Pennsylvania Department of Health
PAUL'S RUN
Patient Care Inspection Results

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PAUL'S RUN
Inspection Results For:

There are  58 surveys for this facility. Please select a date to view the survey results.

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PAUL'S RUN - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and a Civil Rights Compliance survey completed on January 2, 2023, it was determined that Paul's Run was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

§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 policies, information provided by the facility, and clinical records review, and staff interviews, it was determined that the facility failed to ensure that staff report an alleged violation involving an injury of unknown origin within the required timeframe for one of 27 residents reviewed (Resident 21).

Findings include:

A nursing note for Resident 21, dated December 7, 2023, revealed that the resident was observed by the nursing assistant with bluish discoloration above left eyebrow ridge. It measured 1.5 centimeter (cm) x 2.5 cm, and the area was slightly elevated.

Review of facility investigation dated December 7, 2023, at 4:30 p.m., revealed that the nursing assistant reported bruise to left eyebrow ridge measured 1. 5cm x 2. 5cm. The bruise was dark purple in color. Resident stated he was punched in the face by the person that took me to the get my hair cut.

Further review of investigation revealed a statement by Licensed Practical Nurse (LPN), Employee E14, indicated she observe the bruise before lunch time when she was assisting nurse aide, Employee E15, to transfer Resident R21. Employee E14 asked Employee E15 about the bruise, what it was, Employee E15 did not know what it was. The statement did not include any evidence that Licensed Practical Nurse(LPN), Employee E14 reported this allegation to administrator or to the supervisor.

Review of a statement by nurse aide, Employee E16, dated December 7, 2023, revealed that she observed a small spot on the corner of his eye when she went into his room to ask him if he wanted a haircut.

Review of a statement written by Director of Nursing (DON) dated December 8, 2023, revealed that she noticed a bruise to lateral side of his left eye of Resident R21. She asked Resident R21 what happened, and his response was "I was punched", Resident was unable to identify the person but stated "It was the little one that took me to get my haircut." Resident also stated, "she didn't like something and just punched me." Resident R21 told the DON "Please don't tell her I am afraid of her". When asked why resident replied, "because she is always rough with me but now I am afraid she's gonna come back and kill me".

Review of a corrective action document for nurse aide, Employee E15, dated December 12, 2023, revealed that on December 7, 2023, LPN, Employee E14 noticed a red area on the side of the resident's left eye and questioned Employee E15 who provided care to him. Employee E15 stated nothing unusual happened during her shift. Employee E15 was place on investigatory suspension. Continued review of the document revealed that on December 12, 2023, Employee E15 denied anything occurred on her shift. When questioned about LPN's conversation about the resident's area of concern with his left eye she denied anything occurred and did not report this incident.

Review of a corrective action document for nurse aide, Employee E16, dated December 14, 2023, revealed that Employee E16 noticed a red area to the side of Resident R21's left eye. Employee E16 failed to report the finding to any nurse or supervisor. It was the responsibility of all staff to report any concerns (inclusive of but limited to falls, injuries, cuts, and/or bruises) to the assigned charge nurse and/or the nursing supervisor.

Review of a corrective action document for LPN, Employee E14, dated December 14, 2023, revealed that Employee E14 noticed a red area to the side of Resident R21's left eye. Employee E14 failed to report the finding to any nurse or supervisor.

Review of a timeline of the facility camera revealed that LPN, Employee E14 and nurse aide, E15 was in resident's room at 12:08 p.m., (Employee E14 first observed that bruise and questioned Employee E15). At 12:11 p.m., Nurse aide, Employee E16 went into resident's room, she observed the bruise. At 12:17 p.m. resident was taken to the beauty salon. At 2:52 p.m. Nurse aide, Employee E15 left the unit after her shift. At 5:05 nursing assistant, Employee E17, called the nurse to resident's room who called the supervisor at 5:08 p.m.,

Continued review of facility investigation dated December 7, 2023, revealed that Employee E14, E15, and E16 failed to report Resident R21's alleged injury of unknown origin to the administrator or supervisor as required and failed to initiate an investigation in a timely manner.

Interview with the Nursing Home Administrator (NHA) on December 29, 2023, at 11:00 a.m. confirmed that Employee E14, E15, and E16 failed to report Resident R21's bruise to the left eye area in a timely manner. NHA stated Employee E14, E15, and E16 did not report the injury and left for their shift. It was reported by Employee E17, subsequently facility investigation was initiated.

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

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








 Plan of Correction - To be completed: 02/22/2024

Facility failed to ensure that staff report an alleged violation involving an injury of unknown origin within the required timeframe.
Resident is safe and unharmed. Care plan is updated and the CNA involved terminated as well as the LPN present was educated as to our policy and procedure. Staff was educated in regards to our policy on Abuse and Neglect reporting on 12/7 and education is ongoing.
Correction-
1.Abused and Neglect Policy/Mandated Reporters-Huddles on 12/11-12/13.
2.Abused and Neglected Residents In-Service-12/28-12/30.
3.Abused and Neglected Case Study-Nursing Supervisors-1/10/24.
4. Abused and Neglect-See Something Say Something-all Staff-1/18/24.
Administrator n designee will monitor the ongoing education effort and ensure that all the staff are educated monthly for a period of three months. !00% compliance will be achieved and the result will be reported monthly in the QAPI agenda.
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 §483.70(e) and following accepted national standards;

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

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

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

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

Based on observation, clinical record review, and review of facility documentation, it was determined that the facility failed to maintain proper infection control measures for COVID-19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus) in one of two nursing units (second floor).

Findings include:

A review of the facility documentation dated December 28, 2023, revealed 8 residents were residing in the designated COVID-19 rooms on the second floor.

Interview with the Nursing Home Administrator and Director of Nursing on December 27, 2023, at 9:30 a.m. revealed that the facility was having a COVID outbreak, 8 residents are located on the second floor. The required Protective Personal Equipment (PPE) for the COVID rooms as required by facilities policy " Transmission-Based Isolation Precautions that PPE to be donned upon entrance to the resident room includes goggle or face shield, facemask N95, disposable gowns, and gloves. PPE will be doffed prior to exit of the room and discarded in isolation bins placed inside of resident's doorway ". Every staff, and/or visitor going into COVID room must put on all PPE when going into the resident's room who are diagnosed with COVID.

Observation conducted on December 28, 2023, between 10:35 a.m. to 10:40 a.m. on the second floor, revealed Housekeepers, Employee E8 and E9 were going in and out of the COVID rooms without appropriate PPE such as mask N95, and face shield. Also, Employee E9 was observed exiting COVID room without appropriately doffing and putting dirty gown in a clean cart with other clean gowns. When Housekeepers, Employee E8 and E9 were interviewed, they both reported that they were train on PPE to be put on upon entrance and taken prior to exit COVID rooms.

On December 28, 2023, at 11:00 a.m. interview with Director of Nursing, Employee E3 and Assistant Director of Nursing, Employee E10, confirmed that all staff and visitor going into COVID rooms must put on all PPE when going into resident's room who are diagnosed with COVID and doffed when exiting by infection control policies and procedures.

28 Pa. Code 211.10(d) Resident care policies

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

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



 Plan of Correction - To be completed: 02/22/2024

Facility failed to maintain proper infection control measures for the covid-19 in one of two nursing units.
Correction-
Education session for proper PPE/donning and doffing with all housekeeping personnel on 12/28/23.
Staff Education about infection prevention measures to be utilized during normal operating procedures and during outbreaks requiring specialized isolation measures completed and ongoing for all staff.

DON/designee will monitor PPE donning/doffing for completion and accuracy monthly for 3 months and if 100% compliance is achieved, will continue to monitor quarterly. Audit developed and DON/designee, in conjunction with NHA, will report monthly at QA/CQI meetings noting compliance, reeducation, and plans for ongoing improvement/compliance at quarterly QAPI.
483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Observations:



Based on review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete one of 30 residents reviewed (Resident R77).

Findings Include:

Review of Resident R77's dietary progress note dated December 28, 2023, revealed that the resident was trending weight loss for past several months. The dietician was monitoring weekly weights, labs, meal intake and tolerance.

Review of Resident R77's November 2023 meal intake documentation revealed that on 19 days only one meal intake was documented. December 2023's meal intake documentation revealed that for 12 days only one meal was documented. Continued review of December 2023's meal intake documentation on December 5, 9 and 15, 2023 only two meals were documented.

Interview with the Registered Dietician on January 2, 2023, at 12:00 p.m. stated the resident was not on weekly weight when the dietician completed the documentation on December 28, 2023. Dietician also confirmed that the meal intake documentation was not consistently completed for Resident R77.

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













 Plan of Correction - To be completed: 02/22/2024

The facility failed to maintain adequate documentation as it relates to residents with weight loss.
Correction.
The staff were educated on the facility policies on how to properly document what percentages of neal was consume. these staff were also educated on how to follow dietary orders from the physician.

The staff are successfully marking the percentages of food eaten and following the physician orders a to how often residents are weighed and or how frequently their meal intake is monitored according to the facilities policy on monitoring meal intake.

Residents in a meal monitoring program will be audited weekly for a period of3 months to assure compliance to the plan. The results will be reviewed in the monthly QAPI meeting.















































































































































































































































































































































































































































































































































































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483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More: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(f) Medication Errors.
The facility must ensure that its-

§483.45(f)(1) Medication error rates are not 5 percent or greater;
Observations:

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater.

Findings include:

The facility incurred a medication error rate of 6.25%.

Review of R34's physician order revealed an order dated November 1, 2021, to administer Amlodipine Besylate 5 milligrams, give one tablet orally in the morning, for hypertension; hold for systolic blood pressure (SBP) less than 100. (Systolic Blood Pressure indicates how much pressure the blood is exerting against the artery walls when the heart contracts). (Hypertension is high blood pressure; if an individual has high blood pressure, the force of the blood pushing against the artery walls is consistently too high. The heart has to work harder to pump blood).

On December 28, 2023, at 9:38 a.m., observed that Employee E13, a Licensed Nurse, administered Amlodipine Besylate 5 milligrams, one tablet, orally to Resident R34. Employee E13 did not check the blood pressure of Resident R34, prior to or at the time of administration of Amlodipine Besylate 5 Mg tablet.

Review of Resident R34's physician order revealed an order dated November 1, 2021, to administer Losartan 100 mg tablet, give one tablet orally, in the morning, related to Essential (Primary) Hypertension, hold for Systolic Blood Pressure (SBP) less than 100.

On December 28, 2023, at 09:38 a.m., observed that Licensed nurse, Employee E13, administered Losartan 100 milligrams, one tablet, orally to Resident R34. Employee E13 did not check the blood pressure of Resident R34, prior to or at the time of administration of Losartan 100 mg.

At the time of the observation, interviewed with Employee E13, confirmed the findings.



Pa Code:211.12(d)(1)(2)(5) Nursing Services.





 Plan of Correction - To be completed: 02/22/2024

Facility failed to ensure that it was free of medication error rate greater than 5%. The rate was 6.25%.
Clinical Education was provided to the licensed nurse. E13 in regards to the administration. All hypertension medication orders now require nurses to enter the current BP.
Particularly on the orientation to the orders.
The nurse was able to effectively demonstrate there ability to return demonstrate and consistently deliver medications at an acceptable error rate. Random audits will be conducted each shift weekly for 3 months. The results of these audits will be reviewed monthly at the QAPI meeting.
483.25(f) REQUIREMENT Colostomy, Urostomy, or Ileostomy Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(f) Colostomy, urostomy,, or ileostomy care.
The facility must ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:

Based on observation and clinical records review, it was determined that the facility failed to ensure that that physician orders were followed related to urinary catheter size for one of one residents reviewed with a urinary catheter. (Resident R42)

Findings include:

Review of Resident R42's clinical record revealed that Resident R42 was admitted to the facility on June 8, 2023 with the diagnoses of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment; symptoms include forgetfulness, limited social skills, and thinking abilities so impaired that it interferes with daily functioning), Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Anxiety Disorder and Malignant Neoplasm of Right Female Breast (The term "malignant" means the tumor is cancerous and is likely to spread (metastasize) beyond its point of origin).

Review of physician order dated December 1, 2023, for Resident R42, indicated an order for suprapubic catheter size 18 French/10cc balloon.

On December 29, 2023, at 10:29 a.m., reviewed the suprapubic catheter of Resident R42, in the presence of Licensed nurse, Employee E13, and observation completed at the time revealed that Resident R42 had suprapubic catheter size 16 French, with the balloon size not clear.

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






 Plan of Correction - To be completed: 02/22/2024

Facility failed to ensure that physician orders were followed related o urinary catheter size for 1 resident reviewed.
Correction-
1. order for resident was confirmed and corrected with the physician.
2.DON/Designee will monitor catheters for completion and accuracy monthly for3 months and if 100 compliance is achieved will continue to monitor quarterly. Audit developed and DON/Designee, in conjunction with NHA, will report monthly at QA/CQI meetings noting compliance, reeducation and plans for ongoing improvement/compliance
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 review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included continuous oxygen administration for one of 33 residents reviewed (R41)

Findings include:

Review of Resident R41's clinical record revealed that the resident was admitted to the facility on October 2, 2023 with the diagnoses that included Heart Failure (a condition that develops when the heart doesn't pump enough blood for the body's needs. This can happen if the heart can't fill up with enough blood. It can also happen when the heart is too weak to pump properly), Atrial Fibrillation (an irregular and often very rapid heart rhythm; it can lead to blood clots in the heart, increases the risk of stroke, heart failure and other heart-related complications), Acute Kidney Failure (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days, it causes a build-up of waste products in the blood and makes it hard for the kidneys to keep the right balance of fluid in the body).

Review of physician order for Resident R41, dated November 25, 2023, indicated an order to "administer Oxygen continuously at 2 Liters/minute, via nasal canula/mask, every shift".

Review of the care plan for Resident R41, revealed that there were no focus, interventions, and outcomes (goals) care- planned for oxygen administration.

On December 29, 2023, at 10:27 a.m., interview with the Director of Nursing confirmed the above findings.

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

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




 Plan of Correction - To be completed: 02/22/2024

Facility failed to complete a comprehensive CarePlan that included continuous O2 for one of 33 residents.
Correction-
1. O2 was added to the resident's care plan on 12/29/2023e
2. Initiated a checks and balances ststem with the supervisors. All supervisors have been assigned 8-10 room numbers. They are responsible for weekly char checks inclusive of orders and care plans.
Monitor monthly audits for QA meetings.
483.80(b)(1)-(4) REQUIREMENT Infection Preventionist Qualifications/Role:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§483.80(b) Infection preventionist
The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must:

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

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

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

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

Based on review of facility policies and staff interviews, it was determined that the facility failed to ensure that the designated Infection Preventionist completed specialized training in infection prevention and control.

Findings include:

Review of facility infection control practice documentations revealed no evidence that the facility employed an Infection Preventionist who completed specialized training in infection prevention and control.

A request for a copy of the approved Infection Preventionist specialized training in infection prevention and control certification was made to the nursing home administrator, Employee E1, and Director of Nursing, Employee E2, on December 27, 2023, at 10:42 a.m. Facility Nursing Home Administration did not provide the documentation that the facility employed an Infection Preventionist who completed Infection Preventionist completed specialized training in infection prevention and control.

Interview with the Director of Nursing, Employee E2 on January 2, 2024, at 12:08 p.m. confirmed that the Director of Nursing assumed the duties of the Infection Preventionist (IP). The DON confirmed that no facility staff, who was responsible for infection control program, completed the required IP specialized training and education course and was not certified.

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

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

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









 Plan of Correction - To be completed: 02/22/2024

Facility failed to employ a nurse with the specific education that would qualify them to be addressed as the Infection Preventionist.
Correction-
Position offered to an external candidate, awaiting response. The DON and Clinical Coordinator will be taking the Infection Preventionist course to be faculity backup.
In the event no one is hired by 2/22/2024 we will ask for an extension.
483.20(g) REQUIREMENT Accuracy of Assessments:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on clinical record review and interviews with staff, it was determined that the facility failed to accurately complete a resident assessment related to discharge status for one of 27 residents reviewed (Resident R113).

Findings include:

Review of Resident R113's clinical records revealed the resident was admitted to the facility on September 6, 2023, and discharged from the facility on October 2, 2023.

Review of Resident R113's progress note revealed a nursing note dated October 2, 2023, which stated, resident discharged to home.

Review of Resident R113's discharge Minimum Data Set (MDS- assessment of resident care needs) dated October 2, 2023, revealed that the residents discharge status was coded, "Short term general hospital (acute hospital)."

Interview with the Nursing Home Administrator, Employee E1, conducted on January 2, 2024, at 11:30 a.m. confirmed that the MDS discharge status, dated October 2, 2023, for Resident R113 was coded inaccurately.

28 Pa. Code 201.14(a) Responsibility of licensee

2 Pa. Code 211.5(f) Medical records




 Plan of Correction - To be completed: 02/22/2024

Facility failed to complete a resident assessment related to discharge status.
MDS for resident R113 discharge was corrected on 1/2/2024.
Resident is safe and unharmed Care plan is updated. and the MDS coordinator has been educated on the importance of completing accurate MDS assessments.
DON and designee will monitor the accuracy of the discharge mdS assessment monthly for a total of 3 months beginning with a current baseline audit of all the current discharges for discharge plan accuracy. Results will be reported in the monthly qapi meeting.
§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for one of 21 days reviewed. (September 4, 2023)

Findings include:

Review of nursing schedules for 21 days from September 1, 2023, through September 7, 2023, November 19, 2023 through November 25, 2023, and December 23, 2023 through December 29, 2023 revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on night shift (11:00 p.m. to 7:00 a.m.) shift on September 4, 2023.

Facility census was 115 and total nursing assistant hours required, 46.00. (FTE (Full time equivalent (5.75)

Total nursing assistant hours worked 44.50.(FTE-5.56)

Facility did not submit evidence of direct resident care for the remaining required hours.






 Plan of Correction - To be completed: 02/22/2024

Facility failed to meet the minimum NA to resident ratio of one NA for 12n residents on night shift 11pm to 7am on September 4 2023.
Correction-
During the 21 days reviewed the facility was fully staffed and compliant to all the guidelines with exception of 2 hours on 9/4/2023. On the date in question, the facility was fully staffed until an aide was sick. The shift was covered by several staff members. There were six staff members that stayed late from the previous shift and four staff members that came in early from their shift to cover. All of whom clocked in. The remaining 2 hours of coverage were filled by a nurse manager that was on call who does not clock in or out.
The facility will maintain an on-call rotation that will be able to staff shifts as needed. All salaried employees will be noted on the assignment sheets for coverage. The DON/Designee will monitor staffing for compliance and accuracy monthly for 3 months and if 100% compliance is achieved, will continue to monitor quarterly. Audit Staffing Calculation Tool approved by DON/Designee in conjunction with the NHA, will report monthly at QA/CQI meetings noting compliance, reeducation, and plans for ongoing improvement/compliance at quartely QAPI.

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