Pennsylvania Department of Health
 MEADOW VIEW NURSING CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MEADOW VIEW NURSING CENTER
Inspection Results For:

There are  124 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.
MEADOW VIEW NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a complaint survey completed on March 7, 2024, it was determined that Meadow View Nursing 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:


483.20(g) REQUIREMENT Accuracy of Assessments: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.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for seven of 41 residents reviewed (Residents 1, 49, 68, 87, 90, 122, 124).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that if the pneumococcal (pneumonia) vaccine was not received, Section O0300C (pneumococcal vaccine) was to be coded with the reason the pneumonia vaccine was not received. The section was to be coded with a one (1) if the resident was not eligible (medical contraindication); two (2) if the vaccine was offered and declined; or (3) if the vaccine was not offered.

A quarterly MDS assessment for Resident 1, dated January 5, 2024 revealed that Section O0300B was coded with not assessed, no information. However, a pneumococcal consent/declination form, dated June 30, 2023, revealed that Resident 1 was offered the pneumococcal vaccine and declined.

An admission MDS assessment for Resident 49, dated February 19, 2024, revealed that Section O0300B was coded with not assessed, no information. However, an immunization form for Resident 49, dated February 12, 2024, revealed that the resident was offered and refused the flu and pneumococcal vaccine.

An annual MDS assessment for Resident 68, dated December 28, 2023, revealed that Section 00300B was coded with not assessed, no information. However, an immunization form for Resident 68, dated January 5, 2023, revealed that the resident was offered and refused the flu and pneumococcal vaccine.

A quarterly MDS assessment for Resident 87, dated March 6, 2024, revealed that Section O0250C was coded with not assessed, no information; and Section O0300B was coded with not assessed, no information. An immunization form for Resident 87, dated December 8, 2023, revealed that the resident was offered and refused the flu and pneumococcal vaccine.

A quarterly MDS assessment for Resident 90, dated February 16, 2024, revealed that Section O0300B was coded with not assessed, no information. An immunization form, undated, revealed that Resident 90 received a pneumococcal vaccine on July 18, 2019, and August 10, 2020.

An admission MDS assessment for Resident 122, dated January 25, 2024, revealed that Section O0300B was coded with not assessed, no information. However, an immunization form, dated January 18, 2023, revealed that Resident 122 was offered the pneumococcal vaccine and flu vaccine and declined.

An admission MDS assessment for Resident 124, dated February 25, 2024, revealed that Section O0300B was coded with not assessed, no information. However, an immunization form for Resident 124, dated February 17, 2024, revealed that the resident was offered and refused the flu vaccine.

Interview with Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on March 7, 2024, at 12:14 p.m. confirmed that all of the MDS assessments listed above were not coded correctly because the vaccine information was not a part of the electronic medical record and was located in their paper charts.

28 Pa. Code 211.5(f) Clinical Records.



 Plan of Correction - To be completed: 04/17/2024

Resident 49 Minimum Data Set Assessment was reviewed and modified by facility Registered Nurse Assessment Coordinator on 3/25/2024.
Resident 1, 49,68,87,90,122, and 124 Minimum data Set assessment modified.
Director of Nursing/designee will complete an audit of the last thirty days of new admission Minimum Data Set Assessment for accuracy of influenza and pneumonia vaccines Registered Nurse Assessment Coordinator to modify as needed.
Registered Nurse Assessment Coordinator will be re-educated on Minimum Data Set by Clinical Reimbursement Specialist.
Director of Nursing /designee will complete random weekly audits of Minimum Data Set Assessment for accuracy of influenza and pneumonia x 4 weeks and monthly x 2 months.
Results of audit findings will be reported to the Quality Assurance Performance Improvement Committee

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.80 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 review of guidance from the Pennsylvania Department of Health (DOH) and review of the facility's policies, as well as observations and staff interviews, it was determined that the facility failed to follow infection control standards and DOH guidelines to reduce the spread of infections and prevent cross-contamination.

Findings include:

Pennsylvania Department of Health, COVID-19 Infection Control and Outbreak Response Toolkit for Long-Term Care (LTC), dated February 2024, revealed that personal protective equipment (PPE) is a key component of infection prevention practices in LTCF's. PPE is equipment that is worn to minimize exposure to hazards that may cause workplace harm or illness. In LTCF's and other medical settings, health care professionals (HCP) are to wear PPE to protect them from potentially infectious conditions. This includes equipment such as respirators, masks, gowns, gloves, and eye protection. While having the recommended PPE is important to protect the wearer, it is equally critical to ensure the wearer knows how to appropriately don (put on) and doff (take off) PPE to best protect themselves from infectious disease exposure. Source control refers to the use of respirators or well-fitting facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. People, particularly those at high risk for severe illness, should wear the most protective form of source control that they are able to wear.

The facility's current policy regarding Infection Control COVID-19 General Guidelines, dated October 6, 2023, revealed that the core principles of COVID-19 infection prevention is source control used by staff and visitors (defined as well-fitting face covering or mask covering mouth and nose). When the community transmission is high, everyone entering the facility must have a source control mask in place and utilize it at all times. Appropriate staff use of PPE.

Physician's orders for Resident 45, dated March 5, 2024, included an order for the resident to be in contact isolation (steps that healthcare facility visitors and staff need to follow before going into a resident's room).

A nursing note for Resident 45, dated March 5, 2024, revealed that the resident's husband was at the bedside and reported that when the resident called him last night, she seemed confused. There was no confusion today. She was alert to her baseline. Her voice was hoarse. She was tested for COVID-19 and the result was positive.

Observations on March 6, 2024, at 12:00 p.m. revealed that there was sign on Resident 45's doorway indicating PPE usage in red zone COVID-19 Positive or COVID-19 symptoms with test pending. Contact and Droplet Precautions. PPE required at all times. N95 respirator, goggles/face shield. PPE required during patient care: gloves, N95 respirator, goggles/face shield, gown. Observations revealed that there was a cart sitting outside the resident's room with personal belongings on the cart. The Registered Nurse/Staff Development/Nurse Aide Educator was inside the room, opened the door wearing a surgical mask, a gown, and had an N95 mask on under her chin. She obtained items from the cart and took them into the room closing the door behind her. She opened the door and obtained more items from the cart, closing the door several times during the observation.

Interview with the Registered Nurse/Staff Development/Nurse Aide Educator on March 6, 2024, at 12:21 p.m. confirmed that she should have been wearing a N95 mask while in Resident 45's room.

Interview with the Nursing Home Administrator on March 6, 2024, at 3:00 p.m. confirmed that the Registered Nurse/Staff Development/Nurse Aide Educator should have been wearing a N95 mask while in Resident 45's room.

Observations of Agency Licensed Practical Nurse 10 on March 7, 2024, at 12:40 p.m. revealed that she was down the Second Floor B Hallway with the medication cart that had several COVID-19 positive rooms with her surgical mask on down under her chin. She returned the medication cart to the medication room and shortly after came out of the medication room with the medication cart with her surgical mask down under her chin. She proceeded down the Second Floor Hallway B and stopped outside a resident's room.

Interview with Agency Licensed Practical Nurse 10 on March 7, 2024, at 12:52 p.m. revealed that this was her first time working at the facility and she was not sure of the facility's requirements.

Interview with the Nursing Home Administrator on March 7, 2024, at 1:42 p.m. confirmed Agency Licensed Practical Nurse 10 should have been wearing a surgical mask.

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




 Plan of Correction - To be completed: 04/17/2024

Resident 45 recovered from COVID 19 and had no ill effects from improper donning of personal protective equipment.
The Registered Nurse/Staff Development/Nurse Aide Educator was educated by the director of nursing on proper personal protective equipment usage.
Director of nursing/designee will educate all current staff, new hire staff, and agency staff on proper use of personal protective equipment for COVID 19 isolation.
Director of nursing/designee will complete audits for personal protective equipment use in COVID 19 isolation rooms weekly for 4 weeks and monthly for 2 months.
Results of audit findings will be reported to the Quality Assurance Performace Improvement Committee.
483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.
Observations:


Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) surveys ending April 13, 2023, and July 27, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending March 7, 2024, identified repeated deficiencies related to freedom from abuse/neglect, accuracy of Minimum Data Sets (MDS) assessments, services provided to meet professional standards, quality of care, safety and accidents hazards, palatability of food, food procurement/storage/preparation, and infection control.

The facility's plan of correction for a deficiency regarding freedom from abuse/neglect, cited during the survey ending July 27, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F600, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding freedom from abuse/neglect.

The facility's plan of correction for a deficiency regarding completing accurate MDS assessments, cited during the survey ending April 13, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding accurate MDS assessments.

The facility's plan of correction for a deficiency regarding services provided to meet professional standards, cited during the survey ending April 13, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F658, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding services provided to meet professional standards.

The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending April 13, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care.

The facility's plan of correction for a deficiency regarding safety and accident hazards, cited during the surveys ending April 13, 2023, and July 27, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding safety and accident hazards.

The facility's plan of correction for a deficiency regarding palatable food, cited during the survey ending April 13, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F804, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding palatable food.

The facility's plan of correction for a deficiency regarding food procurement/storage/preparation, cited during the survey ending April 13, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding food procurement/storage/preparation.

The facility's plan of correction for a deficiency regarding infection control, cited during the survey ending April 13, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding infection control.

Refer to F600, F641, F658, F684, F689, F804, F812, F880.

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

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



 Plan of Correction - To be completed: 04/17/2024

A Quality Assurance meeting will be held on 3/28/2024 reviewing F641, F 600, F804, F812, F880, F 684 F 689,
The facility department managers and Quality Assurance Performance Improvement Committee will be educated by regional support staff on the function, purpose of the Quality Assurance Performance Improvement Committee.
Random audits of these Federal citations will be reviewed quarterly x 2 for compliance.
The Quality Assurance Performance Improvement meeting will be conducted monthly, and findings reviewed.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
§483.60(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 store food in accordance with professional standards for food service safety by failing to store food under sanitary conditions, failing to ensure that food was served under sanitary conditions, and failing to ensure that ice was made and stored in sanitary ice machines for one of four ice machines (Second Floor Nourishment Station).

Findings include:

Observations in the walk-in freezer on March 4, 2024, at 9:09 a.m. and March 6, 2024, at 11:05 a.m. revealed that there was an accumulation of ice on the ceiling, the floor, and metal storage racks, as well as on cases of asparagus cuts and tips, fresh frozen brussel sprouts, and breaded popcorn shrimp that were stored on the shelves below the freezer condenser.

Interview with the Registered Dietitian on March 6, 2024, at 11:05 a.m. confirmed that there was an accumulation of ice on the food products stored below the freezer condensers in the walk-in freezer.

Review of the main kitchen's daily floor cleaning assignments, undated, revealed that the floors must be swept and mopped daily.

Observations in the main kitchen on March 4, 2024, at 9:15 a.m. and March 6, 2024, at 11:07 a.m. revealed that there was a French fry along with other food debris under a wheeled cart sitting beside the prep table across from the two door ovens.

Interview with the Registered Dietitian on March 6, 2024, at 11:26 a.m. confirmed that there was a French fry along with other food debris under a wheeled cart sitting beside the prep table across from the two door ovens.

The facility's current policy regarding handwashing, dated October 6, 2023, revealed that food handlers will wash their hands before they start work and after touching anything else that may contaminate hands, such as unsanitized equipment, work surfaces, or wash cloths.

Observations during the lunch meal on March 6, 2024, at 11:16 a.m., 11:20 a.m., 11:25 a.m. and 11:32 a.m. revealed that Dietary Worker 9 was at the end of the tray line receiving the trays with the prepared plates. Dietary Worker 9 added the prepared cinnamon scalloped peaches, as well as a roll and jelly, to the tray and then placed them into the cart to be delivered to the residents. When the cart was full, Dietary Worker 9 left the kitchen with the cart to deliver it to the nursing units. Upon return to the main kitchen, Dietary Worker 9 did not perform hand washing, and she continued to take the prepared trays with the prepared plates, place the prepared cinnamon scalloped peaches, as well as a roll and jelly, to the tray and placed them into the carts for delivery.

Interview with the Registered Dietitian on March 6, 2024, at 11:26 a.m. confirmed that Dietary Worker 9 should have performed hand washing each time she returned to the kitchen from the nursing units.

Observations of the Hoshizaki ice machine in the Second Floor Nourishment Station on March 7, 2024, at 9:42 a.m. revealed that the end of the drain line coming from the ice machine had a buildup of a black, removable substance.

Interview with the Director of Maintenance on March 7, 2024, at 10:25 a.m. confirmed that the ice machine in the Second Floor Nourishment Station had a buildup of a black, removable substance on the end of the drain line coming from the ice machine. He indicated that the ice machines are cleaned quarterly.

28 Pa. Code 211.6(f) Dietary Services.

28 Pa. Code 207.4 Ice Containers and Storage.




 Plan of Correction - To be completed: 04/17/2024

Freezer was serviced on Thursday March 7, 2024, at that time part was ordered to be replaced.
Director of dining services will educate dining staff on kitchen sanitation and cleaning schedules.
Director of dining services will educate dining staff on handwashing frequency.
Hand washing audit was conducted on Thursday March 7, 2024, by director of dining services.
Dining services audit will be implemented 3 days a week x 1 months, then monthly x 2 months.
483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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.
§483.60(d) Food and drink
Each resident receives and the facility provides-

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

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


Based on review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures.

Findings include:

The facility's current policy regarding food temperatures and resident tray audits, dated October 6, 2023, indicated that the facility's standards for test tray temperatures were to be 135 degrees Fahrenheit (F) or higher for soups, hot cereals, eggs, pancakes/waffles/French toast, entree/casseroles, starches, and vegetables; 120 to 160 degrees F for hot beverages; and 41 degrees F and lower for salads, desserts, fruit, juice, and milk.

Interview with Resident 12 on March 4, 2024, at 12:51 p.m. revealed that he does not like the taste of the food.

Interview with Resident 45 on March 4, 2024, at 11:45 a.m. revealed that the French fries she receives are cold, and that she threw up when she had the liver and onions.

Observations in the main kitchen on March 6, 2024, revealed that the Second Floor second cart left the main kitchen at 11:39 a.m. and arrived on the Second Floor at 11:40 a.m. Trays were passed to the residents in their rooms at 11:44 a.m. and the last resident was served at 12:11 p.m. At 12:12 p.m. the temperature of the pork and gravy was 119.3 degrees F, the temperature of the rice pilaf was 127.6 degrees F, the temperature of the steamed broccoli was 117.1 degrees F, the temperature of the cinnamon scalloped peaches was 51 degrees F, the temperature of the coffee was 136.7 degrees F, and the temperature of the milk was 44.6 degrees F.

The pork and gravy, rice pilaf, and steamed broccoli were lukewarm and not appetizing.

Interview with the Registered Dietitian at the time of observation revealed that they would like their hot foods to be at a minimum of 135 degrees F.

28 Pa. Code 211.6(b) Dietary Services.



 Plan of Correction - To be completed: 04/17/2024

Director of Dining Services began providing re-education to dietary staff members responsible for preparation of food and staff members responsible for serving food. Re-education provided included the process of ensuring that the meal cart is prepared for delivery to the individual dining areas. Team members responsible for monitoring food temperatures received re-education regarding the correct food temperatures for both cold and hot foods. This re-education included: * Cook will check food temperatures prior to putting food in steam table. * Cook will recheck the food temperatures before service * No food item can be served unless it is at the correct temperature

Director of Nursing/Designee will re- educate nursing staff on timely service of Resident Meal Pass policy.

The dietary manager /designee will audit test trays on the nursing units for proper temperature 3 times a week x 4 weeks and monthly times 2.
Results of audits will be reviewed through Quality Assurance Performance Improvement process.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

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

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

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

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

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

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


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of anti-anxiety medications for one of 41 residents reviewed (Resident 79).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 79, dated December 27, 2023, indicated that the resident was cognitively impaired, received antianxiety medication, and had diagnoses that included dementia.

Physician's orders, dated December 17, 2023, included an order for the resident to receive 0.5 milligrams/milliliter (mg/mL) of lorazepam (an antianxiety medication) gel applied to the inner wrist topically every eight hours as needed for anxiety, and physician's orders, dated January 18, 2024, included orders for the resident to receive 0.5 mg of Ativan (an antianxiety medication) every eight hours as needed for anxiety.

Physician's orders, dated February 1, 2024, included orders for the resident to receive 1 mg/mL of lorazepam gel applied to the inner wrist topically every 12 hours as needed for anxiety/agitation, and physician's orders, dated February 14, 2024, included orders for the resident to receive 1 mg/mL of lorazepam gel applied to the inner wrist topically every six hours as needed for anxiety/agitation.

Resident 79's Medication Administration Records (MAR's) for December 2023 and January, February, and March 2024, revealed that staff administered "as needed" Ativan to the resident on December 25 at 6:35 p.m., December 27 at 12:39 p.m., January 23 at 6:03 p.m., January 24 at 4:38 p.m., and January 28 at 2:12 p.m., February 6 at 9:39 a.m., February 8 at 5:10 p.m., February 14 at 11:37 a.m., February 17 at 12:29 a.m. and 7:58 p.m., and February 24 at 11:18 a.m.

There was no documented evidence in Resident 79's clinical record regarding any non-medication interventions that were attempted prior to the administration of Ativan on the above days.

Interview with Licensed Practical Nurse 8 on March 7, 2024, at 1:07 p.m. confirmed that non-medication interventions were to be attempted prior to medicating residents and the interventions were to be documented.

Interview with the Nursing Home Administrator on March 7, 2024, at 1:38 p.m. confirmed that there was no documentation of any non-medication interventions prior to the administration of Ativan.

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



 Plan of Correction - To be completed: 04/17/2024

Resident 79 orders updated to include non-medication interventions for as needed Ativan.
Residents with as needed medications reviewed for documentation of non-medication interventions. Orders updated to include non-medication interventions
Licensed staff educated by Director of Nursing/ designee on documentation of non pharmalogical interventions prior to administering as needed medications.
Director of Nursing /designee will complete audits of non-pharmalogical interventions documentation weekly x 4 weeks, monthly x 2 months.
Results of audit findings will be reported to the Quality Assurance Performance Improvement Committee

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.25(g)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:


Based on a review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a tube feeding was administered in accordance with the facility's policy for one of 41 residents reviewed (Resident 122).

Findings include:

The facility's policy regarding enteral feeding (nutritional formula provided via a tube inserted into the stomach), dated October 6, 2023, indicated that nursing staff will check and document for residual volume prior to administering the feeding.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 122, dated January 25, 2024, indicated that the resident was cognitively intact, required minimal assistance from staff for all daily care needs, and had a feeding tube (a tube surgically implanted into the stomach for feeding).

Review of Resident 122's clinical record from January 18, 2024, through March 4, 2024, revealed that there was no documented evidence that gastric residuals were checked prior to administering tube feedings per policy.

Interview with the Registered Dietician on March 6, 2024, at 10:32 a.m. confirmed that there was no documented evidence that gastric residuals were checked prior to tube feedings for Resident 122 and should have been per the facility's policy.

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



 Plan of Correction - To be completed: 04/17/2024

Resident 122 orders updated to include checking residual prior to tube feeding administration.
Residents with tube feedings orders reviewed and updated to include checking residual.
Current Licensed staff, new hired licensed staff and agency staff will be educated by Director of Nursing/ designee on tube feeding policy and checking residual prior to administration and documenting residual amount.
Director of Nursing / designee will complete Audits of tube feeding orders and residual checks will be completed weekly x 4 weeks and monthly x 2 months.
Audits will be reviewed during Quality Assurance Committee meetings.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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.
§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify physician's orders for pain management for one of 41 residents reviewed (Resident 19).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.

Physician's orders for Resident 19, dated January 17, 2024, included an order for the resident to receive one 10-325 milligrams (mg) tablet of Norco (a narcotic pain medication) every six hours for moderate to severe pain (4-10) (on a scale of 0 to 10 where 10 is the worst pain). The order did not include instructions for the staff to give the Norco when the resident's pain rating was 0 to 3, and there was no documented evidence that the nursing staff attempted to clarify the orders with the resident's physician.

Resident 19's Medication Administration Records (MAR's) for February and March 2024 revealed the following:

Staff administered one 10-325 mg tablet of Norco for a pain rating of 0 at 12:00 a.m. on February 1, 2, 4, 5, 7, 9, 12, 13, 15, 17, 18, 20, 23-26, and March 2, 2024.

Staff administered one 10-325 mg tablet of Norco for a pain rating of 0 at 6:00 a.m. on February 1-5, 7, 8, 12-15, 17, 19, 23, 25, and 26, and March 1, 2, and 5, 2024.

Staff administered one 10-325 mg tablet of Norco for a pain rating of 0 at 12:00 p.m. on February 1-21, 23, and 25-29, and March 1, 2, 4-6, 2024.

Staff administered one 10-325 mg tablet of Norco for a pain rating of 0 at 6:00 p.m. on February 1-6, 9-20, 22, 24, 25, and 27-29, and March 1, 2, 4, and 5, 2024.

Staff administered one 10-325 mg tablet of Norco for a pain rating of 2 at 6:00 a.m. on February 6, 16, and 21, 2024.

Staff administered one 10-325 mg tablet of Norco for a pain rating of 2 at 6:00 p.m. on February 23, 2024.

Staff administered one 10-325 mg tablet of Norco for a pain rating of 3 at 6:00 a.m. on March 6, 2024.

An interview with the Registered Nurse/Staff Development/Nurse Aide Educator on March 7, 2024, at 8:53 a.m. confirmed that Resident 19's physician's orders for pain medications should have been clarified with the physician.

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





 Plan of Correction - To be completed: 04/17/2024

Resident 19 routine pain medications orders reviewed with Physician and updated on 3/22/2024.
Residents with routine pain meds with parameters reviewed with physicians and updated.
Current Licensed staff, new hired licensed staff and agency staff will be educated by Director of Nursing /designee regarding routine pain medication orders.
Audits of routine pain medication orders will be completed by Director of Nursing /designee weekly x 4 weeks, monthly x 2 months.
Results of audit findings will be reported to the Quality Assurance Performance Improvement Committee

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

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


Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for two of 41 residents reviewed (Residents 88, 115).

Findings include:

The facility's abuse policy, dated October 6, 2023, indicated that each resident had the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and exploitation.

A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 88, dated January 9, 2024, indicated that the resident was cognitively intact and required assistance from staff for all his care needs. Resident 88's care plan, dated December 21, 2023, indicated that the resident was dependent on staff for all activities of daily living.

Facility documents, undated, revealed that Nurse Aide 1 completed the nurse aide training program on December 22, 2023, and that he received education on abuse, resident rights, and resident psychosocial needs in the nurse aide class.

Facility investigation documents, dated February 2, 2024, revealed that Resident 88 reported that Nurse Aide 1 removed his call bell from his reach and told him to stop ringing so much.

A written statement from Nurse Aide 2, dated February 2, 2024, revealed that Nurse Aide 1 told her that Resident 88 rang his bell too much and that he told the resident he was not the only resident that needed care and that he removed his call bell from his reach.

A written statement from Licensed Practical Nurse 3, dated February 2, 2024, revealed that Nurse Aide 1 was complaining about Resident 88 ringing his call bell too much and that she asked Nurse Aide 2 to care for the resident instead.

A review of Nurse Aide 1's time card revealed that he worked a double shift from 3:00 p.m. on Feburary 1, 2024, until 7:00 a.m. on February 2, 2024 and that he was not immediately removed from his shift when Nurse Aide 2 and Licensed Practical Nurse 3 were made aware that he removed the call bell from Resident 88 and told him not to ring any more for the night shift.

Interview with Resident 88 on March 7, 2024, at 4:00 p.m. revealed that he used his call bell for care because he is totally dependent on staff for all of his care needs.

Interview with the the Nursing Home Administrator and the Director of Nursing on March 7, 2024, at 4:00 p.m. confirmed that Nurse Aide 1 should never have removed Resident 88's call bell from his reach and told him not to ring his call bell for assistance. The Nursing Home Administrator stated that Nurse Aide 1 should have been removed from duty when staff were made aware that he removed the call bell from Resident 88 and told the resident not to ring anymore that night; however, the licensed practical nurse did not report the allegation of abuse against Nurse Aide 1 immediately to her supervisor as she should have done.

A comprehensive MDS for Resident 115, dated November 29, 2023, indicated that the resident was cognitively intact and required assistance from staff for all his care needs. Resident 115's care plan, dated November 24, 2023, indicated that the resident was dependent on staff for all activities of daily living.

Facility documents, undated, revealed that Nurse Aide 4 completed the nurse aide education class on October 27, 2023, and that she received education on abuse, resident rights, and resident psychosocial needs in the class.

Facility investigation documents, dated January 22, 2024, revealed that Resident 115 reported that Nurse Aide 4 withheld Resident 115's urinal from him and told him to urinate on himself, made fun of him for having lit himself on fire, and told him he needed tough love, causing Resident 115 to urinate on the floor.

A written statement from Nurse Aide 5, dated January 21, 2024, revealed that Nurse Aide 4 stated she was not going to deliver the lunch tray to or feed Resident 115 because she told him she was not going to hold his f*cking urinal, that he could call his mother to hold it for him.

A written statement from Social Services Director, dated January 22, 2024, revealed that Resident 115 asked Nurse Aide 4 for his urinal and that she refused to get it for him and she told him he could urinate on himself. Resident 115 stated that Nurse Aide 4 told him that he was incontinent just to get her into trouble.

A review of Nurse Aide 4's time card revealed that she worked the entire shift on January 21, 2024, and that she was not removed from duty when staff were made aware of Resident 115's allegations that she had refused to provide care for him and insulted him.

Interview with the Nursing Home Administrator and the Director of Nursing on March 7, 2024, at 4:00 p.m. confirmed that Nurse Aide 4 should not have refused to care for Resident 115. The Nursing Home Administrator stated that she should have been removed from duty when staff were made aware of the allegations at lunch time; however, the Director of Nursing had not arrived at the building until the end of Nurse Aide 4's shift and therefore she was not immediately removed from care.

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

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

28 Pa. Code 201.29(a)(j) Resident Rights.

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




 Plan of Correction - To be completed: 04/17/2024

Resident 88 was interviewed by social worker. Resident reported no ill effects. No concerns reported from incident.
Resident 115 was interviewed by social worker regarding incident. No concerns identified.

Residents on nursing units were interviewed at time of investigation.
All staff educated by Director of Nursing/ designee on abuse and neglect policy, reporting abuse and immediate action required when accusations occur.
Director of Nursing / designee will review documentation and concern forms for allegations of abuse /neglect weekly x 4 weeks, monthly x 2 months.
Results of audit findings will be reported to the Quality Assurance Performance Improvement Committee.


483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow its abuse policy regarding the immediate release of an involved staff member from their duty pending a full investigation, to protect the resident/victim for two of 41 residents reviewed (Residents 88, 115) and to implement its abuse prohibition policies regarding verifying new employees' standing with the Pennsylvania Nurse Aide Registry or the State Board of Nursing for two of five new employees reviewed (Nurse Aide 11, Registered Nurse 12).

Findings include:

The facility's policy regarding abuse, dated October 6, 2023, indicated that every complaint or allegation of resident abuse or neglect shall be promptly reported to the immediate supervisor of the area, and the Nursing Home Administrator and/or his/her designee. Each report shall be treated promptly and with discretion, with the following priorities of concern: protection of the person and rights of the resident (alleged victim); compliance with pertinent laws and regulations; protection of the rights of the alleged abuser, whether employee, contractor, volunteer, visitor, another resident or other individual; maintenance of order and smooth operation of the facility.

A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 88, dated January 9, 2024, indicated that the resident was cognitively intact and required assistance from staff for all his care needs. Resident 88's care plan, dated December 21, 2023, indicated that the resident was dependent on staff for all activities of daily living.

Facility investigation documents, dated February 2, 2024, revealed that Resident 88 reported that Nurse Aide 1 removed his call bell from his reach and told him to stop ringing so much.

A written statement from Nurse Aide 2, dated February 2, 2024, revealed that Nurse Aide 1 told her that Resident 88 rang his bell too much and that he told the resident he was not the only resident that needed care and that he removed his call bell from his reach.

A written statement from Licensed Practical Nurse 3, dated February 2, 2024, revealed that Nurse Aide 1 was complaining about Resident 88 ringing his call bell too much and that she asked Nurse Aide 2 to care for the resident instead.

A review of Nurse Aide 1's time card revealed that he worked a double shift from 3:00 p.m. on Feburary 1, 2024, until 7:00 a.m. on February 2, 2024, and that he was not immediately removed from his shift when Nurse Aide 2 and Licensed Practical Nurse 3 were made aware that Nurse Aide 1 removed the call bell from Resident 88 and told him not to ring any more for the night shift.

Interview with Resident 88 on March 7, 2024, at 4:00 p.m. revealed that he used his call bell for care because he is totally dependent on staff for all of his care needs.

Interview with the Nursing Home Administrator and the Director of Nursing on March 7, 2024, at 4:00 p.m. confirmed that Nurse Aide 1 was not immediately removed from his duty the night of the allegation and that he should have been.


A comprehensive MDS for Resident 115, dated November 29, 2023, indicated that the resident was cognitively intact and required assistance from staff for all his care needs. Resident 115's care plan, dated November 24, 2023, indicated that the resident was dependent on staff for all activities of daily living.

Facility documents, undated, revealed that Nurse Aide 4 completed the nurse aide education class on October 27, 2023, and that she received education on abuse, resident rights, and resident psychosocial needs in the class.

Facility investigation documents, dated January 22, 2024, revealed that Resident 115 reported that Nurse Aide 4 withheld the use of Resident 115's urinal from him, that she told him to urinate himself, made fun of him for having lit himself on fire, and told him he needed tough love, causing Resident 115 to urinate on the floor.

A written statement from Nurse Aide 5, dated January 21, 2024, revealed that Nurse Aide 4 stated she was not going to deliver the lunch tray to or feed Resident 115 because she told him she was not going to hold his f*cking urinal, that he could call his mother to hold it for him.

A written statement from Social Services Director, dated January 22, 2024, revealed that Resident 115 asked Nurse Aide 4 for his urinal and that she refused to get it for him and she told him he could urinate himself. Resident 115 stated that Nurse Aide 4 told him that he was incontinent just to get her into trouble.

A review of Nurse Aide 4's time card revealed that she worked the entire shift on January 21, 2024, and that she was not removed from duty when staff were made aware of Resident 115's allegations that she had refused to provide care for him and insulted him.

Interview with the Nursing Home Administrator and the Director of Nursing on March 7, 2024, at 4:00 p.m. confirmed that Nurse Aide 4 should not have refused to care for Resident 115. The Nursing Home Administrator stated that she should have been removed from duty when staff were made aware of the allegations at lunch time; however, the Director of Nursing had not arrived at the building until the end of Nurse Aide 4's shift and therefore she was not removed from care immediately.


The facility's policy regarding abuse prohibition, dated October 6, 2023, indicated that the facility would check the nurse aide registry for enrollment and state licensure agency for verification prior to employment.

The personnel file for Nurse Aide 11 revealed that she was hired on November 7, 2023; however, her enrollment on the Pennsylvania Nurse Aide Registry was not verified until March 5, 2024, which was 119 days after being hired.

The personnel file for Registered Nurse 12 revealed that she was hired on January 3, 2024; however, there was no documented evidence that her professional license was verified with the State Board of Nursing until March 5, 2024, which was 62 days after being hired.

Interview with the Human Resources Director on March 6, 2024, at 2:30 p.m. confirmed that there was no documented evidence that Nurse Aide 11's enrollment in the nurse aide registry and Registered Nurse 12's licensure were verified prior to employment.

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


 Plan of Correction - To be completed: 04/17/2024

Resident 88 and Resident 115 were assessed for any ill effects by social worker.
Residents on the nursing unit were interviewed during investigation.
Employee Nurse Aide 11 and registered nurse 12 license verified on 3/6/2024.
Human Resources to utilize pre hire check list for license verification.
Director of Human resources completed audit of last 3 months of new hires for verification of license / certification.
Nursing Home Administrator educated Human Resource Director on license / certification verification prior to start date.
Audits of new hires verification will be completed by HR director weekly x 4 weeks, monthly x 2 months.
All staff educated by Director of Nursing/ designee on abuse and neglect policy, reporting abuse and immediate suspension of alleged staff.
All Alleged Perpetrators will be placed on immediate suspension pending an investigation.
Abuse Policy Education will be done with all facility and agency staff, completed by director of nursing / designee.


483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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)(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 clinical record reviews and staff interviews, it was determined that the facility failed to revise resident care plans with individualized interventions to address their care needs for one of 41 residents reviewed (Resident 49).

Findings include:

A facility policy for pacemakers (a small, battery-powered device that prevents the heart from beating too slowly), dated October 6, 2023, revealed that the facility will place the physician's orders for pacemaker monitoring on the resident's care plan.

An admissions Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 49, dated February 19, 2024, revealed that the resident was understood and could understand others, was cognitively intact, required maximum assistance with dressing and toilet use, and had diagnoses of coronary artery disease and heart failure.

The current care plan for Resident 49 revealed that he had a pacemaker; however, there was no documented evidence of an appointment for pacemaker monitoring.

Interview with the Registered Nurse Assessment Coordinator (a nurse who monitors and evaluates resident care to ensure the appropriate execution of prescribed care plans) on March 7, 2024, at 9:05 a.m. confirmed that the care plan should have been updated to reflect resident-specific information for his pacemaker.

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

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





 Plan of Correction - To be completed: 04/17/2024

Resident 49 care plan was updated to include pacemaker care on 3/21/2024.
Director of Nursing /designee will complete an audit of current residents with pacemaker orders for accuracy of care plans.
Current Licensed staff, new hired licensed staff and agency staff interdisciplinary team and will be educated by Director of Nursing /designee on developing and updating resident's care plans to include pacemakers.
Director of Nursing /designee will complete random audits of residents on pacemaker for care plan accuracy weekly x 4 weeks and monthly x 2 months.
Results of audit findings will be reported to the Quality Assurance Performance Improvement Committee.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide medications as ordered by the physician for one of 41 residents reviewed (Resident 107).

Findings include:

Physician's orders for Resident 107, dated December 14, 2023, included an order for the resident to receive 10 milligrams (mg) of Oxycodone HCL every six hours as needed for pain. However, the resident's Medication Administration Record (MAR) for January 2024 revealed that the resident was administered 5 mg Oxycodone on January 17 and January 20, 2024, and not the 10 mg that was ordered.

Interview with Registered Nurse 6 on March 7, 2024, at 2:43 p.m. confirmed that Resident 107 only received 5 mg of Oxycodone on January 17 and 20, 2024, and not the 10 mg he was ordered.

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




 Plan of Correction - To be completed: 04/17/2024

Resident 107 no longer resides in facility
Facility completed medication error report.
Licensed staff educated by director of nursing/designee on five rights of medication administration.
Director of Nursing / designee completed audit of last 14 pain medication administration for accuracy of administration. Discrepancies were reported to physician
Current Licensed staff, new hired licensed staff and agency staff will be educated by Director of Nursing / designee on pain medication administration and following physician's orders
Director of Nursing / designee will audit pain medication administration weekly x 4 weeks and monthly x 2 months
Results of audit findings will be reported to the Quality Assurance Performance Improvement Committee.


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 clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that fall prevention interventions were in place as ordered and care planned for one of 41 residents reviewed (Resident 19).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated December 5, 2023, revealed that the resident was understood, could understand, had a diagnosis which included a cerebral vascular accident (CVA - commonly known as a stroke), and had two or more falls with no injuries since his admission to the facility. A care plan for the resident, dated December 5, 2023, revealed that the resident was at risk for falls and that the resident was to have bilateral fall mats.

Physician's orders for Resident 19, dated November 28, 2023, included an order for the resident to have bilateral fall mats.

Nursing notes for Resident 19, dated December 4, 2023, and January 1, 2, 6, 7, and 8, 2024, revealed that staff entered the resident's room and found the resident out of bed on the fall mat.

Observations of Resident 19 on March 4, 2024, at 11:03 a.m., 12:02 p.m., and 12:06 p.m. revealed that the resident was lying in bed and a fall mat was placed on the floor on the right side of the bed toward the window. There was no fall mat on the floor on the left side of the resident's bed toward the door.

Interview with Agency Nurse Aide 7 on March 4, 2024, at 12:06 p.m. confirmed that Resident 19's fall mat was placed on the right side of the resident's bed toward the wall and not on the left side toward the door.

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





 Plan of Correction - To be completed: 04/17/2024

Resident 19 fall mat placed next to bed when notified on March 4, 2024
Residents with fall mats assessed to ensure mats in place when in bed.
Current Nursing staff, new hired nursing staff and agency staff will be educated by Director of Nursing / designee on ensuring ordered and care planned safety interventions are in place when residents in bed.
Director of Nursing /designee will audit placement of fall mats weekly x 4 weeks and monthly x 2 months.
Results of audit findings will be reported to the Quality Assurance Performance Improvement Committee.

483.25(n)(1)-(4) REQUIREMENT Bedrails: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(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

§483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

§483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

§483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

§483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.
Observations:


Based on observations and clinical record reviews, as well as staff interviews, it was determined that the facility failed to complete a safety assessment for one of 41 residents reviewed (Resident 49) who used top side rails for mobility.

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 49, dated February 19, 2024, revealed that the resident was understood and could understand, and had a diagnosis of arthritis (inflammation or swelling of one or more joints).

Observations of Resident 49 lying in his bed on March 6, 2024, at 10:06 a.m. revealed that the bed had bilateral top side rails.

A review of Resident 49's clinical record revealed no documented evidence that a side rail safety assessment had been conducted prior to the use of bilateral top side rails for mobility purposes.

An interview with Nursing Home Administrator on March 7, 2024, at 11:04 a.m. confirmed that a side rail safety assessment was not completed for Resident 49 and should have been.

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



 Plan of Correction - To be completed: 04/17/2024

Resident 49 bed rails assessed and bed safety assessment completed on 3/6/2024.
Residents with bed rails bed safety assessments reviewed and updated by Director of nursing / designee. Side rails will be assessed quarterly and with any bed modifications.
Current Licensed staff, new hired licensed staff and agency staff will be educated by Director of Nursing /designee on bed safety and completion of assessments when bed rails applied quarterly and with bed modification
Director of nursing /designee will complete audits for new bed rails and assessments weekly x 4 weeks and monthly x 2 months
Results of audit findings will be reported to the Quality Assurance Performance Improvement Committee.


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

§483.45(h) Storage of Drugs and Biologicals

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

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


Based on clinical record reviews, review of pharmacy labels for medications, and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled for one of 41 residents reviewed (Resident 107).

Findings include:

Physician's orders for Resident 107, dated December 14, 2023, included an order for the resident to receive 10 milligrams (mg) of Oxycodone HCL (narcotic pain medication) every six hours as needed for pain. Review of the label on Resident 107's pill card of Oxycodone revealed that the card contained 5 mg tablets and the resident was to receive only one tablet every six hours as needed for pain.

Interview with Registered Nurse 6 on March 7, 2024, at 2:43 p.m. confirmed that Resident 107's current physician's order for Oxycodone did not match the label on the card of Oxycodone and it should have.

28 Pa. Code 211.9(h) Pharmacy Services.



 Plan of Correction - To be completed: 04/17/2024

Resident 107 pain medication label reviewed with pharmacy and updated on 3/25/2024.
Residents with pain medications labels reviewed by director of nursing/ designee for accuracy with current medication order.
Current Licensed staff, new hired licensed staff and agency staff will be educated by Director of Nursing /designee on accuracy of medication label compared to medication administration record
Audits will be completed by director of Nursing/designee for labeling of medications weekly x 4 and monthly x 2.
Results of audit findings will be reported to the Quality Assurance Performance Improvement Committee

§ 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 schedules, staffing information provided by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 12 residents on the day shift for one of 21 days.

Findings Include:

Review of facility census data indicated that on January 1, 2024, the facility census was 115, which required 9.58 (115 residents divided by 12) NA's during the evening shift. Review of the nursing time schedules revealed 8.00 NA's provided care on the evening shift on January 1, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on January 2, 2024, the facility census was 117, which required 9.75 NA's during the evening shift. Review of the nursing time schedules revealed 9.44 NA's provided care on the evening shift on January 2, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on January 6, 2024, the facility census was 120, which required 10.00 NA's during the day shift. Review of the nursing time schedules revealed 8.16 NA's provided care on the day shift on January 6, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 4, 2024, the facility census was 117, which required 9.75 NA's during the evening shift. Review of the nursing time schedules revealed 9.72 NA's provided care on the evening shift on February 4, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 5, 2024, the facility census was 116, which required 9.67 NA's during the evening shift. Review of the nursing time schedules revealed 8.69 NA's provided care on the evening shift on February 5, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 7, 2024, the facility census was 118, which required 9.83 NA's during the evening shift. Review of the nursing time schedules revealed 9.06 NA's provided care on the evening shift on February 7, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 9, 2024, the facility census was 120, which required 6.00 NA's during the night shift. Review of the nursing time schedules revealed 5.75 NA's provided care on the night shift on February 9, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 29, 2024, the facility census was 127, which required 10.58 NA's during the evening shift. Review of the nursing time schedules revealed 10.44 NA's provided care on the evening shift on February 29, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 1, 2024, the facility census was 127, which required 10.58 NA's during the day shift. Review of the nursing time schedules revealed 10.41 NA's provided care on the day shift on March 1, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 2, 2024, the facility census was 126, which required 10.50 NA's during the day shift and 10.50 NA's during the evening shift. Review of the nursing time schedules revealed 9.75 NA's provided care on the day shift and 10.13 NA's provided care on the evening shift on March 2, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 4, 2024, the facility census was 122, which required 6.10 NA's during the night shift. Review of the nursing time schedules revealed 5.78 NA's provided care on the night shift on March 4, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 6, 2024, the facility census was 125, which required 10.42 NA's during the evening shift. Review of the nursing time schedules revealed 10.31 NA's provided care on the evening shift on March 6, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Interview with the Nursing Home Administrator on March 7, 2024, at 2:57 p.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the day listed above and that all of the staffing hours were provided.






 Plan of Correction - To be completed: 04/17/2024

The Administrator, Director of Nursing, Scheduler and Human Resource Director will be educated on the state requirement for nursing hours including the Certified Nurse Assistants to resident ratios by the Quality Clinical Consultant/designee.
Staffing meetings will be held 5 days a week to review the Certified Nurse assistant ratio from the previous day and the projected Certified Nurse Assistant ratio for the current day, as well as the upcoming week to ensure appropriate staffing levels by the Nursing Home Administrator/ designee.
If projected staffing ratios do not meet minimum, then the facility will reach out to current staff and local staffing agencies to enlist to meet the minimum requirement. Facility will continue to recruit staff through all platforms.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:


Based on a review of nursing schedules, staffing information provided by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 40 residents on the overnight shift for one of 21 days (24-hour periods) reviewed.

Findings Include:

Review of facility census data indicated that on December 31, 2023, the facility census was 116, which required 3.87 LPN's during the evening shift and 2.90 LPN's during the night shift. Review of the nursing time schedules revealed 3.69 LPN's provided care on the evening shift on December 31, 2023, and 2.59 LPN's provided care on the night shift on December 31, 2023. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on January 3, 2024, the facility census was 118, which required 4.72 LPN's during the day shift. Review of the nursing time schedules revealed 4.69 LPN's provided care on the day shift on January 3, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on January 4, 2024, the facility census was 117, which required 4.68 LPN's during the day shift and 2.93 LPN's during the night shift. Review of the nursing time schedules revealed 4.53 LPN's provided care on the day shift on January 4, 2024, and 2.47 LPN's provided care on the night shift on January 4, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 7, 2024, the facility census was 118, which required 2.95 LPN's during the night shift. Review of the nursing time schedules revealed 2.75 LPN's provided care on the night shift on February 7, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 9, 2024, the facility census was 120, which required 3.00 LPN's during the night shift. Review of the nursing time schedules revealed 2.63 LPN's provided care on the night shift on February 9, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 1, 2024, the facility census was 127, which required 3.18 LPN's during the night shift. Review of the nursing time schedules revealed 3.00 LPN's provided care on the night shift on March 1, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Interview with the Nursing Home Administrator on March 7, 2024, at 2:57 p.m. confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the day listed above and that all of the staffing hours were provided.





 Plan of Correction - To be completed: 04/17/2024

The Administrator, Director of Nursing, Scheduler and Human Resource Director will be educated on the state requirement for nursing hours including the Licensed practical nurses to resident ratios by the Quality Clinical Consultant/designee.
Staffing meetings will be held 5 days a week to review the Licensed Practical nurse ratio from the previous day and the projected Licensed Practical nurse ration for the current day, as well as the upcoming week to ensure appropriate staffing levels by the Nursing Home Administrator/ designee.
If projected staffing ratios do not meet minimum then the facility will reach out to current staff and local staffing agencies to enlist to meet the minimum requirement. Facility will continue to recruit staff through all platforms.


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