Pennsylvania Department of Health
OAKWOOD HEALTHCARE & REHABILITATION CENTER
Patient Care Inspection Results

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OAKWOOD HEALTHCARE & REHABILITATION CENTER
Inspection Results For:

There are  134 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.
OAKWOOD HEALTHCARE & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Complainace Survey and State Licensure Survey completed on August 29, 2024, it was determined that Oakwood Health Care and Rehabilitation Center, was not in complaince with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Tern 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:


483.10(g)(10)(11) REQUIREMENT Right to Survey Results/Advocate Agency Info: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(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 Department of Health Survey results were readily accessible to residents and visitors on three of three nursing units. (A, B, C nursing units)

Findings Include:

On August 27, 2024, at 10:36 a.m. a resident group meeting was held with nine alert and oriented residents ( R75. R115, R83, R83, 51, R55, R34, R4, R99, R48) who reported that they were not aware of the survey results binder and were not aware of the location where the survey results binder would be located and available to review.

Observation on August 27, 2024, at 11:27 a.m. revealed the survey binder was in the main lobby behind the receptionist desk. Further observation with the Nursing Home Administrator, Employee E1 revealed the survey binder on nursing units A, B, C were all behind the nursing station desk which confirmed that residents do not have access and it is not readily accessible to residents.

Interview on August 27, 2024, at 11:27 with Nursing Home Administrator, Employee E1 confirmed the state survey results were not readily accessible for resident, families, and visitors to review.

28 Pa. Code 201.14 (a) Responsibility of licensee







 Plan of Correction - To be completed: 10/22/2024

Nursing Home Administrator posted survey results accessible to resident and family members.
Nursing Home Administrator and/or designee will conduct weekly audit weekly for four weeks and monthly for two months to ensure doh survey results are available to residents and family members.
Nursing Home Administrator and/or designee will review location of doh survey results with residents at resident council monthly for two months, and audit accessibility of survey results monthly for two months with results reported to Quality Assurance Performance Improvement Committee for further review and recommendations as needed.

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.35(a) Sufficient Staff.
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 §483.71.

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

§483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:

Based on review of staffing schedules, facility documentation, and staff interview, it was determined that the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 26 residents reviewed (Residents R78, R100, R32).

Findings include:

A review of the clinical record revealed Resident 78 was admitted to the facility on May 13, 2023. Review of Quarterly Minimum Data Set (MDS-a periodic assessment of care needs) dated August 222, 2024, indicated that the Brief Interview for Mental Status (BIMS) score of 14-cognition intact

On August 26, 2024, at 10:40 a.m., an interview was conducted with Resident R78, who expressed feeling very upset and began crying. Resident R78 stated, "They don't answer the call bell and make me wait for an hour to be changed. The last time I was changed was at 6:00 a.m. this morning." The surveyor asked her to press the call bell, but it was not functioning, as the indicator light did not turn on. The surveyor then approached licensed nurse, Employee E4, who was distributing medications outside the door. Employee E4 confirmed that the call bell was indeed not working. When asked if the resident had received her morning care, Employee E4 responded, "No," explaining that they were short-staffed. The A wing has 44 residents, but only three nursing assistants and two nurses to cover the area. Some residents require the assistance of two staff members or the use of lifts. Employee E4 further confirmed that Resident R78, who is incontinent, was wet and required assistance with Activities of Daily Living (ADL).

On August 26, 2024, at 12:15 p.m., observations were made in the main dining room, where approximately 10-12 residents were seated, waiting for lunch to be served. No staff members were present in the dining room at that time. At 12:29 p.m., the regional RN, Employee E25, was interviewed regarding supervision requirements in the dining area inthe company of the Assistance Nursing Home Administrator, Employee E1. It was reported that activity staff member or nursing personnel should always be present to oversee the dining room. The Assistance Nursing Home Administrator further stated that the Director of Nursing's (DON) office and the Administrator's office are located outside of the dining hall, allowing them to help if necessary.

Review of the admission record indicated Resident R100 was admitted to the facility on March 1, 2022. Review of Quarterly Minimum Data Set (MDS-a periodic assessment of care needs) dated August 20, 2024, indicated that the Brief Interview for Mental Status (BIMS) score of 15-cognition intact.

On August 26, 2024, at 1:45 p.m., an interview was conducted with Resident R100, who reported receiving care at 5:30 a.m. that morning. He stated that he is typically placed in his wheelchair by 10:30 a.m. or 11:00 a.m., but on this day, Resident R100 was still in bed because no one had come to assist him into his wheelchair. Resident R100 pressed the call bell, and a nursing aide, Employee E25, responded. Employee E25 confirmed that they were behind schedule due to staffing shortages, noting that there were 44 residents and only three nursing aides. She also mentioned that she was responsible for 15 residents that day and give four showers. An assignment sheet was provided as evidence, confirming that Employee E25 was assigned to residents in rooms A6-1, A8-1, A8-2, A9-1, A9-2, A10-1, A10-2, A11-1, A11-2, A12-A, A12-2, A13-1, A13-2, A15-1, and A15-2.

An interview was held with the Resident R32 on August 26, 2024, at 1:57 p.m. that she unable to hear and reported "also it's been months for me to get cataract surgery. I had an appointment but did not go because there was no one who could go with me".

On August 26, 2024, at 2:03 p.m. a nursing assistant, Employee E7 was interviewed and reported that she was assigned to 14 residents and was behind on providing care.

On August 27, 2024, at approximately 8:00 a.m., there were no staff members present on the A wing when the surveyor approached the nursing station. All the nursing aides (Employee E7, and E21) assigned to the unit were observed having breakfast. When the surveyor inquired why the residents had not yet received their morning care, a licensed nurse Employee E15 responded that she had not yet completed the assignment sheet to allocate specific room coverage to the nursing aides.

On August 27, 2024, at 10:36 a.m. a resident group meeting was held with nine alert and oriented residents ( R75. R115, R83, R83, 51, R55, R34, R4, R99, R48) who reported that Sunday, August 25, 2024, a dining room was closed due to shortage of staffing. The facility one main dining room and residents were told due to shortage of staffing they had to eat lunch and dinner in their rooms.

It was further revealed by medical record, Employee E11 who confirmed that Resident R32 had an early cataract appointment schedule for July 29, 2024, at 7:15 a.m.; however, due to staffing shortage there was no available staff to accompany the resident and it was canceled. It was further communicated that transportation showed up at 7:15 a.m. However, there was no staff to accompany the resident. It was rescheduled for September 16, 2024.

28 Pa Code 211.12 (d)(4) Nursing services

28 Pa Code 201.14(a) Responsibility of licensee

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






 Plan of Correction - To be completed: 10/22/2024

R78 received incontinence care. R78's call bell is functioning properly, R100 got into his wheelchair on August 26th, R32 is scheduled for her cataract surgery on
Schedules for the last 30 days audited to ensure adequate staffing ratios were in place/maintained.
Staffing coordinator continues to monitor staffing ratios to ensure sufficient nursing staffing levels.
Nursing Home Administrator or designee will audit schedules weekly for four weeks and monthly for two months, with results reported to Quality Assurance Performance Improvement Committee for further review and recommendations as needed.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

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

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

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


Based on observation, and staff interview, it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of three nursing units (Unit A Medication Cart).

Findings include:

During an observation on August 26, 2024, at 12:50 p.m. the Infection Preventionist, Employee E3 confirmed Medication Cart that was assigned to license nurse, Employee E5 which revealed to be left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. Employee E3 was not in the hallway nor near her medication cart.

During an observation on August 26, 2024, at 2:25 p.m. the license wound nurse, Employee E8 confirmed Medication Cart that was assigned to license nurse, Employee E5 which revealed to be left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. Employee E5 was not in the hallway nor near her medication cart.

On August 29, 2024, at 11:44 a.m. an Administrator, Employee E1 confirmed observation on A wing that Medication Cart which was assigned to registered nurse, Employee E13 revealed to be left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. Employee E13 was not in the hallway or nearby.

During an interview on August 29, 2024, at approximately 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to maintain the confidentiality of residents' medical information as required.

28 Pa Code 211.5(b) Medical records





 Plan of Correction - To be completed: 10/22/2024

Employees E5 and E13 received individual education as it related to maintaining confidentiality and privacy of resident medical information at all times.
Our staff developer and/or designee will provide re-inservice to all licensed nurses regarding maintaining the confidentiality of resident's medical information.
The director of nursing and/or designee will conduct an audit weekly for four weeks and monthly for two months at each medication cart to ensure that residents confidentially of medical information is being practiced, with results reported to Quality Assurance Performance Improvement Committee for further review and recommendations as needed

483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:


Based on clinical record review and staff interview, it was determined that the faciltiy failed to ensure that all grievances are investigated and a prompt resolution provided to the resident for one of 26 sampled residents. (Resident R44)

Findings include:

Clinical record review for Resident R44 revealed an annual comprehensive assessment (MDS -an assessment of care needs) dated May 15, 2024 indicated that Resident R44 was cognitively intact. The assessment indicated that this resident had expressed problems with mood feeling depressed, down or hopeless.

Interview with Resident R44 at 1:00 p.m., on August 26, 2024 revealed that he finds paired care to be demeaning. The resident reported that there are two nursing assistants that are mean toward him. The resident reported a licensed practical nurse, Employee E15 was calling him derogatory names. The resident reported that another licensed practical nurse was dismissed for not giving him the proper medications. The resident also reported that he was not getting showers on a routine basis.

Interview with the Director of Nursing, Employee E2 and the Nursing Home Administrator, Employee E1 at 9:30 a.m., on August 27, 2024 confirmed that the facility was aware that Resident R44 had voiced concerns about his care and services as it related to specific staff members; but the facility had no documented or completed investigations into any of the resident's concerns.

28 Pa Code 201.18(e)(1) Management

28 Pa. Code 201.29(a) Resident Rights






 Plan of Correction - To be completed: 10/22/2024

Director of Nursing and Nursing Home Administrator were made aware of new grievances from Resident R44 during annual survey and investigated any new grievances expressed. Resolutions were provided.
Nursing Home Administrator and/or designee audited last 30 days of grievances to assure grievances were investigated and a resolution was obtained. Any outliers were addressed.
Regional Nurse educated Nursing Home Administrator and Director of Nursing about requirements of F Tag 0585.
Nursing Home Administrator and/or designee will audit grievance binder weekly for four weeks and monthly for two months to ensure that all grievances are thoroughly investigated, and prompt resolutions are obtained, with results reported to Quality Assurance Performance Improvement Committee for further review and recommendations as needed.

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 clinical record, review of policy and procedure, and interviews with staff and residents, it was determined that the facility failed to investigate an allegation of possible abuse and neglect and report to the State survey agency the result of the investigation for one of 26 clinical records reviewed. (Resident R44)

Findings include:

Review of Resident R44's clinical record revealed that the resident was admitted to the facility on May 6, 2023, with the diagnoses of schizophrenia (mental disease characterized by loss of reality contact), major depression, muscle spasticity, low back pain with sciatica (pain going from the lower back down the leg), IV (intravenous) drug abuse.

Review of Resident R44's February 2024 physician orders revealed that the resident was ordered May 3, 2023, the pain/ narcotic medication Oxycodone 5 milligrams (mg) by mouth five times a day for severe pain and on May 5, 2023 Baclofen 10 mg by mouth ever six hours as needed for muscle spasms.

Clinical record review revealed that on February 9, 2024 the nursing note indicated that Resident R44 was found unresponsive to verbal and painful stimuli. The staff attempted to arouse Resident R44 several times with no positive effect. The physician was contacted and ordered the staff to administer Naloxone nasally 4mg. After administration of the naloxone the nursing staff documented that the resident was aroused but had slurred speech and was unaware of time of place. The physician then ordered the nursing staff to send the resident to the hospital emergency room.

Hospital record review revealed that on February 9, 2024 Resident R44 was examined by the emergency room physician who documented that Resident R44 had oxycodone and baclofen use and had an unintentional overdose with these medications. The physician had documented that Resident R44 had experienced hypercapnic respiratory failure and unintentional overdose or polypharmacy. Upon interview Resident R44 told the hospital examining physician that he was given oxycodone and Baclofen at the same time causing him to become unresponsive. Resident R44 reported to the hospital physician that he took two doses of baclofen incidentally with oxycodone and then went to sleep.

Clinical record review on February 12, 2024 for Resident R44 revealed the diagnosis of poisoning by unspecified drugs, medications and biological substances.

Clinical record review for Resident R44 revealed a psychiatry assessment on July 29, 2024 that indicated Resident R44 had diagnoses of depression and schizophrenia. The psychiatrist indicated that Resident R44 was alert and oriented and reporting that nursing staff may have given him too much narcotics because he was diagnosed with medication poisoning at the hospital, last time he was there.

Interview with licensed nursing staff, Employee E15 at 10:00 a.m., on August 29, 2024 revealed that Resident R44 was found unarousable between 9:00 a.m., and 10:00 a.m., on February 9, 2024. The licensed practical nurse, Employee E15 also said that the physician ordered the administration of naloxone HCL nasal spray to be administered to Resident R44 for medication overdose on February 9, 2024. Employee E15 documented neurological checks as low blood pressure 81/53 and low pulse 56 for Resident R44 on February 9, 2024. The licensed nurse, Employee E15 reported that she called for emergency transport to the hospital for Resident R44 on February 9, 2024 as directed by the physician.

Further interview with Employee E15 at 10:30 a.m., on August 29, confirmed that Resident R44 left the facility unescorted by staff for a cardiology appointment on January 16, 2024 and February 29, 2024.

Interview with the Nursing Home Administrator and Director of Nursing at 10:00 a.m., on August 28, 2024 confirmed that there was no investigation into a case of possible neglect for Resident R44; who was found diagnosed at the hospital with unintentional overdose.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(3)(d)(4)(e)(1) Management

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





 Plan of Correction - To be completed: 10/22/2024

Investigation was completed regarding Resident R44 allegation and a reportable was sent to the Department of Health regarding the same.
Regional Nurse conducted audit of allegations of possible abuse and neglect for the last 30 days to identify any allegation that were not investigated or reported to the State survey agency.
Nursing Home Administrator, Director of Nursing and Department Heads will be reeducated on policy and procedure as it relates to investigating allegations of possible abuse and neglect and reporting to state survey agency.
Director of Nursing and/or designee will audit any allegation of possible abuse and neglect to ensure that allegations were investigated and reported appropriately weekly for four weeks and then monthly for two months with results reported to Quality Assurance Performance Improvement Committee for further review and recommendations as needed.

483.20(e)(1)(2) REQUIREMENT Coordination of PASARR and Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(e) Coordination.
A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes:

§483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care.

§483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.
Observations:


Based on clinical record reviews, and staff interviews, it was determined that the PASRR (Pre-admission screening and resident review) was not updated for one of eight resident reviewed. (Resident R29 )

Finding include:

The PASRR (Pennsylvania Preadmission Screening Resident Review) was created in 1987 through language in the OMNIBUS Budget Reconciliation ACT(OBRA) and it has three goals: to identify individuals with mental illness and or intellectual disability, to ensure that they are placed appropriately, whether in the community or in a nursing facility, and to ensure they are placed they receive the services they require of their mental illness or disability
The level I must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A level II PASRR evaluation must be completed if the level I PASRR determined that the person is a targeted person with mental illness of an intellectual disability. The level II PASRR would determine if placement or continued stay in the requested or current nursing facility is appropriate.

Review of Resident R29's clinical record revealed that the resident was readmitted to the facility on May 6, 2024 with the diagnoses of schizophrenia (mental disease characterized by loss of reality contact, delusion and feelings of persecution), and bipolar disorder (condition in which a person has periods of depression and periods of being extremely happy) seizure.

Review of Resident R29's PASRR dated March 18, 2021, revealed that the resident has a mental health condition with the diagnosis of schizophrenia and bipolar disease. The individual has a mental health case manager. Under the Section V11 exceptional admissions revealed that the individual has met the criteria for PASRR level II evaluation.

There was no evidence that a PASRR II was completed.

Interview with Social Service Director, Employee E22 on August 29, 2024 at 1:10 pm revealed that she was unaware that the resident's PASRR had not been updated.

28 Pa. Code 211.5(f)(iv) Medical records

28 Pa. Code 211.10(c) Resident care policies














 Plan of Correction - To be completed: 10/22/2024

Social Services Director completed a Level 2 PASRR for Resident R29
Social Services department audited all residents with PASRR's to ensure accuracy. Any outliers were addressed.
Social Services department will be reeducated about PASRR process for all admissions and readmissions.
Social Services department will continue to review new admissions/ re-admissions PASRR's to ensure accuracy weekly for four weeks and monthly for two months with results reported to Quality Assurance Performance Improvement Committee for further review and recommendations as needed.

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


Based on clinical record review and staff interviews, it was determined the facility failed to develop person-centered care plans related to elopement for one out of 26 residents sampled (Resident 78).

Findings include:

A review of the clinical record revealed Resident 78 was admitted to the facility on May 13, 2023, with diagnoses of depression, anxiety disorder, recurrent, borderline personality disorder, narcissistic personality disorder.

A review of a physician order, initially dated August 21, 2024 revealed the resident had "a wanderguard (device that is place on ankle or wrist that activate the locking mechanism on doors to the outside of the facility) to back/right armrest of W/C (wheelchair)".

A review of progress notes dated, August 21, 2024, written by the license nurse, Employee E16 revealed " resident continuously refused to take her meds. Resident has an increase aggression physically and verbally to staff. Resident was screaming/yelling/swinging at staff. Resident is at risk for elopement, stated "I'm going to get out of here, and I'm not going back to this place" and tends to stay by the exit door".

A review of the current resident's plan of care revealed the resident's care plan failed to identify the resident's is an elopement risk and interventions develop on the resident's care plan to prevent elopment.

An interview with the Resident R78 on August 26, 2024, at 10:54 a.m. revealed that she doesn't like the wander guard on the back right side of her armrest of the wheelchair and yesterday she "cut it off with a butter knife". License Nurse, Employee E4 confirmed that the Resident's R78's wheelchair did not have a wander guard.

Interview with the Director of Nursing on August 29, 2024, at approximately 1:30 p.m. confirmed the facility failed to ensure that comprehensive care plans were developed.


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





 Plan of Correction - To be completed: 10/22/2024

Resident R78's care plan was revised to indicate that she was not at risk of elopement.
Director of Nursing and/or designee will conduct an initial audit for residents at risk of elopement to ensure care plans are in place.
Staff developer and/or designee with provide a re-education to all licensed nurses regarding updating care plans as they relate residents at risk for elopement.
Director of Nursing and/or designee will continue to audit for residents at risk of elopement to ensure care plan are in place weekly for four weeks and monthly for two months, with results reported to Quality Assurance Performance Improvement Committee for further review and recommendations as needed.

483.25(a)(1)(2) REQUIREMENT Treatment/Devices to Maintain Hearing/Vision: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(a) Vision and hearing
To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-

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

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

Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive proper treatment and assistive devices to maintain hearing and vision abilities for one of 26 residents reviewed (Resident R32).

Findings include:

Review of the clinical record indicated that Resident R32 was admitted to the facility on September 4, 2022, with diagnoses to include anxiety disorder, major depressive disorder, rheumatoid arthritis (chronic autoimmune disorder which effects joints, causing inflammation, pain and swelling), osteoporosis (bones loose density, making them thinner and less durable).

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R32, dated, July 18, 2024 revealed that the resident was cognitively intact.

Review of Resident R32's inhouse new Audiology summary dated January 25, 2024, indicated a recommendation for the Resident R32 for in office visit for myringotomy treatment (a surgery performed by an ear, nose, and throat (ENT) specialist to drain fluid from your middle ear). A follow ENT was conducted inhouse on June 26, 2024, for Resident R32 recommending the same treatment as it was not completed. On July 23, 2024, another hearing assessment report was conducting Resident's R32 hearing decreased; however, there was no documentation that Resident R32 was taken for the myringotomy treatment.

Further review of the clinical record for Resident R32 revealed a vision consultation occurred on June 18, 2024 with a recommendation of bilateral cataracts surgery for left eye.

An interview was held with the Resident R32 on August 26, 2024, at 1:57 p.m. that she unable to hear and reported "I want to know about my hearing appointment, also it's been months for me to get cataract surgery. I had an appointment but did not go because there was no one who could go with me." Surveyor had to speak closely to Resident's R32's ear as Resident R32 was unable to hear. License nurse, Employee E24 who came in to administered medication confirmed that Resident R32 was unable to hear.

On August 28, 2024, approximately 11:30 a.m. Director of Nursing, Employee E2 brought in Audiology summary assessment and reported that an appointment has been scheduled for September 5, 2024, by the medical record, Employee E11 for resident to go for myringotomy appointment and another appointment was scheduled for the resident to get her cataracts treatment for her vision on September 16, 2024.

An interview with the medical record, Employee E11 on August 28, 2024, at 1:25 p.m. who reported that it's her responsibility to schedule appointments and she was not aware of the need for myringotomy treatment and scheduled her an appointment on August 27, 2024 when surveyor questioned the recommendation. The protocol she would get a communication request from the unit manager to schedule an appointment for residents and then she calls to schedule. In this case she received a request for the myringotomy appointment request yesterday on August 27, 2024 from the unit manager.

It was further revealed by Employee E11 who confirmed that an early cataract appointment was schedule for July 29, 2024, at 7:15 a.m.; however, "due to staffing shortage there was no available staff to accompany the resident and it was canceled". It was further communicated that even transportation showed up at 7:15 a.m. However, there was no staff to accompany the resident. It was rescheduled for September 16, 2024.

On August 29, 2024, at 8:51 a.m., an interview was conducted with the unit manager, Employee E15, who was responsible for communicating the need for appointments to the medical record staff. Employee E15 confirmed that Resident R32 had originally received a recommendation on January 26, 2024, for myringotomy treatment; however, the appointment was not scheduled until August 27, 2024, following an inquiry by the surveyor. Employee E15 was also unaware that Resident R32's cataract appointment had been canceled by the facility due to a staffing shortage.

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

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



 Plan of Correction - To be completed: 10/22/2024

Resident R32 had a follow up hearing (ENT 09/20/24) and vision (09/16/24) consult completed.
Director of Nursing and/or designee completed an audit of hearing and vision consults completed in the last 30 days to ensure recommendations were being followed.
Staff developer and/or designee will provide a re-education to the unit managers regarding follow up recommendations for hearing and vision consultations.
Director of Nursing and/or designee will conduct audits to ensure recommendations for hearing and vision consultations are being followed weekly for four weeks and monthly for two months, with results reported to Quality Assurance Performance Improvement Committee for further review and recommendations as needed.

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 policy, facility documentation, review of clinical records, observations, and staff interviews, it was determined that the facility failed to appropriately determine the effectiveness of interventions for a resident who was assessed as an elopement risk for one of the 26 residents reviewed (Resident R78)

Findings include:

A review of the facility policy titled "Elopement Risk Evaluation Policy" revised 12/12 revealed " It is the policy of the facility that all residents will be evaluated upon admission, re-admission quarterly and with any changed in the resident's status to assess their risk for elopement. The Elopement Risk Evaluation will be reviewed and completed. Under procedure number 4. Interventions will be developed and implemented by the interdisciplinary Care Plan Team. The Interdisciplinary Team will re-evaluate interventions with each Elopement Risk Evaluation care conference and with any change in the resident's status".

A review of the clinical record revealed Resident 78 was admitted to the facility on May 13, 2023, with diagnoses of depression, anxiety disorder, borderline personality disorder, and narcissistic personality disorder.

Review of Quarterly Minimum Data Set (MDS-a periodic assessment of care needs) dated August 22, 2024, indicated that the Brief Interview for Mental Status (BIMS) score of 14-cognition intact.

A review of a physician order, initially dated August 21, 2024 revealed the resident had "a wander guard (device that is place on ankle or wrist that activate the locking mechanism on doors to the outside of the facility) to back/right armrest of W/C (wheelchair)".

A review of Resident R78's clinical record did not indicate an Elopement Risk Evaluation was completed.

A review of progress notes dated, August 21, 2024, written by the license nurse, Employee E16 revealed " resident continuously refused to take her meds. Resident has an increase aggression physically and verbally to staff. Resident was screaming/yelling/swinging at staff. Resident is at risk for elopement, stated "I'm going to get out of here, and I'm not going back to this place" and tends to stay by the exit door".

An interview with the Resident R78 on August 26, 2024, at 10:54 revealed that she doesn't like the wander guard on the back right side of her armrest of the wheelchair and yesterday she "cut it off with a butter knife". License Nurse, Employee E4 confirmed that the Resident's R78's wheelchair did not have a wander guard.

On August 29, 2024, at 1:34 p.m. with the license nurse, Employee E13 confirmed that for Resident R78's wheelchair does not have a wander guard and the resident unwilling to place the wander guard on Resident R78's wheelchair. It was confirmed that intervention to prevent elopment was ineffective.

On August 29, 2024, at 1:52 p.m. an interview with the unit manager, Employee E15 confirmed there was no other interventions explored by the facility besides the wander guard. Employee E15 confirmed that wander guard intervention was ineffective, and she has removed the physician order. An elopement assessment was requested to see if facility evaluated the significant risk for the resident for elopement.

On August 30, 2024, at 2:00 p.m. Director of Nursing, Employee provided a Quarterly Evaluation which was created on August 21, 2024, documented thatResident R78 had an attempt in the last 30 days to elope and at risk to elope.



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








 Plan of Correction - To be completed: 10/22/2024

R78's interventions for elopement risk were reviewed for effectiveness. Resident is no longer as risk for elopement.
Director of Nursing and/or designee will conduct an initial audit for residents at risk of elopement to ensure that interventions in places are effective.
Staff developer/ designee with provide a re-education to licensed nurses regarding interventions as they relate to residents at risk of elopement.
Director of Nursing and/or designee will conduct audits to ensure appropriate interventions relating to residents at risk of elopement are in place weekly for four weeks and monthly for two months, with results reported to Quality Assurance Performance Improvement Committee for further review and recommendations as needed.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to provide appropriate tracheostomy care for one of 26 residents (Resident R71).

Findings include:

Review of the clinical record indicated that Resident R71 was admitted to the facility on March 25, 2021, with a diagnosis of encounter for attention to tracheostomy (a surgically created opening in the neck that allows direct access to the trache for breathing), chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), acute respiratory failure hypoxia (is an emergency where the lungs are unable to supply enough oxygen to the blood, leading to dangerously low oxygen level (hypoxia).

A review of Resident R71's Quarterly Minimum Data Set (MDS), a periodic assessment of care needs, dated July 21, 2024, showed that the Brief Interview for Mental Status (BIMS), which assesses cognitive function, returned a score of "unknown," indicating that the resident's cognitive status could not be assessed at that time.

On August 26, 2024, at 1:12 p.m., an observation was conducted with Infection Preventionist Employee E3 in Resident R71's room to assess tracheostomy supplies. Based on the physician's order dated April 25, 2024, Resident R71 was to have the following supplies at the bedside: Ambu bag, syringe, spare trach tubes (same trach size/type 6 and smaller trach size/type 4), and water-based lubricant. During the observation, it was confirmed that the required size 6 trach tube was not present at the bedside. Employee E3 then checked the medication cart, but the size 6 trach tube was not available there either.

On August 26, 2024, at approximately 2:05 p.m., a surveyor observed a family member repeatedly entering and exiting Resident R71's room, requesting to speak with the assigned licensed nurse, Employee E5. When the surveyor approached the family member for an interview, it was revealed that Resident R71 had taken a shower earlier that morning, and the trach collar had not been changed, leaving it wet. The surveyor inquired how the family member knew the collar was wet and needed to be changed. The resident's faily memeber confirmed this by touching the collar and stating it was "soaking wet" and should have been changed after the shower. Family member further reported that "a license nurse who was providing care it's not her regular nurse and most likely forgot to change her trach collar after a shower was given".

The surveyor then went to the nursing station to locate Employee E5, only to be informed that Employee E5 was on a break outside the building. At 2:46 p.m., same day Employee E5 returned to change the collar.

On August 29, 2024, at 11:45 a.m., licensed nurse Employee E12 was observed performing a tracheostomy treatment on Resident R71, which included changing the resident's trach collar. During the procedure, Resident R71 required suctioning; however, Employee E12 did not have a disposable inner cannula readily available, either at the bedside or in the medication cart. Another licensed nurse, Employee E17, had to retrieve the cannula from the medication storage room.

On August 29, 2024, at approximately 2:30 p.m., these observations were confirmed by Infection Preventionist Employee E3 and Director of Nursing Employee E2.

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

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



 Plan of Correction - To be completed: 10/22/2024

R71 has tracheostomy collar changed and has appropriate tracheostomy supplies at bedside.
There are no other residents with tracheostomies at the facility at this time.
Staff developer/ designee with provide a re-education to licensed nurses regarding tracheostomy care.
Director of Nursing and/or designee will conduct audits to ensure appropriate tracheostomy care is being provided weekly for four weeks and monthly for two months, with results reported to Quality Assurance Performance Improvement Committee for further review and recommendations as needed.

483.30(a)(1)(2) REQUIREMENT Resident's Care Supervised by a Physician:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.30 Physician Services
A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs.

§483.30(a) Physician Supervision.
The facility must ensure that-

§483.30(a)(1) The medical care of each resident is supervised by a physician;

§483.30(a)(2) Another physician supervises the medical care of residents when their attending physician is unavailable.
Observations:


Based on review of facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of 8 residents reviewed for nutrition.

Finding:

Review of policy titled "Significant Weight Change" revised March 1, 2017, revealed the residents demonstrating unintended weight loss will be identified and appropriate nutritional interventions will be implemented. Monthly weights will be obtained, and the dietician will compare monthly weights and an analysis of weight changes will be examined. 1 month 5 % significant/ 90 days 7.5 % significant/ 180 days 10.0 % significant. The dietician will document in PCC and update the care plan to reflect interventions and the provider will be notified and responsible party and weight changes related changes to plan of care.

The resident was admitted from short term hospital stay with diagnosis of anemia ( a condition that blood does not have enough red blood cells to carry oxygen through the body),dysphagia, coronary artery disease( damage or disease of the hearts major blood vessels), heart failure ( a chronic condition in which the heart does not pump blood as well as it should), Gerd(a digestive disease in which the stomach acid or bile irritates the esophagus), diabetes mellitus (a chronic disease that occurs when you glucose is too high) , schizophrenia (mental disorder characterized by hallucinations, delusions, disorganized thinking and behavior), bipolar (mental illness that causes unusual shifts in a person's mood, energy activity and concentration), pneumonia (inflammation and fluid in the lungs caused by a bacterial , fungal or viral infection) and severe malnutrition (deficiencies or excesses in nutrient intake, imbalance of essential nutrients or impaired nutrient utilization).

Review of the quarterly MDS revealed that Resident 29 was 66 inches and 194 pounds. The resident was currently on a therapeutic diet (a prescribed that controls certain aspects of nutrients or foods as part of a treatment plan meal plan) and a mechanically altered diet (focuses on food texture making it easier to swallow ). the diet includes foods that are soft and small that require minimal chewing)

Review of weight assessment for resident dated July 5, 2024, revealed that the resident weighed 211.1 pounds. Review of weight assessment for resident dated August 8, 2024, revealed that the resident weighed 194.0 pounds which was 8.057 %% weight loss in one month (severe weight loss)

A reweight was obtained on August 9, 2024,which revealed that the resident was 195.7 pounds

The above weights indicating a 17.1-pound weight loss in one month.

Review of Resident R29, clinical notes revealed the only dietary note dated August 26, 2024 written by dietary director Employee E18 which stated that a care conference had been held and that Resident R29 and family were invited but declined to attend. "Dietary care plan reviewed and remained appropriate. Will continue to monitor and follow up as needed."

Further review of Resident R29's progress note revealed a nursing note dated August 13, 2024, that stated "the resident requires total assistance with feeding..."

Review of Resident R29's clinical records revealed that there was no documented evidence that the resident's physican was notified of the resident's weight loss.

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

28 Pa. code 211 (a ) Physician services






 Plan of Correction - To be completed: 10/22/2024

Physician completed an assessment for R29 related to weight loss.
Director of Nursing and/or designee will conduct an initial audit for residents with unplanned weight losses within 30 days to ensure physician assessment was completed. Any outliers will be addressed.
Staff developer/ designee with provide a re-education to dietician regarding notification of physician for unplanned significant weight losses.
Director of Nursing and/or designee will conduct audits of residents with unplanned significant weight loss and to ensure physician notifications and assessments are being completed weekly for four weeks and monthly for two months, with results reported to Quality Assurance Performance Improvement Committee for further review and recommendations as needed.

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 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(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 review of facility provided documentation, and review of clinical record, it was determined that the facility did not ensure to have attending physician address and document pharmacist's identified irregularities for one of 26 residents reviewed (Resident R127)

Findings include:

Review of facility provided policy 'Pharmacy Consultant Recommendations,' revised December 16 (unknown year), indicates that "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."

Review of R127's clinical record on August 29, 2024 at 12:00 PM, revealed Resident R127 was admitted to facility July 26, 2024 with BIMS (Brief Interview of Mental Status) score of 5, which indicated that the resident was cognitively impaired. The resident's diagnoses included of depression, subsequent encounter of falls, muscle wasting and atrophy, dementia with mood disturbance, difficulty swallowing, difficulty walking, transient ischemic attack (stroke), anemia, vitamin D deficiency.

Further review of Resident R127's clinical record revealed an active order for Trazadone HCL oral tablet 50 mg on August 5, 2024 at 10:47 AM, to "give 25 mg (milligrams) by mouth every 12 hours as needed for anxiety/insomnia."

Review of Resident R127's pharmacy review 'comments report' dated August 12, 2024, completed by pharmacist - Employee E9, states that "a duration must be specified for as needed (PRN) psychoactive medications. First order is limited to only 14 days, but if rationale documented by prescriber to continue order, then next duration may be for longer, i.e. 30, 60, or 90 days. Please update order for trazadone per CMS regulations."

Further review of Resident R127's clinical record revealed no evidence of whether the attending physician identifying the need for and continuing use of Trazadone medication identifying and addressing adverse consequences related to medication.


28 Pa Code 211.2(a)Physician Services






 Plan of Correction - To be completed: 10/22/2024

Physician has addressed the drug regimen review for R27
Resident drug regimens were audited for August 2024 to ensure that physicians addressed any identified irregularities.
Staff developer/ designee with provide a re-education to the unit managers regarding addressing drug regimens recommendations with physicians.
DON and/or designee will conduct audits of residents with drug regimen reviews monthly for three months, with results reported to Quality Assurance Performance Improvement Committee for further review and recommendations as needed.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 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 upon review of facility policy and procedure, observation, and clinical record review, it was determined the facility failed to establish Enhanced Barrier Precautions for three of 26 residents observed (Resident 71, Resident 4, and Resident 63)

Findings include:

Review of facility policy and procedure titled "Enhanced Barrier Precaution (EBP) " revealed " All applicable employee to adhere to Enhanced Barrier Precautions, per guidelines". Under Process: A physician order for enhanced barrier precautions is entered in the EHR. The order will contain the a reason for the EBP. EBP will be Care Planned and tasked out to the Care Kardex. An "Enhanced Barrier Precautions" sign will be posted on the door/outside of the room, of Residents that required Enhanced Barrier Precautions. A red Dot (Sticker) will be placed on the affected Resident's door tag to indicate which Resident requires Enhanced Barrier Precautions. The Unit Manger is responsible for: Updating and completion of the Enhanced Barrier Precautions log, Providing the IP or designee an updated EBP log weekly, Enhanced Barrier Precautions signage on the door, A red Dot (Sticker)placed on the affected Resident's door tag. Unit round audits checking for: Proper Signage/Dots, Staff adherence to precautions".

On August 26, 2024, at 12:33 p.m., Resident R4, located in room A22-1, was observed receiving wound treatment from licensed nurse Employee E5 while in bed. During the procedure, Employee E5 did not utilize Enhanced Barrier Precautions (EBP) as required. After exiting the room, Employee E5 confirmed that she had provided wound care to Resident R4's knee without using EBP.

A review of Resident R4's clinical record, including a physician's order dated May 15, 2024, indicated that the resident was to "Maintain Transmission-Based Precautions: Enhanced Barrier Precautions due to MRSA bacteremia in the blood and a right knee sinus tract, as well as MSSA in a bone/joint wound." Additionally, it was noted that Resident R4's door sign did not have a red dot, as per facility policy, which would have alerted staff to the need for EBP.

On August 26, 2024, at 12:39 p.m., licensed nurse Employee E5 provided wound treatment to Resident R63, residing in room A22-2, for a sacral wound without using Enhanced Barrier Precautions (EBP). After completing the treatment, Employee E5 exited the privacy curtain and requested assistance from nursing assistant Employee E25 to help reposition Resident R63, again without applying EBP.

Following the procedure, an interview was conducted with Employee E5, who reported that she was unaware that EBP was required. It was noted that Resident R63's door had a red dot sign, indicating to staff that EBP should have been used during care and treatment.

On August 26, 2024, at 12:50 p.m., an interview was conducted with Infection Preventionist Employee E3, who explained that a red dot on a resident's outside door sign indicates that Enhanced Barrier Precautions (EBP) are required when providing care or wound treatment. It was confirmed that both Residents R4 and R63 should have red dots on their door signs. However, during the interview, it was observed that Resident R4's sign did not have a red dot to communicate the need for EBP.

During the interview, licensed nurse Employee E5 was asked about her understanding of the red dot's meaning, and she reported that she was unaware of its significance. Employee E11 was then retrained on the meaning of the red dot and the implementation of EBP.

Review of the clinical record indicated that Resident R71 was admitted to the facility on March 25, 2021, with a diagnosis of encounter for attention to tracheostomy (a surgically created opening in the neck that allows direct access to the trache for breathing).

On August 29, 2024, at 11:45 a.m., licensed nurse Employee E11 was observed performing a tracheostomy treatment on Resident R71, which involved changing the resident's trach collar without following Enhanced Barrier Precautions (EBP). These precautions are required for all tracheostomy treatments to ensure proper infection control and safety.

On August 29, 2024, at approximately 2:30 p.m., Infection Preventionist Employee E3 confirmed that all tracheostomy treatments for Resident R71 require the use of Enhanced Barrier Precautions (EBP) when providing care or treatment.

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

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



 Plan of Correction - To be completed: 10/22/2024

Employees E5 and E11 were re-educated about utilization of Enhanced Barrier Precautions. Appropriate signage was placed for Resident R4 and Resident 63.
Infection Preventionist completed an audit to ensure residents on Enhanced Barrier Precaution has appropriate signage,
Staff developer/ designee with provide a re-education to the licensed nurses regarding utilization of Enhanced Barrier Precautions.
Infection Preventionist/ designee will conduct random audits to ensure proper signage is in place for residents on Enhanced Barrier Precautions and that staff are following appropriate precautions when caring for residents on Enhanced Barrier Precautions weekly for four weeks and monthly for two months, with results reported to Quality Assurance Performance Improvement Committee for further review and recommendations as needed.




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