Pennsylvania Department of Health
CHAMBERS POINTE HEALTH CARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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CHAMBERS POINTE HEALTH CARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and a Civil Rights Compliance survey completed on March 13, 2024, it was determined that Chambers Pointe Health Care Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

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(d) Food and drink
Each resident receives and the facility provides-

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

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

Observations:

Based on a review of facility's policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items that were palatable and at proper temperatures.

Findings include:

The facility's policy regarding Food Handling Principles dated September 14, 2023, revealed that hot foods are to be served at 135-155 degrees Fahrenheit (F).

Observations on March 12, 2024, at 10:52 a.m. revealed that the food was brought to the kitchenette and initial temperatures were taken. The pasta was 152.0 degrees F, the popcorn chicken was 143.0 degrees F, the shrimp was 173.0 degrees F, the mashed potatoes were 160.0 degrees F, the beets and carrots were 164.0 degrees F, the mechanical chicken was 163.0 degrees F, and the ground shrimp was 156.0 degrees F. The food was then placed in the steam table. The steam table pans containing the hot food were left uncovered throughout the lunch meal service.

After serving lunch to the last resident in the dining room on March 12, 2024, at 12:26 p.m., temperatures for a test tray were obtained. The mechanical shrimp was 137.0 degrees F and cold to taste, the mechanical chicken was 135.0 degrees F and cold to taste, the carrots and beets were 131.0 degrees F and cold to taste, the mashed potatoes with gravy were 133 degrees F and cold to taste, the shrimp with pasta and garlic butter was 136.0 degrees F and cold to taste.

Interview with Dietary Aide 4 on March 12, 2024, at 12:26 p.m. revealed that the lids should have been closed when not plating food.

Interview with the Nursing Home Administrator on March 12, 2024, at 2:16 p.m. confirmed that food should be served at an appropriate temperature, and that the food would be cold if lids are left open during service.

28 Pa. Code 211.6(b) Dietary Services.

Plan of Correction - To be completed: 04/11/2024

1. No residents were identified to have had a negative outcome regarding this meal service and palatability.
2. Team members will serve hot food according to our policy.
3. Team member in-service will occur during the week of 4/1/2024. The team will be re-educated on the food serving procedures and guidelines.
4. The Director of Culinary Services or designee will ensure team members are following the food serving procedure and guidelines policy. This will be monitored using and audit sheet, starting 4/1/2024. Team members will be monitored three times a week for three weeks and then two times a week for two weeks. A summary of the audits will be reviewed at the Quality Assurance and Performance Improvement meetings for further review and recommendations.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§483.60(i) Food safety requirements.
The facility must -

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

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

Observations:

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to serve food in accordance with professional standards for food service safety, by failing to ensure that dietary staff wore hair coverings that completely covered their hair during food handling and not storing food properly.

Findings include:

The facility's dietary policy regarding Use of Hair Restraints, dated September 14, 2023, revealed that staff were to wear a hat or hairnet to cover all visible hair.

The facility's dietary policy regarding Food Storage, dated September 14, 2023, revealed that food is stored in a manner that prevents damage, spoilage, infestation, and bacterial contamination.

Observations in the main kitchen on March 11, 2024, at 10:26 a.m. revealed that the Assistant Dietary Director was wearing a hair restraint and approximately three inches of her bangs were uncovered.

Observations in the freezer on March 11 2024, at 10:26 a.m. revealed a tray containing 22 uncovered, unlabeled and undated grey colored, unidentifiable food patties; 24 patties of pureed cranberry that was uncovered, unlabeled and undated; and a full box of haddock that was uncovered, undated and unlabeled and open to the air.

Observations in the Evergreen kitchenette on March 11, 2024, at 10:41 a.m. revealed that Dietary Aide 5 exited the kitchenette without a hairnet.

Observations in the Dogwood kitchenette on March 11, 2024, at 10:45 a.m. revealed that Dietary Aide 6 had three inches of hair on the back of her head that was not covered by her hair restraint.

Interview with the Executive Culinary Director on March 11, 2024, at 10:46 a.m. confirmed that staff did not have all hair covered with hair restraints and should have, and that the frozen patties and box of haddock were not covered and dated and should have been.

28 Pa. Code 211.6(f) Dietary Services.

Plan of Correction - To be completed: 04/11/2024

1. No residents had ill effect from deficient practice.
2. Team members will cover, label, and date any opened food items to and ensure that stored items are not stored past our storage time frames according to our policy. Team members will wear the proper hair coverings according to our policy.
3. Team member is-service will begin the week of 4/1/2024 and to be re-educated on storage procedure, and hair covering guidelines.
4. Director of Culinary Services or designee will ensure team members are following the storage procedure and guidelines policy, and hair covering policy.
This will be monitored using an audit sheet beginning 4/1/2024. Audits will be conducted three times a week for three weeks, and then two times a week for two weeks. A summary of the audits will be reviewed at the Quality Assurance and Performance Improvement meetings for further review and recommendations.

483.10(j)(1)-(4) REQUIREMENT Grievances:

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(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 observations and review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievances.

Findings include:

A meeting with a group of residents on March 11, 2024, at 10:37 a.m. revealed that the food was cold, unappetizing and unpalatable.

A grievance filed on November 14, 2023, revealed that a resident received cold food on November 11, 2023, and November 12, 2023.

A grievance filed on February 7, 2024, revealed that Resident 8 continued to receive cold food.

Observations of the lunch meal service on March 12, 2024, at 10:52 a.m. in the Evergreen dining room revealed the following temperatures at the beginning of service: the pasta and butter sauce was 152 degrees Fahrenheit (F), the popcorn chicken was 143.0 degrees F, the shrimp was 173.0 degrees F, the mashed potatoes were 160.0 degrees F, the beets and carrots were 164.0 degrees F, the mechanical chicken was 163.0 degrees F, and the mechanical shrimp was 156.0 degrees F.

After the last resident was served lunch in the Evergreen dining room on March 12, 2024, at 12:26 p.m. a test tray was conducted. The pasta with shrimp and butter sauce was 136.0 degrees F and tasted cold, the mashed potatoes with gravy was 133.0 degrees F and tasted cold, the carrots and beets were 131.0 degrees F and tasted cold, the mechanical chicken was 135.0 degrees F and tasted cold, and the mechanical shrimp was 137.0 degrees and tasted cold.

Interview with the Nursing Home Administrator on March 12, 2024, at 4:32 p.m. confirmed that cold food has been an ongoing concern and that it was not resolved based on continued grievances and cold test tray.

28 Pa. Code 201.29(i) Resident Rights.

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

Plan of Correction - To be completed: 04/11/2024

1. No residents were identified to have had a negative outcome with the findings of food temperatures.
2.Grievances for past 30 days were reviewed and followed up to ensure continued satisfaction.
3.Team member education to be provided regarding grievance policy and process. Nursing Home Administrator to meet with residents to ensure understanding of grievance process.
4. Nursing Home Administrator or Designee to audit completed grievance resolutions, satisfaction weekly times 4 weeks, then biweekly times 2, then monthly times 1. Audit findings to be reviewed during quality assurance and performance improvement meetings to identify need for further auditing.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

§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 a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to respond timely to a pharmacy recommendation for one of 30 residents reviewed (Resident 36).

Findings include:

The facility's policy for pharmacy services, dated September 14, 2023, revealed that the licensed pharmacist will collaborate with facility leadership and staff to coordinate pharmaceutical services within the facility, guide development and evaluation of pharmaceutical services procedures, and help the facility identify, evaluate, and resolve pharmaceutical concerns which affect resident care and medical care, or quality of life.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated August 11, 2023, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included atrial fibrillation (irregular heartbeat), high blood pressure, high cholesterol, thyroid disorder, arthritis, and renal failure.

Physician's orders for Resident 36 on admission, dated January 19, 2023, included orders for the resident to receive 7.5 milligrams (mg) of Meloxicam (nonsteroidal anti-inflammatory pain medication) twice a day for pain, 20 milliequivalent (meq) of potassium chloride daily for low potassium levels, 25 mg of Losartan (high blood pressure medication) daily for high blood pressure, 50 micrograms (mcg) of Levothyroxine daily for low thyroid levels, 300 mg of Allopurinol (uric acid lowering medication) daily for gout (high uric acid level causes arthritis), and 20 mg of lasix (diuretic medication) for edema.

Review of the pharmacy medication regime review (MRR) for Resident 36, dated September 27, 2023, revealed recommendations to have blood draws for laboratory testing that included a basic metabolic panel for taking an angiotensin receptor blocker (a type of high blood pressure medication) every six months, a lipid panel yearly for taking a statin (cholesterol lowering medication), an uric acid level yearly when taking Allopurinol, and a thyroid stimulating hormone level yearly for taking Levothyroxine (synthetic thyroid medication). The MRR recommendation was never reviewed, responded to, or signed by the physician to agree or disagree.

Review of a pharmacy MRR for Resident 36, dated November 6, 2023, revealed recommendations to have blood draws for laboratory testing that included a complete metabolic panel for taking furosemide (Lasix), Meloxicam, potassium medication, and Losartan every six months; a full lipid panel yearly for taking a statin; and an uric acid level yearly when taking Allopurinol. The MRR recommendation was never reviewed, responded to, or signed by the physician to agree or disagree.

Interview with the Director of Nursing on March 13, 2024, at 3:41 p.m. confirmed that the pharmacy MRR recommendations for Resident 36 were not addressed by the physician and should have been.

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

Plan of Correction - To be completed: 04/11/2024

1. Resident 36's pharmacy recommendations were sent to physician for review and new orders including lab work obtained, lab work was completed and reviewed by physician.
2. Director of nursing or designee completed an audit of the last 30 days of pharmacy recommendations to ensure completion
3. Pharmacy recommendations will be added to risk and falls meeting with interdisciplinary team to ensure recommendations were addressed.
4. Director of nursing to complete audits of completed pharmacy recommendations monthly times 3 months. Audit findings to be reviewed during quality assurance and performance improvement meetings to identify need for further auditing.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

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

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

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

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

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

Observations:

Based on review of clinical records and staff interviews, it was determined that the facility failed to notify the resident's representative in writing regarding the reason for hospitalization for one of 30 residents reviewed (Resident 38).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated January 30, 2024, indicated that the resident was severely cognitively impaired, required assistance from staff for her daily care needs, and had diagnoses that included stroke and traumatic brain injury.
Resident 38's daughter was listed in the clinical record as the responsible party and first emergency contact.

MDS discharge assessments for Resident 38, dated October 13 and 19, 2023, and November 4, 2023, revealed that the resident was admitted to the hospital on those dates.

Nursing notes for Resident 38, dated October 13 and 19, 2023, and November 4, 2023, indicated that the resident was transferred to the hospital for further evaluation, treatment and admission.

There was no documented evidence in Resident 38's clinical record to indicate that the resident's representative was notified in writing of the purpose for the resident's transfer about the hospitalizations in October and November 2023.

Interview with the Nursing Home Adminstrator on March 12, 2024, at 4:19 p.m. confirmed that there was no documentation that the resident's representative was notified in writing of Resident 38's transfers and hospitalizations in October and November 2023, and there should have been.

28 Pa. Code 201.25 Discharge Policy.

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

Plan of Correction - To be completed: 04/11/2024

1. Resident 38 had no ill effect from deficient practice.
2. Facility reviewed last 30 days of transfers out to validate notification was provided. If any concern(s) were discovered the resident and/ or responsible party would be notified in writing.
3. Director of nursing or designee will educate licensed staff on the process of notification before transfer in writing.
4. Nursing Home Administrator or designee complete audits on unanticipated discharges, and transfers out to validate the notification process has been completed. Audits to be conducted by Nursing Home Administrator/ designee weekly times 4 weeks. A summary of the audits will be reviewed at the Quality Assurance and Performance Improvement meetings for 3 months for further review and recommendations.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

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

Observations:

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 30 residents reviewed (Resident 21).

Findings include:

A facility policy for care planning, dated September 14, 2023, revealed that assessments of residents were ongoing and that care plans were revised as information about the residents' conditions change.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 21, dated January 10, 2024, revealed that the resident was sometimes understood and could usually understand others, was cognitively impaired, and was dependent on staff for daily care needs. A care plan for Resident 21, updated January 10, 2024, revealed that the resident had inadequate oral intake with swallowing difficulty and unintended weight loss.

There was nothing in the care plan to indicate that Resident 21 refused dinner trays.

A note from speech therapy, dated January 25, 2024, revealed that Resident 21 can have a mechanically soft diet if resident is alert, out of bed, and in the dining room.

A note from dietary, dated February 13, 2024, revealed that Resident 21 continues to refuse her dinner tray.

Nursing notes for Resident 21 revealed that the resident refused dinner trays on February 14, February 17, February 18, February 22, February 26, and March 8, 2024.

Interview with Speech Therapist 1 and Speech Therapist 2 on March 12, 2024, at 1:16 p.m. revealed that they were made aware on March 8, 2024, that Resident 21 continues to refuse dinner trays and is on the case load to evaluate safety to remain in bed while eating.

Interview with Nursing Home Administrator on March 12, 2024, at 1:31 p.m. revealed that the care plan needed to be updated to reflect resident's continued refusals of supper trays.

28 Pa. Code 201.24(e)(4) Admission Policy.

Plan of Correction - To be completed: 04/11/2024

1. Resident 21's care plan was updated to reflect her refusal of meals.
2. Dietician reviewed meal refusals for past 30 days. Interdisciplinary team reviewed and updated residents care plans who were identified.
3. Team members responsible for writing and reviewing care plans will be re-educated on the facility's policy for Comprehensive Care Plans.
4. The Director of Nursing or designee will conduct audits of meal refusals weekly times 4, then bi-weekly times 2, then monthly times 1. A summary of the audits will be reviewed at the Quality Assurance and Performance Improvement meetings for further review and recommendations.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§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 observations and staff interviews, it was determined that the facility failed to ensure that controlled medications were stored in a separately-locked, permanently-affixed compartment in one of two medication rooms reviewed (Main), and failed to discard expired medical supplies in one of two medication rooms reviewed (Evergreen).

Findings include:

Observations in the Main medication room refrigerator on March 12, 2024, at 8:12 am. revealed that there was a narcotic storage box containing an unopened bottle of liquid Ativan (a controlled medication used to treat anxiety) and the box was not permanently affixed inside the refrigerator.

An interview with Registered Nurse 1 on March 12, 2024, at 8:14 a.m. confirmed that the narcotic storage box containing the bottle of Ativan should have been permanently affixed inside the Main medication room.

Observations in the Evergreen medication room on March 12, 2024, at 8:17 a.m. revealed that there were multiple intravenous catheters (medical supplies used in the vein to provide fluids or medication) that expired in February, September and December of 2023, and three syringes that expired in October 2022 and December 2023.

An interview with Registered Nurse 1 on March 12, 2024, at 8:19 a.m. confirmed that the medical supplies were expired and should not have been in circulation to be used on residents.

Interview with the Nursing Home Administrator on March 12, 2024, at 3:24 p.m. confirmed that the facility had no policy that spoke to expired medical supplies or narcotic boxes being permanently affixed in the medication refrigerator. Furthermore, she confirmed that the narcotic storage box containing Ativan was not permanently affixed inside the refrigerator and expired medical supplies were in circulation, and they should not have been.

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

Plan of Correction - To be completed: 04/11/2024

1. No residents had ill effect due to deficient practice.
2.Narcotics refrigerator permanent tether was replaced immediately during survey. Expired items were removed from medication storage room.
3. Education to be provided to clinical team members regarding the disposal and monitoring of expired items as well as monitoring of narcotics affixed storage units.
4. Director of nursing or designee will conduct audits of medication rooms for expired items, and medication refrigerators permanently affixed locks. Audits will be conducted weekly times 4 weeks, biweekly times 2, and monthly times 1 month. A summary of the audits will be presented at the Quality Assurance and Performance Improvement meetings for further review and recommendations.

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