow rate of 5 liters per minute via nasal canula.

Interview with the Director of Nursing on January 23, 2024, at 2:58 p.m. confirmed that Resident 53's oxygen was not being administered at the correct flow rate.

A quarterly MDS assessment for Resident 70, dated November 17, 2023, revealed that the resident required moderate assistance with activities of daily living and used oxygen. A care plan for Resident 70, dated August 25, 2023, indicated to instruct the resident in oxygen safety and use.

There was no documented evidence that a physician's order was obtained for Resident 70's use of oxygen.

Observations on January 23, 2024, at 9:22 a.m. revealed that Resident 70 was receiving 4 liters per minute of oxygen via nasal cannula (device that provides oxygen through your nose)

Interview with Licensed Practical Nurse 1 on January 24, 2024, at 11:43 a.m. confirmed that Resident 70 did not have an order for oxygen.

Interview with Director of Nursing on January 23, 2024, at 11:43 a.m. confirmed that there was no documented evidence that a physician's order was obtained for Resident 70 to use oxygen.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 277, dated January 23, 2024, revealed that the resident was cognitively impaired, was dependent on staff for all care, was incontinent, received all nutrition through a feeding tube (a flexible plastic tube placed into the stomach in order to receive nutrition when a person is unable to eat), and had diagnoses that included cerebral palsy (a group of conditions that affect movement and posture that is caused by damage to the developing brain).

Observations of Resident 277 on January 23, 2024 at 9:59 a.m. revealed that the resident was receiving oxygen at 4 liters per minute via nasal cannula (device that provides oxygen through nose).

There was no documented evidence that a physician's order was obtained for Resident 277's use of oxygen.

Interview with Licensed Practical Nurse 1 on January 24, 2024, at 11:41 a.m. confirmed that Resident 277 did not have an order for oxygen.

Interview with Director of Nursing on January 24, 2024, at 11:57 a.m. confirmed that there was no documented evidence that a physician's order was obtained for Resident 277 to use oxygen.

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



 Plan of Correction - To be completed: 02/29/2024

The facility will ensure that oxygen therapy is provided as ordered by the physician and that a physician order is obtained for oxygen therapy for residents. The facility cannot retroactively correct the concern identified for resident R53. A physician order will be obtained for oxygen therapy for residents R70 and R277.
A house audit will be completed to identify residents who require oxygen therapy to validate a physician order is in place for oxygen therapy and the oxygen is administered as ordered.
The Director of Nursing or Designee will re-educate licensed nurses, including new hires and agency on the facility policy and procedures for oxygen administration, detailing obtaining a physicians order and administering the oxygen as ordered by the physician.
The Director of Nursing or Designee will complete an audit weekly times four weeks then monthly for three months to validate that any resident using oxygen therapy has a physician order in place and that the oxygen is administered as ordered.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review and frequency of audits.

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


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to revise/update care plans for five of 33 residents reviewed (Residents 8, 9, 39, 53, 62).

Findings include:

The facility's policy regarding care plans, dated January 2, 2024, indicated that nurses and interdisciplinary team members were responsible for updating the resident's care plan to reflect changes in the resident's status.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated December 5, 2023, indicated that the resident was cognitively intact, usually understood, could sometimes understand, required assistance from staff for his daily care needs, and had diagnoses that included pneumonia and acute respiratory failure with hypoxia (infection of the lungs leading to low oxygen in the tissues).

A physician's order for Resident 8, dated November 20, 2023, included an order for supplemental oxygen 2-4 liters via nasal cannula; and on November 21, 2023, the oxygen was ordered to be increased to 4-5 liters per minute. Clinical records, dated November 28, 2023, and December 6 and 7, 2023, indicated that Resident 8 was frequently noncompliant and refused to wear his oxygen. Staff were routinely encouraging the resident to keep the oxygen in place. However, the resident's current care plan, dated May 24, 2023, did not include the oxygen order or address that the resident was refusing to wear his oxygen.

Observations of Resident 8 on January 22-25, 2024, revealed that at no time during the survey did the resident have his oxygen on.

Interview with the Registered Nurse Assessment Coordinator (RNAC) on January 25, 2024, at 9:25 p.m. confirmed that Resident 8's care plan should have been updated to reflect the current oxygen order and that the resident frequently refuses to wear the oxygen.

Interview with the Director of Nursing on January 25, 2024, at 9:39 p.m. confirmed that Resident 8's care plan should have been updated to reflect the current oxygen order and that the resident frequently refuses to wear the oxygen, and it was not.

A quarterly MDS assessment for Resident 9, dated November 17, 2023, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included depression, anxiety, bipolar disorder, schizophrenia, and Post Traumatic Stress Disorder (a mental and behavioral disorder that develops related to a terrifying event).

A Psych 360 consult note for Resident 9, dated October 26, 2023, revealed that the resident's current stressor was the 33rd anniversary of putting her son up for adoption.

A review of Resident 9's plan of care revealed that there was no documented evidence that a care plan was revised to address Resident 9's triggers related to PTSD.

Interview with the Director of Nursing on January 25, 2024, at 10:35 a.m. confirmed that Resident 9's care plan should have included her triggers related to PTSD.

A quarterly MDS assessment for Resident 39, dated December 12, 2023, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnosis that included end-stage renal disease and was dependent on dialysis.

Nursing communication notes from the nursing home to Resident 39's dialysis center revealed that the center was using a dialysis port in the residents left chest wall.

A care plan for Resident 39, dated September 6, 2023, indicated that the resident had an AV fistula (a connection made between an artery and a vein in the arm for dialysis connection).

Interview with Resident 39 on January 22, 2024, at 1:05 p.m. revealed that he did not have an AV fistula and had a dialysis port in his left chest wall.

Interview with the Director of Nursing on January 25, 2024, at 2:15 p.m. confirmed that Resident 39's care plan was not revised to indicate the resident had a dialysis port in his left chest wall.

An annual MDS assessment for Resident 53, dated December 13, 2023, revealed that the resident was cognitively impaired, required substantial assistance with care needs, was using supplemental oxygen, and had diagnoses that included cardiomyopathy (a disease that affects the heart muscle that makes it harder for the heart to pump blood) and edema.

A nurse's note, dated January 8, 2024, at 3:44 a.m., indicated that Resident 53's oxygen saturation (blood oxygen level) was ranging from mid-80's to 92 on 2 liters of oxygen and she was having difficulty breathing. She was sent to the hospital and returned on January 8, 2024, at 1:30 p.m. with a physician's order for oxygen at 5 liters via nasal cannula every shift for hypoxia (low levels of oxygen in body tissues).

Observations of Resident 53 on January 23, 2024, at 8:57 a.m.; January 24, 2024, at 1:09 p.m.; and January 25, 2024, at 11:10 a.m. revealed that the resident was receiving supplemental oxygen continuously.

A respiratory care plan for Resident 53, revised on January 13, 2024, indicated that the resident was assessed for oxygen saturation, but the care plan was not revised to reflect her need for oxygen.

Interview with the Director of Nursing on January 24, 2024, at 11:54 a.m. confirmed that Resident 53's care plan should have been revised to reflect her need for oxygen.

A quarterly MDS assessment for Resident 62, dated November 3, 2023, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnosis that included high blood pressure, end-stage renal disease, and was dependent on dialysis.

A nursing note for Resident 62, dated October 30, 2023, at 10:58 a.m. revealed that the resident was seen today for a PEG tube removal (a tube inserted into the abdomen for feeding).

A care plan for Resident 62, dated August 23, 2023, included to provide PEG tube maintenance as ordered.
Physician's orders for Resident 62, dated January 5, 2024, included an order that physical and occupational therapy could assist with ambulation weight bearing as tolerated.

A care plan for Resident 62, dated December 15, 2023, indicated that the resident was non-weight bearing to the right lower extremity.

An interview with the Director of Nursing on January 25, 2024, at 11:23 a.m. confirmed that Resident 62's care plan was not revised for the PEG tube removal and weight bearing status change and should have been updated to reflect the resident's current care needs.




 Plan of Correction - To be completed: 02/29/2024

Care plans for residents 8, 9, 39, 53, and 62 have been updated to reflect their current status.
House Audit for all residents has been completed.
Nursing Home Administrator/Designee will educate the Licensed Practical Nurse Assessment Coordinator and the Registered Nurse Assessment Coordinator on the facility policy and procedures for updating care plans.
The RNAC/Designee will complete an audit of care plans weekly for four weeks then monthly for three months to validate care plans are updated to reflect the status of the resident.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's responsible party was notified timely about suicidal ideations (thinking about or planning suicide) for one of 33 residents reviewed (Resident 69).

Findings include:

The facility's policy regarding notification, dated January 2, 2024, revealed that the facility would immediately inform the resident's physician and family/legal representative whenever an occurrence takes place and pertinent information is documented.

A nursing note for Resident 69, dated February 23, 2023, revealed that the resident made a statement that he would hurt himself if he was unable to go home. The social worker, nursing staff, and physician were notified. There was no documented evidence that the legal guardian was notified about the resident's suicidal statement.

An interview with the Director of Nursing on January 24, 2024, at 11:18 a.m. confirmed that staff failed to contact Resident 69's legal guardian after the suicidal statement.

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






 Plan of Correction - To be completed: 02/29/2024

The facility will ensure that resident representatives are informed of all changes in conditions. The facility cannot retroactively correct the concern for resident 69, however representative will be informed of any new suicidal statements.
The Director of Nursing/Designee will educate licensed nurses, including new hires and agency, on the facility policy and procedures for resident representative notification of resident changes in conditions in a timely manner.
The Director or Nursing/Designee will complete an audit two times a week for four weeks then weekly for four weeks to validate resident representatives are informed of change in behaviors and Medication changes.
The results of these audits will be forwarded to the Quality assurance and Performance Improvement Committee for review.

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

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

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

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

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

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

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

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

§483.75(e) Program activities.

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

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

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

§483.75(g) Quality assessment and assurance.

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

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


Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies 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 a State Survey and Certification (Department of Health) survey ending February 24, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending January 25, 2024, identified repeated deficiencies related to a homelike enviornment, activities to meet the needs of each resident, quality of care services, bowel and bladder incontinence, QAPI improvement activities.

The facility's plan of correction for a deficiency regarding a homelike environment, cited during the survey ending February 24, 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 F584, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding a homelike enviornment.

The facility's plan of correction for a deficiency regarding activities to meet the needs of each resident, cited during the survey ending February 24, 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 F679, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding activities to meet the needs of each resident.

The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending February 24, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care services.

The facility's plan of correction for a deficiency regarding bowel and bladder incontinence, cited during the survey ending February 24, 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 F690, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding bowel and bladder incontinence.

The facility's plan of correction for a deficiency regarding QAPI improvement plan, cited during the survey ending February 24, 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 F867, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding QAPI improvement plan.

Refer to F584, F679, F684, F690, F867.

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

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



 Plan of Correction - To be completed: 02/29/2024

Quality Assurance Plans will be updated and reviewed in the Quality Assurance Performance Improvement Plan (QAPI) meetings to validate compliance with the Plan of Correction. The Committee will review repeat deficiencies and monitor compliance regularly.
Nursing Home Administrator/Designee will educate staff on QAPI process, committee, and functions of the QAPI meetings.
Director of Nursing/Designee will implement a binder of deficiencies. Staff will return completed audits of deficient practices to the Director of Nursing/Designee. Director of Nursing/Designee will bring binder of audits to the QAPI meetings for review of continued compliance.
The QAPI committee will review root cause of recurring deficiencies to develop/implement changes that may be needed in policies.

483.70(e)(1)-(3) REQUIREMENT Facility Assessment: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.
§483.70(e) Facility assessment.
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include:

§483.70(e)(1) The facility's resident population, including, but not limited to,
(i) Both the number of residents and the facility's resident capacity;
(ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population;
(iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population;
(iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and
(v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

§483.70(e)(2) The facility's resources, including but not limited to,
(i) All buildings and/or other physical structures and vehicles;
(ii) Equipment (medical and non- medical);
(iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies;
(iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;
(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
(vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

§483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.
Observations:


Based on review of facility documentation and staff interviews, it was determined that the facility failed to ensure that the Facility Assessment included required information related to ethnic, cultural, or religious factors that may potentially affect the care provided by the facility and staff competencies that are necessary to provide the level and types of care needed for the resident population.

Findings include:

Review of the Facility Assessment, dated January 2, 2024, revealed that it did not contain required information related to ethnic, cultural, or religious factors that may potentially affect the care provided by the facility and staff competencies that are necessary to provide the level and types of care needed for the resident population.

Interview with the Nursing Home Administrator on January 25, 2024, at 12:10 p.m. confirmed that the Facility Assessment did not contain the required information related to ethnic, cultural, or religious factors that may potentially affect the care provided by the facility and staff competencies that are necessary to provide the level and types of care needed for the resident population.

28 Pa. Code 201.18(e) Management.



 Plan of Correction - To be completed: 02/29/2024

Facility assessment was corrected prior to end of survey to contain information related to include ethnic, cultural, and religious factors that may potentially affect the care provided by the facility and staff competencies that are necessary to provide the level and types of care needed for the resident population.
The Nursing Home Administrator will review the typed revision quarterly to ensure that all data is included.
The facility assessment will be reviewed in the Quality Assurance Performance Improvement meeting to ensure accuracy.

483.50(a)(2)(i)(ii) REQUIREMENT Lab Srvcs Physician Order/Notify of Results: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.
§483.50(a)(2) The facility must-
(i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws.
(ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for one of 33 residents reviewed (Resident 9).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated November 17, 2023, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included depression, anxiety, bipolar disorder, schizophrenia, and Post Traumatic Stress Disorder (PTSD).

Physician's orders for Resident 9, dated September 10, 2023, included an order for staff to obtain bloodwork that included Hemoglobin A1C (measures your average blood sugar levels over the past three months), Thyroid Stimulating Hormone (measurement to determine if the thyroid is not producing hormones), Free T4 (measurement of thyroid hormone), Vitamin D (measurement for vitamin d deficiency), Lipid (measurement of cholesterol levels), Liver Function test (test to monitor for liver problems), Lithium Level (test to determine side effects of antipsychotropic use), Valproic Acid Level (measurement used to monitor seizure medication), and Basal Metabolic Panel (monitor electrolytes and kidney function) every six months (March 10, 2023, and September 11, 2023).

There was no documented evidence that staff obtained the bloodwork on September 11, 2023, as ordered by the physician.

Interview with the Director of Nursing on January 25, 2024, at 12:35 p.m. confirmed that there was no documented evidence that staff obtained the bloodwork on September 11, 2023, for Resident 9 as ordered by the physician.

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




 Plan of Correction - To be completed: 02/29/2024

The facility will obtain laboratory studies as ordered by the physician for residents. The facility cannot retroactively correct the concern identified for resident R9.
The facility will complete a 30 day look back of residents who were ordered laboratory studies to validate they were obtained as ordered.
The Director of Nursing or Designee will re-educate licensed nursing, including new hires and agency, on the facility policy and procedures for obtaining laboratory studies as ordered.
The Director of Nursing or Designee will complete an audit weekly for four weeks then monthly for three months to validate laboratory studies are obtained as ordered by the physician.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review and frequency of audits.

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 maintain accountability for controlled medications (drugs with the potential to be abused) for one of 33 residents reviewed (Resident 2).

Findings include:

The facility's policy regarding medication administration, dated January 2, 2024, indicated that the resident's Medication Administration Record (MAR) is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 15, 2023, revealed that the resident was cognitively intact, required substantial assistance with care needs, had pain frequently, and was receiving controlled pain medication.

Physician's order for Resident 2, dated March 15, 2023, included an order for the resident to receive 50 milligrams (mg) of Tramadol every six hours as needed for severe breakthrough pain.

Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 2 for December 2023 indicated that a dose of Tramadol was signed out on December 5, 2023, at 9:00 p.m. and December 16, 2023, at 4:14 p.m.

Review of Resident 2's Medication Administration Record (MAR) and nursing notes revealed no documented evidence that the signed-out doses of Tramadol were administered to the resident on these dates and times.

Interview with the Director of Nursing on January 24, 2024, at 1:30 p.m. confirmed that there was no documented evidence in Resident 2's clinical records to indicate that the signed-out doses of Tramadol were administered to the resident on the above-mentioned dates and times.

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

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




 Plan of Correction - To be completed: 02/29/2024

The Facility will maintain accountability for controlled medications for residents. The facility cannot retroactively correct the concern identified during survey for resident R2.
Investigation has been completed and no misappropriation has been noted.
The Director of Nursing or Designee will re-educate the licensed nurses including new hires and agency on the facility policy and procedures for medication administration, detailing completing documentation in the residents medication administration record (MAR) for controlled substances.
The Director of Nursing or Designee will complete an audit of five residents MAR and Controlled substance accountability sheet to validate signed out medications are administered and Documented accurately.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of 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.
§483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:


Based on observations and staff interviews, it was determined that the facility failed to maintain personal privacy for one of 33 residents reviewed (Resident 69).

Findings include:

Observations of Resident 69's room on January 24, 2024, at 11:35 a.m. revealed that the resident's window blind would not close properly. Licensed Practical Nurse 1 was providing care and there were residents smoking outside the window.

Interview with Licensed Practical Nurse 1 on January 24, 2024, at 11:40 a.m. confirmed that the window blind in Resident 69's room would not close properly and that there should be privacy while performing care.

Interview with the Director of Nursing on January 24, 2024, at 11:55 a.m. confirmed that Resident 69 should have had privacy during care.

28 Pa. Code 201.29(j) Resident Rights.




 Plan of Correction - To be completed: 02/29/2024

Concern identified in room of resident 69 has been corrected. House audit was completed. Order has been placed to replace blinds identified as not properly functioning.

Director of Nursing/Designee will educate staff on maintaining personal privacy of residents and reporting maintenance/environmental concerns through the facilities electronic work order system.

Director of Nursing/Designee will audit staff to ensure residents' personal privacy is maintained. Audits will consist of 5 staff members weekly for four weeks, then monthly for 2 months.

The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

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 observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms for one of 33 residents reviewed (Resident 69).

Findings include:

Observations of Resident 69's room on January 24, 2024, at 11:35 a.m. revealed that the resident's window blind would not close properly. Licensed Practical Nurse 1 was providing care and there were residents smoking outside the window.

Interview with Licensed Practical Nurse 1 on January 24, 2024, at 11:40 a.m. confirmed that the window blind in Resident 69's room would not close properly and that there should be privacy while performing care.

Interview with the Director of Nursing on January 24, 2024, at 11:55 a.m. confirmed that Resident 69's window blind would not close and was being replaced immediately.

28 Pa. Code 201.29(j) Resident Rights.

28 Pa. Code 207.2(a) Administrator's Responsibility.






 Plan of Correction - To be completed: 02/29/2024

Concern identified in the room of resident 69 was corrected immediately during survey.
Director of Environmental Services/Designee will complete a house audit of facility to ensure a homelike environment is provided to all residents.
Director of Environmental Services/Designee will educate environmental staff on the facility's "Environmental Services, Clean, Safe and Orderly Environment" policy which states that the interior environment of the facility is to be maintained in a clean, safe, and orderly manner in order to provide a homelike environment.
Director of Environmental Services/Designee will audit resident rooms weekly for 4 weeks, then monthly for 2 months to ensure a clean and homelike environment is maintained.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements: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.
§483.15(c) Transfer and discharge-
§483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i) Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the legal guardian of a transfer to the hospital and failed to update the hospital with information about the resident on three occasions for one of 33 residents reviewed (Resident 8).

Findings include:

The facility's current policy for Admission, Transfer and Discharge Notification indicated that upon transfer the resident and resident's family or legal representative will be notified, and a treatment/care summary of the resident will be sent to the hospital.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated December 5, 2023, indicated that the resident was cognitively intact, usually understood and could sometimes understand, required assistance from staff for his daily care needs, and had diagnoses that included pneumonia and acute respiratory failure with hypoxia (infection of the lungs leading to low oxygen in the tissues).

Review of Resident 8's clinical record indicated that he had no family, and that staff from a Professional Eldercare company were his legal guardians.

There was no documented evidence in Resident 8's clinical record that the legal guardian was notified of the purpose for Resident 8's transfer to the hospital on September 9, 2023; October 21, 2023; and November 8, 2023, and there was no documented evidence that the hospital was updated by the facility with a summary of treatment given at the nursing home for those same hospitalizations.

Interview with the Director of Nursing on January 24, 2024, at 11:23 a.m. confirmed that there was no documented evidence that Resident 8's legal guardian was notified of transfers to the hospital on September 9, 2023; October 21, 2023; and November 8, 2023, or that the facility updated the hospital with information about the resident for those same hospitalizations, and there should have been.

28 Pa. Code 201.25 Discharge Policy.

28 Pa. Code 201.29(f)(g) Resident Rights.




 Plan of Correction - To be completed: 02/29/2024

The facility cannot retroactively correct the concern for resident 8, however representative will be notified of any further transfers to the hospital.
Audit will be completed for residents that have been sent out to the hospital within the last 30 days to verify representative notification.
Director of Nursing/Designee will educate staff on facility's policy for transfer notification that the resident and resident's family or legal representative will be notified and a treatment/care of summary of the resident will be sent to the hospital and documented in the resident's electronic medical record (EMR).
Director of Nursing/Designee will audit transfers to the hospital to ensure documentation that the resident's family member or legal representative has been notified and a treatment/care of summary of the resident has been sent to the hospital weekly for 4 weeks and monthly for 2 months.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

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

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

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

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


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and legal guardian in writing regarding the reason for hospitalizations, and failed to notify the ombudsman about hospitalizations in September, October and November 2023 for one of 33 residents reviewed (Resident 8).

Findings include:

The facility current policy for Admission, Transfer and Discharge Notification indicated that upon transfer to the hospital the resident and legal guardian will be notified in writing, and the ombudsman will be notified.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated December 5, 2023, indicated that the resident was cognitively intact, usually understood and could sometimes understand, required assistance from staff for his daily care needs, and had diagnoses that included pneumonia and acute respiratory failure with hypoxia (infection of the lungs leading to low oxygen in the tissues).

Review of Resident 8's clinical record indicated that he had no family, and that staff from a Professional Eldercare company were his legal guardians.

There was no documented evidence in Resident 8's clinical record to indicate that the resident and/or legal guardian was notified in writing of the purpose for the resident's transfer, or that the ombudsman was notified about the hospitalizations in September, October and November 2023.

Interview with the Director of Nursing on January 24, 2024, at 11:23 a.m. confirmed that there was no documentation that the resident and/or legal guardian were notified in writing of Resident 8's transfer to the hospital, or that the ombudsman was notified regarding the residents hospitalizations in September, October and November 2023, and there should have been.

28 Pa. Code 201.25 Discharge Policy.

28 Pa. Code 201.29(f)(g) Resident Rights.




 Plan of Correction - To be completed: 02/29/2024

The facility cannot retroactively correct the concern for resident 8, however Ombudsman will be notified of any further transfers to the hospital.
Audit will be completed for residents that have been sent out to the hospital within the last 30 days to verify Ombudsman notification.
Nursing Home Administrator/Designee will educate the Social Services Director on tracking residents who are transferred out of the facility.
Social Services Director/Designee will send tracking data to the Ombudsman one time per month.
Nursing Home Administrator/Designee will audit to ensure the Ombudsman is notified of transfers monthly for 2 months.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:This is a less serious (but not lowest level) deficiency and 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.
§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident's legal guardian regarding the facility's bed hold policy for hospitalizations in September, October, and November 2023 for one of 33 residents reviewed (Resident 8).

Findings include:

The facily's bed hold policy and procedure, dated January 2, 2024, indicated that upon transfer to the hospital, the resident's legal guardian will be notified of the facility's bed hold policy.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated December 5, 2023, indicated that the resident was cognitively intact, usually understood, could sometimes understand, required assistance from staff for his daily care needs, and had diagnoses that included pneumonia and acute respiratory failure with hypoxia (infection of the lungs leading to low oxygen in the tissues).

Review of Resident 8's clinical record indicated that he had no family, and staff from a professional eldercare company were his legal guardians.

There was no documented evidence that Resident 8's legal guardian was notified about the facility's bed hold policy for hospitalizations in September, October, and November 2023.

Interview with the Director of Nursing on January 24, 2024, at 11:23 a.m. confirmed that there was no documented evidence that Resident 8's legal guardian was notified about the facility's bed hold policy for hospitalizations in September, October and November 2023.

28 Pa. Code 201.25 Discharge Policy.

28 Pa. Code 201.29(f)(g) Resident Rights.




 Plan of Correction - To be completed: 02/29/2024

The facility cannot retroactively correct the concern for resident 8 or any resident sent to hospital prior to February 2024, however representative will be notified of the bed hold policy with any further transfers to the hospital.
Nursing Home Administrator/Designee will educate Business Office Manager and Social Services Director regarding sending written information of Bed Hold Policy to resident's representative.
Director of Nursing/Designee will educate licensed staff on the need to provide to the resident and the resident representative written notice which specified the duration of the bed-hold policy at the time of transfer.
Director of Nursing/Designee will audit transfers to the hospital to ensure documentation that the resident and resident's family member or legal representative has been notified of the bed-hold policy weekly for 4 weeks and monthly for 2 months.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on a review of 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 two of 33 residents reviewed (Residents 9, 46).

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 N0415A Antipsychotic (medication used for behaviors) was to be coded if the resident took the medication during the seven-day look-back period.

Physician's orders for Resident 9, dated June 13, 2023, included an order for the resident to receive 3 milligrams of Risperidone (an antipsychotic medication) every day. The resident's Medication Administration Record (MAR) for November 2023 revealed that the resident received Risperidone daily during the assessment's seven-day look-back period.

A quarterly MDS assessment for Resident 9, dated November 17, 2023, revealed that Section N0401A was not coded, indicating that the resident did not receive an antipsychotic medication during the seven-day look-back period.

The RAI User's Manual, dated October 2023, indicated that Section J0200 (pain assessment interview) should be attempted with all residents and coded (yes) if the resident is at least sometimes understood. Section J0200 should be coded (no) if the resident is rarely/never understood. Section J0800 (staff assessment for pain) should be completed if coded (no).

A quarterly MDS for Resident 46, dated December 7, 2023, revealed that the resident was usually understood, could usually understand, was able to complete the cognitive and mood interviews, and received "as needed" pain medication for pain. Section J0200 was coded (no) indicating that the resident was rarely/never understood. Section J0800 was completed indicating the pain assessment interview could not be attempted.

An interview with the Director of Nursing on January 25, 2024, at 11:23 a.m. confirmed that the assessments for Residents 9 and 46 were coded incorrectly.

28 Pa. Code 211.5(f) Clinical Records.





 Plan of Correction - To be completed: 02/29/2024

The facility will ensure that the Minimum Data Set (MDS) assessments accurately reflect the residents' status. The MDS for residents 9 and 46 have been updated to reflect the residents' abilities and care needs prior to the end of the survey. Other residents have been reviewed and no other issues noted.
Nursing Home Administrator/Designee will educate the Registered Nurse Assessment Coordinator (RNAC) and Licensed Practical Nurse Assessment Coordinator (LPNAC) on Section J0200 and Section J0800 of the Resident Assessment Instrument (RAI) User's Manual.
The RNAC/Designee will audit MDS assessments daily for four weeks, then two times per week for four weeks, then weekly for four weeks, then monthly for six months to ensure accuracy.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to clarify questionable physician's orders for one of 33 residents reviewed (Resident 277).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 277, dated January 23, 2024, revealed that the resident was cognitively impaired, was dependent on staff for all care, was incontinent, received all nutrition through a feeding tube (a flexible plastic tube placed into the stomach in order to receive nutrition when a person is unable to eat), and had diagnoses that included cerebral palsy (a group of conditions that affect movement and posture that is caused by damage to the developing brain),

Physician's orders for Resident 277, dated January 9, 2024, included an order for the resident to receive 30 mL of magnesium hydroxide suspension (an oral laxative to help promote bowel movement) 400 mg/5 mL by mouth as needed for constipation.

Physician's orders for Resident 277, dated January 10, 2024, included an order to give 640 mg (20 mL) of acetaminophen liquid, 160 mg/5 mL (for pain and for temperature 2 degrees above normal) by mouth every six hours as needed not to exceed 3000 mg daily.

Physician's orders for Resident 277, dated January 17, 2024, included an order for the resident to receive nothing by mouth.

There was no documented evidence in the clinical record to indicate that the facility attempted to clarify the physician's orders for Resident 277 to receive medications by mouth when he was ordered to have nothing by mouth.

Interview with Licensed Practical Nurse 2 on January 23, 2024, confirmed that the medications for Resident 277 were ordered by mouth and the resident was to receive nothing by mouth.

Interview with the Director of Nursing on January 24, 2024, at 3:17 p.m. confirmed that the physician should have been called to clarify the orders for magnesium hydroxide suspension and acetaminophen liquid for Resident 277.

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




 Plan of Correction - To be completed: 02/29/2024

The facility will ensure questionable physician's orders are clarified for residents. The Magnesium hydroxide order and the acetaminophen liquid order for resident R277 will be clarified with the physician.
The facility will complete a house audit to identify residents who have orders for nothing by mouth to validate orders are clarified to reflect resident current status.
The Director of Nursing or Designee will re-educate licensed nurses, including new hires and agency, on the federal regulation 0658, detailing ensuring questionable physician orders are clarified related to residents who are ordered to receive nothing by mouth.
The Director of Nursing or Designee will complete an audit two times a week for four weeks then monthly for three months to validate questionable physician orders are clarified for residents who are ordered to receive nothing by mouth.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review and frequency of audits.

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


Based on review of facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice by failing to follow physician's orders for three of 33 residents reviewed (Residents 29, 36, 70).

Findings include

The facility's policy regarding medication administration, dated January 2, 2024, revealed that medications were to be administered in accordance with written orders of the attending physician.

A annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated November 6, 2023, revealed that the resident was moderately cognitively impaired, usually understood and could understand, and had diagnoses that included chronic leg pain due to previous traumatic injuries.

Physician's orders for Resident 29, dated March 15, 2023, included an order for the resident to receive one 600 milligram (mg) tablet of ibuprofen (a medicine used to treat moderate pain) every 8 hours as needed for moderate leg pain rated 4-6, and one 15 mg tablet of morphine sulfate (a medicine used to treat severe pain ) every 12 hours as needed for severe leg pain rated 7-10.

Resident 29's Medication Administration Record (MAR) for January 2024 revealed that staff administered one 15 mg tablet of morphine sulfate on January 2, 2024, for a pain level rating of 6; on January 7, 2024, for a pain level rating of 5; and on January 14, 2024, for a pain level rating of 3.

There was no documented evidence in Resident 29's clinical record to indicate that the nurses were instructed to give him morphine sulfate despite the lower pain levels.

Interview with Licensed Practical Nurse 3 and Registered Nurse Supervisor 4 on January 25, 2024, at 8:43 a.m. confirmed that Resident 29 should not have been given 15 mg of morphine for pain ratings of 3, 5 and 6 (mild to moderate pain).

Interview with the Director of Nursing on January 25, 2024, at 9:39 a.m. confirmed that Resident 29 was administered morphine 15 mg for pain ratings of 3, 5 and 6 (mild to moderate pain) and he should not have.


A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated December 29, 2023, revealed that the resident was cognitively impaired and required extensive assistance with daily care needs.

Physician's orders for Resident 36, dated December 13, 2023, included an order for the resident's right elbow to be cleansed with soap and water, a small amount of triple antibiotic ointment applied to it, and then a dry dressing applied daily.

Physician's orders for Resident 36, dated December 13, 2023, included an order to cleanse the bridge of the resident's nose with soap and water, apply a small amount of triple antibiotic ointment, and the leave open to air daily.

Review of Resident 36's Treatment Administration Record (TAR) for December 2023 revealed no documented evidence that the resident received the ordered treatment to his right elbow on December 25, 27, 28 and 29, 2023, and no documented evidence that he received the ordered treatment to the bridge of his nose on December 25, 27, and 28, 2023.

Interview with the Director of nursing on January 24, 2024, at 3:19 p.m. confirmed that there was no documented evidence that the treatments were done to Resident 36's right elbow and the bridge of his nose on the dates and times listed.


A quarterly MDS assessment for Resident 70, dated November 11, 2023, revealed that the resident was cognitively intact, required assistance from staff for all his care needs, and was incontinent of bowel.

Physician's orders for Resident 70, dated August 25, 2023, included orders for the resident to receive 4 ounces of prune juice as needed if there was no bowel movement by the second day (48 hours), 30 milliliters (ml) of magnesium hydroxide suspension (an oral laxative to promote bowel movements) if no bowel movement in 3 days, one Bisacodyl suppository (a laxative inserted rectally) if there was no bowel movement in 4 days, and one Fleet's enema (a liquid inserted rectally to stimulate a bowel movement) if there was no bowel movement after 12 hours of administration of the Bisacodyl suppository.

Resident 70's bowel records revealed that he did not have a bowel movement on December 1 and 2, 2023 (2 Days); December 15-18, 2023 (4 Days); December 26 and 27, 2023 (2 Days); December 31 and January 1, 2024 (2 Days); and January 3-6, 2024 (4 Days). The resident's Medication Administration Record (MAR) revealed that staff did not administer the prune juice, magnesium hydroxide suspension, Bisacodyl or Fleet's Enema in accordance with the physician's orders.

Interview with the Director of Nursing on January 24, 2024, at 3:13 p.m. confirmed that staff should have followed the physician's orders for Resident 70's bowel protocol, and they did not.

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





 Plan of Correction - To be completed: 02/29/2024

The facility will provide care and treatment to residents in accordance with professional standards of practice by following physician orders. The concerns identified during survey for residents R29, R36 and R70 cannot be retroactively corrected.
The Director of Nursing or Designee will re-educate licensed nurses on the federal regulation 0684 and the facility policy and procedures for following physician orders when providing care to residents.
The Director of Nursing or Designee will complete an audit weekly for four weeks then monthly for three months to validate physician orders are followed.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:


Based on a review of policies and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that residents received proper care for indwelling urinary catheters for one of 33 residents reviewed (Resident 69).

Findings include:

The facility's policy regarding catheter care, dated January 2, 2024, indicated that catheter care will be performed with morning and evening care and as needed after incontinence or bowel movements.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 69, dated December 8, 2023, revealed that the resident was cognitively impaired and required extensive assistance from staff for all care.

A nurse's note for Resident 69, dated January 4, 2024, revealed that the resident returned from the hospital on January 4, 2024, with an indwelling foley 18 French, 10 cc balloon catheter (a thin flexible tube inserted into the bladder to drain urine).

There was documented evidence in Resident 69's clinical record to indicate that physician's orders were obtained to continue with the indwelling urinary catheter or for catheter care.

Observations of Resident 69 on January 24, 2024, at 11:35 a.m. revealed that the resident was in bed and the indwelling foley that was in place was a 14 French, 10 cc balloon catheter.

There was no documented evidence in Resident 69's clinical record that staff provided care for the resident's indwelling urinary catheter from January 4, 2024, until January 24, 2024.

Interview with the Director of Nursing on January 24, 2024, at 11:55 a.m. confirmed that Resident 69 did not have physician's orders for the catheter or for catheter care, and that there was no documented evidence that staff provided care for the resident's indwelling urinary catheter from January 4, 2024, until January 24, 2024.

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



 Plan of Correction - To be completed: 02/29/2024

The facility will ensure that the attending physician will be updated with recommendations from the hospital and document the notification in the electronic medical record. Orders obtained from the attending physician for the use of an indwelling urinary catheter will be placed in the electronic medical record on the Treatment Administration Record (TAR) and documented on every shift by the licensed nursing staff.
Audit of residents with an indwelling urinary catheter will be completed to ensure continued need and ensure orders for care and treatment of the indwelling urinary catheter.
Resident 69's TAR has been updated and licensed nursing staff are documenting every shift on the care of the urinary catheter.
Director of Nursing/Designee will educate licensed nursing staff on transcription of orders and of the overnight shift licensed nursing staff rechecking orders obtained to ensure proper transcription and placement of orders.
Registered Nurse Supervisor/Designee will complete an audit of orders daily for 2 weeks, then weekly for 2 weeks, then monthly for 2 months.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

483.25(f) REQUIREMENT Colostomy, Urostomy, or Ileostomy Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(f) Colostomy, urostomy,, or ileostomy care.
The facility must ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:


Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents who require colostomy, urostomy, or ileostomy services receive such care consistent with professional standards of practice for one of 33 residents reviewed (Resident 46).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated December 7, 2023, revealed that the resident was moderately cognitively impaired, required substantial assistance from staff with daily care needs, and had an ostomy (a hole/stoma in the abdominal wall which allows waste to leave the body). A care plan for Resident 46, revised on May 23, 2023, indicated that the resident had an ileostomy and staff were to observe for signs and symptoms of infection at the stoma site and to notify the physician.

A review of the clinical record revealed no documented evidence that physician's orders were obtained for the care and assessment of Resident 46's ileostomy.

A nurse's note for Resident 46, dated January 15, 2024, at 6:39 a.m. indicated that his ileostomy bag was changed due to it no longer adhering. A nurse's note on January 22, 2024, at 5:07 p.m. indicated that the resident's abdominal skin was red from the ostomy appliance leaking and that staff would monitor.

Interview with the Director of Nursing on January 25, 2024, at 9:11 a.m. confirmed that Resident 46 had no orders in place to address assessment or care of the ileostomy.

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




 Plan of Correction - To be completed: 02/29/2024

The facility will ensure that orders are obtained for the care of colostomy, urostomy, or ileostomy services.
Physician orders have been obtained for the care and assessment of resident 46's ileostomy.
Audit of residents with an ileostomy, urostomy, and/or colostomy will be completed to ensure orders for care and treatment of the appliance.
Director of Nursing/Designee will educate licensed nursing staff on obtaining orders for ileostomy, urostomy, and colostomy services to include care and assessment.
Registered Nurse Supervisor/Designee will complete a house audit of residents with ileostomy, urostomy, and colostomy appliances to ensure physician orders have been obtained for the care and assessment of appliances.
Registered Nurse Supervisor/Designee will complete an audit of ileostomy, urostomy, and colostomy appliances weekly for 2 weeks, then monthly for 2 months.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

483.35(g)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§483.35(g) Nurse Staffing Information.
§483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

§483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.

§483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

§483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.
Observations:


Based on observations and staff interviews, it was determined that the facility failed to ensure that the required nursing staffing information was posted daily.

Findings include:

Observations on January 24, 2024, at 12:29 p.m. revealed that the posted nursing staffing information was dated for Wednesday, November 23, 2023.

Interview with the Nursing Home Administrator on January 24, 2024, at 12:30 p.m. confirmed that the posting was old and that staffing hours were to be posted daily.

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


 Plan of Correction - To be completed: 02/29/2024

The facility will ensure the posting of Nurse Staffing Information.
Director of Nursing/Designee will educate the licensed nursing staff/Scheduler on posting requirements of the Nurse Staffing Information.
The Director of Nursing/Designee will audit posting five times per week for two weeks, then weekly for two weeks, then monthly for two months.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

§ 201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:


Based on review of Pennsylvania state law, as well as staff interviews, it was determined that the facility failed to ensure that the multi-disciplinary infection control committee met at least quarterly and included representation from applicable members.

Findings include:

The Act 52 Infection Control Plan, dated January 2, 2024, revealed that a health care facility should develop and implement an internal infection control plan that should be established for the purpose of improving the health and safety of residents and health care workers, and should include a multi-disciplinary committee including a representative from each of the following, if applicable to the specific health care facility. Applicable members included medical staff that could include the chief medical officer or the nursing home medical director, the nursing home administrator, laboratory personnel, nursing staff that could include the director of nursing or a nursing supervisor, pharmacy staff, physical plant personnel, a patient safety officer, and a community member that may not be an agent, employee or contractor of the facility.

As of January 25, 2024, the facility was unable to provide any documented evidence that the facility's multi-disciplinary infection control committee met at least quarterly and included representation from the chief medical officer or the nursing home medical director, the nursing home administrator, laboratory personnel, nursing staff that could include the director of nursing or a nursing supervisor, pharmacy staff, physical plant personnel, a patient safety officer, and a community member that was not an agent, employee or contractor of the facility.

Interview with the Director of Nursing on January 25, 2024, at 10:14 a.m. confirmed that there was no documented evidence that the facility's multi-disciplinary infection control committee met at least quarterly and included representation from the chief medical officer or the nursing home medical director, the nursing home administrator, laboratory personnel, nursing staff that could include the director of nursing or a nursing supervisor, pharmacy staff, physical plant personnel, a patient safety officer, and a community member that was not an agent, employee or contractor of the facility.






 Plan of Correction - To be completed: 02/29/2024

The facility will ensure documentation that the Infection Control Committee meets at least quarterly and include representation from the chief medical officer or the nursing home medical director, the nursing home administrator, laboratory personnel, nursing staff that could include the director of nursing or a nursing supervisor, pharmacy staff, physical plant personnel, a patient safety officer, and a community member that was not an agent, employee or contractor of the facility.
The Director of Nursing/Designee will educate the Infection Preventionist on the requirement of meeting at least quarterly to discuss improving the health and safety of residents and health care workers and the representation needed.
The Infection Preventionist will complete an audit every 3 months for 6 months to ensure that the above representation has attended the quarterly infection control meeting.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

§ 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 review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a disposition of medications was completed for one of 33 closed records reviewed (Resident 76).

Findings include:

Review of the closed medical record for Resident 76 revealed that there was no documented evidence that a disposition of medications was completed after the death of the resident.

Interview with the Director of Nursing on January 24, 2024, at 1:23 p.m. confirmed that the disposition of medication for Resident 76 was not completed and placed in the medical record.



 Plan of Correction - To be completed: 02/29/2024

The facility will ensure that a disposition of medications was completed and placed in the resident's medical record upon discharge of resident.
The Director of Nursing/Designee will educate the licensed nursing staff on completing a disposition of medications form upon resident's discharge from facility.
Licensed nursing staff will complete a disposition of medication form for all resident discharges.
Medical Records staff will notify the Registered Nurse Supervisor and Director of Nursing of the need for completion of any disposition of medications form that was not included in the chart.
Medical Records staff will complete an audit of closed records to ensure a disposition of medications form has been completed. This audit will be completed monthly for three months of all closed records.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

§ 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 review of nursing schedules, staffing information provided by the facility, and staff interviews, it was determined that the facility failed to meet the required nurse aide-to-resident staffing ratio on the overnight shift for two of 21 days (24-hour periods) reviewed.

Finding include:

Nursing time schedules provided by the facility for the days of January 4 through January 24, 2024, revealed that the facility provided one nurse aide per 24 residents on January 6, 2024, and provided one nurse aide per 26 residents on January 21, 2024, during the overnight shift.

Interview with the Nursing Home Administrator on January 25, 2024, at 2:30 p.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the days listed above.



 Plan of Correction - To be completed: 02/29/2024

The facility cannot correct that nurse aide staffing ratios were not met on 1/6/2024 and 1/21/2024. There were no adverse effects to the residents on the identified dates.
The facility will ensure that staffing ratios are met every shift. If staffing ratios are not able to be met then admissions will be halted.
Nursing administration and the nursing scheduler has been educated by the Nursing Home Administrator/Designee on ensuring staffing ratios are met each shift.
Daily shift staffing ratios will be reviewed at Standup.
The nursing supervisors will review shift staffing ratios on the weekends. If the facility projects not to meet staffing ratios on a shift, the scheduler/designee will be responsible to call off duty personnel or extra support staff to assist, department heads, bonuses will be offered if needed, corporate clinical staff will be contacted, as well as agencies for assistance.
The Nursing Home Administrator/Designee will audit staffing daily for 4 weeks and monthly for 3 months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.


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