Pennsylvania Department of Health
FOX SUBACUTE AT MECHANICSBURG
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

FOX SUBACUTE AT MECHANICSBURG
Inspection Results For:

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FOX SUBACUTE AT MECHANICSBURG - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights survey completed on February 22, 2024, it was determined that Fox Subacute at Mechanicsburg 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:

483.12(a)(3)(4) REQUIREMENT Not Employ/Engage Staff w/ Adverse Actions:

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.

§483.12(a) The facility must-

§483.12(a)(3) Not employ or otherwise engage individuals who-
(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;
(ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or
(iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.

§483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff.

Observations:

Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to ensure that residents were protected from the potential for abuse by failing to preform criminal history background checks prior to hire for one of five personnel files reviewed (Employee 14); and failed to verify the standing of professional licenses and/or nurse aide registry enrollment prior to hire for five of five personnel files reviewed (Director of Nursing [DON] and Employees 13, 14, 15, and 16).

Findings include:

Review of facility policy, titled "Abuse Reporting", with an update of November 28, 2018, revealed, " ...criminal history background checks shall be performed on all newly hired employees seeking employment and monthly thereafter. In addition, the Nurse Aid Registry and appropriate state licensing boards shall be contacted for verification of status of every applicant seeking licensed position ..."

Review of the Director of Nursing's (DON) personnel file revealed their nursing license verification was completed February 2, 2024, which was after her date of hire of February 1, 2024.

Review of the personnel file for Employee 13 (Registered Nurse) revealed their nursing license verification was completed February 22, 2024, which was after her date of hire of February 12, 2024.

Review of the personnel file for Employee 14 (Registered Nurse) revealed their nursing license verification was completed February 2, 2024, which was after his date of hire of February 1, 2024.

Further review of Employee 14's personnel file revealed that, at the time of hire, Employee 14 had not been a resident of Pennsylvania for two consecutive years. There was no evidence a Federal Bureau of Investigation (FBI) background check was conducted for Employee 14 prior to hire or starting at the facility.

Review of the personnel file for Employee 15 (Registered Nurse) revealed their nursing license verification was completed February 5, 2024, which was after her date of hire of November 9, 2023.

Review of the personnel file for Employee 16 (Nurse Aide) revealed their nurse aide registry verification was completed February 22, 2024, which was after his date of hire of February 1, 2024.

During a staff interview with the DON and Nursing Home Administrator (NHA) on February 22, 2024, at approximately 1:30 PM, it was confirmed the facility failed to conduct a FBI background check for Employee 14. The NHA stated it is the expectation of the facility that professional licenses and/or nurse aide registry verifications and background checks are completed prior to hire.

28 Pa code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18 (b)(1)(e)(1) Management
28 Pa. Code 201.19 (3)(8) Personnel policies and procedures

Plan of Correction - To be completed: 04/12/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
One, actions taken for situation identified:
1. Human Resources was educated on not permitting staff to orientate until License and Certification are verified
2. Human Resources was educated on reviewing potential new hires to ensure Criminal and FBI background checks are completed before orientation
3. All new hires were reviewed to ensure criminal background checks and license verifications were completed
4. Employee 14 was removed from the active schedule until his FBI Background check has been received
Two, how the facility will respond regarding residents in similar situations:
The facility recognizes that all residents have the potential to be affected. Please see sections three and four for system changes and monitoring mechanisms.
Three, system changes and measures that will be taken:
1. Human Resources will be In-serviced on the timeliness of Criminal Background and License/Certifications verification
Four, monitoring mechanism to assure compliance:
1. The Administrator or his designee will conduct audits of 2 random new hires per week for 1 month, then weekly for 1 month, and then monthly thereafter for compliance
2. The Administrator will report findings at Continuous Quality Improvement Committee meetings

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 review of personnel training records and staff interview, it was determined that the facility failed to ensure each nurse aide was provided with the required in-service training consisting of no less than 12 hours per year for five of five nurse aide employee records reviewed (Employees 8, 9, 10, 11 and 12); failed to provide annual training that included dementia management and resident abuse prevention for four of five nurse aide employee records reviewed (Employees 8, 9, 10, and 11); and failed to provide annual training that included dementia management for one of five nurse aide employee records reviewed (Employee 12).

Findings Include:

Review of personnel information revealed Employee 8's hire date was November 28, 2014; Employee 9's hire date was July 8, 2022; Employee 10's hire date was November 24, 2020; Employee 11's hire date was August 15, 2021; and Employee 12's hire date was March 28, 2019.

Review of facility training records failed to reveal that the aforementioned Employees completed 12 hours of required annual training in the past 12 months.

Further review of facility training records failed to reveal evidence that dementia management or abuse prevention training was completed by Employees 8, 9, 10, and 11 within the past 12 months.

Further review of facility training records failed to reveal evidence that dementia management training was completed by Employee 12 within the past 12 months.

During an interview with the Nursing Home Administrator on February 22, 2024, at 2:25 PM, he acknowledged that he had no documentation of actual training hours or additional training information to provide. He confirmed that he would expect required training be completed.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
28 Pa. Code 201.19 (2) (7) Personnel policies and procedures
28 Pa. Code 201.20(a)(d) Staff development

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

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

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

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

Plan of Correction - To be completed: 04/12/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
One, actions taken for situation identified:
1. All food items identified in the kitchen area were removed and discarded
2. Facility pantries that had unlabeled or undated food items had the items removed and discarded
3. Food Items were visually inspected to ensure there were no scoops or utensils stored in them
4. Trash and Recycle receptacle bins were closed immediately
5. Food Service staff were immediately in-serviced on ensuring dishwasher's final rinse reaches a minimum of 180 degrees and what to do if the dishwasher fails to hit 180 degrees.
Two, how the facility will respond regarding residents in similar situations:
The facility recognizes that all residents have the potential to be affected. Please see sections three and four for system changes and monitoring mechanisms.
Three, system changes and measures that will be taken:
1. All food service staff were in-serviced on the food storage policy
2. All Food Service staff were immediately in-serviced on ensuring dishwasher's final rinse reaches a minimum of 180 degrees and what to do if the dishwasher fails to hit 180 degrees.
3. Food Service staff and the Nursing staff will in-serviced on safe storage of food in the resident pantries
4. All staff who utilize the outside trash receptacle bins will be in-serviced on the importance of the lid and doors being shut
5. A new dishwasher has been purchased and will be installed in the Dietary Department
Four, monitoring mechanism to assure compliance:
1. The Dietitian or her designee will conduct random audits of Food Storage located in the kitchen, Dishwasher temperatures, Food items stored on the unit pantries, and that the garbage and recycle doors are closed. This will be done 3 times per week for 1 month, then weekly for 1 month, and then monthly thereafter for 3 months for compliance
2. The Dietitian will report findings at Continuous Quality Improvement Committee meetings

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More:

§483.45(f) Medication Errors.
The facility must ensure that its-

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

Observations:

Based on facility policy review, product manufacturer label, observations, and clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (17 errors in 32 observations, 53.13%).

Findings include:

Review of the clinical record for Resident 7 revealed the resident has a gastric tube (tube inserted through the abdomen that delivers nutrition directly to the stomach).

Review of Resident 7's current physician orders revealed medication orders for the following medications: Valium (medication for seizures) 5 mg, Metoclopramide (medication to treat stomach) 10 mg, Lamotrigine (medication for seizures) 25 mg, Lamotrigine 200 mg, Lasix (diuretic medication) 40 mg, Baclofen (medication for muscle spasms) 10mg, and Metoprolol (blood pressure medicine) 25mg.

Observation on February 21, 2024, at 8:56 AM, revealed Employee 1 (Licensed Practical Nurse [LPN]) was observed administering the above listed medications to Resident 7. Employee 1 crushed all of the above listed medications together and administered the medications together, and did not flush the tube with water between medications.

Review of the clinical record for Resident 7 revealed the Resident has a gastric tube (tube inserted through the abdomen that delivers nutrition directly to the stomach).

Review of the current physician orders for Resident 24 revealed medication orders for the following medications: Adderall (amphetamine medication) 5 mg, Sodium Chloride 2 mg, Senna (constipation medication) 8.6 mg, Magnesium Oxide (magnesium supplement) 800 mg, Losartan Potassium (blood pressure medication) 100 mg, Lasix 20 mg, Aspirin 81 mg, Amlodipine (blood pressure medication) 5 mg, and Esomeprazole Magnesium (heart burn medication) 40 mg.

Observation on February 21, 2024, at 9:15 AM, revealed Employee 1 was observed administering the above listed medications to Resident 24. Employee 1 crushed all of the above listed medications together and administered the medications together, and did not flush the tube with water between medications.

Further observation of Employee 1 at that time revealed her preparing to inject Resident 24 with Lantus (insulin) 25 units subcutaneously. Observation of the insulin bottle revealed that it was opened on January 20, 2024, and should not be used after February 16, 2024.

Review of product information for Lantus insulin revealed that it is to be discarded 28 days after opened or removed from refrigeration.

During an interview with the Director of Nursing on February 22, at 12:15 PM, she revealed that she would have expected Employee 1 to give the medications according to the standard of practice, and also not give insulin beyond its expiration date.

Based on 17 medication errors observed out of a possible 32 opportunities, the facility medication error rate was a calculated 53.13 percent.

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

Plan of Correction - To be completed: 04/12/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
One, actions taken for situation identified:
1. Employee 1 was educated on ensuring all medications are not expired before administration
2. Facility inspected med carts for medication expiration
3. Facility has Physician Orders to have Medications Crushed together, unless contraindicated by Physician or Pharmacy to administer separately , with flush as ordered
Two, how the facility will respond regarding residents in similar situations:
The facility recognizes that all residents have the potential to be affected. Please see sections three and four for system changes and monitoring mechanisms.
Three, system changes and measures that will be taken:
1. All Professional Nursing Staff will be In-serviced on proper Medication storage and Administration
2. Pharmacy will be notified via electronic Physician orders
3. Pharmacy will monitor and make recommendations as needed for contraindications
Four, monitoring mechanism to assure compliance:
1. The Director of Nursing or her designee will conduct random audits of 3 carts per week for 1 month, then 3 carts every other week for 1 month, and then monthly thereafter for compliance of storage and labeling of medications
2. The Director of Nursing or her designee will conduct random audits for medication administration as per MD orders and Facility policy, of 3 residents per week for 1 month, then 3 residents every other week for 1 month, and then monthly thereafter for 3 months for compliance
3. Consultant Pharmacist will continue to monitor Resident Physician orders monthly and report any contraindications
4. The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings

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 review of select facility personnel documentation and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for three of five nurse aides reviewed (Employees 9, 10, and 11) and failed to ensure that in-service education was provided based on the outcome of these reviews for five of five nurse aides reviewed (Employees 8, 9, 10, 11, and 12).

Findings Include:

Review of personnel information revealed Employee 8's hire date was November 28, 2014, and that they had an annual performance review completed on May 22, 2023, but failed to reveal that in-service education was provided based on the outcome of this review.

Review of personnel information revealed Employee 9's hire date was July 8, 2022; Employee 10's hire date was November 24, 2020; and Employee 11's hire date was August 15, 2021.

Further review of personnel information for Employees 9, 10, and 11, failed to reveal that annual performance reviews were completed and that in-service education was provided based on the outcome of these reviews.

Review of personnel information revealed Employee 12's hire date was March 28, 2019, and that they had an annual performance review on May 12, 2023, but failed to reveal that in-service education was provided based on the outcome of this review.

During an interview with the Nursing Home Administrator on February 22, 2024, at 2:25 PM, he acknowledged that he had no additional documentation to provide. He confirmed that he would expect annual performance reviews to be completed and subsequent education based on the performance review be completed and documented.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 201.19(2)(7)Personnel policies and procedures
28 Pa. Code 201.20(a)(d) Staff development

Plan of Correction - To be completed: 04/12/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
One, actions taken for situation identified:
1. The facility recognizes that it cannot retroactively correct the situation for Employees 9, 10, and 11 in regards to past years employee performance evaluations
2. An performance evaluation will be completed for the identified employees
3. The facility recognizes that it cannot retroactively correct the situation for Employees 8 and 12 for in-servicing related to employee performance evaluations. Both of these employees did not have any areas that were noted to need improvement.
Two, how the facility will respond regarding residents in similar situations:
The facility recognizes that all residents have the potential to be affected. Please see sections three and four for system changes and monitoring mechanisms.
Three, system changes and measures that will be taken:
1. Director of Nursing and Human Resources will be In-serviced on timeliness of Employee Performance Evaluations, and to provide education as needed based on the performance evaluation that would need improvement is indicated
2. All Nurse aides will have Performance evaluations conducted based on date of hire to ensure that they are annual, any that are past due will be completed by completed by April 1, 2024
Four, monitoring mechanism to assure compliance:
1. The Human Resource Assistant or her designee will conduct monthly audits of evaluations of 5 employees for compliance
2. The Human Resource Assistant will report findings at Continuous Quality Improvement Committee meetings
3. The Human Resource Assistant will notify NHA of any noncompliance

483.25(l) REQUIREMENT Dialysis:

§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of one residents reviewed for diapysis services (Resident 18).

Findings Include:

Review of facility policy, titled "Hemodialysis", with a last revision date of November 30, 2018, and a last review date of December 27, 2023, indicated under section titled "Documentation" that "1. The dialysis unit doing the dialysis will supply copy of their completed record for the patient chart; and 3. All patient observations, interventions, etc. will be recorded in the patient record."

Review of Resident 18's clinical record revealed diagnoses that included end stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis) and bipolar disorder (a lifelong mood disorder and mental health condition that causes intense shifts in mood, energy levels, thinking patterns, and behaviors).

Review of Resident 18's physician orders revealed the following orders: Dialysis (external filtering of the blood performed by a machine by removing the blood and replacing it) three times a week on Tuesday, Thursday, and Saturday, at 5:30 AM, at US Renal Care, dated February 9, 2024 (their most recent readmission date).

Further review of Resident 18's order history and medication administration records revealed that they had been receiving dialysis for the entire calendar year of 2023.

Review of Resident 18's clinical record on February 21, 2024, at 12:15 PM, failed to reveal any dialysis communication notes/forms.

During an interview with the Director of Nursing (DON) on February 21, 2024, at 12:20 PM, she indicated that communication sheets are completed to accompany the Resident to dialysis, but that these forms are kept in the dialysis center. She further indicated that a staff member accompanies Resident 18 to dialysis, so that is how they would know if there were any concerns with Resident 18 during their dialysis treatment.

During a follow-up interview with the Nursing Home Administrator (NHA) and DON on February 21, 2024, at 1:50 PM, the concern of no documentation to support facility communication or coordination of care with dialysis was shared. Additional information was requested.

Email communication from the NHA on February 22, 2024, at 1:38 AM, included facility dialysis communication sheets dated February 13, 15, 17, and 20, 2024. No other documentation was provided.

Review of Resident 18's nutritional assessments revealed that they had been assessed by the dietician
on the following dates April 5, 2023; July 5, 2023; September 27, 2023; November 20 and 27, 2023; December 28, 2023; January 18 and 25, 2024; and February 5 and 14, 2024 (a total of ten assessments).

Further review of these ten completed nutritional assessments revealed that the seven assessments completed on July 5, 2023; November 20, 2023; December 28, 2023; January 18 and 25, 2024; and February 5 and 14, 2024, failed to include any documentation of Resident 18 receiving dialysis or communication with the dialysis dietician.

Review of Resident 18's clinical record progress notes failed to reveal any nutritional notes addressing dialysis or communication with the dialysis dietician since March 20, 2023, which was in the previous survey year.

During an interview with the NHA and DON on February 22, 2024, at 10:27 AM, the concern of the lack of documentation to show communication between the dietician here and the dialysis dietician was shared to include the aforementioned nutritional assessments and nutrition notes. It was also shared at that time that only four dialysis communications sheets had been provided and that more would be needed for review. He indicated that they have a binder of them, which was requested for review. The DON indicated that she would get the binder for review.

During an interview with the Employee 6 (Registered Dietician) on February 22, 2024, at 11:04 AM, she indicated that she maintains contact with the dialysis dietician, but confirmed that she could not provide any documentation to support this. She also confirmed that her nutritional assessments did not all indicate that Resident 18 was receiving dialysis, and that there were no dietary progress notes outside of her assessments that referenced any documentation regarding communication with the dialysis dietician since March 20, 2023.

During a follow-up interview with the NHA on February 22, 2024 at 11:45 AM, he confirmed that he had no binder or dialysis communication sheets to provide. He provided copies of Resident 18's clinical progress notes that were documented under "Note Type: Dialysis" that showed nurses' notes that the Resident went to dialysis. It was discussed that all these notes had been reviewed, but that these notes did not indicate any communication with the dialysis center and were sporadic. The concern that there was no evidence of ongoing communication between the facility and the dialysis center each day that Resident 18 was emphasized again. The NHA indicated that the dialysis center used to send a report over after every dialysis treatment, but that when a new person took over at dialysis, that person determined that they [dialysis center] did not need to be sending those documents and stopped doing so.

During a final interview with the NHA and DON on February 22, 2024, at 12:10 PM, the NHA confirmed that he had no additional documentation to provide to show collaboration or communication with the dialysis center and the facility nursing staff or facility dietician. He confirmed that he would expect this communication to occur and that documentation should be present to support the ongoing coordination of nursing and nutritional care.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(a)(c) Resident care policies
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

483.20(g) REQUIREMENT Accuracy of Assessments:

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

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 review, policy review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 15 residents reviewed (Residents 18 and 20).

Findings include:

Review of facility policy, titled "Care Plan and Conference", last revised November 30, 2018, revealed, in part, "Purpose: To facilitate communication of all disciplines of pertinent patient information to formulate a useful care plan that will drive patient care and improve outcomes ...The care plan process will be monitored by all disciplines as necessary based on the resident's assessment of problems and needs."

Review of Resident 18's clinical record revealed diagnoses that included bipolar disorder (a lifelong mood disorder and mental health condition that causes intense shifts in mood, energy levels, thinking patterns, and behaviors) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things).

Review of Resident 18's physician orders revealed an order for Venlafaxine Hydrochloride oral tablet (an antidepressant medication) 112.5 milligrams give one tablet by mouth, dated February 9, 2024.

Review of Resident 18's care plan revealed a care plan focus for "potential for adverse reaction to prescribed psychotropic medications: Anti-depressant medications: Trazodone, Mirtazapine, Venlafaxine. Resident has diagnosis of depression", with a date initiated of November 28, 2023, and a last revision date of December 29, 2023.

Further review of Resident 18's physician order history revealed that their Trazodone and Mirtazapine (both antidepressant medications) were discontinued on January 19, 2024.

During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on February 21, 2024, at 1:50 PM, the aforementioned care plan concern was shared, and they indicated they would look into the concern.

During a follow-up interview with the NHA and DON on February 22, 2024, at 10:31 AM, the NHA indicated that he had spoken to the Social Worker and that she said that she continued the care plan because she was on antidepressants. It was shared again that there were specific medications listed on the care plan that Resident 18 was no longer taking.

During a final interview with the NHA and DON on February 22, 2024, at 1:29 PM, the NHA indicated that the social worker thought that she was being proactive in leaving the discontinued medications on the care plan should Resident 18 be placed back on those medications. He further indicated that, moving forward, the facility would not be including specific medications on resident care plans.

Review of facility policy, titled "Weights", last revised November 30, 2020, revealed, in part, "The Registered Dietitian will update/revise the resident's care plan to reflect the significant weight change, goals, and approaches."

Review of Resident 20's clinical record revealed diagnoses that included protein calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets), dysphagia (difficulty swallowing), and type 2 diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin).

Review of Resident 20's medical record revealed a significant weight gain of 12 pounds from November 4, 2023, to December 3, 2023, and then a significant weight loss of 21.4 pounds from January 2, 2024, to January 6, 2024, confirmed by a re-weigh measure on January 7, 2024.

Review of Resident 20's care plan revealed a focus area of, "Feeding tube as a result of swallowing problems/dysphagia ...and is at risk of ...imbalanced nutrition. Physician documented malnutrition", last revised May 25, 2023.

Further review of Resident 20's care plan failed to mention Resident 20's significant weight changes.

During an interview with the NHA on February 22, 2024, at 12:05 PM, revealed he would expect Resident 20's care plan to be updated to include the significant weight changes.

42 CFR 483.21(b) Comprehensive Care Plans
28 Pa. Code 211.12(d)(5) Nursing services

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain adequate personal grooming of residents dependent on staff for assistance with these activities of daily living (ADLs) for two of 15 residents reviewed (Residents 31 and 37).

Findings Include:

Review of facility policy, titled "Quality of Life", dated November 28, 2018, revealed "1. The facility will promote, maintain and enhance each resident's dignity and respect his or her individuality. a. Grooming residents as they wish to be groomed."

Review of Resident 31's clinical record revealed diagnoses that included acute and chronic respiratory failure, paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within seven days), and chronic kidney disease stage 4 (kidneys are moderately or severely damaged and are not working as well as they should to filter waste from the blood).

Review of Resident 31's current care plan revealed an intervention with a revision date of October 13, 2023, "Resident is dependent on ADLs: toileting, transfers, hygiene, dressing, bed mobility, showers/bathing." Further review of Resident 31's care plan failed to reveal any preference for facial hair or refusals of care.

Observation of Resident 31 on February 20, 2024, at 11:41 AM, and February 21, 2024, at 9:52 AM, revealed Resident 31 with what appeared to be several days of facial hair growth.

On February 21, 2024, at 1:35 PM, the Nursing Home Administrator (NHA) and Director of Nusing (DON) were made aware of the observations of Resident 31's facial hair and questioned if this was Resident 31's preference. They stated they would look into it.

Review of Resident 31's nursing progress note dated February 21, 2024, at 4:25 PM, revealed that facility staff spoke with Resident 31's daughter who stated that she "prefers resident to be shaved if/when he is agreeable to it. She expressed understanding that her father is sometimes behavioral and resistive to care and is ok if he is not shaved under those circumstances."

Observation of Resident 31 on February 22, 2024, at 9:31 AM, revealed Resident 31 continued with several days of facial hair growth.

During an interview with the NHA, DON, and Assistant Director of Nursing (ADON) on February 22, 2024, at 11:57 AM, the ADON stated that Resident 31 sometimes has behaviors and refuses to be shaved.

Review of Resident 31's task sheet for the past 30 days for hygiene, which included shaving, revealed no documentation of any refusals.

Review of Resident 31's task sheet for rejection of care over the past 30 days revealed no refusals documented.

On February 22, 2024, at 1:26 PM, during an interview with the NHA, DON, and ADON, the ADON confirmed that there was no evidence of Resident 31 refusing to be shaved.

Review of Resident 37's clinical record revealed diagnoses that included acute and chronic respiratory failure and functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord).

Review of Resident 37's current care plan revealed an intervention dated January 18, 2023, "Resident is dependent with ADLs: transfers, toileting, hygiene, dressing, bathing/showers, bed mobility." Further review of Resident 37's care plan failed to reveal any preference for facial hair or refusals of care.

Observation of Resident 37 on February 20, 2024, at 10:21 AM, and February 21, 2024, at 9:53 AM, revealed revealed Resident 37 with what appeared to be several days of facial hair growth.

On February 21, 2024, at 1:30 PM, the NHA and DON were made aware of the observations of Resident 37's facial hair and questioned if this was Resident 37's preference. They stated they would look into it.

Observation of Resident 37 on February 22, 2024, at 9:31 AM, revealed Resident 37 continued with several days of facial hair growth.

During an interview with the NHA, DON, and ADON on February 22, 2024, at 11:56 AM, the ADON stated that residents should be shaved on their scheduled shower days.

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

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on observation, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident 12).

Finding include:

Review of facility policy, titled "wound care and pressure ulcer care", with an update date of November 30, 2018, failed to reveal guidance for hand hygiene during wound care.

Review of facility policy, titled "hand hygiene", with a revision date of November 30, 2022, revealed procedure section B read, in part, "hand hygiene is performed using hand washing or ABHR (alcohol based hand rub) before and after the following scenarios: before and after direct contact with residents, before performing any non-surgical invasive procedures, before handling clean or soiled dressing, gauze pads, etc., after removing gloves or an entire set of PPE (personal protective equipment), before performing an aseptic task"; and section H, which read "the use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as best practice for preventing healthcare-associated infections."

Review of Resident 12's clinical record revealed diagnoses that included pressure ulcer of other site, unstageable (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar) and candidiasis (fungal infection caused by a yeast).

Review of Resident 12's current physician orders revealed a treatment order dated February 12, 2024, to cleanse the left lateral foot with normal sterile saline (NSS), apply medihoney (ointment with anti-inflammatory effects) to the wound bed, and cover with foam adhesive dressing daily and as needed (PRN).

Observation of Resident 12's wound care on February 21, 2024, at 12:04 PM, revealed Employee 5 (Licensed Practical Nurse) preformed ABHR prior to donning a gown and gloves. During the wound treatment and dressing change, it was observed that Employee 5 failed to preform hand hygiene after removing the soiled dressing and donning clean gloves. It was also observed that Employee 5 failed to perform hand hygiene and change of gloves between cleansing the wound and applying a new dressing.

During the observation, Employee 5 failed to provide a barrier between Resident 12's wound and bed linens. After removal of the old dressing, Employee 5 placed Resident 12's left foot on the bed with the wound bed directly touching the bed linens. It was also observed that when Employee 5 cleansed the wound with NSS, liquid drained onto the bed linen causing a wet spot. Employee 5 failed to provide clean and dry linens, and placed Resident 12's left foot over the wet/soiled linen prior to covering Resident 12's foot with the top blankets.

During a staff interview on February 21, 2024, at 1:48 PM, with the Director of Nursing (DON) in the presence of the Nursing Home Administrator, the DON stated it is the expectation of the facility that hand hygiene policies would be followed.

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

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Observations:

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of two residents reviewed (Resident 84).

Findings include:

Review of Resident 84's clinical record revealed diagnoses that included cerebral infarction (a stroke-damage to the brain from interruption of its blood supply), anoxic brain damage (injury to the brain that occurs when the oxygen supply to the brain is compromised or interrupted), and muscle weakness.

Review of Resident 84's physician orders revealed an order for Resident to wear bilateral resting hand
splints during the day to prevent contracture of wrist and fingers. Approach: Bilateral resting hand splints to be worn four hours a day, three times a week. Off for self-care, ROM (range of motion), skin checks, monitor for skin breakdown, dated January 31, 2024.

Observation of Resident 84 on February 20, 2024, at 10:38 AM, revealed that they had both of their hands closed and both of their hands were bent inwards toward the inner arm with no resting hand splints noted to be present on Resident 84, nor were they noted to be visible in Resident 84's room.

Subsequent observations on February 20, 2024, at 2:07 PM; February 21, 2024, at 9:55 AM; and February 21, 2024, at 12:15 PM, all revealed the same findings as above.

During an interview with the Director of Nursing (DON) on February 21, 2024, at 12:20 PM, the aforementioned observations were shared and splint documentation was requested.

During a follow-up interview with the DON on February 21, 2024, at 12:36 PM, she indicated that the splints had been removed for care earlier and that they had now been reapplied. All additional observations above were again shared with the DON, and she said she would follow back up with nursing staff for additional information.

During an interview with the Nursing Home Administrator (NHA) and DON on February 21, 2024, at 2:00 PM, all aforementioned observations were shared and splint documentation was again requested.

Observation of Resident 84 on February 22, 2024, at 9:15 AM, again revealed that they had both of their hands closed and both of their hands were bent inwards toward the inner arm with no resting hand splints noted to be present on Resident 84, nor were they noted to be visible in Resident 84's room.

During an interview with the NHA and DON on February 22, 2024, at 10:21 AM, the observation of Resident 84 at 9:15 AM was shared and splint documentation was requested.

During an interview with the NHA and DON on February 22, 2024, at 12:12 PM, the NHA indicated that they had put a sheet in the restorative book yesterday for staff to track specific times that the splints were applied. When asked if they had documentation prior to yesterday in regard to Resident 84's splint program, the NHA indicated that this information was documented on paper and was located in a binder on the unit. He further indicated that Resident 84 did not have their splints on today because it was their "rest day." Splint documentation was again requested for review.

Review of Resident 84's "Restorative Nursing" form, undated but appeared to be February 2024's documentation, provided by the facility indicated that Resident 84's program was established on January 24, 2024, and that Resident 84's goals were: "1) PROM (passive range of motion)/AAROM (active assistive active range of motion) BUE's[bilateral upper extremities] and BLE's [bilateral lower extremities] and 2) will wear bilateral resting hand splints 4 hours during the day to prevent contractures of the wrist and fingers." The form also indicated that the frequency of the program was 2-3 times a week.

Further review of this documentation revealed that Resident 84 was only documented as having their bilateral resting hand splints applied on February 2, 5, 9, 12, 13, and 20, 2024; that there were no documented refusals noted on the form; that their splints were not provided at a minimum of twice a week as ordered for the week of February 12-16, 2024; and as of February 22, 2024, at 1:00 PM, Resident 84 had only been provided their splints one time during the week of February 19-23, 2024. In addition, the form did not include the time applied or removed to ensure the ordered wearing schedule was followed.

During a final interview with the NHA and DON on February 22, 2024, at 1:25 PM, the NHA confirmed that he would expect Resident 84's ordered splint wearing schedule to be followed and that he thought the information was in place to show documentation of the splint wearing times. He again shared that, as of yesterday, they made changes to show a time on and time off to ensure Resident 84's wearing schedule would be followed.

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

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§483.25(g) Assisted nutrition and hydration.
(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)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Observations:

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper monitoring for acceptable parameters of nutritional status for one of 15 residents reviewed (Resident 20).

Findings include:

Review of facility policy, titled "Weights", last revised November 30, 2020, revealed, in part, "Notify Medical Provider, RNAC (Registered Nurse Assessment Coordinator), and Registered Dietitian within 24 hours, if the re-weight verifies a significant weight change for the resident. The Registered Dietitian will update/revise the resident's Care Plan to reflect the significant weight change, goals, and approached."

Review of Resident 20's clinical record revealed diagnoses that included protein calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets), dysphagia (difficulty swallowing), and type 2 diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin).

Review of Resident 20's care plan revealed a focus area of: "Feeding tube as a result of swallowing problems/dysphagia...and is at risk of...imbalanced nutrition. Physician documented malnutrition", last revised May 25, 2023, with an intervention for "Dietitian to assess per policy and make recommendations as indicated", last revised June 22, 2018.

Review of Resident 20's medical record revealed a significant weight gain of 12 pounds from November 4, 2023, to December 3, 2023, and then a significant weight loss of 21.4 pounds from January 2, 2024, to January 6, 2024, confirmed by a re-weigh measure on January 7, 2024.

Review of Resident 20's clinical record failed to reveal any nutrition assessments in response to the aforementioned significant weight changes, and that no nutritional assessments were conducted on Resident 20 between the dates of November 17, 2023, and February 15, 2024; the significant weight changes were not mentioned in the nutritional assessment on February 15, 2024.

During an interview with Employee 6 (Registered Dietitian) on February 22, 2024, at 10:14 AM, the surveyor revealed the concern with the lack of nutritional assessments completed in response to significant weight changes, and Employee 6 replied, "I see where you are coming from."

Interview with the Nursing Home Administrator (NHA) on February 22, 2024, at 12:15 PM, revealed he would expect comprehensive nutritional assessments to be completed in response to significant weight changes.

28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(1)(3) Nursing services

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:

§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 observation, clinical record review, and staff interview, it was determined that the facility failed to follow physician orders for residents receiving tube feedings for one of seven residents reviewed for tube feedings (Resident 31).

Findings Include:

Review of Resident 31's clinical record revealed diagnoses that included acute and chronic respiratory failure, paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within seven days), and chronic kidney disease stage 4 (kidneys are moderately or severely damaged and are not working as well as they should to filter waste from the blood).

Review of Resident 31's current physician orders revealed an order dated October 27, 2023, for enteral feed (also known as tube feeding, is a way of sending nutrition right to the stomach or small intestine), Nepro at 50 mL/hour with free water flush of 40 mL every hour.

Observation of Resident 31's feeding tube on February 20, 2024, at 11:29 AM, and February 21, 2024, at 9:49 AM, revealed Resident 31's feeding pump was set to give a free water flush of 50 mL every hour.

During an interview with the Nursing Home Administrator and Director of Nursing on February 22, 2024, at 1:25 PM, they stated that water flushes should be administered per physician's order.

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

483.25(n)(1)-(4) REQUIREMENT Bedrails:

§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.

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

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

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

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

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

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

Observations:

Based on observation, clinical record review, facility policy review, and staff interview, it was determined that the facility failed to maintain infection control practices to prevent the spread of infection for one of 13 residents reviewed (Resident 12).

Findings include:

Review of facility policy, titled "wound care and pressure ulcer care", with an update date of November 30, 2018, revealed section titled procedure B 4, " Discard the dressing and gloves in the waterproof red trash bag."

Review of Resident 12's clinical record revealed diagnoses that included pressure ulcer of other site, unstageable (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar) and candidiasis (fungal infection caused by a yeast).

Review of Resident 12's current physician orders revealed a treatment order dated February 12, 2024, to cleanse the left lateral foot with normal sterile saline (NSS), apply medihoney (ointment with anti-inflammatory effects) to the wound bed, and cover with foam adhesive dressing daily and as needed (PRN) and lifetime contact precautions related to MDR candida auris colonization (multi-drug resistant yeast).

Review of Resident 12's plan of care revealed the resident is at risk for infection related to positive candida auris PCR (polymerase chain reaction) and is to have lifetime contact precautions related to MDR candida auris colonization with an intervention for all disposables to be placed in a red trash bag.

Observation of Resident 12's left lateral foot pressure ulcer dressing change on February 21, 2024, at 12:04 PM, revealed Employee 5 removed the dressing that was covering Resident 12's pressure ulcer and placed it in a clear, plastic trash bag. Employee 5 then proceeded to perform the rest of Resident 12's dressing change. Upon completion of the dressing change, Employee 5 was observed tying the trash bag closed and discarding it in the trash bin in Resident 12's room, which did not contain a red biohazard bag (a container for materials that have been exposed to blood or other biological fluids).

During a staff interview on February 21, 2024, at 1:48 PM, with the Director of Nursing (DON) and in the presence of the Nursing Home Administrator, the DON revealed it was the expectation of the facility that Employee 5 would have followed facility policy and disposed of Resident 12's trash in a red bag and trash receptacle.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 211.12(d)(1)(5) Nursing services

483.80(b)(1)-(4) REQUIREMENT Infection Preventionist Qualifications/Role:

§483.80(b) Infection preventionist
The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must:

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

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

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

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

Observations:
Based on review of regulations, facility policy review, and staff interviews, it was determined that the facility failed to have an Infection Preventionist (IP) that worked at least part time at the facility.

Findings Include:

The Centers for Medicare and Medicaid Services regulation states, "The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility ' s IPCP. The IP must: Work at least part-time at the facility. ... The IP must physically work onsite in the facility. He/she cannot be an off-site consultant or perform the IP work at a separate location such as a corporate office or affiliated short term acute care facility."

Review of facility policy, titled "Infection Preventionist", with a review date of November 30, 2023, revealed "The IP works at least part-time at the facility."

During an interview with the Nursing Home Administrator (NHA) on February 21, 2024, at 11:41 AM, he stated that the prior IP left the role in December 2023 and Employee 2 has been the designated IP since then. He further stated that they have hired a new IP, but she has not yet completed the required IP training. He stated that Employee 2 comes to the facility about "two or more times per month."

At that time, the NHA was made aware that the IP needed to work at least part-time at the facility and be physically present at the facility. The NHA acknowledged understanding.

During an interview with Employee 2 on February 22, 2024, at 10:16 AM, she stated that she took over the IP role in January 2024 and confirmed that she is only physically in the building "a few times a month." Employee 2 stated that will change going forward.

On February 22, 2024, at approximately 11:30 AM, Employee 2 provided an updated Infection Preventionist policy, with an updated date of February 22, 2024. The updated policy now stated that the IP "Must work physically onsite at the facility- the infection preventionist cannot be an offsite consultant or perform the infection preventionist's work at a separate location."

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management

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