Pennsylvania Department of Health
ACCELERATE SKILLED NURSING AND REHABILITATION PHILADELPHIA
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ACCELERATE SKILLED NURSING AND REHABILITATION PHILADELPHIA
Inspection Results For:

There are 193 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.


ACCELERATE SKILLED NURSING AND REHABILITATION PHILADELPHIA - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to three complaints, completed on February 28, 2024, it was determined that Accelerate Skilled Nursing and Rehabilitation Phila, was not in compliance with the 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 related to the health portion of the survey process.

Plan of Correction:

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.80 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 observations, interview with staff and review of facility provided documentation, it was determined that the facility did not provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections related to hand hygiene and maintaining an effective prevention program related to infection surveillance. (Unit 3, 3rd floor). The facility failed to conduct an infection control surveillance for identifying, tracking and monitoring and or reporting infections, communicable diseases and outbreak among residents.

Findings include:

During medication administration observation on February 26, 2024 at 9:30 a.m. observed licensed nurse, employee E11, put on gloves prior to preparing medications; E11 proceeded to check residents vital signs and administered medications with gloves on, without hand hygiene before or after procedure. E11 did not disinfect blood pressure cuff after direct contact with resident.

Review of facility infection control documentation conducted on February 27, 2024 at 10:22 a.m. with outgoing Infection preventionist Employee E15 and newly hired infection preventionist Employee E16 revealed that there was no infection control surveillance for identifying, tracking and monitoring and or reporting infections, communicable diseases and outbreak among residents from May 2023 to November 2023.

Further review of facility infection control documentation revealed that there were no documented evidence of any infection control program being implemented from May 2023 to June 2023. Further, there was no documented evidence the an infection control meetings were conducted from May 2023 to September 2023.

Interview with infection control preventionist, Employee E1, confirmed that they have not done any documentation tracking until December 2023.

28 Pa Code 201.14(a) Responsibility of licensee

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

28 Pa Code 211.12(d)(2)Nursing services

Plan of Correction - To be completed: 04/22/2024

1. No residents were named or shown to have harm from practices identified.
2. All residents have the potential to be impacted by infection control practices.
3. DON/ADON or Designee to re-educate staff nurse educator and Infection Prevention nurse on surveillance for identifying, tracking and monitoring and or reporting infections, communicable diseases and outbreak among residents. In addition, the re-education will also be on documentation of infection control meetings as scheduled. All licensed nurses will be re-educated on hand hygiene by April 22,2024 .
4. The DON/ADON will audit hand hygiene and infection control surveillance weekly x 3 then monthly x 3. Results of the audits will be presented and discussed at the facility QAPI monthly meeting for further review.

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime:

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(f) Frequency of Meals
§483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

§483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

§483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.

Observations:

Based on resident council interview, staff interviews, and review of the established mealtime schedule, it was determined that the facility failed to ensure a nourishing snack was provided when 14 hours are between a substantial evening meal and breakfast on four of four nursing units. (2nd floor, 3rd floor, 4th floor, and 5th floor).

Findings include:

A review of the established meal schedule for the residents revealed the following scheduled mealtimes: On 2nd floor, breakfast is served at 9:00 a.m. and dinner is served at 5:30 p.m. On 3rd floor, breakfast is served at 8:45 a.m. and dinner is served at 5:15 p.m. On 4th floor, breakfast is served at 9:15 a.m. and dinner is served at 5:45 p.m. On 5th floor, breakfast is served at 8:15 a.m. and dinner is served at 4:45 p.m. The above schedule indicates an elapsed time between dinner and breakfast of 15 hours and 30 minutes.

An interview conducted on February 27, 2024, at 10:37 a.m. during the resident council with nine alert and oriented residents, residents R5, R6, R7, R25, R26, R60, R61, R75, and R299, revealed that snack provided at bedtime included "sugar cookies", "crackers", and "coffee cakes".

Employee E1, the Nursing Home Administrator, was made aware of the above findings on February 27, 2024, at 2:26 p.m.

There was no documented evidence that the facility offered bedtime snacks that were substantial and nourishing.

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

Plan of Correction - To be completed: 04/22/2024

1. R5, R6, R7, R25, R26, R60 and R61 unable to be retroactively correct. R75 and R299 no longer reside in the facility.
2. All residents in the facility have potential to be affected by the frequency of meals or snacks at bedtime, currently none have been noted.
3. The Administrator shall re-educate Dietary and Nursing staff on providing a nourishing snack when 14 hours are between a substantial evening meal and breakfast by April 22, 2024.
4. The DON/ADON and/or Food Director (E12) will audit the snacks provided to ensure it is a nourishing snack weekly x 3 then monthly x 3 until. Results of the audits will be presented and discussed at the facility QAPI monthly meeting for further review.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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

§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:

Based on interview with residents and staff and review of facility documentation, it was determined that facility did not ensure residents were treated with dignity and care in a manner and in an environment that promotes the enhancement of their quality of life related to fresh air breaks for nine of 24 residents reviewed (Resident R17, R26, R61, R5, R7, R75, R299, R25, R6)

Findings include:

An interview with Resident R17 on February 23, 2024 at 10:45 am, on 3rd floor unit, revealed that the only time he has fresh air is when he is "rushed out to the hospital," and "no activities here.."

An interview with Resident R26 on February 23, 2024 at 11:00 am, on 3rd floor unit, revealed that "the last time I was outside for fresh air was when I was transferred for dermatology appointment, on January 30th,.." and "I don't think they have enough staff to assist with activities.."

An interview with facility's activities director, employee E13, on February 23, 2024, at 2:00 p.m., revealed that residents are assisted for fresh air breaks on 5th floor patio upon request and/or during physical therapy.

Review of facility provided activities schedule for February 2024 revealed the following activities for February 23, 2024: 10 am - morning stretch, 11 am book mobile, 1:30 pm food committee 3rd floor, 2:00 pm resident council 3rd floor.

February 24, 2024 and February 25, 2024 had only two activities for whole day; 10 am room to room visit and 2pm bingo.

Review of daily activities schedules for the rest of month of February 2024 revealed at most three activities for each day, excluding fresh air brakes, and including 'snack' as part of activities.

During the resident council group meeting that was held on February 27, 2024, at 10:37 a.m. with seven alert and oriented Residents (R61, R5, R7, R75, R299, R25, R6) reported that they were not offered fresh air brakes and were not aware that it was available to them. All resident desire to have fresh break times.

28 Pa. Code 201.29(d) Resident rights

Plan of Correction - To be completed: 04/22/2024

1. R17, R26, R61, R5, R7, R75, R25 and R6 remain in the facility and will be offered to go outside for fresh air. R75 and R299 are not in the facility.
2. All residents have the potential to be affected by not having enough activities such as going outside for fresh air upon request.
3. An initial audit identified residents that would like to go outside for fresh air during activities and therapy, if weather permits. Activities Director (E13) or Assistants to offer and take residents outside upon request to take fresh air breaks on the 5th floor patio, to ensure residents are treated with dignity and care in a manner and in an environment that promotes the enhancement of their quality of life. Guest Services Director to re-educate the Activities Director and staff on offering residents to go outside for fresh air by April 22, 2024.
4. Activities Director or Guest Services Director will conduct audits of residents requesting to go outside weekly X 3 then monthly X 3. Findings of the audits will be reported to the QAPI committee monthly to ensure compliance is maintained.

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

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

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

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

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

Observations:

Based on observation, facility policy review, and staff interview, it was determined that the facility failed to provide residents access to grievance information on three out of four nursing units. (2nd, 3rd, 5th Nursing Floor Units).

Findings include:

On March 29, 2023, at 12:36 an interview was held with Resident R150 reported that he's not aware how to report grievance and desires to speak to a Grievance officer.

An interview and observation on February 28, 2024, at 11:56 a.m., the Grievance Officer Employee, E7, it was revealed that the facility failed to display the contact information of independent entities where grievances could be filed, such as the State Survey Agency on 2nd, 3rd, 5th Nursing Floor Units. The poster containing the State Long-Term Care Ombudsman phone number was not positioned at wheelchair-accessible eye level but instead, it was placed at a height suitable for standing individuals.

During the resident council group meeting that was held on February 27, 2024, at 10:37 a.m. with 7 alert and oriented Residents (R61, R5, R7, R75, R299, R25, R6) reported that they were not aware of the State Survey Agency phone number and wanted to have this contact information.

28 Pa. Code 201.18(b)(2) Management

28 Pa. Code 201.29(a)(i) Resident rights

Plan of Correction - To be completed: 04/22/2024

1. R150 no longer remains in the facility and cannot be retroactively corrected.
2. All residents have the potential to be affected and will be provided information on who to contact and how to report and file a grievance.
3. All staff will be re-educated by the Grievance Officer and/or Social Worker Specialist on how to provide residents access to grievance information and who the dedicated grievance officer is. Education to be completed by April 22, 2024. On 3/19/24 the Grievance Officer updated the information on all units to ensure the State LTC poster is repositioned at wheel-chair accessible eye level.
4. The Grievance Officer and/or Social Worker Specialist will conduct audits of all new admissions weekly x 3 weeks then monthly X3 to ensure they are receiving Grievance information and that the information is visible on all units. Findings of the audits will be reported to the QAPI committee monthly to ensure compliance is maintained.

483.20(k)(1)-(3) REQUIREMENT PASARR Screening for MD & ID:

§483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability.

§483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with:
(i) Mental disorder as defined in paragraph (k)(3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission,
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
(B) If the individual requires such level of services, whether the individual requires specialized services; or
(ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission-
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
(B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability.

§483.20(k)(2) Exceptions. For purposes of this section-
(i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital.
(ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual-
(A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital,
(B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and
(C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services.

§483.20(k)(3) Definition. For purposes of this section-
(i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1).
(ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b)(3) or is a person with a related condition as described in 435.1010 of this chapter.

Observations:

Based on clinical record review and staff interviews, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for one of three residents reviewed related to PASRR assessments (Resident R77).

Findings include:

The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability.

The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A Level II PASRR evaluation must be completed if the Level I PASRR determined that the person is a targeted person with mental illness or an intellectual disability. The Level II PASRR would determine if placement or continued stay in the requested or current nursing facility is appropriate.

Review of Resident R77's Admission MDS (Minimum Data Set - a mandatory periodic assessment of resident needs) dated December 19, 2023, revealed that the resident was admitted to the facility on December 13, 2023, and had a diagnosis of schizophrenia (mental illness associated with loss of reality contact, delusions, and hallucinations).

Review of Resident R77's PASRR Level I assessment, dated December 12, 2023, revealed that the resident had serious mental illness, with a diagnosis of bipolar disorder (a condition characterized by extreme mood swings which can include extreme excitement episodes or extreme depressive feelings) and that as a result her current residence was a Long Term Structured Residence (LTSR, defined by the PASRR as "a highly structured therapeutic residential mental health treatment facility designed to treat persons ...who are eligible for hospitalization but who can receive adequate care in an LTSR").

Continued review of the assessment revealed that the resident met the criteria to have a Level II PASRR evaluation completed, however, the resident was marked as an exempted hospital discharge because she was expected to remain in the facility for less than 30 days. The form further indicated that if the resident will be in the facility for more than the allotted days, that a Level II evaluation must be done on or before the 40th day from admission.

Continued review of the clinical record revealed that there was no indication in the record that a Level II PASRR evaluation had been completed for Resident R77.

In an interview on February 28, 2024, at 11:45 a.m., licensed Social Worker, Employee E6, confirmed that a request for a Level II PASRR evaluation was not completed for resident R77 until February 27, 2024, 76 days after the resident's admission to the facility.

28 Pa. Code 201.8(b)(1) Management

28 Pa. Code 201.8(e)(1) Management

Plan of Correction - To be completed: 04/22/2024

1. R77 still remains in the facility and the Level II PASRR was completed on 2/27/24.
2. Residents whose PASRR was determined that the person with mental illness or an intellectual disability can potentially be impacted, if placement or continued stay in the requested or current nursing facility is appropriate and evaluated and must be done on or before the 40th day from admission.
3. The Social Services Director will educate Social Services staff on completion of PASRR Level II, if appropriate for a resident by April 22, 2024.
4. The Social Service Director and/or Social Worker Specialist will conduct an initial audit to ensure all residents who require a PASRR have a completed PASRR in their chart. Social Service Director and/or Social Worker Specialist will conduct audits of all new admissions for completion of PASRR Level I and II weekly X 3 then monthly X 3. Findings of the audits will be reported to the QAPI committee monthly to ensure compliance is maintained.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§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 did not complete a comprehensive care plan for one of 24 residents reviewed (Resident R55).

Findings include:

Review of Resident R55's clinical record revealed that the resident was admitted to the facility on December 15, 2023 with the diagnoses of spastic hemiplegia affecting the left nondominant side (refers to a condition characterized by muscle stiffness or spasticity and paralysis or weakness on the left side of the body, particularly in individuals for whom the left side is not the dominant side), chronic respiratory failure and congenital malformations of trachea.

Review of Resident R55's physician orders revealed an order dated December 15, 2023, for "Type of trach shilly size of trach #4 (spare trach kept at bedside) and ambu bag at bedside."

Observation conducted on February 23, 2024, at 1:12 p.m., revealed that Resident R55 had a trach in place.

Review of Resident R55's care plan dated February 28, 2024, at 10:49 a.m., revealed that there were no focus, interventions, and outcomes (goals) care planned for trach care.

On February 28, 2024, at 10:49 a.m. interview with Employee E5, a Licensed Nurse and unit manager, confirmed the above findings.

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

Plan of Correction - To be completed: 04/22/2024

1. R55 continues to reside in the facility and a comprehensive care plan was completed on 2/28/24 with focus, goal and interventions for trach care plan.
2. All residents with a comprehensive care plan for trach care will be reviewed by the ADON/DON and/or Nurse Educator immediately as they have the potential to be impacted. The care plans will be updated as necessary.
3. The nurse educator and ADON will re-educate licensed nurses on comprehensive care planning for trach care by April 22, 2024.
4. Nurse Educator and ADON will conduct an initial audit of all residents receiving trach care to ensure a comprehensive care plan including trach care and needs is in place. Nurse Educator, ADON and/or DON will conduct audits weekly X 3 then monthly X 3 to ensure comprehensive care plans for trach care and needs are in place. Findings of the audits will be reported to the QAPI committee monthly to ensure compliance is obtained and maintained.

483.25 REQUIREMENT Quality of Care:

§ 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 review of clinical records and interviews with residents and staff, it was determined that the facility did not ensure that residents receive treatment and medications in accordance to physician orders related to tube grips and medication via tube feeding for two of 24 residents reviewed (Resident R26 and Resident 47).

Findings include:

Review of Resident R26's clinical records revealed diagnosis of type 2 diabetes mellitus with hyperglycemia, morbid obesity, venous insufficiency, chronic pain, lymphedema, abnormalities of gait and mobility, repeated falls and difficulty walking.

Review of R26's consult completed on January 30, 2024 by nurse practitioner, Employee E30 and medical director, Employee E29 for "lower leg discoloration and painful nodules," with following findings: multiple tender nodules of the lower legs, bound down skin of ankles and dyspigmentation. Some areas of scale. Palpable pedal pulses."
Diagnosis of " phlebolith (small local, usually rounded calcification within a vein), stasis dermatitis (skin inflammation in the lower legs caused by fluid build up," and lipodermatosclerosis (chronic inflammatory disorder of lower extremities). Resident R26 had the following recommendations: "Tubigrip F applied today. Wear as much as tolerated during day, okay to remove at night. Stockings are washable."

Review of Resident R26's progress notes from January 30, 2024 at 5:45 p.m. revealed "patient returned from his appointment at 1740 (5:40 p.m.) with new order. N.O. (new order) Tubigrip F to wear as much as tolerated during the day, ok to remove at night."

Interview with Resident R26 on February 23, 2024 at 11:00 a.m. revealed that the resident had an appointment with a dermatologist on January 30, 2023, with new order for tubi grips to be worn during day. Resident R26 stated that he had an incontinence incident on February 3, 2024 during which tubigrips were soiled and were discarded.

Interview with Nursing supervisor, Employee E10, on February 23, 2024 at 11:30 a.m. indicated that facility will provide a new pair of tubi grips for Resident R26.

Interview with Nursing supervisor, Employee E10, on February 27, 2024 revealed that R26 had previously received incorrect size of tubi grips and a bigger size tubi grips will be ordered again.

Review of Resident R47's clinical record revealed the resident was admitted to the facility on May 5, 2022 with diagnosis of cerebral infarction, unspecified (stroke), unspecified fracture of shaft of humerus, and gastrostomy.

On February 28, 2024, at 1:53 p.m. review Resident R47's electronic medication administration report with Licensed nurse, Employee E5 revealed that the resident was ordered the medication Amlodipine besylate tablet 5 milligrams to be given once a day via peg tube on January 31, 2024. Continued review of the electronic medication administration record with Employee E5 confirmed that Amlodipine besylate tablet 5 mg medication was given late on:

February 27, 2024, at 2:09 p.m.
February 26, 2024, at 11:44 a.m.
February 25, 2024, at 10:37 a.m.
February 24, 2024, at 10:06 a.m.
February 23, 2024, at 10:33 a.m.
February 22, 2024, at 10:41 a.m.
February 20, 2024, at 10:13 a.m.
February 22, 2024, at 11:19 a.m.

Employee E5 confirmed that all of the above times were late, and it should have been given between 8:00 am and 10:00 a.m.

28 Pa. Code 211.10( c) Resident care policies

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

Plan of Correction - To be completed: 04/22/2024

1. R26 remains in the facility and R47 is currently discharged to hospital unable to retroactively correct and will be reassessed upon return.
2. All residents that receive treatment and medications in accordance with physician orders related to tube grips and medications via tube feeding have the potential to be affected.
3. Nurse Educator, ADON or Designee will educate nursing staff on following treatment and medications orders by April 22, 2024.
4. Nurse Educator and ADON will conduct weekly audits x 3 then monthly audits x 3 to ensure treatment and medications orders are being followed related to tube grips and medications for tube feeding. Findings of the audits will be reported to the QAPI committee meeting to ensure compliance is obtained and maintained.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on observation and staff interviews, it was determined that the facility failed to provide appropriate urinary catheter care to prevent urinary tract infections for one of four residents with a urinary catheter (Resident R257).

Findings include:

Review of Resident R257's clinical record revealed that he was admitted to the facility on February 19, 2024 with diagnoses of Chronic Obstructive Pulmonary Disease ( a disease that causes decreased air flow to the lungs), End Stage Renal Disease ( a didease of the Kiondeys that causes the kidneys to stop functioning), Benighn Prostatic Hypertrophy, Retention of Urine (Urine is not expelled from the bladder through normal urination).

Further review of Resident R257's clinical record revealed a physician's order dated February 25, 2024, for bedside urinary drainage bag to have dignity cover two times a day for dignity and an order for indwelling catheter 22 FR (french) with 10cc balloon to bedside straight drainage for Retention of Urine.

Observation of Resident R257 conducted during tour of the Fourth floor nursing unit on February 23, 2024 at 12:28 p.m. revealed that resident was sleeping on his bed.

Further observation revealed that Resident R257 had a tube coming from under his sheet connected to a urine bag with yellowish liquid inside.

Further observation revealed that the urine bag was lying flat on the floor under Residnt R257's bed.

Follow-up observation of Resident R257 conducted on February 28, 2024 at 8:58 a.m. revealed that Resident R257 was sleeping on his bed. Further observation revealed a tube coming from under his sheet connected to a urine bag with light yellow liquid.

Further observation revealed that the urine bag was lying flat on the floor

Interview with Licensed nurse, Employee E14, conducted on February 28, 2024 at 9:04 a.m. confirmed that the urine bag was on the floor.

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

Plan of Correction - To be completed: 04/22/2024

1. R257 no longer remains in the facility, unable to retroactively correct.
2. All residents with an indwelling foley catheter have the potential to be affected by not keeping the catheter bag off the floor.
3. DON/Nurse Educator to re-educate nursing staff on care of indwelling catheters by April 22, 2024.
4. DON/Nurse Educator to complete an initial audit of all residents with indwelling foley catheters to ensure that urinary catheter care is provided. DON/Nurse Educator will complete an audit of 5 residents with foley catheters for urinary catheter care weekly x3 then monthly x3. Findings of audits will be reported to the QAPI committee meeting to ensure compliance is obtained and maintained.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on observation and clinical records review, resident and staff interview, it was determined that the facility failed to follow physician orders for tracheostomy care and ensure proper respiratory care for two of two residents reviewed receiving respiratory care. (Resident 55).

Findings include:

Review of Resident R55s clinical record revealed that the resident was admitted to the facility on December 15, 2023 with diagnoses included spastic hemiplegia affecting the left nondominant side (a condition characterized by muscle stiffness or spasticity and paralysis or weakness on the left side of the body), quadriplegia, unspecified (paralysis of all four limbs and typically the trunk as well, chronic respiratory failure, other congenital malformations of trachea.

Review of physician order dated on December 15, 2023, for Resident R55, indicated an order for " Type of trach shilly size of trach #4 (spare trach kept at bedside) and ambu bag at bedside.

On February 23, 2024, at 1:12 p.m., Resident R55 was observed with tracheostomy and tracheal suctioning in place. A license nurse, Employee E4 confirmed that there was no ambu bag at the bedside, in the medication storage nor in the crash cart on the 5th floor nursing unit.

On February 23, 2024, at 1:45 p.m. a License nurse, Employee E4 confirmed that ambu bag was located at the crash cart and was placed by the bedside for the Resident R55.

Review of Resident R257's list of diagnoses revealed that resident had a diagnoses of Chronic Obstructive Pulmonary Disease ( a group of lung diseases that block airflow and make it difficult to breath).

Review of Resident R257's physician's order dated February 24, 2024 revealed an order for oxygen at 2 liters per minute via nasal cannula every shift.

Observation conducted during the tour of the 4th floor unit on February 23, 2024 at 12:28 p.m. and on February 28, 2024 at 8:58 a.m. revealed that Resident R257 was sleeping on his bed. Further observation revealed that Resident R257's oxygen concentrator at 2 liters/ minute. Continued observation revealed that the oxygen tubing was not dated.

Interview with Licensed nurse, Employee E15, conducted at the time of the observation confirmed that the oxygen tubing was not dated

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

Plan of Correction - To be completed: 04/22/2024

1. R55 remains in the facility and a spare trach is currently at bedside. R257 discharged on 3/1/24, unable to retroactively correct.
2. All residents with physician orders for tracheostomy care and respiratory care have the potential to be impacted.
The nurse educator/ADON will re-educate licensed nurses by April 22, 2024 on ensuring an ambu bag is at the bedside for residents with tracheostomies and ensure residents receiving therapy have their oxygen tubing dated as per guidelines.
3. The ADON or designee will complete an initial audit of all residents receiving trach care to ensure spare ambu bags are placed at bedside and oxygen tubing is dated.
4. Nurse Educator and ADON will conduct weekly audits x 3 then monthly audits x 3 of 5 residents with tracheostomies to ensure oxygen tubing is dated and physician orders for tracheostomy care are being followed. Findings of the audits will be reported to the QAPI committee monthly meeting to ensure compliance is obtained and maintained.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:

§483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Observations:

Based on clinical record review and interview with staff, it was determined that the facility did not provide requested evidence of competency trainings for licensed nursing staff.

Findings include:

Initial request for documentation was made during the entrance conference on February 23, 2024, at 11:20 a.m. with Regional Licensed nurse, Employee E2, and interim Director of Nursing, Employee E14. Documentation was provided and reviewed at this time which indicated that the facility was to provide evidence of at least annual inservice training, including, but not limited to, infection prevention and control, resident confidential information, resident psychosocial needs, restorative nursing techniques, and resident rights, including nondiscrimination and cultural competency, personal property rights, privacy, preservation of dignity and the prevention and reporting of resident abuse.

This information was again requested via email from Employee E1, the Nursing Home administrator, on Monday, February 26, 2024, at 2:34 p.m., on February 28, 2024, at 9:56 a.m., and a final time on February 28, 2024, at 11:52 a.m.

At theconclusion of the survey on February 28, 2024, at 2:30 p.m., the facility had not provided the required documentation.

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

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

Plan of Correction - To be completed: 04/22/2024

1. All licensed nurses education files have the potential for incompletion of the mandatory in-servicing.
2. DON/Nurse Educator to re-educate licensed nurses on required mandatory training.
3. DON/Nurse Educator to complete an initial audit of licensed nurses for completion of mandatory training.
4. DON/Nurse Educator to complete monthly audits x 3 of nursing education training for completion of scheduled mandatory training. Results of audits to be reported to the QAPI committee monthly to ensure compliance is obtained and maintained.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:

§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).

Observations:

Based on clinical record review and interview with staff, it was determined that the facility did not provide requested evidence of annual competency trainings and yearly performance reviews for nurse aides.

Findings include:

Initial request for documentation was made during the entrance conference on February 23, 2024, at 11:20 a.m. with Regional licensed nurse, Employee E2, and interim Director of Nursing, employee E14. Documentation requested included evidence of annual competency trainings and yearly performance reviews for nurse aides.

This information was again requested via email from Employee E1, the Nursing Home administrator, on Monday, February 26, 2024, at 2:34 p.m., on February 28, 2024, at 9:56 a.m., and a final time on February 28, 2024, at 11:52 a.m.

At the conclusion of the survey on February 28, 2024, at 2:30 p.m., the facility had not provided the required documentation.

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

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

Plan of Correction - To be completed: 04/22/2024

1. All nurse aides have the potential for incompletion of 12 hr/yr in-servicing and incompletion of yearly performance reviews.
2. DON/Nurse Educator to re-educate nurse aides on completion of mandatory in-service requirements. NHA/ Designee to re-educate DON on timely completion of yearly performance evaluations for nursing aides.
3. DON/Designee to conduct an audit of nurse aide education files for verification of 12hr/ yr in-servicing completion. NHA/Designee to conduct an audit of all nursing aides for completion of yearly performance evaluations.
4. Performance evaluations to be completed for all active nurse aides identified without having a yearly performance evaluation. DON/Designee to complete an audit of in-services completed by nurses aides weekly x 3 then monthly audits x 3. Results of the audits to be reported to the QAPI monthly to ensure compliance is obtained and maintained.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on interview with residents and staff and review of clinical records, it was determined that the facility did not provide pharmaceutical services to meet the needs of residents for one of 24 residents reviewed (Resident R26)
Findings include:

Review of facility's policy "Medication Shortages/Unavailable Medications," revised on January 1, 2022, states "when a missed dose is unavoidable, facility nurse should document the missed dose and the explanation for such missed dose on the MAR (Medication Administration Record) or TAR (Treatment Administration Record) and in the nurse's notes per facility policy. Such documentation should include the following information:
9.1 a description of the circumstances of the medication shortage
9.2 a description of pharmacy's response upon notification, and
9.3 action(s) taken"

Review of Resident R26's clinical records revealed diagnosis of atherosclerotic heart disease, high blood pressure, obstructive sleep apnea, venous insufficiency.

Review of Resident R26's consult completed on January 30, 2024 by nurse practitioner, Employee E30 and medical Director, Employee E29 for "lower leg discoloration and painful nodules," with following findings: multiple tender nodules of the lower legs, bound down skin of ankles and dyspigmentation. Some areas of scale. Palpable pedal pulses."

Diagnosis of "phlebolith (small local, usually rounded calcification within a vein), stasis dermatitis (skin inflammation in the lower legs caused by fluid build up," and lipodermatosclerosis (chronic inflammatory disorder of lower extremities). Resident R26 had the following recommendations: "Begin Pentoxifylline 400 mg (milligrams) 3x daily... return visit with dermatology in 8 weeks."

Interview with Resident R26 on February 23, 2024 at 11:00 a.m. revealed that he had a concern about his "blood flow" medication which was skipped three nights in a row.

Review of Resident R26's electronic medication administration records for February 2024 revealed Pentoxifylline ER 400 mg was to be given one time a day for circulation for 8 weeks. Continued review of the medication administration record revealed that Resident R26 did not receive this medication on Monday, February 19, 2024 through Wednesday, February 21, 2024.

Review of Resident R26's nursing notes revealed no documentation for February 19, 2024, regarding missed dose of Pentoxifylline 400 mg. Further review revealed nursing note for February 20, 2024 at 2:01 a.m. "pentoxifylline ER oral tablet extended release 400mg - give 1 tablet by mouth one time a day for circulation for 8 weeks; none on hand." Nursing note from February 20, 2024 at 20:35 p.m. states "pentoxifylline ER oral tablet extended release 400 mg - give 1 tablet by mouth one time a day for circulation for 8 weeks," without explanation provided. Nursing note from February 21, 2024 at 21:14 p.m. stated "pentoxifylline ER oral tablet extended release 400mg - give 1 tablet by mouth one time a day for circulation for 8 weeks - on order reordered today."

28 Pa Code 201.14(a)Responsibility of licensee.

28 Pa Code 211.9(a)(1)(f)(2)(4)(g)(h)(k) Pharmacy services

Plan of Correction - To be completed: 04/22/2024

1. R26 remains at the facility and cannot be retroactively correct.
2. All residents have the potential to be impacted by medication unavailability. ADON/DON will complete an initial audit of the MARs (Medication Administration Record), TARs (Treatment Administration Record) and nursing documentation for any missed dose of medications that are unavoidable for compliance and actions taken.
3. The DON/ADON nurse educator will re-educate all nursing staff on Medication Shortages/Unavailable facility policy by April 22, 2024.
4. Nurse Educator, ADON, or designee will conduct weekly audits x 3 then monthly x 3 to ensure the nursing staff document the missed dose and the explanation for such missed dose on the MAR, TAR and nurses note including actions taken. Findings of the audits will be reported to the QAPI committee monthly to ensure compliance is obtained and maintained.

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

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

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

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

Observations:

Based on observation and staff interview, it was determined that the facility failed to properly label and dispense drugs for one out of three carts observed. (4th floor back hall cart)

Findings include:

Observation of the 4th floor back hall cart conducted on February 26, 20204 at 9:02 a.m. with Licensed nurse, Employee E17 revealed that a medication cup with 4 tablets (one red tablet, one yellow tablet and two white tablets) were observed inside the medication cart top drawer where the over the counter stock medications were located.

Interview with Employee E17, Licensed Nurse, conducted at the time of observation confirmed that a medication cup with 4 tablets (one red tablet, one yellow tablet and two white tablets) were in the medication cart top drawer where the over the counter stock medications were located.

Further, Employee E17 stated that it must have been left by the previous nurse.

28 Pa Code 211.12(c) Nursing services

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

Plan of Correction - To be completed: 04/22/2024

1. Medication cart on the 4th floor was corrected immediately and medication were destroyed.
2. The facility had no opportunity to correct the deficient practice.
3. The ADON/DON and nurse educator shall re-educate licensed nursing staff on medication storage by April 22, 2024.
4. Nurse Educator or Designee will complete an initial audit of all nursing carts to ensure no medication cups with medication are being stored in the medication cart. The Nurse Educator or Designee will complete an audit of all medication carts weekly x 3 then monthly x 3 to ensure medication cups with medication are not being stored in the medication cart. Results of the audits will be presented and discussed at the facility QAPI monthly meeting for further audits and/or action plans.

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

§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 observation, interview with residents, review of facility provided documentation and test tray, it was determined that the facility did not ensure to provide food that is at a safe and appetizing temperature during lunch meal for one of four units observed (Unit 3, 3rd floor Nursing Unit)

Findings include:

Review of facility's "Food Handling," revealed "All time/temperature control for safety food must maintain an internal temperature of 41 F (Fahrenheit) or lower, or 135 F (Fahrenheit) or higher while being held for service."

Based on findings during resident council meeting on Tuesday, February 27, 2024 at 10:30 a.m. revealed that Residents R17, R26, R61, R5, R7, R75, R299, R25, and R6 complained of cold food temperatures served.

Observations completed during a test tray with Dietary Manager, Employee E12, on Tuesday, February 27, 2024 at 12:30 p.m., on 3rd floor unit revealed that the lunch meal consisted of turkey burger, soup, fruit drink, dessert. The The following food temperatures were obtained:
turkey burger - 112.8 F
grape drink - 46.5 F
mandarins/oranges - 44.5 F

28 Pa Code 201.14(a)Responsibility of licensee

28 Pa Code 201.18(b)(3) Management

28 Pa Code 211.6(f) Dietary services

Plan of Correction - To be completed: 04/22/2024

1. R17, R26, R61, R5, R7, R25 and R6 unable to retroactively correct. R75 and R299 no longer reside in the facility.

2. All residents in the facility have potential to be affected by food temperatures, currently none have been noted.

3. The Food Director and dietary staff will be in-serviced by the Administrator on all time/temperature control for safety by April 22, 2024.

3. The Administrator will audit the food temp while being held for service weekly x 3 then monthly x 3. Results of the audits will be presented and discussed at the facility QAPI monthly meeting for further review.

483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program:

§483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.

Observations:

Based on observation, review of facility records, and interviews with staff and residents, it was determined that the facility did not maintain an adequate pest control program related to mice for four of four units (2nd floor, 3rd floor, 4th floor, and 5th floor).

Findings include:

An interview with alert and oriented Resident R29 on February 23, 2024, at 11:55 a.m., revealed that the resident regularly saw mice "at night".

An interview with alert and oriented Resident R59 on February 23, 2024, at 1:18 p.m., revealed that the resident had seen mice "about twice" since his admission on February 7, 2024.

An interview was conducted on February 27, 2024, at 10:37 a.m. during the resident council with nine alert and oriented residents, residents R5, R6, R7, R25, R26, R60, R61, R75, and R299. This interview revealed pest control concerns including multiple sightings of mice per day, nurse aides not properly reporting mice and other pests, residents being unsure of where and how to report seeing pests, and holes in the wall allowing mice to enter the living areas.

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

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

28 Pa. Code: 207.2 (a) Administrator's responsibility

Plan of Correction - To be completed: 04/22/2024

1. R5, R6, R7, R25, R26, R60, R61, no residents harmed from practices identified. R75 and R299 no longer remain at the facility.
2. All residents have the potential to be impacted related to pest control. Pest control vendor services facility 2 or 3 x weekly.
3. All staff will be in-serviced on where and how to report sightings of pests by the maintenance director by April 22, 2024.
4. The maintenance director will audit for mice sightings weekly x 3 then monthly x 3. Results of the audits will be presented and discussed at the facility QAPI monthly meeting for further review.

483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides:

§483.95(g) Required in-service training for nurse aides.
In-service training must-

§483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

§483.95(g)(2) Include dementia management training and resident abuse prevention training.

§483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at § 483.70(e) and may address the special needs of residents as determined by the facility staff.

§483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.

Observations:

Based on clinical record review and interview with staff, it was determined that the facility did not provide requested evidence of inservice trainings for nurse aides.

Findings include:

Initial request for documentation was made during the entrance conference on February 23, 2024, at 11:20 a.m. with RegionalLlicensed nurse, Employee E2, and interim Director of Nursing, Employee E14. Documentation requested included evidence of at least annual inservice training for nurse aides, including, but not limited to, infection prevention and control, resident confidential information, resident psychosocial needs, restorative nursing techniques, and resident rights, including nondiscrimination and cultural competency, personal property rights, privacy, preservation of dignity and the prevention and reporting of resident abuse.

This information was again requested via email from employee E1, the Nursing Home administrator, on Monday, February 26, 2024, at 2:34 p.m., on February 28, 2024, at 9:56 a.m., and a final time on February 28, 2024, at 11:52 a.m.

At the conclusion of the survey on February 28, 2024, at 2:30 p.m., the facility had not provided the required documentation.

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

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

Plan of Correction - To be completed: 04/22/2024

1. All nurse aides have the potential for incompletion of 12 hr/ yr in-servicing.
2. DON/Nurse Educator to re-educate nurse aides on completion of mandatory in-service requirements.
3. DON/Designee to conduct an audit of nurse aide education files for verification of 12 hr/ yr in-servicing completion
4. DON/Designee to complete an audit of in-services completed by nurses aides weekly x 3 then monthly audits x 3

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