Pennsylvania Department of Health
 WYNDMOOR HILLS REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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WYNDMOOR HILLS REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  148 surveys for this facility. Please select a date to view the survey results.

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WYNDMOOR HILLS REHABILITATION AND NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to two complaints, completed on February 23, 2024, it was determined that Wyndmoor Hills Rehabilitation and Nursing Center, was not in compliance with the requirements of 42 CFR part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.


 Plan of Correction:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:


Based on review of facility policy, facility documentation, review of clinical records, interviews with staff and the resident, it was determined that the facility did not ensure residents were free from verbal abuse which resulted in actual harm to Resident R14 who was verbally abuse by a nursing staff for one of 16 residents reviewed. (Resident R14)

Findings Include:

Review of facility policy titled "Abuse Prevention Program" dated January 1, 2022 reads, "Our residents have the right to be free from abuse, neglect, misappropriation or resident property and exploitation."

Review of the admission record for Resident R14 incident he was admitted to the facility on August 19, 2023 with diagnoses of Metabolic Encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), Unspecified abnormalities of gait, muscle weakness, polydipsia (an urge to drink too much associated with dry mouth or throat), acute kidney failure and anemia.

Review of Resident R14's admission Minimum Data Set (MDS resident assessment of care needs) dated August 19, 2023, revealed a BIMS (Brief Interview for Mental Status) score of 14 indicating that the resident's cognition was intact.

Review of facility documentation submitted to the State Agency on January 19, 2024 revealed that on January 14, 2024, Employee E15 was in the doorway of Resident R14's room and nurse aide, Employee E22 approached Employee E15 and asked what the resident was requesting. Employee E15 said that the resident was requesting water but he was on fluid restrictions. Employee E22 asked the nurse and the nurse said that the resident could have a small cup of water. Upon Employee E22 returning to Resident's R14's room with water, Employee E22 heard Employee E15 calling resident names. The facility substantiated the allegation of verbal abuse.

Review of facility grievance form from January 15, 2024, involving Resident R14 and nurse aide Employee E15. Grievance form summary of concern reads, "Resident said his nurse has been calling me all types of names. Resident also said she was rough with him and she refused to give him ice and water."

Review of facility witness statement form Licensed nurse, Employee E21 revealed, "This nurse overheard [nurse aide, Employee E15] and [nurse aide, Employee E22] disagreeing as they were both coming down the hallway. [Resident R14] requested water and [nurse aide Employee E15] told [nurse aide, Employee 22] he could not have water due to restrictions. Nurse aid Employee E15 can been seen going into the resident's room and nurse aid Employee E22 was standing at the nurse's station we could hear nurse aide, [Employee E15] yelling at [Resident R14[ about the water. [Nurse aide, Employee E22] approached the nurses station asking could she give Room... [Resident R14]water. This nurse informed her so could do so with supervision, one small cup only. [Nurse aide, Employee E22] from the low side informed this nurse, that [nurse aide, Employee E1]5 told her not to give him water. I then encourage [nurse aide, Employee E22] to give the resident water no one can refuse him water if he is asking. [Nurse aide, Employee E15] told me I do not work here you do not tell me because I am with him every day he has a restriction. [Nurse aide, Employee E15] told [nurse aide, Employee E22] do not go on my side telling me what to do who are you nobody you are an ugly Muslim and you lie on me. This nurse encouraged both ladies to calm down and write statements to give to the supervisor. [Nurse aide, Employee E22] told [nurse aide Employee E15] that she was wrong for cursing at the patient, and she should be fired for all the abuse and wrong doing she does and that she was tired of it. [Nurse aide, Employee E22] was crying she appeared very emotional. [Nurse aide, Employee E15] told [nurse aide, Employee E22] she can go to h*** and report me all you want you will see nothing will happen you will get fired first you ugly Muslim you are evil. [Nurse aide, Employee E15] went to [Resident R14's room] asking him why did he lie I could hear her yelling. She returned to the nurse station telling his nurse I can not tell her what to do you are not staff only agency and a license practical nurse nobody. As the supervisor was approaching asking to talk in the lounge [nurse aide, Employee E15] followed behind me still yelling and calling me names. [Nurse aide, Employee E15] went into the patient room and for the third time she could be seen by this nurse pulling the sheet off the patient[ Resident R14]." "[Resident R14] stated, "She, she threw my water on me and my cup is on the floor." [Resident R14] appeared afraid and uncomfortable. [nurse aide, Employee E15] was asked to leave the patient room for safety reasons and privacy to talk to the nurse. [nurse aide, Employee E15] used prejudice/harmful words about my religious beliefs attacking my work ethic as well. [Licensed nurse, Employee E8] encouraged [nurse aide, Employee E15] to leave. She refused until the end of shift."

Review of facility witness statement form completed January 14, 2024, from nurse aide, Employee E22 read, "I was done my last round at 10:15 p.m. so I decided to go see why room 220 light had been going off for hours. Once I got to the room, nurse aid Employee E15 was sitting outside the room. I asked her why his light was going off and she said he want some water. But he on fluid restriction. I went into the room anyway. When I got in the room the patient said he wanted water but she was not going to give me none. That when I asked the charge nurse if he can have some water she told me yes but a small cup. I pour the cup of water and was on my way down to the room 220 when I heard nurse aid Employee E15 call the resident all kinds of name, (mother f**, if he reported her just see) that's when I went in the room to give him his water, told nurse aid Employee E15 to step out of the room. That's when I told her she can not talk to him like that. I reported her to the charge nurse that's when she told me I was ugly because I am Muslim."

Review of facility witness statement form completed January 14, 2024, from Licensed nurse, Supervisor, Employee E8, "While sitting in the nurse's office approximately 10:30 p.m. I heard a commotion in the hallway. I immediately went onto the unit and observed the charge nurse Employee E21 and nurse aid Employee E15 going/arguing back and forth with one another. I asked what is going on and spoke with each staff member assigned to the second floor. Nurse aide Employee E22 reported to me that she witness nurse aid Employee E15 cursing at Resident R14 and talking loud to the resident. I asked nurse aid Employee E15 to get her things she have to leave, because it's been reported to me that she cursed at the resident. At that time nurse aid Employee E15 attempted to go int to the resident room. I told [Employee E15] not to go in the room and she went in the room anyway. After [Employee E15] left the room. I spoke with resident he stated she spilled my water, I don't know why she doesn't like me. When I left the resident room and went to the nurse's station. The CNA [Employee E15] went back to resident's room. I asked her to leave and if she didn't leave. I told her I will call the police. Staff left the building, after that."

Interview held with Licensed nurse, Supervisor, Employee E8 on February 21, 2024, at 1:31 p.m. Licensed nurse, Employee E8 stated she was unsure of the exact time the incident with Resident R14 and nurse aide Employee E15 started. Licensed nurse, Employee E8 stated, "Towards the end of shift I heard commotion. I go down the hallway and see the nurse and nurse aid Employee E15 arguing on the floor. I took the nurse into the break room and got her story about what was going on. I then got nurse aide Employee E15 into the break room to get her story. I told her there was an allegation of abuse and she had to leave. I told her she could call and talk to the Director of Nursing in the morning. Not long after she was still here and she wouldn't leave. She was down the unit hallway towards where her bags were. She wasn't leaving right away she was in the hallway and she may have tried to go near the room again after she got her stuff. She left a little after 11:00 p.m. because the next shift was coming in and was asking what was going on. I'm not going to say she left immediately because it was hard to get her to leave, I had to tell her I was going to call the police."

Interview with nurse aide, Employee E22 on February 23, 2024, at 3:38 p.m. revealed nurse said that Resident R14 could have a small cup. [Employee E15] was inside room and she overheard Employee E15 calling the resident names. "I then was able to get [Employee E15] out of the room and she started to call me names. This all happened around 10:30 p.m. and it was hard to get her off of the floor. There were staff from the second shift coming in asking what happened because I was upset."

Interview conducted with Resident R14 on February 23, 2024, at 9:41 a.m. confirmed that the resident was involved in verbal abuse situation. The resident stated, that aide was rude to me so they fired her.

Interview with the Director of Nursing on February 22, 2024, at approximately 1:30 p.m. stated that Employee E15 did not returned to work at the facility and was terminated from employment.

Interview with Nursing Home Administrator, Employee E1 on February 22, 2024, at 2:10 p.m. confirmed the above findings.

The facility failed to ensure that Resident R14 was free from verbal abuse which resulted in actual harm to Resident R14 who called a derogatory name by nurse aide, Employee E15.


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

28 Pa. Code 211.10 (c) (d) Resident Care policies

28 Pa. Code 211.12 (d) (1)(2)(3)(5) Nursing services





















 Plan of Correction - To be completed: 03/15/2024

1. Resident #14 was re-assessed by a licensed nurse interviewed by the SSD to ensure there were no undesired outcomes related to the facility's alleged deficient practice.
2. Residents with abuse allegations in the last 90 days will be interviewed to ensure that there were no undesired outcomes related to any alleged abuse reported.
3. Facility staff will be educated regarding the Abuse Policy and Procedure to ensure that staff are knowledgeable regarding the resident's right be free from abuse and neglect.
4. IDT Team will interview 5 residents who are deemed cognitively intact and 5 responsible parties of those who are not weekly x4 weeks then 2x a month x2 months then monthly x2 months to ensure that they are free from abuse and neglect. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:


Based on facility policy, observations, interview with residents and staff, it was determined that the facility failed to prevent transmission of infection precautions and implement policies and procedure to prevent infections related to the transporting and handling of linens on one of one laundry rooms observed and failed to conduct assesment to identify Legionella and other opportunistic waterborne pathogens.

Finding include:

Review of facility policy titled " Infection Prevention and Control Program" revised October 2018 revealed important facets of infection prevention include : educating staff and ensuring that they adhere to proper techniques and procedures, immunizing residents and staff to try to prevent illness, and following established general and disease specific guidelines such as those of the Center for Disease Control (CDC), the facility provides personal protective equipment, checks for proper use, and provides appropriate means for needle disposal.

Review of the facility's Infection preventionist job description reveals the infection preventionist's duties include collecting, analysis, and interpreting health data in order to plan implement, evaluate, and disseminate appropriate public health practices. Among responsibility the infection preventionist is responsible for coordinating the annual infection control risk assessment.

Included in infection prevention, the facility is required as necessary, and at least annually, to review and revision of the IPCP (Infection Prevention Control Plan), based upon the facility assessment.

The IPCP which includes that the facility must be able to demonstrate its measures to minimize the risk of Legionella ("Legionellosis" refers to two clinically and epidemiologically distinct illnesses: Legionnaires' disease, which is typically characterized by fever, myalgia, cough, and clinical or radiographic pneumonia; and Pontiac fever, a milder illness without pneumonia (e.g., fever and muscle aches). Legionellosis is caused by Legionella bacteria.) and other opportunistic pathogens in building water systems such as by having a documented water management program. Legionella can grow in parts of building water systems that are continually wet (e.g., pipes, faucets, water storage tanks, decorative fountains), and certain devices can spread contaminated water droplets via aerosolization.

Review of the center on disease control CDC policy titled Legionella (Legionnaires' Disease and Pontiac Fever), revealed that environmental testing for Legionella is useful to validate the effectiveness of control measures. The program team should determine if environmental testing for Legionella should be performed and, if so, how test results will be used to validate the program.

Interview with Nursing Home Administrator, Employee E1 revealed a document stating the water was tested but sample was lost. There was no more information regarding the plans and surveillance of the water system in the facility.

Further review of the facility Infection Prevention Policy revised 2018, revealed important facets of infection prevention include educating staff and ensure they adhere to proper techniques and procedures.

Review of facility policy Laundry and bedding soiled revised 2009 revealed that soiled laundry must be handled in a manner that prevent gross microbial contamination of the air and person handling the laundry. Place contaminated laundry in a bag or container at location where it is used. Anyone who handles laundry must wear protective gloves and other appropriate protective equipment.

Center for Disease Control and Prevention (CDC) guidelines for environment infection control in health care facilities dated 2003, revealed contaminated fabrics often contain high numbers of microorganisms from body substance, including blood, skin, stool, urine, and fluids. Disease transmission attributed to health care laundry has involved contaminated fabrics that were handled inappropriately. Standard precautions of handling contaminated laundry and can be transported by cart or chute. Loose pieces of laundry should not be tossed into chutes, and laundry bags should be closed or secured to prevent falling out into the chute.

Observation of laundry room on February 21,2023 at 12:32 p.m. and again February 22, 2023, at 1:30 p.m. revealed a soiled laundry cart under laundry chute with soiled unbagged and unseparated linens. Interview with Employee E5 at time of observation confirmed that lines were not bagged or separated as they are supposed to be to prevent infection.

Continued observation of the laundry room on February 21, 2023, at 12:32 and on February 22, 2023, at 1:30 p.m. revealed that the three housekeeping employees handling the linens were not wearing personal protective equipment to aid in the prevention of cross contamination of linens.

Interview with Housekeping Supervisor, Employee E5 at time of observation confirmed this observation.


28 Pa. Code 201.14(a) Responsibility of Licensee

28 Pa. Code 210.18 (b)(1)(b)(2) Management










 Plan of Correction - To be completed: 03/15/2024

1. No residents were cited in this F-Tag
2. The Legionella samples will be collected and sent to the testing vendor with required paperwork to process the samples. Personal Protective Equipment will be ordered for laundry to ensure protection when handling soiled linen.
3. Maintenance will be educated regarding collecting and mailing Legionella samples with the necessary paperwork to the testing vendor. NHA/designee will make follow-up calls to the testing vendor weekly to ensure proper paperwork is received and samples are processed timely. The Housekeeping Director will educate laundry employees on wearing personal protective equipment when handling soiled linen.
4. NHA will audit Legionella paperwork to ensure the necessary paperwork is sent to process samples for results. NHA/designee will document weekly calls to testing vendor on a phone call log. The call log and Legionella sample paperwork will be reported to QAPI monthly x3 months or until the testing process has been completed. Housekeeping Supervisor will audit the laundry weekly x4 weeks then monthly x3 months to ensure laundry staff are wearing personal protective equipment. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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.
§483.10(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, interviews with residents, and interviews with staff, it was determined tha tthe facility did not ensure a safe, clean, comfortable, homelike environment for three of three floors observed. (First floor, Second floor, and Third floor).

Findings include:

Observation of the First-floor therapy room revealed four buckets and one large trash can with standing water. Water was observed leaking consistently onto the wall and floor where a puddle was located.

Interview with Assistant Director of Maintenance, Employee E6 and Nursing Home Administrator, Employee E1 confirmed that the space had not been in use since around November 2023 when the water leaks started. When asked who was supposed to be checking on these leaks assistant Director of Maintenance, Employee E6 stated he should be. He last checked on Friday and that the trash can was empty when he left. Currently, the large trash can was full three quarters of the way with standing water. There was black substance with the apperance of mold located on the wall surrounding the leak and a large puddle of water on the floor. The Nursing Home Administrator, Employee E1 stated that the leaks started in December 2023, and they are unknown where they are coming from.

Observation of the Second floor revealed Assistant Director of Maintenance, Employee E6 on February 20, 2024 at 9:46 a.m. in the resident room 227 with the call light on. Further observation revealed the resident had a hand bell at bedside. Assistant Director of Maintenance, Employee E6 revealed he was working on the resident's call bell because it currently would not turn off.

Observation of the restroom located on the Third floor, across from the elevator revealed the bathroom was being used to store a mop as well as a infectious waste trash can. The ceiling paint was peeling off in several areas of the room.

Observation of Resident R20's room on February 20, 2024, at 10:30 a.m. revealed dirty floors.

Observation of the Third-floor shower room on February 20, 2024, at 10:41 a.m. revealed the right shower room was currently not working. The water would not turn on. The faucet appeared to be broken and the tile behind the faucet was broken off. The space of tile broken behind the faucet was so large you could see straight through into the storage closet located behind the shower room.

Further observation of the Third-floor shower room on February 20, 2024 at 10:41 a.m. reaveled the left shower had no shower curtain to allow for privacy during showers.

Observation of Resident R14's room on February 21, 2024 at 1:01 p.m. revealed the resident's door to his room would not shut all the way.

During a later interview with the Nursing Home Administrator on February 22, 2024, at 2:47 p.m. revealed the facility usually has three maintenance workers and they currently only have one.

28 Pa. Code 201.14 (a) Responsibility of licensee

















 Plan of Correction - To be completed: 03/15/2024

Resident #14's door was adjusted and Resident #20's floor and room were deep cleaned.
2. The buckets were removed from the therapy gym and the wall was repaired where there was a black substance on the wall. A plumber will be contacted to determine root cause and repair the leaks in the therapy gym. The call bell in resident room 227 was repaired and the hand bell was removed. The infectious waste container and mop was removed from the bathroom across from the 3rd floor. The ceiling of the rest room will be repainted. The third-floor shower room will be repaired. The shower curtains were replaced in the third-floor shower room.
3. Maintenance and Housekeeping staff will be educated regarding a policy and procedure on maintaining a clean, comfortable home like environment. The NHA/Housekeeping Director will be developing and implementing a deep clean schedule.
4. Environmental Rounds will be completed by Maintenance and Housekeeping weekly x4 and then monthly x4 months to ensure a clean, comfortable homelike environment is being maintained for the residents. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.80(d) Influenza and pneumococcal immunizations
§483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

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


Based on review of policies and resident clinical records, staff and resident interviews, it was determined that the facility failed to implement infection control by not ensuring availability of immunization and offering vaccination to eight of 16 residents reviewed. (

Findings include:

Review of facility policy, "Infection Prevention and Control Program" revised 2018, revealed the elements of this program consists of policies, surveillance, data analysis, antibiotic stewardship, prevention of infection, including immunization of residents and staff to prevent illness.

Review of the facility policy titled "Influenza Vaccine" revealed that all resident and employees who have no medical contradictions to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza.

Further review of the policy titled "Influenza Vaccine" revealed that employees hired, or residents admitted between October 1, and March 31, shall be offered the vaccine within five working days of the employees' job assignment or the resident's admission to the facility.

Review of Resident R6, Resident R24, Resident R33, Resident R55, Resident R59, Resident R164, Resident R166 and Resident R216 revealed no documentation that the resident received or was offer, declined or was education on the influenza vaccine.

Interview with Resident R6, Resident R24, Resident R33, Resident R55, Resident R59, Resident R164, Resident R166 and Resident R216 on February 21, 2024 between 8:00 a.m.-12:00 p.m. the stated that they would like to receive the influenza vaccine.

Interview with DON, acting Infection Preventionist Employee E2 on February 21,2024, revealed that the influenza vaccine was not available after the last shipment was delivered in November 2023.


28 Pa. Code 201.14 (a)Responsibility of Licensee

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

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








 Plan of Correction - To be completed: 03/15/2024

1. Resident 6, R24, R33, R55, R59, R164, RR166, R216 were offered the flu vaccine.
2. Current Residents vaccine status will be reviewed by DON/designee to determine which resident would like to have the flu vaccine.
3. DON, Unit Manager, and the Licensed Nurses will be educated regarding the Influenza and Pneumococcal Vaccine Policy and Procedure.
4. The DON/designee will audit the vaccination status of residents weekly x4 and then monthly x5 months to ensure that residents have been offered vaccines and that they have been administered if requested. . The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on review of facility policy, interviews with staff and residents, it was determined that the facility did not ensure privacy and dignity was upheld for two of 16 residents reviewed. (Residents R20 and R26).

Findings Include:

Review of facility policy titled, "Resident Rights" with a revision date of December 2016 states, "Employees shall treat all residents with kindness, respected, and dignity." "1. Federal and state laws guarantee basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence, b. be treated with respect, kindness, and dignity."

An interview was held with Resident R20 on February 20, 2024 at 10:11 a.m. During the resident interview Resident R20 mentioned on the Third-floor shower room there was no shower curtain. Resident R20 stated he has mentioned this to staff a few times and there is still no curtain. Resident R20 stated that he will be in the shower room taking a shower and staff or other residents will walk right into the space outside of the shower and be able to see him naked.

Observation made on February 20, 2024 at 10:20 a.m. of the third floor shower room and both of the showers had no shower curtains.

Observation was made on the lunch meal at 11:45 a.m. on February 20, 2024. During the lunch meal observation is was noticed that Resident R26 had a pink sweatshirt on with her full name and room number written on the outside back of her sweatshirt in large font with permanent marker.

28 Pa. Code 201.29 (d) Resident Rights




 Plan of Correction - To be completed: 03/15/2024

1. A shower curtain was installed prior to survey exit for the working shower on 3rd Floor. Resident #20 will be informed of the installation of shower curtain. Resident #26's family was educated regarding on ensuring that resident's clothing is marked only on the inside where it is not visible to others while being worn.
2. Shower curtains will be installed for additional showers without one.The IDT team will ensure that no other residents have clothing with their name/room number visible to others while being worn.
3. Facility staff will be educated on the components of this regulation with an emphasis on ensure that residents' dignity, rights, and privacy are maintained.
4. Maintenance/designee will audit shower room curtains weekly x4 weeks, 2x a month x2 months, then monthly x2 months. The IDT Team will conduct 10 resident observations weekly x4 weeks, 2x a month x2 months, then monthly x2 months to ensure clothing is free of visible markings with name and room number. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee.


483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response: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(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:

Based on review of the facility policy, facility grievance log, review of facility grievances, interviews with residents and staff, it was determined that the facility did not ensure resident grivance was documented for one of 16 residents reviewed. (Resident R4)

Findings Include:

Review of facility policy titled "Grievance/Complaints, Filing" with a revised dated on April 2017 states, "Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.

Interview during resident council held on February 21, 2024 at 10:00 a.m. with nine awake, alert, and oriented residents revealed Resident R4 had a concern with missing clothing. Resident R4 revealed a concern regarding never receiving an explanation about clothing items of his that went missing back in November 2023.

After resident council was held the facility was asked if a grievance form was filled for Resident R4 regarding his missing clothing.

Review of facility grievance log from November 2023 on February 20, 2024 at 2:55 p.m. revealed a grievance filed by the facility for the resident.

The facility produced a grievance from November 12, 2023 stating "Resident said his clothing was missing." The grievance was signed by Social Worker, Employee E4.

Interview with facility Social Worker, Employee E4 revealed the employee started working at the facility in the month of November 2023. Further during interview with Social Worker, Employee E4 revealed he started at the facility the Monday after Thanksgiving (November 27, 2023). When further questioned regarding Resident R2's grievance from November 12, 2023 Social Worker Employee E4 stated he did not fill out such a grievance. When showed the completed grievance form Social Worker, Employee E4 stated that was his handwriting and signature. Further questioning of the Social Worker, Employee E4 revealed the Social Worker, Employee E4 was instructed by Administration to complete the grievance form due to the Social Worker, Employee E4 talking to the resident, Resident R2 about his clothing during the month of December 2023. Social Worker, Employee E4 confirmed he did not fill out a grievance for Resident R4 for the month of December 2023.


28 Pa. Code 201.29 (a) Resident Rights

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







 Plan of Correction - To be completed: 03/15/2024

1. R4's original grievance was discovered prior to survey exit with documentation that clothing was found and returned. Activities Director/designee interviewed resident regarding any additional missing clothing and if any are identified a grievance will be completed.
2. Resident Council Minutes and grievances will be for the last 30 days will be reviewed by the Activities Director/designee to ensure resident concerns are documented on a resident council concern form, or grievance form and that they have been addressed appropriately.
3. Social Services Director was educated regarding documenting grievances and the grievance policy and procedure including ensuring that they are addressed in a timely manner.
4. Grievances will be audited weekly x4 weeks, 2x a month x2 months, then monthly x2 months by NHA/designee to ensure prompt resolution to grievances. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee.

483.10(g)(10)(11) REQUIREMENT Right to Survey Results/Advocate Agency Info: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)(10) The resident has the right to-
(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and
(ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.

§483.10(g)(11) The facility must--
(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility.
(ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and
(iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.
(iv) The facility shall not make available identifying information about complainants or residents.
Observations:


Based on observation and an interview with staff, it was determined that the facility failed to ensure that the most recent Department of Health survey results were readily accessible to residents and visitors.

Findings Include:

Observation on Ferbruary 22, 2024 at 8:50 a.m. and February 23, 2024 at 11:05 a.m. revealead a survey binder located in the lobby area with past Department of Health survey reports only available through April 30, 2023.

Interview and observation of the Department of Health's survey results binder on February 23, 2024 at 11:07 a.m. with Nursing Home Administrator confirmed that the State survey results were not kept up to date for resident, families and visitors to review.

28 Pa. Code 201.14 (a) Responsibility of licensee







 Plan of Correction - To be completed: 03/15/2024

1. No specific residents were cited in this F-Tag
2. The annual health survey (survey ending 05-11-23) was placed in the survey binder.
3. Survey binder will be updated NHA/designee with surveys from 2023 and reviewed to ensure survey binder includes 3 years of survey activity. NHA was educated by the RDCS. regarding the maintenance of the survey binders to ensure 3 years of surveys are present.
4. NHA/designee will audit survey binder weekly x4 the monthly x2 to ensure surveys for the past 3 years are in the survey binder. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on review of facility policy, facility documentation, review of clinical records, interviews with staff and the resident, it was determined that the facility failed to implement an abuse prohibition policy that included a complete a thorough investigation of an incident involving verbal abuse for one of 16 residents reviewed. (Resident R14)

Findings Include:

Review of facility policy titled "Abuse Prevention Program" dated January 1, 2022 reads, "Our residents have the right to be free from abuse, neglect, misappropriation or resident property and exploitation." "Role of the Investigator: 16. The individual conducting the investigation will, as a minimum:
a.Review the completed documentation forms:
b.Review the resident's medical record to determine events leading up to the incident;
c.Interview the person (s) report the incident;
d.Interview any witnesses to the incident;
e.Interview the resident (as medically appropriate)
f.Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition;
g.Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident;
h.Interview the resident's roommate, family members, and visitors;
i.Interview other residents to whom the accused employee provides care or services; and
j.Review all events leading up to the alleged incident.

Review of the admission record for Resident R14 incident he was admitted to the facility on August 19, 2023 with diagnoses of Metabolic Encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), Unspecified abnormalities of gait, muscle weakness, polydipsia (an urge to drink too much associated with dry mouth or throat), acute kidney failure and anemia.

Review of Resident R14's admission Minimum Data Set (MDS resident assessment of care needs) dated August 19, 2023, revealed a BIMS (Brief Interview for Mental Status) score of 14 indicating that the resident's cognition was intact.

Review of facility documentation submitted to the State Agency on January 19, 2024 revealed that on January 14, 2024, Employee E15 was in the doorway of Resident R14's room and nurse aide, Employee E22 approached Employee E15 and asked what the resident was requesting. Employee E15 said that the resident was requesting water but he was on fluid restrictions. Employee E22 asked the nurse and the nurse said that the resident could have a small cup of water. Upon Employee E22 returning to Resident's R14's room with water, Employee E22 heard Employee E15 calling resident names. The facility substantiated the allegation of verbal abuse.

Review of facility witness statement form Licensed nurse, Employee E21 revealed, "This nurse overheard [nurse aide, Employee E15] and [nurse aide, Employee E22] disagreeing as they were both coming down the hallway. [Resident R14] requested water and [nurse aide Employee E15] told [nurse aide, Employee 22] he could not have water due to restrictions. Nurse aid Employee E15 can been seen going into the resident's room and nurse aid Employee E22 was standing at the nurse's station we could hear nurse aide, [Employee E15] yelling at [Resident R14[ about the water. [Nurse aide, Employee E22] approached the nurses station asking could she give Room... [Resident R14]water. This nurse informed her so could do so with supervision, one small cup only. [Nurse aide, Employee E22] from the low side informed this nurse, that [nurse aide, Employee E1]5 told her not to give him water. I then encourage [nurse aide, Employee E22] to give the resident water no one can refuse him water if he is asking. [Nurse aide, Employee E15] told me I do not work here you do not tell me because I am with him every day he has a restriction. [Nurse aide, Employee E15] told [nurse aide, Employee E22] do not go on my side telling me what to do who are you nobody you are an ugly Muslim and you lie on me. This nurse encouraged both ladies to calm down and write statements to give to the supervisor. [Nurse aide, Employee E22] told [nurse aide Employee E15] that she was wrong for cursing at the patient, and she should be fired for all the abuse and wrong doing she does and that she was tired of it. [Nurse aide, Employee E22] was crying she appeared very emotional. [Nurse aide, Employee E15] told [nurse aide, Employee E22] she can go to h*** and report me all you want you will see nothing will happen you will get fired first you ugly Muslim you are evil. [Nurse aide, Employee E15] went to [Resident R14's room] asking him why did he lie I could hear her yelling. She returned to the nurse station telling his nurse I can not tell her what to do you are not staff only agency and a license practical nurse nobody. As the supervisor was approaching asking to talk in the lounge [nurse aide, Employee E15] followed behind me still yelling and calling me names. [Nurse aide, Employee E15] went into the patient room and for the third time she could be seen by this nurse pulling the sheet off the patient[ Resident R14]." "[Resident R14] stated, "She, she threw my water on me and my cup is on the floor." [Resident R14] appeared afraid and uncomfortable. [nurse aide, Employee E15] was asked to leave the patient room for safety reasons and privacy to talk to the nurse. [nurse aide, Employee E15] used prejudice/harmful words about my religious beliefs attacking my work ethic as well. [Licensed nurse, Employee E8] encouraged [nurse aide, Employee E15] to leave. She refused until the end of shift."

Review of facility witness statement form completed January 14, 2024, from nurse aide, Employee E22 read, "I was done my last round at 10:15 p.m. so I decided to go see why room 220 light had been going off for hours. Once I got to the room, nurse aid Employee E15 was sitting outside the room. I asked her why his light was going off and she said he want some water. But he on fluid restriction. I went into the room anyway. When I got in the room the patient said he wanted water but she was not going to give me none. That when I asked the charge nurse if he can have some water she told me yes but a small cup. I pour the cup of water and was on my way down to the room 220 when I heard nurse aid Employee E15 call the resident all kinds of name, (mother f**, if he reported her just see) that's when I went in the room to give him his water, told nurse aid Employee E15 to step out of the room. That's when I told her she can not talk to him like that. I reported her to the charge nurse that's when she told me I was ugly because I am Muslim."

Review of facility witness statement form completed January 14, 2024, from Licensed nurse, Supervisor, Employee E8, "While sitting in the nurse's office approximately 10:30 p.m. I heard a commotion in the hallway. I immediately went onto the unit and observed the charge nurse Employee E21 and nurse aid Employee E15 going/arguing back and forth with one another. I asked what is going on and spoke with each staff member assigned to the second floor. Nurse aide Employee E22 reported to me that she witness nurse aid Employee E15 cursing at Resident R14 and talking loud to the resident. I asked nurse aid Employee E15 to get her things she have to leave, because it's been reported to me that she cursed at the resident. At that time nurse aid Employee E15 attempted to go int to the resident room. I told [Employee E15] not to go in the room and she went in the room anyway. After [Employee E15] left the room. I spoke with resident he stated she spilled my water, I don't know why she doesn't like me. When I left the resident room and went to the nurse's station. The CNA [Employee E15] went back to resident's room. I asked her to leave and if she didn't leave. I told her I will call the police. Staff left the building, after that."

Interview held with Licensed nurse, Supervisor, Employee E8 on February 21, 2024, at 1:31 p.m. Licensed nurse, Employee E8 stated she was unsure of the exact time the incident with Resident R14 and nurse aide Employee E15 started. Licensed nurse, Employee E8 stated, "Towards the end of shift I heard commotion. I go down the hallway and see the nurse and nurse aid Employee E15 arguing on the floor. I took the nurse into the break room and got her story about what was going on. I then got nurse aide Employee E15 into the break room to get her story. I told her there was an allegation of abuse and she had to leave. I told her she could call and talk to the Director of Nursing in the morning. Not long after she was still here and she wouldn't leave. She was down the unit hallway towards where her bags were. She wasn't leaving right away she was in the hallway and she may have tried to go near the room again after she got her stuff. She left a little after 11:00 p.m. because the next shift was coming in and was asking what was going on. I'm not going to say she left immediately because it was hard to get her to leave, I had to tell her I was going to call the police."


There were no interviews completed with other residents that nurse aide, Employee E15 was assigned to during that shift, other than the resident involved (Resident R14).

The above findings were confirmed by the Nursing Home Administrator, Employee E1 on February 22, 2024 at 11:11 a.m.

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

28 Pa. Code 201.19 Personnel policies and procedures

28 Pa. Code 201.29 (a) Resident rights

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
















 Plan of Correction - To be completed: 03/15/2024

F610
1. The investigation was closed by the facility on January 19, 2024 regarding Resident 14's allegation of verbal abuse. Employee 15 was terminated
2. Abuse Investigations for the last 90 days will be reviewed to ensure that a full investigation was completed per regulation.
3. NHA, DON, and IDT Team will be educated regarding the abuse investigation process.
4. NHA will audit abuse investigations weekly x4 then monthly x5 months to ensure the entire investigative process was completed. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee.


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 the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer in a timely manner, in writing and in a language and manner they understood for three of 16 residents reviewed (Residents R23 and R61).

Findings include:

Review of Resident R23's clinical record revealed that the resident was transferred to the hospital on September 6, 2023, due to a change in mental status.

Review of clinical record revealed no evidence that Resident R23 was not notified of the transfer to the hospital and the reasons for the transfer in writing, and in a language and manner they understood.

Review of Resident R61'sclinical record revealed that the resident was "sent to ER" (emergency room) on December 18, 2023, due to foot infection.

Review of clinical record revealed no evidence that Resident R61 was notified of the transfer to the hospital and the reasons for the transfer in writing, and in a language and manner they understood.

Interview with the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, on February 22, 2024, at 3:05 p.m. confirmed that the Residents R23 and R61 were not notified in writing of the reasons for the transfer, and in a language and manner they understood.


28 Pa. Code 201.14(a) Responsibility of license

28 Pa. Code 201.29(a) Resident rights





 Plan of Correction - To be completed: 03/15/2024

1. Corrective actions for Resident #23 cannot occur retroactively and Resident #61 was discharged to the hospital and didn't return to the facility.
2. The last 30 days of unplanned discharges will be reviewed by the Social Services Director/designee to ensure that notice of transfer/discharges are provided to the resident or responsible party.
3. Licensed Nurses and Social Services Director will be educated on providing the resident a notice of transfer/discharge when an unplanned discharge occurs.
4. The Social Services Director/designee will audit unplanned discharges weekly x4 weeks then monthly x5 months to ensure a notice of transfer/discharge was provided the resident or responsible party. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee.


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 clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital for two of 32 residents reviewed. (Resident R91 and R71)

Findings include:

Review of Resident R23's clinical record revealed that the resident was transferred to the hospital on September 6, 2023, due to a change in mental status.

Review of Resident R61's clinical record revealed that the resident was "sent to ER" (emergency room) on December 18, 2023, due to foot infection.

Further review of Resident R23 and R61's clinical record revealed that there was no documented evidence that the residents' were provided with a written notice of the facility bed-hold policy at the time of Resident R23 and R61's facility-initiated transfer to the hospital.

Interview with the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, on February 22, 2024, at 3:05 p.m. confirmed that the Residents R23 and R61 were not provided with the bed hold policy, that included information explaining the duration of the bed-hold, bed reserve payment and permitting return to a bed at the facility.

28 Pa Code 201.14(a) Responsibility of licensee

28 PA Code 201.29(f) Resident rights






 Plan of Correction - To be completed: 03/15/2024

1. Corrective action for Resident #23 cannot occur retroactively and Resident # 61was discharged to the hospital and didn't return to the facility.
2. The last 30 days of unplanned discharges will be reviewed by the Social Services Director/designee to ensure that notice of bed hold policy is being sent with the resident or mailed to the responsible party.
3. Licensed Nurses and Social Services Director will be educated on providing the resident a notice of bed hold when an unplanned discharge occurs.
4. The Social Services Director/designee will audit unplanned discharges weekly x4 weeks then monthly x5 months to ensure a notice of bed hold was provided the resident or responsible party. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on review of facility documentation, review of clinical records, and staff interviews, it was determined that the facility failed to provide safe wheelchair transport resulting in a fall and laceration of scalp for one of 16 residents reviewed (Resident R41).

Findings include:

Review of facility documentation dated, February 6, 2024, revealed that Resident R41 fell out of wheelchair while being wheeled on a wheelchair by the nurse aide, Employee E25. Review of clinical records revealed that Resident R41's fall resulted in a "laceration to left forehead with 1 inch raised hematoma" and a transport to the hospital for evaluation.

Review of written statement by nurse aide, Employee E25, dated February 6, 2024, revealed that when pushing the resident on the wheelchair, Resident R41 portrayed resistive behavior by placing her feet on the floor, to stop the wheelchair, "and she went flying out of her chair, and her head hit the floor and she was bleeding."

Review of nursing progress notes for Resident R41, dated February 6, 2024, revealed that the nurse aide, Employee E25, "stated resident became agitated when she was trying to propel her out of the dining area ..."

Interview conducted with the nurse aide, Employee E25, on February 21, 2024, at 12:10 p.m. revealed that Resident R41 was observed asleep in her wheelchair, in the dining room. Employee E25 proceeded to wheel the resident from the dining room towards the resident's room, to place her in bed. Employee E25 stated that the resident was "half asleep" and did not realize she was putting her feet down as she was being wheeled; the resident continued to "resist". Further interview revealed that Resident R41 is "very confused and cannot make her needs known." Employee confirmed that wheelchair leg rests were not attached to the wheelchair during transport.

Review of occupational therapy treatment documentation and interview with the Physical Therapist, Employee E26, and Occupational Therapy Assistant, Employee E27, conducted on February 21, 2024, at approximately 1:30 p.m. revealed that Resident R41 was "able to propel wheelchair with standby assistance for safety." Further interview confirmed that per professional standards of practice, leg rests are required when wheeling a resident who is "half asleep" or confused.

28 Pa. Code 211.10 (d) Resident care policies

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




 Plan of Correction - To be completed: 03/15/2024

1. R41's wheelchair was adjusted and provided with wheelchair leg rests.
2. Current residents in wheelchairs were audited to determine appropriateness of wheelchair leg rests.
3. Leg rests will be purchased for residents identified as requiring them.
5. Rehab Staff/Designee will audit new admissions and residents with a quarterly MDS weekly x 4 weeks then monthly x5 months to ensure residents are being identified as needing leg rests. Corrective action for Resident #23 cannot occur retroactively and Resident # 61was discharged to the hospital and didn't return to the facility.
6. The last 30 days of unplanned discharges will be reviewed by the Social Services Director/designee to ensure that notice of bed hold policy is being sent with the resident or mailed to the responsible party.
7. Licensed Nurses and Social Services Director will be educated on providing the resident a notice of bed hold when an unplanned discharge occurs.
4. The Social Services Director/designee will audit unplanned discharges weekly x4 weeks then monthly x5 months to ensure a notice of bed hold was provided the resident or responsible party. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff: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.
§483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:

Based on review of personnel files and staff interviews, it was determined that the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents for four of four nursing staff reviewed. (Employeees E2, E10, E11, E29)

On February 23, 2024 at 1:24 p.m. nurse aides competencies were reviewed for the following staff Licensed Nurses Employee E2, E10, E11, and E29.

Review of Director of Nursing, Employee E2's personnel file revealed the licensed nurse, E2 was hired February 4, 2020. Further review of Director of Nursing, Employe E2's personnel file revealed no competencies were available to ensure that the licensed nurse was competent in skills and techniques necessary to care for residents needs including infection control, hand hygiene, wound care, and medication administration.

Review of licensed nurse, Employee E10's, personnel file revealed the licensed nurse was hired by the facility on October 4, 2022 and there had been no nursing competencies completed between October 4, 2022 and February 20, 2024. Further review of Licensed Nurse, Employee E10's personnel file revealed no competencies were available to ensure that the licensed nurse was competent in skills and techniques necessary to care for residents needs including infection control, hand hygiene, wound care, and medication administration.

Review of license nurse, Employee E11's personnel file revealed the license nurse was hired October 30, 2023 and there were no nursing competencies completed between October 2023 and February 20, 2024. Further review of Licensed Nurse, Employee E11's personnel file revealed no competencies were available to ensure that the licensed nurse was competent in skills and techniques necessary to care for residents needs including infection control, hand hygiene, wound care, and medication administration.

Review of licensed nurse, Employee E29's personnel file revealed the licensed nurse was hired December 18, 2023 and did not have competencies completed. Further review of Licensed Nurse, Employee E29's personnel file revealed no competencies were available to ensure that the licensed nurse was competent in skills and techniques necessary to care for residents needs including infection control, hand hygiene, wound care, and medication administration.

Interview with Director of Human Resources, Employee E7 confirmed on February 23, 2024 at 2:40 p.m. that there was no documentation evidence available to demostrate that lincsed nurses Employees E2, E10, E11, and E29 were evaluated for competencies. Director of Human Resources, Employee E7 stated that there was an annual training binder but it had been lost.

Interview with Nursing Home Administrator, Employee E1 on February 23, 2024 at 2:52 p.m. confirmed the above findings.

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

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






 Plan of Correction - To be completed: 03/15/2024

1. Employee E2, E10, E11, E29 competencies were completed.
2. Current Nursing Staff employees will have their competencies completed.
3. Newly hired Nursing staff will have their competencies completed upon hire and annually. DON, Human Resources, NHA will be educated on ensuring that competencies are completed.
4. HR/designee will audit nursing staff competencies weekly x4 then monthly x5 months to ensure nursing staff competencies are completed annually and upon hire. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee

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

§483.45(h) Storage of Drugs and Biologicals

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

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


Based on facility policy, observation and staff interviews it was determined that the facility failed to assure that medications were labeled, current, securely stored, properly disposed of and inaccessible related to one of four medication carts (Second floor low side), one of two medication rooms (Third floor), and one medication refrigerator (Second floor).

Findings include:

Review of the American Diabetes Association recommendation of safe storage of insulin, insulin products contained in vials or cartridges supplied by manufacture (opened or unopened) may be left unrefrigerated at a temperature between 59degrees and 86degrees for up to 28 days.

Review of Sanofi pharmaceutical insert of Lantus insulin dated 2022, (glargine is an unbranded biologic for Lantus insulin). Revealed the storage of this product, the 10 ml multi-dose vial and the 3 ml single dose pen, in use and or unopened room temperature are only to be used up until 28 days of opening.

Review of Seqirus pharmaceutical insert revised 2022, for the vaccine Afluria quadrivalent influenza vaccine, revealed the storage and handling of this vaccine must be stored in refrigerated temperature at 2-8 Celsius (36-46) Fahrenheit.

Observation of medication cart second floor low side on February 20, 2024 at approxiamtely at 9:30 a.m. revealed a small medication cup in cart drawer containing three unidentifiable pills. Licensed nurse Employee E 21 stated that the pills belonged to a resident that was unavailable during med pass. Interview with licensed nurse, Employee E21 at time of observation confirmed that there is no identifier on the cup or pills.

Further review of medication cart second floor low side revealed an insulin pen which belong to Resident R48 date of opening was documented as January 8, 2024. Continued observation revealed a Glargine insulin pen with no documentation of date of opening belonging to Resident R167.

At time of observation Licensed nurse, Employee E21 left the floor. The facility's medication cart was not kept locked or under direct observation of authorized staff in an area where residents could access it. Employee E21 was called to the cart and confirmed that the cart was left unlocked and unattended.

Observation on February 21, 2024, at 11:15 a.m. of the Third-floor medication room, revealed the room containing supplies and medications, was observed to be unlocked. Interview with Licensed nurse, Employee E11 at time of observation confirmed the door lock was broken.

Observation On February 22, 2023, at 10:10 a.m. of second floor medication room revealed a medication refrigerator containing three vials of influenza vaccine, with the temperature reading 50 degrees. This observation was confirmed by unit manager Employee E22.

28 Pa. Code 205.28.(c)(3) Nursing station

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

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








 Plan of Correction - To be completed: 03/15/2024

1. No residents were cited in this F-Tag
2. The medications were disposed of by the Unit Manager. Maintenance was notified who checked the temperature and temperature for the refrigerator was in range.3
3. Nursing Staff/Designee will be education on ensuring that refrigerator temperatures are monitored and logged as required by regulation and ensuring that medications are stored appropriately. 4.
4. DON/designee will audit the medication refrigerator temperature logs weekly x4 then monthly x5 months to ensure temperatures are within range to properly store medications. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee

483.60 REQUIREMENT Provided Diet Meets Needs of Each Resident:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60 Food and nutrition services.
The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.
Observations:

Based on clinical record review, observations of the food and nutrition department, and interviews with residents and staff, it was determined that the facility failed to provide residents with nourishing, palatable, well-balanced diets that met their daily nutritional and special dietary needs for one of two nursing units observed (third floor nursing unit).

Findings include:

Dining observations conducted on the third floor, on February 21, 2024, at 12:40 p.m. revealed that Resident R18 received chicken and potatoes on his lunch meal tray, but no vegetable. Review of resident's meal slip, under "food dislikes," failed to reveal any food items listed. Interview with Resident R18 at 12:41 p.m. revealed that he preferred a vegetable with his lunch meal.

At 12:41 p.m. observations revealed that Resident R26 received chicken and potatoes on her lunch meal tray, but no vegetable. Review of Resident R26's meal slip, under "food dislikes" failed to reveal the vegetable of the day listed, which was corn. Further observations failed to reveal dining staff offer Resident R26 a vegetable or vegetable alternative.

At 12:45 p.m. observations revealed that Resident R9 received beef over rice and no vegetable. Review of Resident R9's lunch meal slip revealed the following "food dislikes": Brussel sprouts, green salad, lima beans, tossed salad, mashed potato, mixed vegetables, green peas, green beans, shellfish, collard greens, sweet potatoes, and bananas. Further review failed to reveal the vegetable of the day, which was corn, listed on the meal slip.

Interview with the Director of Nursing, Employee E2 on February 21, 2024, at 12:48 p.m. where the above-mentioned findings were brought to the attention and confirmed the above findings.

28 Pa. Code 201.14(a) Responsibility of licensee





 Plan of Correction - To be completed: 03/15/2024

1. R9 and R26 were provided vegetables by Dietary upon discovery. Resident #9 and #26 will be interviewed by the Director of Dining Services regarding their preferences. R9 and R26's preferences and dietary tickets will be updated as needed by the Director of Dining Services.
2. Current residents' preferences and diet tickets will reviewed by the Director of Dietary Services to ensure accuracy.
3. Dietary Staff will be educated on ensuring that resident's are providing as per the resident's preferences on their dietary tickets
4. Director of Dietary Services will interview 5 residents per week x4 weeks then 2x a month x2 months then monthly x2 months to ensure their preferences are being honored and if they have any changes to them. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(d) Food and drink
Each resident receives and the facility provides-

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

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

Based on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food that was palatable and served at the proper temperature for 3 of 16 residents reviewed (Residents R15, R22, R11).

Findings include:

Review of undated facility policy titled, "Food Temperatures," revealed that the "point of service temperature to residents will be within the range of 120-140 degrees ..." and "the temperature of potentially hazardous cold foods will be not greater than 40 degrees when served to the resident."

Interview with Resident R15 on February 21, 2024, at 10:28 a.m. revealed that "morning eggs come frozen."

Interview with Resident R22 on February 21, 2024, at 10:34 a.m. revealed that "food is always cold, especially breakfast."

Interview with Resident R11 on February 22, 2024, at 10:44 a.m. revealed that hot food comes cold.

Observations during a test tray conducted with the Food Service Director (FSD), Employee E24, on February 22, 2024, at 12:44 p.m. revealed that the milk registered at 45.1 degrees Fahrenheit (F); juice 47.3 degrees F; Pudding 51.4 degrees F; mashed potatoes 111.2 degrees F; fish sticks 114.3 degrees F; vegetable medley 117.3 degrees F; and baked chicken quarter 114.5 degrees F.

Interview with the FSD on February 22, 2024, at 12:56 p.m. confirmed that the above-mentioned food items were below and above the acceptable temperatures and therefore too cold to be palatable.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.6(f) Dietary services






 Plan of Correction - To be completed: 03/15/2024

1. R15, R22, and R11 will be visited by the Director of Dining Services regarding food temperatures and to ensure that they meet the residents' preferences.
2. Grievances and Resident Council minutes for the last 60 days will be reviewed for food temperature issues. Food Committee meeting will be held to assess food temperatures.
3. Nursing Staff will be in serviced by the DON/designee regarding the passing trays timely to the residents at the point of service. Dietary staff will be educated on ensuring that food temperatures are appropriate when leaving the kitchen.
4. NHA/Designee will conduct 5 random resident interviews and audit 5 test trays at various mealtimes weekly x4 then 2x a month x2 months, then monthly x2 months to ensure proper temperatures. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee

483.70 REQUIREMENT Administration: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 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Observations:


Based on a review of facility policy, facility documentation, job descriptions, and interviews with staff, and interviews with residents, it was determined that the Nursing Home Administrator failed to effectively manage the facility related to grievances being filed properly for one of 16 residents reviewed (Resident R4).

Findings Include:

Review of the job description for the Nursing Home Administrator revealed, "the primary purpose of the job position is to manage the Facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times."

Review of the job description for the Social Worker reads, "The Social Worker provides medically related social services to assigned caseload that assist residents to attain or maintain the highest practicable physical, mental, and psycho-social well-being. Services provided meet professional standards of social work practice, consistent with state and federal laws and regulations. The Social Worker guides facility staff in matters of resident advocacy, protection and promotion of resident rights." This job description was signed by social worker, Employee E17 on November 27, 2023.

Review of facility policy titled "Grievance/Complaints, Filing" with a revised dated on April 2017 states, "Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.

Interview during resident council held on February 21, 2024 at 10:00 a.m. with nine alert, and oriented residents revealed Resident R4 had a concern with missing clothing. Resident R4 revealed a concern regarding never receiving an explanation about clothing items of his that went missing back in November 2023.

After resident council was held the facility was asked if a grievance form was filled for Resident R4 regarding his missing clothing.

Review of facility grievance log from November 2023 on February 20, 2024 at 2:55 p.m. revealed a grievance filed by the facility for the resident.

The facility produced a grievance from November 12, 2023 stating "Resident said his clothing was missing." The grievance was signed by Social Worker, Employee E4.

Interview with facility Social Worker Employee E4 revealed the employee started working at the facility in the month of November. Further questioning of Social Worker Employee E4 revealed he started at the facility the Monday after Thanksgiving (November 27, 2023). When further questioned regarding Resident R2's grievance from November 12, 2023 Social Worker Employee E4 stated he did not fill out such a grievance. When showed the completed grievance form Social Worker Employee E4 stated that was his handwriting and signature. Further questioning of the Social Worker Employee E4 revealed the Social Worker Employee E4 was instructed by Administration to complete the grievance form due to the Social Worker Employee E4 talking to the resident, Resident R2 about his clothing during the month of December. Social Worker Employee E4 confirmed he did not fill out a grievance for Resident R4 for the month of December.

Interview with the Nursing Home Administrator Employee E1 on February 22, 2024 at 2:43 p.m. confirmed the above findings. The Nursing Home Administrator Employee E1 stated that Social Worker Employee E4 was educated on falsifying documentation.

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

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

28 Pa. Code 201.18(d) Management






 Plan of Correction - To be completed: 03/15/2024

1. R4's grievance was located prior to survey exit. The Activities Director interviewed R4 to determine if additional clothes are missing and no other concerns were identified.
2. Grievances for the last 30 days will be reviewed to ensure they are documented appropriately.
3. Social Services Director was educated on ensuring that documentation related to grievances is accurate. The grievance binders will be combined to ensure proper and accurate documentation of grievances are maintained.
4. NHA/designee will audit the grievance binder weekly x4 then monthly x5 months to ensure grievances are being documented accurately. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee


483.75(a)(1)-(4)(b)(1)-(4)(f)(1)-(6)(h)(i) REQUIREMENT QAPI Prgm/Plan, Disclosure/Good Faith Attmpt: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(a) Quality assurance and performance improvement (QAPI) program.
Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must:

§483.75(a)(1) Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities;

§483.75(a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation;

§483.75(a)(3) Present its QAPI plan to a State Survey Agency or Federal surveyor at each annual recertification survey and upon request during any other survey and to CMS upon request; and

§483.75(a)(4) Present documentation and evidence of its ongoing QAPI program's implementation and the facility's compliance with requirements to a State Survey Agency, Federal surveyor or CMS upon request.

§483.75(b) Program design and scope.
A facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. It must:

§483.75(b)(1) Address all systems of care and management practices;

§483.75(b)(2) Include clinical care, quality of life, and resident choice;

§483.75(b)(3) Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a SNF or NF.

§483.75(b) (4) Reflect the complexities, unique care, and services that the facility provides.

§483.75(f) Governance and leadership.
The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that:

§483.75(f)(1) An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities.

§483.75(f)(2) The QAPI program is sustained during transitions in leadership and staffing;
§483.75(f)(3) The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed;

§483.75(f)(4) The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information.

§483.75(f)(5) Corrective actions address gaps in systems, and are evaluated for effectiveness; and

§483.75(f)(6) Clear expectations are set around safety, quality, rights, choice, and respect.

§483.75(h) Disclosure of information.
A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section.

§483.75(i) Sanctions.
Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.
Observations:


Based on review of facility documentation and interviews with staff, it was determined that the facility failed to maintain an effective, comprehensive, data-driven quality assurance and performance improvement program (QAPI) that focuses on indicators of the outcomes of care and quality of life as required.

Findings include:

Review of facility policy, "Quality Assurance and Performance Improvement (QAPI) Plan" revised April 2014, revealed that the facility will: "develop, implement, and maintain an ongoing, facility wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems ... This committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees."

Further review of facility policy revealed, "Feedback, data systems and monitoring: Systems are in place to monitor care and services; care process and outcomes are monitored using performance indicators. These performance indicators are measures against benchmarks and targets that the facility has establishes; adverse events are tracked, monitored, and investigated as they occur." Under "Performance Improvement Projects" (PIPs) the policy indicated that, "PIPs involve systematically gathering information to clarify issues and to intervene for improvements."

Continued review revealed, "The following steps are employed or will be employed to support and enhance the facility QAPI program: Gathering and using QAPI data in an organized and meaningful way. Areas that may be appropriate to monitor and evaluate include Clinical outcomes (pressure ulcers, infections, medication use, pain, falls, etc.); complaints from residents and families; re-hospitalizations; staff turnover and assignments; staff satisfaction; care plans; state survey deficiencies; and MDS assessment data."

Review of QAPI Committee Meeting records, failed to reveal documentation of meeting minutes for the months of May, June, July, August 2023. The facility failed to provide further documentation of QA meetings and attendees during the survey.

Review of QAPI Committee Meeting records, dated "September 2023; Q3 October 24; November 16; December 14, 2023; January 11, 2024," revealed that an attendance log and a PIP (Performance Improvement Project) log were provided. No items were noted on the PIP log.

Review of QAPI Committee Meeting records, undated chart titled, "Quality Assurance and performance Improvement Action Plan" revealed the following topics were noted: Resident centered Care Plans; Infection Control Immunizations; Stand up and morning meeting forms" and had a documented tentative completion date of March 1, 2024. No documentation or tracking events, data collection or analysis, no established performance indicators or goals, no monitoring of progress or any facility wide systems evaluation for the months of May, June, July, August, September, October, and November 2023, were provided during survey for the topics mentioned above.

Review of QAPI Committee Meeting records, titled "Nursing QAPI December 2023" revealed that the following topics were noted: Infection Prevention; Staff Education; Comprehensive Care Plans; Falls; UDA; and POC completion." No documentation or tracking events, data collection or analysis, no established performance indicators or goals, no monitoring of progress or any facility wide systems evaluation for the months of May, June, July, August, September, October, and November 2023, were provided during survey for the topics mentioned above.

Interview with the Nursing Home Administrator on February 23, 2024, at 2:46 p.m. confirmed that he had no further data to provide related to the facilities QAPI program.

28 Pa Code 201.14(a) Responsibility of licensee

28 Pa Code 201.18(e)(2) Management







 Plan of Correction - To be completed: 03/15/2024

1. No residents were cited by this F-Tag.
2. QAPI Minutes for the last 6 months will be reviewed.
3. The IDT Team will be educated regarding the new QAPI process.
4. The RDCS/Designee will audit the QAPI minutes monthly x6 months to ensure that an appropriate QAPI program is occurring per regulation. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee: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(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 a review of facility documents of Quality Assurance meeting attendance and staff interviews, it was determined that the facility failed to ensure that the Infection Preventionist or designee attended quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for one of four quarterly meeting (November 2023 through January 2023).

Findings Include:

A review of QAPI committee meeting sign-in sheets for the period of January
An interview with the Nursing Home Administrator (NHA) on February 23, 2024, at approximately 10:38 a.m. revealed that committee meetings are conducted monthly. Further interview revealed that the last Infection Preventionist, Employee E30, was last employed on November 3, 2023.

Further interview revealed that the current Director of Nursing, Employee E2, had no completion records of the Nursing Home Infection Preventionist training and was not certified by The Centers for Disease Control and Prevention (CDC) at the time of survey.

A review of QAPI committee meeting sign-in sheet for the third quarter, dated "Q3 October 24," confirmed the last month of Infection Preventionist attendance.

Further review of QAPI committee meeting sign-in sheets for the period of November, December, and January 2023, revealed that a certified Infection Preventionist was not in attendance, virtually or in-person, at the QA meetings, missing 3 monthly/quarterly meetings.

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







 Plan of Correction - To be completed: 03/15/2024

1. No residents were cited in this F-Tag
2. The ADON has been identified as facility's Infection Preventionist.
3. The DON and NHA will be educated regarding the requirement of indicating the Infection Preventionist on the QAPI committee.
4. RDCS/Designee will audit the QAPI meeting minutes and signature sheets monthly x6 months to ensure an Infection Preventions is indicated. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee

483.80(b)(1)-(4) REQUIREMENT Infection Preventionist Qualifications/Role:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.80(b) Infection preventionist
The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must:

§483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;

§483.80(b)(2) Be qualified by education, training, experience or certification;

§483.80(b)(3) Work at least part-time at the facility; and

§483.80(b)(4) Have completed specialized training in infection prevention and control.
Observations:


Based on review of facility policy's, job description documentation, review of employee's employment file and employee interview, it was determined that the facility failed to ensure the Infection Preventionist was qualified by training and certification to implementing programs and activities to prevent and control infections.

Finding include:

Review of the facility policy infection prevention and control program revised 2018 revealed that the program is developed to address the facility specific infection control needs and consist of oversight, policies procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. This program is overseen coordination and oversight of this program is to be overseen by an infection prevention specialist .

Review of the facility InfectionPpreventionist job description reveals the infection preventionist's duties include collects, analyses, and interprets health data to plan implement, evaluate, and disseminate appropriate public health practices. The qualification of this position includes a bachelor's degree in applied clinical science, five years clinical experience, current professional licensure in the state in which working, certificate in infection control.

Review of Director of Nursing, Employee E2's employee file revealed that the Employee E2 began the position infection preventionist on November 6, 2023. The employee file does not contain Employee E2 certification of infection control that is required of the job description title of Infection Preventionist.

Interview with Director of Nursing, Employee E2 on February 21, 2023, at 1:35 p.m., revealed that she had not completed the mandatory training required to hold the position of Infection Preventionist.

28 Pa. Code 201.14 (a) Responsibility of Licensee

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





 Plan of Correction - To be completed: 03/15/2024

1. No residents were cited in this F-Tag
2. The Unit Manager will be taking an approved Infection Preventionist Certification course.
3. NHA, DON, Unit Manager will be educated regarding the Infection Preventionist requirement.
4. NHA will report to the QAPI Committee the completion and certificate received by the Unit Manager. The QAPI Committee will review the completion and certificate to ensure it is from an approved Infection Preventionist Certification course. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee

483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition: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.
§483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.
Observations:

Based on observations of the food and nutrition department, review of facility policy and interviews with staff, it was determined that the facility failed to maintain essential food service equipment in safe operating condition.

Findings Include:

An initial tour of the main kitchen was conducted on February 20, 2024, at approximately 9:30 a.m. with the Food Service Director (FSD), Employee E24.

Observations of the stove, in the main cooking area, revealed that the stove control knobs were missing. Further observations revealed that one of the stove piolet lights was lit more than 2-3 inches with yellow and orange flames and protruding through the two burners on the right side.

Interview conducted with the FSD at the time of observation revealed that the stove has has not funtion properly for approximately six months. Further interview revealed that the piolet light is defective and does not fully shut off; and that the 2-3-inch flame remained on.

Review of the stove manufacturer's instructions, titled "Installation and operation Owner's Manual," revealed that "for complete shutdown, turn control knob to OFF position," indicating that the piolet light shut completely shut off when shutting down the stove.

Interview with the facility administrator, Employee E1, on February 23, 2024, at approximately 1:15 p.m. revealed that the facility does not have a contract with a company or vendor who supplied the stoved.

Interview with Regional Culinary staff, Employee E14, conducted on February 23, 2024, at approximately 9:00 a.m. confirmed that the kitchen stove was out not working properly.

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

28 Pa. Code 211.6(d) Dietary services





 Plan of Correction - To be completed: 03/15/2024

1. No residents were cited in this F Tag
2. The identified stove was locked out and tagged out immediately.
3. A new stove was ordered on February 23, 2024, and awaiting delivery.
4. Director of Dining Services will audit the essential equipment required to operate the kitchen. Director of Dining Services will report the essential equipment audit, progress of repairs and stove delivery to QAPI monthly x6 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee

483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides: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.
§483.95(g) Required in-service training for nurse aides.
In-service training must-

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

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

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

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

Based on review of staff education records and interviews with staff, it was determined that the facility failed to conduct at least twelve hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of two nurse aides personnel files reviewed. (Employees E19 and E20)

Finding Include:

Review of Nurse Aide, Employee 19's personnel file revealed that the employee was hired on May 6, 2022. There was no documented evidence of in-service education hours between May 6, 2022 and February 20, 2024.

Review of Nurse Aide, Employee E20's personnel file revealed that the employee was hired on June 16, 2022. There was no documented evidence of in-service education hours between June 16, 2022 and February 20, 2024.

Interview held on February 23, 2023 at 2:47 p.m. with Human Resources Director, Employee E7 stated that there was a binder that has yearly competencies that had been lost. Human Resources Director, Emplyoee E7 confirmed that Employees E19 and E20 did not have their yearly competencies in their personnel's file.

28 Pa. Code 201.14(a) Responsibility of licensee







 Plan of Correction - To be completed: 03/15/2024

1. E19 and E20's 12 hours of education was completed.
2. Current CNAs 12 hours of education will be completed per regulation by the DON/designee.
3. NHA, DON and Human Resources Director will be educated regarding the 12 hour in-service requirements for CNAs. Newly hired CNAs will have their training completed within 12 months of their anniversary date annually.
4. Current CNAs 12 hours of education will be audited by NHA/designee to ensure current education is up to date. Newly Hire CNAs training records will be audited weekly x4 and monthly x6 to ensure they have their 12 hours of education completed. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee

35 P. S. § 448.809b LICENSURE Photo Id Reg:State only Deficiency.
Law amended July 11, 2022 Act 79 2022 HB 2604

(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.

(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.


(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.


Observations:


Based on review of facility policy, observation, and interviews with staff, it was determined that the facility failed to ensure that staff displayed photo identification badges on their uniforms for five of five employees observed. (Employee E9, Employee E11, Employee E12, Employee E13 and

Findings Include:

Review of facility policy titled, "Dress Code and Personal Hygiene Policy Statement" with no date states, "4. Employee Identification must be worn at all times. If Employee ID is misplaced, it is the responsibility of the employee to notify Human Resources within 24 hours for a replacement."

Observation on February 20, 2024 at 10:03 a.m. revealed that nurse aide, Employee E9, was not wearing an identification badge. Nurse Aide Employee E9 revealed that she has worked at the facility over a year and has not had a badge for several weeks.

Observation on February 20, 2024 at 10:10 a.m. revealed that licensed nurse, Employee E11, was not wearing an identification badge. Licensed Nurse Aide Employee E11 stated her clip broken and she has not gotten a new one since it broke.

Observation on February 20, 2024 at 12:03 p.m. revealed nurse aide, Employee E12 was not wearing an identification badge. Nurse aide Employee E12 stated she had one but she just did not have it with her.

Observation on February 20, 2024 at 12:11 p.m. revealed licensed nurse, Employee E13 was not wearing an identification badge. Licensed nurse Employee E13 revealed her badge was broken and she has not been given a replacement due to her being told that the machine that makes the badges being broken.

Observation on February 20, 2024 at 2:22 p.m. revealed Director of Nursing Employee E2 had a piece of tape as a name badge. The Director of Nursing had a piece of tape as a name badge on February 21, 22, and 23 2024.




 Plan of Correction - To be completed: 03/15/2024

1. Employees 9, 11, 12, and 13 were provided paper name tags for the duration of the survey. Employees 9, 11, 12, and 13 obtained new name badges at the receptionist desk.
2. NHA and IDT will ensure facility staff have facility name badges.
3. Facility staff and IDT were educated regarding the importance having name badges for identification to the residents, families, and visitors.
4. IDT Team/designee will make facility rounds weekly x4 then monthly x 5 months to ensure facility staff are wearing name badges. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee




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