Pennsylvania Department of Health
WILLIAMSPORT SOUTH REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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WILLIAMSPORT SOUTH REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  115 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
WILLIAMSPORT SOUTH 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, State Licensure Survey, Civil Rights Compliance Survey, and two Complaint Investigations, completed on February 16, 2024, it was determined that Williamsport South Rehabilitation and Nursing Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(i) Food safety requirements.
The facility must -

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

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

Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen and employee breakroom.

Findings include:

Observation of the facility's main kitchen on February 13, 2024, at 9:30 AM with Employee 1, food service director revealed the following:

A large gray garbage can in the food preparation area across from the coolers was observed with visible dried food and dried liquid runs on the exterior of the lid and can, crumbs and debris were observed collected in the grooves of the handles.

The coating of shelves in the coolers by the floor mixer was peeled/worn off in several locations exposing rust colored metal.

Flooring throughout the kitchen under preparation tables, steam table, and coolers, along with the wall edges in corners and behind equipment was observed with significant debris and black buildup.

The lower shelf of the preparation table and steam table contained dried spills and splatter, and dried food debris. Pans and cooking equipment on the shelves also had dried food splatter.

A single door cooler containing juices had dried spills in the interior and on the vent on the front of the cooler.

A three-tier cart parked beside the juice cooler was covered in large brown stains on the top shelf, along with several dried brown spills throughout the cart.

A foot pedal garbage can located in the corner by the juice cooler was observed with a soiled exterior with dried food and dried liquid. Dried food was observed on the wall behind the garbage can.

The bottom shelf of the table holding the toaster was observed covered in crumbs and debris. A power strip running along the wall behind the toaster table contained a buildup of dust and dried food, which extended along the wall.
The lower shelf of the steamer was covered in debris, dried food, and pots. The lids sitting on the shelf were covered in a dried white substance. The shelf was greasy and sticky to touch. Dried liquid spills/splatter were observed down the side of the stove directly beside the steamer.

The exhaust vent panels over the stove/cooktop area contained thick visible dust buildup throughout, the pipe of the fire suppression system directly above the cooktop/stove was covered in dust. The white wall behind the stove was covered in brown buildup.

The top of the convection ovens had visible dust and was sticky to touch. Employee 1 stated he had just wiped it off that morning.

Three large clear bins with lids were observed sitting on the lower shelf of a preparation table, one was filled with a white granular substance, another with a white powdery substance, and the third with a brown granular substance. None of the containers were labeled with the contents of the bin, when it was placed there, or when it expired. Employee 1 indicated the containers were white sugar, flour, and brown sugar.

Flooring throughout the dish room area under the machine and along the walls was observed with dirt and debris. Used bottles, lids, cups, pudding cup, and wrappers were observed scattered under the machine area. The pipes under the machine and wall area under the machine had dried splatter and dust. A metal panel covering the grease trap was dirty and appeared rusty. Tile grout surrounding the grease trap area was broken and crumbling along the wall behind the grease trap.

A meal tray/silverware/condiment cart was observed in the dish room with some plates on the top shelf and serving trays on the lower shelf. Employee 1 indicated they were clean. The shelves holding the plates and trays was covered in crumbs and dust. The tops had plastic containers covered in plastic bags stuck down in the holes on the top of the cart, which were holding various condiments such as salt, pepper, and sugar packets. The bags were sticky to touch. The bags were sticking to the metal holder when trying to remove the containers from the holes. Brown, sticky rings were observed around the holes where the containers covered in bags were removed.

A metal ceiling vent over the dish machine was rusted.

Flooring in the dry storage room was observed with debris throughout under the shelving units. The floor behind the door to the dry storage room, which was propped open upon entering was observed with a large pile of dirt, cereal pieces, and other debris behind the door.

The lower shelve in the dry storage area had various food products that contained dust and debris. One shelf was observed with a black apron sitting on the shelf behind food products covered in a white powdery substance.

Two ceiling vents in the dry storage room were observed with visible thick dust.

The chemical room was filled with boxes of paper products (plates, cups, etc.), stored directly on the floor. Employee 1 indicated there was no place to store the paper products when they ordered them for infection control outbreaks.

An observation of the facility ice machine located across from the kitchen in the employee break room on February 14, 2024, at 1:03 PM revealed a wet floor sign sitting in front of the ice machine. The floor under and extending out around the ice machine was saturated with water pooling under the ice machine. The floor under the machine was observed with a black build up, a piece of curled plastic resembling cove base material, as well as a pink plastic bin shoved up along the wall. Concurrently Employee 3, nurse aide, entered the room with a cooler on a cart. Employee 3 indicated the ice machine was used to obtain ice in the cooler carts for water pass on the units.

Employee 3 proceeded to lift the cooler off the top of the cart and dump water from the cooler in the sink in the area. A large gray plastic drainage bin was observed underneath where the cooler was removed from the cart with approximately one inch of water in the bin. A significant amount of white debris was observed floating in the water and settled on the bottom of the bin. A pink film was observed on the interior bottom of the bin extending to the sides. Employee 3 indicated the dietary staff were to clean the ice carts but was not sure when that happens.

The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on February 14, 2024, at 3:24 PM.

483.60(i)(2) Store, prepare, food safe and sanitary
Previously cited 7/13/23, 11/8/23

28 Pa. Code 201.14 (a) Responsibility of Licensee


 Plan of Correction - To be completed: 04/02/2024

1-Cited: Garbage cans, kitchen floor and dry storage area floor, lower shelf of the preparation table and steam table, cooking equipment, coolers, vents, three-tier cart, kitchen walls, toaster area, power strip on wall, shelves, stove, the exhaust vent panels over the stove, cooktop area, the fire suppression system, the top of the convection ovens, the pipes under the dish machine and wall area under the machine, the grease trap area, the meal tray/silverware/condiment cart, shelves in dry storage area were cleaned. The black aprons were cleaned. The coating on the shelves in the coolers were repaired. The tile grout surrounding the grease trap was repaired. The metal ceiling vent over the dish machine was repaired. The bins holding the white sugar, flour, and brown sugar were labeled and dated. Used bottles, lids, cups, pudding cups, and wrappers were cleaned up from under the dish machine area. The paper products were stored in the lower level of the facility. The ice machine area in the employee breakroom was cleaned and plastic bin to retrieve ice is stored in bag. The cooler was cleaned.
2-Like: Facility sweep will occur to ensure ice coolers are sanitary. There is only one ice machine and one kitchen/dry storage area in the facility. Facility wide ceiling vents will be audited.
3-Educations: NHA/designee will educate the food service director on sanitary storage of kitchen (including equipment), dry storage, and the ice machine. NHA/designee will also educate staff of the routinely cleaning schedule of ice chests already in place, done weekly.
4-Audits: BOM/designee will audit the kitchen, dry storage area, and ice machine weekly x 4 weeks and monthly x 2 months. Results will be taken through QAPI.
483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to provide treatment and services regarding skin assessments and treatments for four of five residents reviewed (Residents 27, 95, 93, and 82).

Findings include:

Review of Resident 95's clinical record revealed a follow up progress note from a wound care consultant company dated October 17, 2023, that indicated that her sacral area was assessed, and that the treatment plan would be cleaning Resident 95's sacral area with acetic acid (helps kill microorganisms in the wound), applying Santyl (a gel that helps debride wounds), and apply a foam dressing. Review of the facility's physician order dated October 17, 2023, did not contain the recommended acetic acid, nor was there documented evidence to indicate contraindication to its use.

The wound care consultant assessed Resident 95's sacral wounds on October 31, 2023, and indicated that the treatment plan should remain the same as on October 17, 2023. A physician's order dated October 31. 2023, indicated that the facility would use calcium alginate (for wounds with excess drainage) dressing in place of the Santyl gel. The two medications are not similar in their use for wound care. There was no documented evidence in Resident 95's clinical record to indicate why the Santyl was not continued for Resident 95's wound care.

On November 28, 2023, December 5, 2023, and again on December 12, 2023, indicated that the wound care consultant recommended that the facility initiate e-stim (electrical stimulation to facilitate wound healing) or diathermy (using heat to stimulate circulation and/or relieve pain) treatments to Resident 95's right heel wound. There was no documented evidence in Resident 95's clinical record to indicate that the facility attempted to initiate these treatments.

The wound care consultant assessed Resident 95's right heel wound on January 9, 2024, and indicated that the treatment plan should be betadine and a dry protective dressing every day. A physician's order dated January 9, 2024, indicated that the facility would use acetic acid to clean Resident 95's right heel wound. There was no documented evidence to indicate why the facility did not follow the wound care consultants plan of care for Resident 95's right heel wound.

Review of Resident 95's current physician order for sacral wound care dated February 6, 2024, indicated that nursing staff should apply MetroCream (an antibiotic cream used for wound infections) 0.75% every day to Resident 95's sacral wound.

Observation on February 15, 2024, at 10:23 AM revealed Employee 2, licensed practical nurse, performing wound care for Resident 95's sacral wound. Employee 2 cleansed Resident 95 sacral wound with wound cleanser, applied the MetroCream, and covered the sacral wound with a foam dressing. There was no current order in Resident 95's clinical record for nursing staff to use wound cleanser or a foam dressing on her sacral wound.

Interview with the Director of Nursing on February 16, 2024, at 9:26 AM confirmed the above findings for Resident 95.

In an interview with Resident 93 on February 13, 2024, at 12:09 PM the resident indicated she had some skin issues on her "heel, bottom, and side." Resident 93 stated everything was healed up except an area on her side. Resident 93 was not sure how she got the area on her side and stated she thought it was an abrasion from her wheelchair, and the heel she stated was just very dry. Resident 93 stated she had a history of a stroke and "sometimes they don't realize people with a stroke are hypersensitive to that." The resident stated her wheelchair was her own personal wheelchair and she would not utilize a different wheelchair, the resident also indicated she would not use a cushion because then her legs would not reach the floor.

Clinical record review for Resident 93 revealed the resident was being treated for moisture associated skin damage (MASD) on her sacrum and a Stage 3 pressure ulcer to the back of her right thigh. Treatment to her right heel was discontinued on February 15, 2024.

Review of a skin observation tool for Resident 93 completed by a licensed practical nurse (LPN) dated December 2, 2023, noted the identification of a 1.0 cm (centimeter) by 1.0 cm unstageable area on the resident's right heel. There was no evidence of any new interventions added on December 2, 2023, for the area on Resident 93's right heel or any further assessment by a registered nurse. Further clinical record review for Resident 93 revealed a nursing note dated December 3, 2023, at 2:17 PM by the same LPN, noting the resident complains of her heel hurting and upon observing noted to have a necrotic (dead tissue) area the size of a dime. The LPN noted making the resident aware she needs to keep her heels elevated and she would have the wound nurse see her also.

There was no evidence Resident 93 had any interventions initiated or assessment of the area on her right heel by a registered nurse or physician, unit seen by the wound care consultant on December 5, 2023, which noted a Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without sloughing or bruising) pressure area to the resident's right heel measuring 1.0 cm x 1.0 cm and 0.1 cm deep. The area to the right heel was noted as resolved on February 13, 2024. Observation of Resident 93's right heel on February 15, 2024, at 11:22 AM revealed the area was healed.

The above finding regarding Resident 93 were reviewed with the Nursing Home Administrator and Director of Nursing on February 15, 2024, at 2:30 PM.

Clinical record review revealed the facility admitted Resident 27 on January 19, 2024. Review of the Admission Nursing Assessment dated January 19, 2024, under the category of skin noted "see wound notes." There was no documented assessment of Resident 27's skin until January 23, 2024.

Review of the wound care consultant's initial evaluation on January 23, 2024, noted a Stage 3 (full thickness tissue loss, subcutaneous fat may be visible) pressure ulcer to Resident 27's sacrum, measuring 7.0 by 8.0 by 0.1 centimeters. The wound care consultant ordered a treatment to cleanse Resident 27's sacral wound with acetic acid 0.25%, apply Santyl, cover with foam, and change every day and as needed. Review of Resident 27's Treatment Administration Record (TAR, a form utilized by the facility to document treatments) dated January 2024 revealed nursing staff did not document the administration of Resident 27's treatment until January 25, 2024.

Further review of Resident 27's clinical record revealed the facility did not initiate a plan of care addressing Resident 27's sacral wound until January 24, 2024. There was no initial plan of care addressing Resident 27's skin.

An interview with the Director of Nursing on February 16, 2024, at 12:25 PM confirmed the above findings for Resident 27. The Director of Nursing stated that he believed Resident 27 had a sacral ulcer upon admission to the facility, but confirmed there was no documented evidence of this.

The facility failed to assess and implement interventions timely and consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing.

Clinical record review for Resident 82 revealed he was admitted to the facility on February 14, 2023.

Review of Resident 82's care plan dated February 14, 2023, revealed the resident required the assistance of one staff for turning and repositioning in bed. The care plan dated March 19, 2023, identified the resident as having the potential for impairment of skin integrity. There was no evidence that the resident was on a turning and repositioning program to prevent pressure ulcers.

Clinical record review for Resident 82 revealed he was hospitalized form December 11 to 21, 2023. Review of a nursing admission assessment dated December 21, 2023, revealed that the resident's skin was red but intact. There was no documentation indicating where the skin was red.

Review of a nursing note for Resident 82 dated January 4, 2024, at 8:16 PM indicated the resident had open areas on his buttocks. The resident stated that they are pressure areas, and that nursing is already aware. Barrier cream (a cream used for routine incontinence care to protect the skin) was applied to the area and it was covered. The registered nurse supervisor was notified due to no prior documentation on these areas.

Review of the TAR for Resident 82 dated January 8, 2024, revealed that a treatment was initiated to cleanse the areas on the buttocks with soap and water, apply collagen powder (a powder with healing properties), and apply zinc (protectant) cream. Apply border foam dressing once a day and as needed.

Review of a wound consultant note for Resident 82 dated January 9, 2024, revealed a Stage 3sacral (the bony section located at the base of the back) pressure ulcer that measured 4 cm (centimeter) length x 4 cm width x 0.2 cm depth. Further down the wound consultation, revealed conflicting documentation to include active problems that included a pressure ulcer of the sacral region, Stage 2. The treatment recommendations were for the nurse to cleanse the wound with acetic acid 0.25 % (vinegar solution) and apply Santyl (a healing treatment that also removes dead tissue), dry protective dressing, daily and as needed. If not covered by insurance, use collagen particles and zinc. In addition, turning and repositioning and offloading pressure was recommended.

Clinical record review for Resident 82 revealed no treatment for the open areas on the buttocks until January 8, 2024, and there was no documented assessment of the wound, including size, depth, or description until assessed by the wound consultant on January 9, 2024, when it was described as a Stage 2 or Stage 3.

Review of Resident 82's care plan identified a Stage 3 pressure ulcer of the sacrum on January 10, 2024. One intervention included avoiding positioning the resident on the sacrum. There was no evidence of the frequency of turning and repositioning.

Clinical record review for Resident 82 revealed he was hospitalized from January 13 to 22, 2024.

Review of a nursing admission assessment for Resident 82 dated January 22, 2024, revealed the resident was assessed to have a Stage 3 pressure ulcer. There was no measurements or description entered on this form.

Review of a wound consultant note for Resident 82 dated January 23, 2024, revealed the sacral pressure ulcer was a Stage 3 that measured 0.5 cm length x 0.5 cm width x 0.2 cm depth.

Review of a wound consultant note for Resident 82 dated January 30, 2024, revealed the sacral pressure ulcer was a Stage 3 that measured 0.5 cm length x 0.5 cm width x 0.1 cm depth.

Review of a wound consultant note for Resident 82 dated February 6, 2024, revealed the sacral pressure ulcer was a Stage 3 that measured 2 cm length x 2 cm width x 0.2 cm depth.

Review of a physical therapy evaluation and plan of treatment for Resident 82 dated February 7, 2024, revealed the resident is totally dependent for bed mobility. There is no documented evidence that the resident was on a turning and repositioning program to promote healing of the pressure ulcer.

Review of a wound consultant note for Resident 82 dated February 13, 2024, revealed the sacral pressure ulcer was a Stage 3 that measured 5 cm length x 6 cm width x 0.2 cm depth.

Observation of the sacral dressing change for Resident 82 completed by Employee 2, LPN, on February 15, 2024, at 1:40 PM revealed the resident needed assistance to turn on his side in bed. The dressing was saturated with serosanguinous (drainage that includes blood, can be healthy) drainage.

During a meeting with the Director of Nursing and Nursing Home Administrator on February 15, 2024, at 3:10 PM the surveyor reviewed the findings of Resident 82's pressure ulcer that was not assessed, they did not have a physician ordered treatment for four days after being identified, and lack of a turning and repositioning program to prevent and heal the pressure ulcer.

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



 Plan of Correction - To be completed: 04/02/2024

1-Cited: Resident 95's plan of care related to wound treatment was appropriately addressed by the wound care consultant. Resident 93's right heel is healed. Resident 27's plan of care was updated related to her sacral wound. Resident 82 is on a turning and repositioning program to attempt to prevent pressure ulcers. Resident 82's pressure ulcer was assessed, including a physician order for treatment.
2-Like: Admission skin assessments (to include measurements/descriptions) will be completed accurately upon admission. Residents who receive wound care will have careplans to reflect their wounds including appropriate interventions. Facility wide sweep of residents with pressure ulcers evaluated for turning and repositioning programs.
3-Educations: DON/designee will educate licensed staff on treatment and services to prevent/heal pressure ulcers.
4-Audits: DON/designee will completed an audit weekly x 4 weeks then monthly x 2 months of residents followed by wound team to ensure appropriate wound treatment is ordered. Health Information Manager/designee will audit residents to ensure they are on a turning and repositioning program to assist with services to prevent/heal pressure ulcers. Results will be taken through QAPI.
483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for two of six residents reviewed (Residents 58 and 24) and failed to ensure that the consulting pharmacist identified potential appropriateness for psychoactive medications for one of six residents reviewed (Resident 23).

Findings include:

Review of Resident 23's clinical record revealed a physician's order dated December 15, 2023, for nursing staff to administer Ativan (used to treat anxiety) 0.5 mg (milligrams) every four hours as needed for restlessness and agitation for three months. There was no documented evidence in Resident 23's clinical record to indicate a rationale for extending the as needed Ativan past 14 days. Review of Resident 23's pharmacy consultation report dated January 10, 2024, did not identify the inappropriateness of Resident 23's Ativan order past 14 days.

Review of Resident 58's clinical record revealed a consultant pharmacy recommendation dated July 18, 2023, indicating that the pharmacist recommended an attempted gradual dose reduction (GDR) for Melatonin (used for insomnia) 5 mg at bedtime. Resident 58's attending physician signed the form on July 23, 2023, and indicated that an attempted "GDR in past, no changes." There was no documented evidence in Resident 58's clinical record to indicate that a gradual dose reduction was ever attempted during her stay. Resident 58's Melatonin order was initiated on her admission at the same dose on July 27, 2022.

A pharmacy recommendation dated October 15, 2023, again recommended an attempted dose reduction for Resident 58's Melatonin. Resident 58's attending physician signed the form on October 31, 2023, indicating "disagree" and "refer to psych." There was no documented evidence in Resident 58's clinical record to indicate that her physician documented a clinical rationale, which included the risk versus the benefits of continuing Resident 58's Melatonin at the current dosage.

Interview with the Director of Nursing on February 16, 2024, at 9:30 AM confirmed the above findings for Resident 23 and 58.

Clinical record review for Resident 24 revealed a Consultant Pharmacist Medication Regimen Review dated August 14, 2023, indicating Resident 24 currently receives Prilosec (a proton pump inhibitor, PPI) 30 mg twice a day, since 2021. The consultant pharmacist noted guidelines and recent literature recommended duration of treatment for PPI's is four to 12 weeks, depending on the type and severity of the disease. PPI's are generally not indicated for continuous use beyond three months. Please evaluate if a trial reduction or discontinuation would be appropriate. Resident 24's physician disagreed with this recommendation on August 22, 2023, but provided no rationale in the resident's medical record.

Interview with the Director of Nursing on February 16, 2024, at 11:08 AM confirmed the above findings for Resident 24.

483.45(c)(4) Drug Regimen Review
Previously cited 3/17/23

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


 Plan of Correction - To be completed: 04/02/2024

1-Cited: Resident 58 and resident 24 did not have any ill effects from physician not addressing the pharmacy recommendations. Resident 23 had no ill effects from the consulting pharmacist not identifying potential appropriateness for psychoactive medications.
2-Like: Facility sweep will be completed to ensure pharmacy recommendations are followed up on including, if appropriate, rationale to physician disagree.
3-Educations: DON/designee will educate practicing clinicians regarding addressing pharmacy recommendation, and physician required rationale related to disagreeing with a recommendation.
4-Audits: Health Information Manager/designee will audit pharmacy recommendations weekly x 4 then monthly x 2 to ensure accuracy and rational if appropriate. Results will be taken through QAPI.
483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide care, consistent with physician orders, for the administration of supplemental oxygen for five of eight residents reviewed for oxygen use (Residents 27, 78, 97, 60, and 93).

Findings include:

Review of Resident 27's clinical record revealed a physician's order dated January 20, 2024, for nursing staff to administer two Liters of oxygen per minute via nasal cannula continuously (a tubing that connects the flow of oxygen to the resident's nose) every day related to chronic obstructive pulmonary disease.

Observation on February 13, 2024, at 12:39 PM revealed Resident 27 was in bed and his oxygen was running at 6 liters per minute. Observation on February 14, 2024, at 9:37 AM and 12:05 PM revealed Resident 27 was in bed with his oxygen running at 6 liters per minute. Observation with Employee 2 (licensed practical nurse) on February 14, 2024, at 12:15 PM confirmed these findings.

The facility failed to provide supplemental oxygen as ordered by Resident 27's physician.

The surveyor reviewed the above information for Resident 27 during an interview with the Nursing Home Administrator and Director of Nursing on February 14, 2024, at 2:05 PM

Clinical record review for Resident 60 revealed a physician's order dated November 24, 2023, for the resident to have oxygen with humidification via trach collar (a device that goes over the tracheostomy [a hole that surgeons make through the front of the neck and into the windpipe for breathing] and provides humidification and supplemental oxygen as needed) every shift.

An observation of Resident 60 on February 13, 2023, at 11:54 AM revealed the resident was sleeping in bed with a trach (a device inserted through the windpipe to provide an alternative airway). A gallon jug with a manufacturer's label of "distilled water" was observed sitting on a tray table beside the resident's bed. The bottle was dated across the front in marker "7/30/23," and did not have any lid present on the jug. A follow up observation on February 14, 2024, at 8:25 AM revealed the same jug sitting in the same spot without a lid.

The above observations of Resident 60 were reviewed with the Nursing Home Administrator and Director of Nursing on February 14, 2024, at 2:45 PM.

Observation of Resident 78 on February 13, 2024, at 12:18 PM revealed an oxygen concentrator beside the resident's bed. The resident was not in the room. The oxygen tubing and nasal cannula (tubing piece inserted into the nostrils to administer supplemental oxygen) were observed hanging on the top of the oxygen concentrator. A nebulizer machine (a device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) was observed sitting directly on the floor beside the oxygen concentrator. The tubing and mouthpiece for the nebulizer was detached from the machine and sitting on top of the oxygen concentrator with the oxygen tubing. Neither the nebulizer mouthpiece or nasal cannula were bagged or covered. There was no bag or storage device observed in the area.

An observation of Resident 93 on February 13, 2024, at 12:15 PM revealed the resident sitting in her wheelchair in her room. A nebulizer with tubing and mouthpiece was observed sitting on the resident's bedside stand surrounded by magazines and papers. The mouthpiece was not bagged or covered. In a concurrent interview with the resident the resident stated she had the nebulizer in her room since November or December 2023, but has not used it, it has just been sitting there.

Clinical record review for Resident 93 revealed an inhalation medication to be administered via the nebulizer as needed was ordered on December 28, 2023. A review of Resident 60's treatment administration record from January to February 14, 2024, revealed Resident 60 has not used the nebulizer treatment.

A follow up observation of Resident 93's room on February 14, 2024, at 8:15 AM revealed the nebulizer was no longer on the resident's bedside stand. Resident 93 indicated staff had come in last night and took it out of her room.

An observation of Resident 97 on February 13, 2024, at 11:45 AM revealed a CPAP (a continuous positive airway pressure machine used to keep airways open while you sleep) sitting on the resident's tray table with the mask lying on top of the machine uncovered. Resident 97 indicated she can take the mask off herself. There was no bag or storage container observed in the area for Resident 97's CPAP mask/tubing. Resident 97 stated she only recalls being provided a bag or storage for the mask/tubing once or twice.

The above findings regarding Residents 78, 93, 97 were reviewed with the Nursing Home Administrator and Director of Nursing on February 14, 2024, at 2:00 PM.

483.25(i) Respiratory/tracheostomy Care and Suctioning
Previously cited 6/22/23

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


 Plan of Correction - To be completed: 04/02/2024

1-Cited: Resident 27 oxygen orders are being followed. Water jug in resident 60's room was disposed of. Resident 78's oxygen cannula and nebulizer mouthpiece was stored appropriately. Resident 93's nebulizer with inhalation medication was discontinued per physician recommendation due to no use. Resident 97's CPAP mask was stored appropriately.
2-Like: Facility sweep will be conducted to ensure oxygen orders are being followed, water jugs in rooms are not expired, oxygen cannuala's, nebulizer mouthpieces, and CPAP masks are stored appropriately.
3-Educations: DON/designee will educate nursing staff on oxygen orders, appropriate respiratory storage.
4-Audits: DON/designee will complete an audit weekly x 4 weeks, then monthly x 2 months to ensure oxygen orders are being followed. Admissions Director/designee will complete an audit weekly x 4 weeks to ensure respiratory care is stored appropriately and expired water jugs are disposed of and replaced. Results will be taken through QAPI.
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 observation and resident and staff interviews, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for two of 21 residents sampled (Residents 27 and 56).

Findings include:

Observation on February 13, 2024, at 10:48 AM and 1:47 PM revealed Resident 56 was in bed with his urinary catheter bag hanging full of urine on the door side of the bed, uncovered. The urinary catheter bag was able to be observed from the hallway.

Observation on February 13, 2024, at 12:38 PM revealed Resident 27 was in bed with his urinary catheter bag hanging full of urine on the door side of the bed, uncovered. The urinary catheter bag was able to be observed from the hallway. Resident 27 was in a hospital gown at this time and when questioned, he confirmed that he went to therapy this morning in the hospital gown.

Observation on February 14, 2024, at 1:13 PM revealed Resident 27 was in his wheelchair in a hospital gown. Resident 27 confirmed he wears the hospital gown to therapy every day. He stated that he has clothes and would prefer he was dressed before going to therapy.

Observation on February 15, 2024, at 10:15 AM revealed Resident 27 was dressed in a hospital gown with a blanket over his shoulders. Further interview with Resident 27 confirmed he would like to be dressed prior to going to therapy.

The surveyor reviewed the above findings during a meeting with the Nursing Home Administrator and Director of Nursing on February 14, 2024, at 2:05 PM

28 Pa. Code 201.29(a) Resident rights

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


 Plan of Correction - To be completed: 04/02/2024

1-Cited: Resident 56 and resident 27's catheter bags were covered and placed on side of bed facing away from hallway. Resident 27's clothing preferences will be honored as at times he changes his mind on his preferences.
2-Like: Residents with catheter bags will be offered a bag to place it in and will honor resident preferences. Residents clothing preferences will be reviewed and honored.
3-Educations: DON/designee will educate staff on honoring residents preferences related to choice of clothing and covering bags for catheter bags.
4-Audits: NHA/designee will audit residents with catheter bags to ensure they are in bags-audit will be conducted weekly x 4 weeks. All findings will be taken through QAPI.
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 observation and staff interview, it was determined that the facility failed to secure medications on one of two nursing units (South Hall; Residents 36 and 82).

Findings include:

Observation on February 14, 2024, at 8:41 AM revealed an open bottle of acetic acid solution (strong vinegar solution to cleanse wounds, that can be harmful if not used properly) on Resident 36's dresser.

Concurrent observation of Resident 82's windowsill revealed an open bottle without a lid of acetic acid solution.

During an interview with Employee 5, licensed practical nurse, on February 14, 2024, at 10:12 AM revealed that Resident 36 takes items that belong to Resident 82 and the acetic acid was used for Resident 82's dressing changes. Employee 5 removed the items from the room and indicated they should be stored in a locked area.

The facility failed to safely store medications.

The above findings for Residents 36 and were reviewed with the Nursing Home Administrator and Director of Nursing on February 14, 2024, at 2:30 PM.

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

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


 Plan of Correction - To be completed: 04/02/2024

1-Cited: The bottle of acetic acid solution was immediately removed from resident 36's dresser and from resident 82's windowsill.
2-Like: Facility sweep will be conducted to ensure medications are stored appropriately.
3-Educations: DON/designee will educate staff on proper medication storage.
4-Audits: Department Manager/desginee will audit residents rooms weekly x 4 weeks, then monthly x 2 months, to ensure medications are stored properly. Results will be taken through QAPI.
483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:This is a less serious (but not lowest level) deficiency and 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(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

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

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

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

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

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

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for two of six residents reviewed (Residents 23 and 107).

Findings include:

Review of Resident 23's clinical record revealed a physician order dated December 15, 2023, for nursing staff to administer Ativan (used to treat anxiety) 0.5 mg (milligrams) every four hours as needed for restlessness and agitation. This order was to continue for three months. There was no documented evidence in Resident 23's clinical record to indicate a rationale for the Ativan to extend past the 14 day timeframe for as needed psychoactive medications.

Review of Resident 23's Medication Administration Record (MAR, a form used to document the administration of medications) dated December 2023 indicated that Resident 23 did not require nursing staff to administer the Ativan.

Review of Resident 23's MAR dated January 2024 revealed that nursing staff administered Resident 23 the Ativan one time on January 2, 2024.

There was no documented evidence in Resident 23's clinical record to indicate that nursing staff attempted non-pharmacological interventions prior to the administration of the Ativan on January 2, 2024. Review of Resident 23's clinical record revealed no documented evidence to indicate that the facility was tracking her exhibited behaviors for the use of the Ativan.

Clinical record review for Resident 107 revealed the resident was 82 years old and was admitted to the facility on August 14, 2023. The resident had diagnoses of Alzheimer's Dementia (a progressive disease that destroys memory and important mental functions), depression, and generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities). Resident 107 was transferred to the hospital on January 1, 2024, after falling and sustaining an acute fracture of the T1 vertebral body (neck). Upon discharge from the hospital, the resident was discharged from the facility and admitted to a dementia unit in another facility on January 4, 2024.

Review of a medical provider note dated November 13, 2023, at 11:14 AM revealed the medical provider received a fax notification from the nurse requesting an "as needed" medication for anxiety for Resident 107. The medical provider indicated the resident was currently on Cymbalta (medication to treat depression/anxiety) 60 mg daily, Buspar (medication to treat anxiety) 15 mg twice daily, clonazepam (a controlled substance called a benzodiazepine used to treat anxiety) 0.5 mg twice daily, and Seroquel (medication ordered to treat psychosis, hallucinations/delusions) 25 mg twice daily. The medical provider indicated the Seroquel was recently increased from 25 mg at bedtime to 50 mg twice daily (effective November 2, 2023). The medical provider increased the Buspar to 15 mg three times daily and clonazepam 0.5 mg to three times daily. The medical provider also recommended psychiatry to reevaluate for increased anxiety with history of behavioral disturbances and the primary care provider would appreciate further medication recommendations.

Review of a psychiatry consultation dated November 14, 2024, at 11:00 PM revealed that Resident 107 was struggling with anxiety and depressive symptoms. The recommendations were to increase the Cymbalta from 60 mg to 90 mg daily for depressive and anxiety symptoms.

Review of Resident 107's MAR (Medication Administration Record) for November 2023, revealed that the resident's dosage of Seroquel was increased on November 2, 2023, dosages of Buspar and clonazepam were increased on November 13, 2023, and then the resident's dosage of Cymbalta was increased on November 16, 2023.

During a meeting with the Nursing Home Administrator on February 16, 2024, at 1:57 PM the surveyor reviewed Resident 107 increased dosages of four psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) from November 2 through November 16, 2023, without adequate time for monitoring the effectiveness of each medication before the increase of another medication. In addition, the surveyor reviewed the recommended dose of Cymbalta exceeded the recommended dose of 60 mg daily. According to Drugs.com, a dosage of Cymbalta greater than 60 mg daily does not have any additional benefit.

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

28 Pa. Code 211.10(a) Resident care policies

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


 Plan of Correction - To be completed: 04/02/2024

1-Cited: Resident 23 had no ill effects from psychoactive medications extended past the 14 day time frame. Resident 107 no longer resides at the facility.
2-Like: Facility sweep will be conducted to ensure residents who receive psychoactive medications have a rationale to extend past the 14 day timeframe.
3-Educations: DON/designee will educate clinicians on the rationale for medication to extend past 14 day timeframe as needed for psychoactive medications and the need to must attempt non-pharmacological interventions prior to administration of psychoactive medications. Must allow for adequate time for monitoring the effectiveness of each medication before increase of another medication.
4-Audits: DON/designee will audit weekly x 4 weeks, then monthly x 2 months, to ensure the facility remains to be free from unnecessary psychotropic medications. Results will be taken through QAPI.
483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

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

Based on clinical record review and staff interview, it was determined that the facility failed to consult a physician for a deterioration in health status for one of seven residents reviewed for hospitalization (Resident 65).

Findings include:

Review of a nursing progress note for Resident 65 dated December 7, 2023, at 4:30 PM revealed that the resident asked for the nurse and "he usually does not." The resident had an emesis (vomited). Resident 65 reported his stomach was upset. He was coughing and wheezing (a high-pitched noise that indicates narrowing and inflammation of the airway in any location, from the throat to the lungs). Resident 65 had a temperature of 100.8 degrees (feverish, possibly indicating an infection). The resident was given Tylenol (medication to reduce fever). With a temperature recheck, the resident was afebrile (no fever). The resident refused tube feeding (nutrition given by way of a tube that is inserted in the stomach). The resident had adventitious breath sounds (abnormal sounds in the lungs). The resident refused the suggestion of going to the emergency room. Oxygen saturations were 91percent on room air (the level of oxygen in the blood, normal is between 96-100 percent).

Review of a nursing progress note for Resident 65 dated December 8, 2023, at 7:19 AM revealed the resident had a dark brown emesis coming out of the tracheostomy (opening placed surgically in the trachea/breathing tube for a person to breathe from) and mouth. The resident told the nurse that he took out the inner cannula (a tube within the outer tube inside the tracheostomy) because he was having a hard time breathing. The resident's vital signs were taken. His oxygen saturation was 84-86 percent on room air and his heart rate was 106 beats per minute (normal 60-100 beaths per minute). The supervisor was notified.

Review of a nursing progress note for Resident 65 dated December 8, 2023, at 7:35 AM revealed the resident was transported to the hospital by emergency services.

Review of a nursing progress note for Resident 65 dated December 8, 2023, at 2:08 PM revealed the resident was admitted to the hospital for aspiration pneumonia (infection of the lung when food or liquid is breathed into the airways or lungs), hypoxia (the absence of enough oxygen to sustain bodily functions) and hematemesis (the vomiting of blood, has an appearance of coffee grounds).

Clinical record review for Resident 65 revealed that there was no documented evidence that the physician was notified when the resident first displayed signs of breathing difficulty and having a brown emesis possibly indicating blood. There were no further documented assessments of the resident's condition and physician notification until the next morning approximately 15 hours later when the resident's condition declined further.

During an interview with the Nursing Home Administrator on February 16, 2024, at 9:10 AM
it was confirmed that there was no documented evidence of the nurse notifying the physician of Resident 65's declining condition.

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


 Plan of Correction - To be completed: 04/02/2024

1-Cited: Resident 65 is stable and residing within the facility.
2-Like: Clinical assessments will be completed and physician will be notified with declines.
3-Educations: DON/designee will educate licensed staff on clinical assessments and notification of the physician timely related to declines.
4-Audits: DON/designee will review significant declines in daily clinical meeting and will audit notification and assessments of declines weekly x4 weeks then monthly x 2 months. All findings will be taken through QAPI.
483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:
Based on observation and staff interview, it was determined that the facility failed to provide a clean and safe environment and maintain resident medical equipment free of disrepair on two of two nursing units (North and South Hall; Residents 60 and 65).

Findings include:

An observation of Resident 60, north hall, on February 13, 2024, at 11:54 AM revealed the resident sleeping in bed. An enteral feeding pump was observed to be running and attached to the resident. Several spots of a dried brown substance (the same color as the feeding formula hanging in the bag above) were observed on the feeding pump. The head of the resident's bed was elevated. The frame of the resident's bed was very dusty.

A suction machine sitting on a tray table near Resident 60's bed was observed with several rusty spots on the machine. The machine contained a maintenance check sticker that indicated the machine was last checked by maintenance in June 2021.

The floor of Resident 60's bathroom contained holes in the linoleum.

A follow up observation of Resident 60's enteral feeding pump on February 14, 2024, at 8:25 AM revealed the areas of dried brown substance remained on the pump.

The above findings regarding Resident 60 were reviewed with the Nursing Home Administrator and Director of Nursing on February 14, 2024, at 2:45 PM.

An observation of Resident 65's room on the south hall on February 14, 2024, at 9:02 AM revealed the pole that held the device used to administer tube feedings (formula delivered in a tube directly to the stomach) was rusty, the base of the suction machine (a device for removing secretions or obstructions in a person's airway) was rusty, and the cover to the pressure level indicator gauge on the suction machine was missing, which exposed the gauge to malfunction.

The above findings for Residents 65 were reviewed in an interview with the Director of Nursing and the Nursing Home Administrator on February 14, 2024, at 2:30 PM.

483.10(i)(1)-(7) Safe/clean/comfortable/homelike Environment
Previously cited 6/22/23 and 3/17/23

28 Pa. Code 201.14(a) Responsibility of licensee


 Plan of Correction - To be completed: 04/02/2024

1-Cited: Resident 60's feeding pump, pole, suction machine, and frame of the bed was immediately cleaned. The maintenance director inspected the equipment with appropriate labels. Resident 60's bathroom floor was repaired by the maintenance director. Resident 65's feeding pole and suction machine was cleaned. The cover to the pressure level indicator gauge on the suction machine was repaired.
2-Like: A facility audit will be completed to ensure feeding pumps, poles, suction machines and frame of beds are appropriately cleaned. Medical equipment will be inspected by the maintenance director with appropriate labeling. A facility audit will be completed to ensure resident bathroom floors are not damaged.
3-Educations: NHA/designee will educate staff on ensuring medical equipment are clean and rust free with appropriate maintenance inspection labels. NHA/designee will educate housekeeping staff on ensuring bed frames are appropriately cleaned. NHA/designee will educate maintenance director on appropriate bathroom floors.
4-Audits: Housekeeping manager/designee will complete an audit weekly x 3 weeks then monthly x 2 months of feeding pumps, poles, suction machines, and bed frames to ensure appropriate cleaning is completed. Maintenance Director/designee will complete an audit weekly x 3 weeks then monthly x 2 months of medical equipment inspection with appropriate labeling. Maintenance Director will complete an audit weekly x 2 weeks to ensure resident bathroom floors are without damage. Results will be taken through QAPI.
483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on clinical record review, observation, and resident, family, and staff interview, it was determined that the facility failed to assist with mouth care for residents requiring staff assistance for two of four residents sampled for activities of daily living (Residents 24 and 3) and nail care for one of four residents sampled for activities of daily living (Resident 3).

Findings include:

Observation and interview with Resident 24 on February 13, 2024, at 10:38 AM revealed a build-up of film on Resident 24's teeth. Resident 24 stated she is afraid of losing her teeth. Resident 24 stated she is not able to brush her own teeth without some help from staff.

Clinical record review revealed an annual MDS (an assessment tool completed at specific intervals to determine care needs) dated February 2, 2024, noting staff assessed Resident 24 as requiring supervision or touching assistance for oral hygiene.

A follow-up interview with Resident 24, on February 16, 2024, at 10:00 AM revealed she is not able to brush her teeth in the bathroom due to her wheelchair being too low, not able to reach the sink, and not being able to wheel herself out of the bathroom. Resident 24 revealed that the staff does not assist her. Resident 24 stated there was a nurse who no longer works at the facility who used to set her up at the bedside so she could brush her teeth, but Resident 24 indicated the staff does not currently help her.

Review of Resident 3's care plan revised May 12, 2023, revealed the resident required the assistance of one staff with personal hygiene and oral care.

During a telephone interview with a family member of Resident 3 on February 13, 2024, at 12:00 PM it was relayed that the family member discussed with the facility that the resident was not capable of brushing her teeth and told the facility that the resident needed help.

Observation of Resident 3's teeth on February 13, 2024, at 2:26 PM revealed a build-up of white and yellow substance on the resident's teeth and a brown substance under the resident's long fingernails. Resident 3 indicated that she would like her fingernails shorter.

The facility failed to assist with oral hygiene for two residents requiring assistance and nail care with one resident requiring assistance.

Findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on February 15, 2024, at 2:12 PM.

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


 Plan of Correction - To be completed: 04/02/2024

1-Cited: Assistance was provided to resident 24 with oral care. Assistance was provided to resident 3 with oral care and nail care.
2-Like: Health Information Manager/designee will complete a sweep to ensure residents preferences are honored related to oral care and nail care.
3-Educations: DON/designee will educate nursing staff on honoring resident preferences related to oral care and nail care.
4-Audits: Social Services Director/designee will audit resident preferences related to oral care and nail care weekly x 4 weeks then monthly x 2 months. Results will be taken through QAPI.
483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician orders for one of three discharged residents reviewed (Resident 107) and care of a mediport for one of 21 current residents reviewed (Resident 56).

Findings include:

Review of Resident 107's physician orders dated August 29. 2023 through October 2, 2023, revealed that staff was to administer Carvedilol (medication to treat hypertension which is high blood pressure) 12.5 milligrams tablet by mouth twice daily for hypertension. If Resident 107's heart rate was less than 60 beats per minute staff was to not administer the medication.

Review of the Medication Administration Record for Resident 107 revealed the following times when Carvedilol was documented as being administered for a heart rate under 60 beats per minute:

September 22, 2023, at 9:00 AM, heart rate 58 beats per minute
September 23, 2023, at 9:00 AM, heart rate 57 beats per minute
September 28, 2023, at 9:00 AM, heart rate 58 beats per minute
September 29, 2023, at 9:00 AM, heart rate 46 beats per minute

During an interview with the Nursing Home Administrator on February 16, 2024, at 2:00 PM it was confirmed that Resident 107 received medication outside the physician ordered heart rate parameters.

Clinical record review revealed the facility admitted Resident 56 on July 2, 2022. Further review of Resident 56's clinical record revealed he was diagnosed with colon cancer on March 20, 2023.

Interview with Resident 56 on February 13, 2024, at 2:15 PM revealed that he leaves the facility to get his chemotherapy. Resident 56 stated that he receives chemotherapy through his mediport (a small medical appliance that is surgically installed beneath the skin). Resident 56 stated he returns to the hospital a few days later to have his chemotherapy disconnected.

Observation of Resident 56 on February 15, 2024, at 9:47 AM revealed he was seated in his wheelchair and his pump was connected.

Resident 56's clinical record contained no physician's order or plan of care addressing Resident 56's mediport, the care of, or potential complications of Resident 56's mediport.

Interview with the Director of Nursing on February 16, 2024, at 11:50 AM revealed that he was unsure when Resident 56's mediport was placed and would have to collect the information. During this interview, the Director of Nursing confirmed the above findings for Resident 56.

The facility failed to provide the highest practical care to Resident 56 regarding his mediport and chemotherapy.

483.25 Quality of Care
Previously cited 10/13/23 and 3/17/23

28 Pa. Code 211.10(a)(d) Resident care policies

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


 Plan of Correction - To be completed: 04/02/2024

1-Cited: Resident 107 had no ill effects from receiving medication outside the physician ordered heart rate parameters. Resident 56 has physician orders and careplan addressing mediport, the care of, including potential complications related to diagnosis of colon cancer and chemotherapy.
2-Like: Unit Manager/designee will complete a facility sweep to ensure physician heart rate parameters are being followed. There are no other resident at the facility receiving chemotherapy or receiving care related to a mediport for a cancer diagnosis.
3-Educations: DON/designee will educate licensed staff regarding following physician heart rate parameters as well as appropriate plan of care for residents receiving chemotherapy related to a cancer diagnosis.
4-Audits: Unit Manager/designee will audit weekly x 4 weeks then monthly x 2 months to ensure physician heart rate parameters are followed as well as appropriate plan of care for residents who are receiving chemotherapy. Results will be taken through QAPI.
483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to implement interventions to address a decline in range of motion for one of one resident reviewed (Resident 95).

Findings include:

Review of Resident 95's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated December 13, 2023, indicating that the facility assessed Resident 95 as having range of motion limitations to one side of her lower extremities. Previous MDS assessments dated June 28, 2023, and September 23, 2023, indicated that the facility assessed Resident 95 as having no range of motion limitations to her lower extremities.

There was no documented evidence in Resident 95's clinical record to indicate that the facility identified her change in range of motion after the facility completed the December 13, 2023, MDS nor implemented or assessed Resident 95 for a restorative range of motion program.

Interview with the Director of Nursing on February 16, 2024, at 9:26 AM confirmed the above findings for Resident 95 and provided a document to indicate that the facility is now referring her to therapy for screening regarding her change in range of motion.

483.25(c)(2)(3) Mobility
Previously cited 3/17/23

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


 Plan of Correction - To be completed: 04/02/2024

1-Cited: Resident 95 has since passed on hospice services.
2-Like: Residents who trigger a decline on the MDS will be reviewed by the interdisciplinary team to discuss plan of care.
3-Educations: DON/designee will educate licensed staff on notification to the therapy department regarding a decline and will be discussed during daily clinical meeting with the interdisciplinary team.
4-Audits: RNAC/designee will complete and audit weekly x 4 weeks for residents who trigger with a decline in ROM/Mobility to ensure careplan is reviewed. Results will be taken through QAPI.
483.35(g)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
§483.35(g) Nurse Staffing Information.
§483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

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

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

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

Based on observation, review of posted daily nurse staffing data, and staff interview, it was determined that the facility failed to ensure accurate and complete daily nursing time posting for both units (North and South hall).

Findings include:

Observation on February 14, 2024, at 9:25 AM revealed the facility's posted nursing time did not include the total number and the actual hours worked by licensed and unlicensed staff directly responsible for resident care per shift.

A review of the previous four weeks of the posted daily nursing time revealed that each posting did not include the total number and the actual hours worked by licensed and unlicensed staff directly responsible for resident care per shift. Interview with Employee 4 (scheduling manager) confirmed these findings.

These findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on February 15, 2024, at 2:12 PM

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

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


 Plan of Correction - To be completed: 04/02/2024

1-Cited: Daily staffing postings were immediately corrected to include total number and the actual hours worked by licensed and unlicensed staff.
2-Educations: NHA/designee will educate the staffing coordinator on appropriate staffing postings.
3-Audits: Staffing coordinator/designee will audit weekly x 4 weeks, then monthly x 2 months, to ensure the staffing postings include the total number and the actual hours worked by licensed and unlicensed staff. Results will be taken through QAPI.

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