Pennsylvania Department of Health
CLIVEDEN NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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CLIVEDEN NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  191 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.
CLIVEDEN NURSING AND REHABILITATION CENTER - 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 a complaint, completed on August 30, 2024, it was determined that Cliveden Nursing and Rehabilitation Center, 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:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(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 observation and interviews with residents and facility staff, it was determined that the facility failed to provide care and services to enhance residents' dignity related to serving meals on disposable paperware, serving residents meals timely on one of three dining rooms (Third floor dining room) and no catheter dignity bag for one of 28 Residents reviewed (Resident R244).

Findings include:

Observations during the initial tour of the facility on August 27, 2024, at 10:50 a.m. in Resident R244's room revealed that resident had an indwelling foley catheter in place and that the urine collection bag attached to the catheter was hanging from the side of the bed not covered with a dignity bag exposing a clear plastic bag with a amber colored fluid inside of it. The urine collection bag was clearly visible through the doorway hallway.

Interview with the Licensed nurse, Employee E9, on August 27, 2024, at 11:15 a.m. confirmed that Resident R100's catheter bag, which was hanging on the side of her bed, was visible from the doorway and was not covered. During further interview with Employee E9, she stated that the urine collection bag should be in a dignity bag, or the privacy curtain should be drawn.

Dining observation was made on the third floor in the dining room on August 27, 2024 starting at 12:18 p.m. There were 22 residents present and seated in the dining room waiting on their mails. At 12:23 p.m. the first food truck arrived on only 12 of the 22 residents were served their meals. At one table 4 were served and 2 were missing their meals. At the second table four were served and one was missing their meal. At the third table 3 were served and two were missing their meals. At the fourth table 3 were served and 1 was missing their meal. There were also 2 residents seated alongside the wall not served with their tray tables in front of them. When asked about the timing of the meals, the nurse aide Employee E12 stated that she would prefer that all residents' trays in the dining room are brought up at the same time but it hasn't been. Employee E12 stated the second food truck usually does not arrive till closer to 1:00 p.m. Continued observation revealed the second truck came up to the dining room at 12:55 p.m. Nurse aide Employee E13 began passing on the food to the remaining residents, and she did not take the food of the trays when placing them in front of the residents. Resident R7 who needed feeding assistance was served his food tray at 12:58 p.m. but did not receive the assistance for eating until 1:09 p.m. due to nurse aides Employee E12 and E13 feeding two other residents first.

Observations during the lunch meal on August 28, 2024, at 12:25 p.m. in the third-floor dining room revealed facility staff delivering trays to the residents who were sitting at tables in the dining room. Further observation revealed clear plastic disposable cups with lids on multiple trays containing applesauce and a yellow pudding like substance which was being served to many residents. Further observation revealed that the residents were not offered clothing protectors and several residents had food spilled on their clothing and that they ate their food from the trays for the entire meal.

Interview with the Administrator on August 30, 2024, at 12:10 p.m. confirmed that in the dining room staff would be expected to offer clothing protectors and to remove the meal from the tray when serving in the dining room.

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

28 Pa. Code: 201.29(a) Resident rights





 Plan of Correction - To be completed: 10/14/2024

1. Urinary drainage bag was visible for 1 resident (R244). Dignity bag was provided for resident.
2. Timely tray arrival from the kitchen. 3. Trays on the meal truck to coincide with resident seating in 3rd floor dining room.
4. Nursing staff removing items from their tray and placing on table in front of resident.
5. Clothing protectors offered to residents.
6. Initiating feeding of all residents in the dining room at the same time.
1. A list of all residents with a urinary drainage bag was compiled and if a resident was listed they were evaluated. If a dignity bag/cover was not present one was applied.
2. Updated tray truck arrival schedule. 3. Seating chart given to dietary department for all 3 meals so trays can be placed in the appropriate tray truck. 4. Staff educated on tray distribution protocol. Tray distribution.
5. Staff educated on offering clothing protectors to residents at meal times. 6. Staff educated on ensuring feeders are assigned to the dining room as appropriate.
Staff will be educated on the following then an audit will be done weekly times 4 then monthly times 2 of residents' with urinary drainage bags; checking for the presence of a dignity bag/cover.
An audit will be done of the 3rd floor dining room practices: Checking the times food truck arrived onto the 3rd floor dining room.
Trays were able to be distributed by table, according to seating chart.
Food items were removed from trays in front of residents and empty trays placed on food truck.
Clothing protectors offered or utilized. Feeding initiated timely.
Audits will be reviewed by the DON or ADON then the results documented in the monthly QAPI meeting
483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.60(i) Food safety requirements.
The facility must -

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

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

Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Findings include:

An initial tour of the Food Service Department was conducted on August 27, 2024, at 9:30 a.m. with Employee E4, Food Service Director (FSD), which revealed the following:

Observation in the receiving area revealed trash including paper and plastic on the ground near the door and dumpster.

Observation in the walk-in refrigerator revealed a dark substance on the walls and an accumulation of dirt and dust on the floor, especially in the corners.

Observation in the hot food production area revealed a prep table with the undershelf setting directly on the ground, the shelf was pitted with rust colored stains and there was no way to clean under it without moving it.

Further observations revealed the outsides of the convection oven and reach-in refrigerator were covered with a layer of grease and grime, and the door gaskets were torn on the right door of the reach in refrigerator. The interior of the convection ovens were also covered in a build-up of dark colored baked on coating of burned food.

Observations of the dish machine revealed a build-up of light brownish substance in the corners of the top of the machine.

Interview with FSD on August 27, 2024, at 9:45 a.m., confirmed the above findings.

28 PA Code: 201.14(a) Responsibility of licensee.

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


 Plan of Correction - To be completed: 10/14/2024

FSD and staff will be educated to ensure ensure that food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety.

FSD/designee will do audit random trays 2X weekly X4 then monthly X2 to monitor.

Results will be reviewed in QAPI and determined if further review is necessary.
483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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.
§483.35(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 yearly performance reviews for nurse aides.

Findings include:

On August 29, 2024, at 12:39 p.m., an email was sent to the Nursing Home Administrator, Employee E1 requesting evidence of yearly performance reviews for nurse aides.

During an interview on August 30, 2024, at 10:15 a.m. the Director of Nursing, Employee E2 stated that there were "no yearly reviews" for the nurse aides.

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

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




 Plan of Correction - To be completed: 10/14/2024

No retroactive corrective action
An audit will be conducted to identify what outstanding performance evaluations need to be completed.
Monthly list from HR of the C.N.A.'s that require evaluations for the month given to the DON. Completed evaluations will be given to the DON or his/her designee at the end of each month due then turned into HR for the staffs' file. HR/designee will audit evaluation returned from DON to ensure timely completion monthly. Audit monthly times 3.
The number of completed evaluations will be reported to QAPI monthly.
483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff: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.
§483.35 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 personnel records and interview with staff, it was determined that the facility did not provide requested evidence of competency trainings for licensed nursing staff for four of four employees records review. (Employees E9, E18, E20, and E21)

Findings include:

On August 29, 2024, at 2:15 p.m., the surveyor requested skills competency evaluations for Licensed Nurses, Employees E9, E18, E20, and E21. The requested skills were to related to medication administration, oxygen administration, care of gastrostomies and administration of nutrition, tracheostomy care, wound care, and abuse prevention and reporting.

In an interview on August 30, 2024, at 10:30 a.m. with the Nursing Home Administrator, Employee E1, stated that the facility was unable to supply the surveyor with all of the requested skills competencies for the nurses, stating that they "didn't have" them.

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

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






 Plan of Correction - To be completed: 10/14/2024

No retroactive corrected action.
An audit will be conducted to determine what competencies are missing for current licensed nurses.
Licensed nurses will be educated and competencies completed for med, oxygen, and nutrition administration, care of gastrostomies, trach and wounds. All staff are educated in abuse prevention and reporting.
Audits of education and competency completion to be done weekly times 4 then monthly times 2. Completion of competencies will be reported in monthly QAPI.
483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observations and interviews with residents and staff, it was determined that the facility failed to provide a drawer or cabinet in the resident's room that can be locked for storage of the resident valuable items for two of 35 residents reviewed.

Findings include:

Review of facility policy, Inventory of Resident Personal Belongings/ Property, revised July 1, 2023, revealed that, "Money, jewelry, or collectibles should be kept in a lock drawer. If a resident doesn't have a key, one will be provided."

Observations during the initial tour of the second-floor nursing unit on August 27, 2024, at 11:30 a.m. in room 204, bed A revealed a wardrobe with a silver hasp, but no lock and the top drawer on the chest next to her bed had a lock. Interview with Resident R77, who lives in Room 204, Bed A, revealed that she was missing almost all of her tops, and that they told her that they would lock them in her wardrobe so that they would be safe, but she did not have a lock for the wardrobe. She further stated people steal everything, and that she did not have the key for her locking top drawer where she could store valuables.

Observations during the initial tour of the second-floor nursing unit on August 27, 2024, at 11:35 a.m. in room 207, bed A revealed that the top drawer on the chest next to her bed had a lock. Interview with Resident R51, who lives in Room 207, Bed A, revealed that she was missing a lot of clothing, including T-Shirts, sweatshirts and sweat pants, and soaps and sprays that her family had brought her. She said that she did not have a key to her locked drawer to keep her valuables.

Interview with the Unit Manager, Employee E7, on the second-floor nursing unit on August 27, 2024, at 11:45 a.m. confirmed that these residents did not have keys to their locked drawers to protect their valuables.

Interviews with residents during Resident Council on August 29, 2024 at 10:00 a.m. revealed residents had complaints about money being stolen from their rooms and clothing items being taken to be laundered and never being returned.

Resident R55 stated at 10:20 a.m. that the evening before she had approximately $20.00 to $30.00 dollars stolen from her during the night shift. She reported that she told the nurse on shift about the stolen money, but nothing has yet to be done. Resident R55 also stated that she had a family member buy her fifteen pairs of socks a few months ago due to none of her socks coming back in the laundry. Resident R55 stated that at this point she does not currently have any socks. Resident R55 showed the surveyor her shoes and stated she did not have any socks on which was observed. Review of the facility grievance log from the last six months revealed no grievance completed for Resident R55.

Resident R89 stated at 10:23 a.m. during resident council that he has had clothing stolen and nothing has been done about it. Resident R89 stated that his sister bought new clothes a few weeks ago to replace clothing that has been missing. Resident R89 stated that he reported the clothing being stolen six weeks including jeans from his room. Resident R89 stated that his sister now does his laundry so that his items will not be stolen or not returned. Review of the facility grievances for the last six months revealed no grievances completed for Resident R89.

At 10:40 a.m. Resident R98 stated that he had clothing taken to the laundry and a lot of them had not been returned. Resident R98 stated that a lot of the items were labeled with his name and still were not returned. When asked if the resident mentioned this to staff he stated, "I mention it to everyone I see because I want my stuff back". Resident R98 stated that this has been going on for several weeks. Review of the facility grievance log revealed no grievance form completed for Resident R98.

Review of the facility grievances revealed Resident R31's family filed grievance on July 20, 2024 in regards to missing clothing and missing a virtual assistance device. The "Findings and Disposition" of the form revealed, "Room was searched for missing belongings and condition of room. [virtual assistance device] was not found after searching both sides of room. Recreation therapy loaned one to the daughter to program its intentions."

Review of Resident R31's clinical record revealed no inventory sheets had been completed for the resident since his admission on October 7, 2023. There was no evidence that Resident R31's item would be replaced or that the family would be reimbursed for the item. There was also no evidence of the facility completing a new inventory sheet for the resident.

28 Pa. Code 204.5 (f) Resident Rooms.




 Plan of Correction - To be completed: 10/14/2024

Facility will ensure to provide a drawer or cabinet in the identified resident rooms that can be locked for storage of the resident valuable items.

Maintenance was educated to ensure to provide a drawer or cabinet in residents room that can be locked for storage of the resident valuable items.

Maintenance director/designee will do random audits 1X weekly X4 then monthly X2 to monitor.

Results will be reviewed in QAPI and determined if further review is necessary.
483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions: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(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.
Observations:

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that a resident was allowed to participate in decisions regarding medical appointment requests for one of twenty-eight residents reviewed. (Resident 135).

Findings Include:

Interview with Resident R135 on August 27, 2024 at 9:52 a.m. revealed the resident had concerns with seeing outside physicians which she had mentioned multiple times and no one ever followed through with giving her an answer or scheduling any appointments with her.

Review of Resident R135's clinical record revealed on August 1, 2024 there was an Interdisciplinary Progress Note that stated, "Care Conference scheduled on 8/1/24. IDT (Interdisciplinary Team) visited with resident by bedside. Resident had concerns for nursing and the in-house physician. Resident wishes to get vitamin supplements D-3, to get print out of all their medications getting. Requesting to see the cardiologist specialist at (hospital). Wanting to get a MRI x-ray to check why not using legs. Requested to be updated when they had a virus several months ago. Aware of the POLST code status."

Interview with the Director of Nursing Employee E2 on August 30, 2024 at 2:12 p.m. revealed the physician was aware of the requests made by Resident 135 but had not yet followed up on them.

28 Pa Code 201.18(b)(2) Management

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







 Plan of Correction - To be completed: 10/14/2024

Dr. Cohen was notified of R135 request to be seen by outside physicians and MRI that she feels she needs done. Physician was verbally notified and a note of the above documented in the residents' record. No harm to resident
A look back of 30 days of care conference progress will be done to determine if any other resident request for outside physician care was requested and if follow up had been addressed. Nurses will notify physician and document findings in their individual record.
Nursing staff will be educated to notify physician of residents' request to see outside physicians and/or test and document. Random audit will be done weekly of residents' request for tests and outside physician visits times 4 then monthly times 2. Audits will be reviewed by the DON and her/his designee for appropriate F/U.
Audits will be reviewed in monthly QAPI mtg, and further follow up will be determined at that time.

483.10(g)(4)(i)-(vi) REQUIREMENT Required Notices and Contact Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including:
(i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes -
(A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section;
(B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act.
(C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and
(D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.
(ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.)
(iii) Information regarding Medicare and Medicaid eligibility and coverage;
(iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program;
(v) Contact information for the Medicaid Fraud Control Unit; and
(vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.
Observations:

Based on the tour of facility, observations and interviews with staff, it was determined the facility failed to ensure State Department of Health information was posted visible in a prominent place to residents in two out of three of the units. (Second Floor and Third Floor)

Findings include:

On August 28, 2024 at approximately 11:11 a.m. a tour of the facility with Social Worker, Employee E14 and it was determined that only one of three units had the State Department of Health contact information posted and visible for residents and/or family.

The first floor has a paper printed State Department of Health signs with small print that were posted in a glass case before you entered unit one. The printed paper we posted high in the glass case which would make it non-visible for residents who were wheelchair bound.

A tour of the second-floor nursing unit revealed no printed State Department of Health signs located on the unit.

A tour of the third-floor nursing unit revealed no printed State Department of Health signs located on the unit.

Social Worker Employee E14 confirmed the facility failed to ensure that the process for filing a complaint and the State Department of Health Hotline number was posted as required.

28 Pa. Code 201.20(a) Resident rights.





 Plan of Correction - To be completed: 10/14/2024

Facility ensured that the the State Department of Health Hot line number was posted as required for all units.
Random audits will be done weekly X4 then monthly X2 to ensure that the state number is posted.
Results will be reviewed in QAPI and determined if further auditing is necessary.
483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records: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(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:

Based on observation, staff interview, review of clinical record, it was determined that the facility failed to maintain privacy related to personal privacy during tracheostomy care and sensitive patient health information during medication administration for three of 28 residents reviewed (Resident R9, Resident R121, and Resident R97).

Findings include:

Medication administration observation with Licensed nurse, Employee E18 conducted on August 28, 2024, at 9:05 am revealed that after preparing the morning medications for Resident R9 Employee E18 went inside Resident R9's room to give her medications.

Further observation revealed that Employee E18 left her laptop open with the laptop facing the hallway with Resident R9's medical information visible.

Further medication administration observation with Employee E18, revealed that, during medication administration for Resident R121, after preparing the morning medications for Resident R121, Employee E18 went inside Resident R121s room to give him his medications.

Further observation revealed that Employee E18 left her laptop open with the laptop facing the hallway with Resident R121s medical information visible.

Interview with Employee E18 conducted after the medication administration observation confirmed that the laptop was left open unattended while she went inside Resident R9 and Resident R121.

Tracheostomy care observation for Resident R97 with Licensed nurse, Employee E17 conducted on August 30, 2024, at 8:50 am revealed that Resident R97 was in a single room. Further, there was no privacy curtain around Resident R97's bed.

Further observation revealed that after Licensed nurse, Employee E17 finished setting up the dressing kit and the dressing supplies, Employee E17 started to perform the tracheostomy care on Resident R97.

Further observation revealed that the door to the resident's room was left open the entire time nurse was performing trach care with Resident R97 visible from the hallway.

Interview with Licensed nurse, Employee E17 conducted after the tracheostomy care was completed, confirmed that the door was left open during the tracheostomy care.

Interview with Employee E2 conducted on August 30, 2024, at 9:38 a.m. revealed that the facility did not have a policy for privacy.


28 Pa. Code 210.29(i) Resident rights


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



 Plan of Correction - To be completed: 10/14/2024

Education was given to nursing staff in reference to ensuring resident privacy when providing any type of care to a resident. Education was also given to licensed nursing staff on utilizing the privacy screen during med pass.
Observations during rounds with emphasis in resident privacy during med pass times and when the majority of resident care and treatments are being done on each unit
Education was given to nursing staff in reference to ensuring resident privacy when providing any type of care to a resident. Education was also given to licensed nursing staff on utilizing the privacy screen during med pass. Audit will be done of observations for privacy violations that includes re-education when found.
Random audits will be done weekly times 4 then monthly times 2, then reviewed by the DON or his/her designee then reported to monthly QAPI meeting.
483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

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

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

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


Based on observations, review of facility policy, review of facility records, and interviews with residents and staff, it was determined that the facility failed to ensure that grievance forms were accessible for residents who wish to file a grivance anonymously and there was no grievance box availble on two of three nursing floors (First and Third floor).

Findings Include:

Review of facility policy titled, "Grievance Program" dated April 1, 2022 states, "Purpose: To promote an environment and culture open to feedback positive and or negative from residents, family members, employees, physicians, and any other visitors. Both positive and negative comments from these individuals helps to provide information which will be incorporated into policies, procedures, and practices within the organization that focus on creating a culture of excellence through identification and resolution within continuous quality improvement. Right to file Grievances: residents and visitors have the right to present concerns/grievances on behalf of himself or herself or others to the staff or administrator of the facility either verbally or in writing, to governmental officials, or to any other persons; to file grievance anonymously; to receive a written decision related to the grievance filed, if requested; to recommend changes in policies and services to facility personnel; and to join with other residents or individuals within or outside the facility to work for improvements in resident care, and be free of restraint, interference, coercion, discrimination, or reprisal."

Review of the facility "Resident Concern Report" revealed that there was no place to check off that the form was being filled out anonymously.

A tour of the facility was taken on August 28, 2024 at 11:11 a.m. with Social Worker Employee E14. A tour of facility revealed that there were no grievance forms located throughout the facility that were accessible for residents to obtain anonymously. The tour of the facility also revealed there was no grievance box on the first or third floor nursing units allowing residents to turn in anonymous grievances. The grievance box located on the social workers office on the second floor is high up on the door, not allowing for residents who are wheelchair bound to turn in grievance forms anonymously.

Interview with Social Worker Employee E14 on August 28, 2024 at 11:15 a.m. revealed that residents must obtain a copy of the Resident Concern Report from a social worker or from a nurse at the nurses station currently. Resident Concern Reports are located on the door of the social workers office on the second floor, but this is in the administration office, where there is a sign stating residents are not welcome to enter. Further interview with the Social Worker Employee E14 revealed there are no grievance logs that are accessible prior to June 2024 due the facility not keeping a log of facility grievances.

Interview with Nursing Home Administrator Employee E1 on August 28, 2024 at 12:24 p.m. confirmed there is no facility grievance log available prior to June 2024. Employee E1 stated that the previous Nursing Home Administrator was not keeping a log of grievances each month. Employee E1 stated that there were some grievance forms available for January 2024 through May 2024, but the facility may be missing some due to a process not being in place for filing them.

Interviews held during resident council on August 29, 2024 at 10:00 a.m. revealed residents stated that they did not know how to file a grievance form including Residents R55.

Interviews held during resident council on August 29, 2024 at 10:00 a.m. revealed several residents stated that they did not have any resolve to grievances formed regarding missing clothing items including Residents R55, R89, and R98.

Resident R55 stated at 10:20 a.m. that the evening before she had approximately $20.00 to $30.00 dollars stolen from her during the night shift. She reported that she told the nurse on shift about the stolen money, but nothing has yet to be done. Resident R55 also stated that she had a family member buy her fifteen pairs of socks a few months ago due to none of her socks coming back in the laundry. Resident R55 stated that at this point she does not currently have any socks. Resident R55 showed the surveyor her shoes and stated she did not have any socks on which was observed. Review of the facility grievance log from the last six months revealed no grievance completed for Resident R55.

Resident R89 stated at 10:23 a.m. during resident council that he has had clothing stolen and nothing has been done about it. Resident R89 stated that his sister bought new clothes a few weeks ago to replace clothing that has been missing. Resident R89 stated that he reported the clothing being stolen six weeks including jeans from his room. Resident R89 stated that his sister now does his laundry so that his items will not be stolen or not returned. Review of the facility grievances for the last six months revealed no grievances completed for Resident R89.

At 10:40 a.m. Resident R98 stated that he had clothing taken to the laundry and a lot of them had not been returned. Resident R98 stated that a lot of the items were labeled with his name and still were not returned. When asked if the resident mentioned this to staff he stated, "I mention it to everyone I see because I want my stuff back". Resident R98 stated that this has been going on for several weeks. Review of the facility grievance log revealed no grievance form completed for Resident R98.

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

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









 Plan of Correction - To be completed: 10/14/2024

Facility ensured that grievance forms were accessible for residents who wish to file a grievance anonymously on all units.
Random audits will be done weekly X4 then monthly X2 to ensure that grievance forms are accessible.
Results will be reviewed in QAPI and determined if further auditing is necessary.
483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on clinical record review and interview with staff, it was determined that the facility did not ensure that resident assessments accurately reflected resident status related to discharge for one of three closed records reviewed (Resident R141).

Findings include:

Review of clinical documentation revealed that Resident R141 was admitted to the facility on February 8, 2024, and discharged from the facility on June 11, 2024. A nursing note written on June 11, at 8:11 p.m. stated, "Resident discharged. Left facility at about 5pm via medical transport with family. All scripts and personal belongings were taken by family prior to discharge. Home care services referral in place". The resident's discharge instructions, signed by licensed nurse, Employee E15, on June 11, 2024 included referral for homecare physical therapy and occupational therapy services.

Review of the resident's discharge MDS (Minimum Data Set, a periodic evaluation of resident needs), section A2105, Discharge Status, signed on June 14, 2024, by the Registered Nurse Assessment Coordinator, Employee E16, stated that the resident was discharged to a "short-term general hospital".

Interview with employee E16, on August 29, 2024, at 1:30 p.m. revealed that the resident had been discharged to his home by staff, and that the assessment had been coded in error.

28 Pa Code 211.5(f) Clinical records





 Plan of Correction - To be completed: 10/14/2024

MDS, resident assessment accurately reflects the resident status for (R141), a closed record was corrected during the survey when it was bought to the RNACs' attention.
RNAC's reviewed August and Septembers MDSs' for accuracy and found none that needed corrections.
RNACs' were educated to ensure accuracy of resident assessments. The RNAC's will audit 5, discharge resident MDSs' for accuracy and correct as appropriate for 5 per month times 3 months.
Audits will be reviewed by the DON or his/her designee then reported to monthly QAPI meeting.
483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:

Based on review of facility policies, review of clinical records, and staff interviews, it was determined at the facility failed to develop a baseline care plan that includes the instructions needed to provide effective and person-centered care within 48 hours of admission for respiratory care, pressure ulcer, catheter, and pain for three of twenty-eight residents reviewed (Residennt R130, Resident R138 and Resident R444).

Findings include:

Review facility policy for baseline care plan, comprehensive care plan, and ongoing care plan updates dated April 1/20/22. Reveal that under section "Policy Statement": Bedrock Care will follow a uniform process for initiating the baseline care plan upon admission, the Comprehensive Care Plan upon CAA completion and ensuring care plans are updated to reflect the resident's status. Under subsection baseline care plan. The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. The baseline care plan will: #1. Be developed within 48 hours of a residence admission; #a. The admitting nurse will initiate baseline care plan in facility electronic health record utilizing the nursing admission assessment and the admission Used Defined Assessment (UDA's), orders, and clinical knowledge of the resident. #2. Include the minimum health care information necessary to properly care for your resident, including but not limited to; #a. Initial goals based on admission orders, #b. Physician orders, #c. Dietary orders, #d. Therapy services, #e. social services, and #f. PASARR recommendations if applicable. The facility will provide the resident and the representative with the summary of the baseline care plan when requested. That includes, but not limited to, the initial goals of the resident, and a summary of the resident's medications and dietary instructions. This written summary of the baseline care plan must be provided to the resident and or the representative by completion of the comprehensive care plan.

Review of Resident R130's clinical record revealed that Resident R130 was admitted to the facility on August 9, 2024, with diagnoses of Chronic Kidney Disease (A long standing disease of the kidneys leading to renal failure), Burn of unspecified body region, Severe Protein Calorie Malnutrition, Sepsis (is a life threatening emergency that happens when the body's response to an infection damages vital organs and often causes death).

Further review of Resident R130's clinical record revealed a physician's order obtained August 16, 2024 to insert Foley Catheter to promote sacrum wound healing.

Further review of Resident R130's clinical record revealed that there was no baseline care plan for the unrinary catheter developed within 48 hours of Resident R130's admission.

Review of Resident R138's clinical record revealed that Resident R138 was admitted to the facility on August 7, 2024 with diagnoses of Extradural and Subdural Abscess, Dorsalgia (Dorsalgia is a collective name given to a group of conditions that produce moderate to intense pain in the muscles, nerves, bones, joints, or other structures associated with the spinal column of the body.), Osteomyelitis of the vertebra (lumbar region) and infective myositis (Infectious myositis is a rare infection of the skeletal muscles caused by a variety of pathogens, including bacteria, fungi, viruses, and parasites.) of unspecified left leg, Opioid Abuse.

Further review of Resident R138'd clinical record revealed a physician's order for: Oxycodone oral tablet 10 milligrams, give 10 milligrams by mouth every six hours as needed for pain-ordered August 19, 2024, Roxicodone 10 milligram tablet, give 2 tablets by mouth every six hours as needed for pain for 10 days-ordered August 7, 2024, Ibuprofen oral tablets 600 milligrams, give one tablet by mouth three times a day for pain for 10 days-ordered August 7, 2024, Gabapentin Oral capsule 400 milligrams, give 2 capsules by mouth every eight hours for a neuropathy for 360 days-order date August 7, 2024, Acetaminophen Tablet 325 milligrams. Give 2 tablets by mouth every eight hours for pain, for 10 days- ordered August 7, 2024, Lidocaine external patch 5% applied to affected area topically in the morning for pain and remove per schedule-ordered August 8, 2024.

Further review of Resident R138's clinical record revealed that there was no baseline care plan for pain management developed within 48 hours of Resident R138's admission.

Review of Resident R444's clinical record revealed that Resident R444 was admitted to the facility on August 21, 2024, with diagnoses of Anoxic brain damage, Type 2 diabetes mellitus. Pressure ulcer, Tracheostomy Status (tracheostomy in place)

Review of Resident R444's clinical record revealed a physician's order for: Santyl external ointment, 250 units per gram, apply to sacrum topically every day shift for wound. Cleanse sacrum with NS (normal saline), pat dry apply Santyl ointment adaptic bordered dressing-ordered August 23, 2024, Santyl external ointment, 250 unit per gram apply to sacrum topically as needed for wound. Cleanse Sacrum with NS (normal saline), pat dry apply Santyl ointment, adaptic border dressing-order date August 22, 2024, #8 Shiley Cuffed/Non-Fenestrated trach every shift -Start Date-August 22, 2024, Oxygen humidification: O2 5 liters via trach collar, 28% humidification every shift 5L-Start Date- August 22, 2024, Suction trach PRN every shift-Start Date-August 22, 2024

Further review of Resident R444's clinical record revealed that there was no baseline care plan for wound-care, pressure ulcer or skin breakdown developed within 48 hours of Resident R444's admission.




28 Pa. Code 211.10(d) Resident care policies




 Plan of Correction - To be completed: 10/14/2024

Baseline Care Plans: were not completed for 3 of 28 residents for respiratory care, pressure ulcer, catheter and pain. No harm came to any resident. Care plans were completed for R130, R138, and R444.
Report obtained of admissions from last 6 weeks and care plans initiated and updated as needed.
Licensed nursing staff will be educated on ensuring care plans are initiated upon admission: Resident admitted, care plan initiated by during shift; care plan updated during next shift, care plan further updated revised during clinical rounds.
Random audit will be done weekly times 4, monthly times 2 insure completion of baseline care plans. The audits will be turned in to the DON or his/her designee and appropriate changes added. The audits will be reported to monthly QAPI.
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 review of facility policy, review of clinical records, and interviews with staff it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for three of twenty-eight residents reviewed. (Residents R31, R55, R97)

Findings Include:

Review of facility policy titled "Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates" dated April 1, 2022 states, "Policy Statement- Facility will follow a uniform process for initiating the baseline care plan upon admission, The Comprehensive care plan upon CAA completion, and ensure care plans are updated to reflect the resident's status". Further review of the policy states, "Ongoing updates to care plans- Nursing staff will update the care plan related to physician's orders and/or changes in care needs. The nursing staff will initiate and/or update acute care plans for the resident as they are warranted".

Resident R31 was observed on August 27, 2024 at 11:01 a.m. with oxygen on. Review of Resident R31's care plan revealed there was no current care in place for oxygen therapy. Review of Resident R31's current physician orders revealed an order for oxygen therapy that was initiated on September 30, 2023.

An interview held with the Director of Nursing, Employee E2 on August 30, 2024 at 12:02 p.m. confirmed Resident R31's current care plan did not have oxygen therapy included. Employee E2 provided a document that showed Resident R31 did have a care plan in place for Oxygen therapy but the focus was checked off as "resolved/cancelled".

Review of Resident R55's clinical record revealed the resident had a diagnosis of Dementia. Review of the resident's care plan revealed the resident did not have a care plan focus in place for the Dementia (progressive degenerative disease of the brain) diagnosis.

An interview with the Director of Nursing Employee E2 at 10:29 a.m. confirmed that Resident R55 did not have a current care plan focus in place for Dementia care.

Review of the clinical record for resident R97 revealed that he was admitted to the facility on April 28, 2021, and had diagnoses including, but not limited to, acute and chronic respiratory failure, aphasia (inability to process speech), anoxic brain damage (caused by going for an extended period of time without oxygen), and encounter for attention to gastrostomy (an opening made into the stomach through the abdominal wall, in this case for the purpose of inserting a tube to assist with feeding).

Review of the resident's care plan revealed that it included instructions for both "every shift Jevity 1.5 (a type of nutrition made to go through a gastrostomy tube) @65 mL x12 hrs TV = 780 mL via PEG" Which was ordered May 16, 2024, and "ISOSOURCE (another type of tube feed formula) 1.5 x20 hrs total volume=1,200 mL via PEG, which was ordered on May 11, 2024. According to review of the resident's physician orders, the isosource had been discontinued on May 16, 2024.

During an interview on August 30, 2024 at 11:00 a.m., the Director of Nursing, Employee E2, confirmed that only the Jevity order was active and that the care plan should have been revised to remove the isosource instrutions.

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








 Plan of Correction - To be completed: 10/14/2024

Comprehensive Care Plan: residents' care plan was updated/revised to reflect the resident's specific care needs for 3 of 28 residents. No harm came to any resident. Care plans were updated for R31, R55, R97.
Care plans were updated for R31, R55, R97. Care plans will be reviewed and updated during their scheduled care conferences and signed off as reviewed
Licensed nursing staff will be educated on care plan revisions during residents scheduled care conferences. Random audit will be done of care plans and care conference schedule to ensure compliance. The audit will be given to DON or his/her designee to review compliance, weekly times 4 then monthly times 2.
Report of audits will be given during monthly QAPI who will determine if goal has been met.
483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on a review of clinical records, review of facility policy, and interviews with residents and staff, it was determined the facility failed obtain a physican order for tracheostomy care and suctioning for one resident and failed to notify the physician after one resident missed medication doses for two out of 28 residents reviewed. (Resident R 97 and Resident R138)

Findings include:

Tracheostomy care observation for Resident R97 with Employee E17 conducted on August 30, 2024, at 8:50 am revealed that Employee E17 performed tracheostomy care dressing of tracheostomy site with normal saline, replaced the disposable inner cannula and suctioned Resident R97.

Review of Resident R97's clinical record revealed that there was no physician's order to suction Resident R97.

Interview with Director of Nursing, Employee E2 conducted on August 30, 2024, at 9:38 a.m. confirmed that there were no orders for suctioning. Employee E2 further stated that she will have an order for suctioning put in.

Review of Resident R138's clinical record revealed that Resident R138 was admitted to the facility on August 7, 2024 with diagnoses of Extradural and Subdural Abscess, Dorsalgia (Dorsalgia is a collective name given to a group of conditions that produce moderate to intense pain in the muscles, nerves, bones, joints, or other structures associated with the spinal column of the body.), Osteomyelitis of the vertebra (lumbar region) and infective myositis (Infectious myositis is a rare infection of the skeletal muscles caused by a variety of pathogens, including bacteria, fungi, viruses, and parasites) of unspecified left leg, Opioid Abuse.

Further review of Resident 138's clinical record revealed the following physician's order :
Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously one time a day for Infection for 32 Days-Start Date-08/08/2024-D/C Date-08/10/2024
Daptomycin- Sodium Chloride Intravenous Solution 500-0.9 MG/50ML- % Use 475 mg intravenously one time a day for Infection for 32 Days-Start Date-08/11/2024-D/C Date-08/19/2024
Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously at bedtime for Infection for 32 Days-Start Date-08/19/2024-D/C Date- 08/20/2024
Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously at bedtime for Infection for 32 Days-Start Date-08/21/2024

Reviews of Resident R138's MAR (medication administration record) for August 2024 revealed that on August 10, 2024, the MAR was coded "5"; on August 12. 2024, the MAR was coded "9"; on August 18, 2024, the MAR was coded "9"; on August 19, 2024, the MAR was coded "9"; on
August 25, 2024, the MAR was coded "5" and on August 27, 2024, the MAR was coded "9".

Review of the MAR Code Chart revealed that "5" was for "Hold/see progress note and "9" was for Other/see progress notes.

Review of Resident R138's progress notes revealed the following notes:

On August 26, 2024, 6:16 NOT GIVEN: Resident AAOx4, able to make needs known. Waiting on Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML, from pharmacy. Resident did not receive ABT I.V. There was no documented evidence that the physician was made aware that Daptomycin was not administered to Resident R138. Review of MAR revealed that the MAR was coded as given.
On August 25, 2024, 12:57 NOT GIVEN: Resident AAOx4, able to make needs known. Waiting on Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML, from pharmacy. Resident did not receive ABT I.V. Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML. There was no documented evidence that the physician was made aware that Daptomycin was not administered to Resident R138.
On August 25, 2024, 22:04 NOT GIVEN: Resident AAOx4, able to make needs known. Pharmacy was called and notified about ABT on Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML, from pharmacy. Pharmacy said it will arrive tomorrow by Noon. Resident did not receive ABT I.V. Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML on shift. There was no documented evidence that the physician was made aware that Daptomycin was not administered to Resident R138.
On August 25, 2024, 6:24 NOT GIVEN: Resident continues on I.V. ABT, no s/s of adverse reaction, afebrile during this shift. RUE PICC site in place, no s/s of infection, bleeding. Resident denies pain/discomfort during this shift. Resident didn't receive I.V. awaiting pharmacy to delivery later today, DON (director of nursing) made aware. There was no documented evidence that the physician was made aware that Daptomycin was not administered to Resident R138. There was no documented evidence that the physician was made aware that Daptomycin was not administered to Resident R138.
On August 25, 2024, NOT GIVEN: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously at bedtime for Infection for 32 Days Awaiting pharmacy to delivery. There was no documented evidence that the physician was made aware that Daptomycin was not administered to Resident R138.
August 19, 2024, 21:23 NOT GIVEN: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously at bedtime for Infection for 32 Days not administered, waiting pharmacy delivery, supervisor informed. There was no documented evidence that the physician was made aware that Daptomycin was not administered to Resident R138.
August 18, 2024, 11:21 NOT GIVEN: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously one time a day for Infection for 32 Days Medication unavailable, waiting on pharmacy. There was no documented evidence that the physician was made aware that Daptomycin was not administered to Resident R138.
August 12, 2024, 9:56 NOT GIVEN: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously one time a day for Infection for 32 Days pending delivery. There was no documented evidence that the physician was made aware that Daptomycin was not administered to Resident R138.



28 Pa. Code 211.9(d) Pharmacy services


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




 Plan of Correction - To be completed: 10/14/2024

Physician order was placed in residents' chart for trach care and suctioning for R97. Physician was notified of missed meds for resident R138.
1. All residents with trachs' had their orders checked for orders for trach care and suctioning. And orders were present. 2. An audit was obtained for the last 7 days for missed meds and other missed meds were identified.
1. Licensed nurses will be educated to notify physician of any missed medications and document accordingly in residents record. Licensed nurses will be educated to check admission orders at the times of admission, the following shift and during clinical rounds. 2. Missed administration report will be obtained every shift by the nursing supervisor will inform licensed nursing staff the appropriate measured to be done and documented. 3. Residents on admission will have their orders checked by the following shift from admission and during clinical rounds for accuracy.
Random audit will be done by unit managers to identify any missed orders and missed med administration. Weekly times 4 then monthly times 2. The results of the audits will be turned into the DON or his/her designee and the results of compliance reported during monthly QAPI.
483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25(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 review of facility policy, review of clinical records, observations, and interviews with staff, it was determined that the facility failed to ensure that physician orders were followed regarding oxygen administration for two of two residents observed on oxygen. (Resident R4 and R31)

Findings Include:

Review of facility policy titled, "Oxygen Administration" with a policy date of December 4, 2023 state, "Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration." "Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed." "Steps in the Procedure: Wash and dry your hands thoroughly. Remove all potentially flammable items from the immediate area where the oxygen is to be administered. Check the tubing connected to the oxygen cylinder to assure that it is free or kinks. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute."

Observation on August 27, 2024 at 9:55 a.m. revealed Resident R4's oxygen was administered and was set at 5 liters. Review of the resident's clinical record revealed an order for continuous oxygen at a rate of 2 liters.

Review of Resident R4's clinical record revealed the resident was re-admitted to the facility August 27, 2022 with the following diagnoses: cerebral palsy (a group of conditions that affect movement and posture caused by brain damage before birth), pneumonia (an infection of the air sacs in one of both lungs), asthma (a condition in which the airways narrow and swell) .

Interview and observation of Resident R4's oxygen with licensed nurse Employee E9 on August 27, 2024 at 12:04 p.m. revealed Resident R4's oxygen was set wrong and the licensed nurse Employee E9 reset the level to 2 liters.

Observation on August 27, 2024 at 10:10 a.m. revealed Resident R31's oxygen was administered and was set at 1 liter. Review of the resident's clinical record revealed an order for continuous oxygen at a rate of 3 liters.

Interview and observation of Resident R31's oxygen with licensed nurse Employee E8 at 12:18 p.m. revealed Resident R31's oxygen was set wrong and the licensed nurse Employee E31 reset the level to 3 Liters.

28 Pa. Code 211.12(d)(1)(2) Nursing Services






 Plan of Correction - To be completed: 10/14/2024

Audit was done for all residents on oxygen; orders check against resident settings and corrected as appropriate.
ADON/designee will do at random audits of residents oxygen orders against residents actual settings weekly X4 then monthly X2. Audit results will be turned into the ADON/designee for further review and corrections made as needed.
Audit results will be reviewed in QAPI and determined if further audits are necessary.
483.25(l) REQUIREMENT Dialysis:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(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 review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to maintain ongoing communication between the facility and a dialysis provider for three of eight dialysis residents reviewed (Residents R44, R133 and R28).

Findings include:

A review of the Dialysis Policy dated April 1, 2022, revealed that the facility will utilize the Dialysis Communication form each time a resident attends dialysis as a tool to relay pertinent information regarding the resident's condition and coordinate care and services with the dialysis provider.

Review of Resident R33's clinical record revealed that the resident was admitted on January 23, 2024, with diagnoses including but not limited to end stage renal disease (condition where the kidney reaches advanced state of loss of function).

Further review of Resident 33's clinical record revealed that the resident has dialysis treatments three times per week on Monday, Wednesday and Friday at 5:15 a.m. at a dialysis center.

A review of Resident R33's dialysis communication book revealed that on four dates (June 26, 2024, July 12, 2024, August 19, 2024, and August 23, 2024) had no documented communication from the dialysis center. Further review revealed that on the August 16, 2024, log page there was no documentation from the facility nurse after the resident returned from dialysis.

An interview on August 29, 2024, at 12:50 p.m. with the Licensed Nurse, Employee E9, confirmed the above findings, acknowledging that the log sheets should be completed each time the resident goes to dialysis, and that the dialysis center should be completing the middle section of the report, and the nurse on duty when the resident returns should complete the bottom section.

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

28 Pa Code 211.5(f)(ix) Clinical records

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



 Plan of Correction - To be completed: 10/14/2024

No retroactive correction.
An audit was conducted to ensure the dialysis residents' communication books were completed.
Licensed nurses will be educated that dialysis communication books must be checked upon residents return from dialysis for completion. The unit managers will be educated to check dialysis communication books daily.
Random audit will be done weekly times 4 then monthly times 2; to ensure communication books completion on each unit. Audits will be turned into the DON or his/her designee and the results of compliance reported to QAPI monthly.
483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.45 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 review of clinical records, it was determined that the facility failed to provide pharmaceutical services to assure the acquiring and administering of medications to meet the residents need of one resident for one of twenty-eight residents reviewed. (Resident R138)

Findings include:

Review of Resident R138's clinical record revealed that Resident R138 was admitted to the facility on August 7, 2024 with diagnoses of Extradural and Subdural Abscess, Dorsalgia (Dorsalgia is a collective name given to a group of conditions that produce moderate to intense pain in the muscles, nerves, bones, joints, or other structures associated with the spinal column of the body.), Osteomyelitis of the vertebra (lumbar region) and infective myositis (Infectious myositis is a rare infection of the skeletal muscles caused by a variety of pathogens, including bacteria, fungi, viruses, and parasites.)of unspecified left leg, Opioid Abuse.

Further review of Resident 138's clinical record revealed the following physician's order for Daptomycin:
Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously one time a day for Infection for 32 Days-Start Date-08/08/2024-D/C Date-08/10/2024
Daptomycin- Sodium Chloride Intravenous Solution 500-0.9 MG/50ML- % Use 475 mg intravenously one time a day for Infection for 32 Days-Start Date-08/11/2024-D/C Date-08/19/2024
Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously at bedtime for Infection for 32 Days-Start Date-08/19/2024-D/C Date- 08/20/2024
Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously at bedtime for Infection for 32 Days-Start Date-08/21/2024

Reviews of Resident R138's MAR (medication administration record) for August 2024 revealed that on August 10, 2024, the MAR was coded "5"; on August 12. 2024, the MAR was coded "9"; on August 18, 2024, the MAR was coded "9"; on August 19, 2024, the MAR was coded "9"; on
August 25, 2024, the MAR was coded "5" and on August 27, 2024, the MAR was coded "9".

Review of the MAR Code Chart revealed that "5" was for "Hold/see progress note and "9" was for Other/see progress notes.

Review of Resident R138's progress notes revealed the following notes:
On August 27, 2024, NOT GIVEN: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously at bedtime for Infection for 32 Days. Attempted to call pharmacy several times, spoke with Dr. Lewis. Medication was not delivered overnight. On call pharmacy told me to call back after 8am to speak with pharmacist, they are not available right now.
On August 26, 2024, 6:16 NOT GIVEN: Resident AAOx4, able to make needs known. Waiting on Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML, from pharmacy. Resident did not receive ABT I.V.
On August 25, 2024, 12:57 NOT GIVEN: Resident AAOx4, able to make needs known. Waiting on Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML, from pharmacy. Resident did not receive ABT I.V. Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML.
On August 25, 2024, 22:04 NOT GIVEN: Resident AAOx4, able to make needs known. Pharmacy was called and notified about ABT on Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML, from pharmacy. Pharmacy said it will arrive tomorrow by Noon. Resident did not receive ABT I.V. Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML on shift.
On August 25, 2024, 6:24 NOT GIVEN: Resident continues on I.V. ABT, no s/s of adverse reaction, afebrile during this shift. RUE PICC site in place, no s/s of infection, bleeding. Resident denies pain/discomfort during this shift. Resident didn't receive I.V. awaiting pharmacy to delivery later today, DON (director of nursing) made aware.
On August 25, 2024, NOT GIVEN: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously at bedtime for Infection for 32 Days Awaiting pharmacy to delivery.
August 19, 2024, 21:23 NOT GIVEN: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously at bedtime for Infection for 32 Days not administered, waiting pharmacy delivery, supervisor informed.
August 18, 2024, 11:21 NOT GIVEN: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously one time a day for Infection for 32 Days Medication unavailable, waiting on pharmacy.
August 12, 2024, 9:56 NOT GIVEN: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously one time a day for Infection for 32 Days pending delivery.



28 Pa. Code 211.9(d) Pharmacy services



 Plan of Correction - To be completed: 10/14/2024

R138 is receiving IV med as ordered.
Missed administration report was obtained and no other resident is missing IV antibiotic for last 7 days.
Licensed nursing staff educated on protocol for medications not received from pharmacy. Administrator has discussed with pharmacy the importance of sending IV medications whether the insurance company has approved or not, the facility will pay. Missed administration report reviewed every shift by the nursing supervisor and the appropriate interventions if meds have not been received with call to MD and documented.
Random audit of missed medication will be done weekly times 4 then monthly times 2.
483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on a review of clinical records and facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for three of 36 residents clinical records reviewed (Resident R18 and R35).

Findings Include:

Review of the "Pharmacy Services: Drug Regimen Review" Policy dated October 24, 2022, revealed, the pharmacist will report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports will be acted upon.

Review of Resident R18's clinical record revealed that resident was admitted on October 19, 2021, with diagnoses including anxiety.

A review of Resident R18's pharmacy progress notes revealed the following note:
August 6, 2024 - Medication Regimen Reviewed. Recommendations made. SeeMedication Regimen Review Report.

Further review of Resident R18's clinical record revealed no further pharmacy notes or recommendations related to the August 6, 2024, recommendation.

Interview with the Director of Nursing on August 30, 2024, at 11:15 p.m. confirmed that there was no further documentation available for review for the related to the August 6, 2024, recommendation.

Review of Resident R35's clinical record revealed that resident was admitted on August 22, 2020, with diagnoses including depression and post-traumatic stress disorder.

A review of Resident R35's pharmacy progress notes revealed the following note:
July 16, 2024 - Medication Regimen Reviewed. Recommendations made. See Medication Regimen Review Report.

Further review of Resident R35's clinical record revealed no further pharmacy notes or recommendations related to the July 16, 2024, recommendation.

Interview with the Director of Nursing on August 30, 2024, at 11:15 p.m. confirmed that there was no further documentation available for review for the related to the July 16, 2024, recommendation.


28 Pa. Code 211.9 (k) Pharmacy services.

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



 Plan of Correction - To be completed: 10/14/2024

Drug review process was completed for R18 and R 35.
All current Drug Regimen Reviews were reviewed by the DON and all were addressed by nursing or the primary Physician . They were signed and returned to the DON for further review.
Drug Regimen Reports are sent to the DON, ADON and Unit Managers at the same time. The DON will print out the reviews and distributed to the unit managers to ensure delivery, so they can be addressed. The nursing reviews will be checked for completion of all recommendation. Random audit monthly times 3.
Completion of Drug Regimen Report will be audited by the DON and compliance reported in monthly QAPI meeting.
483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff: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.
§483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e)

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.
Observations:

Based on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employees E4).

Findings include:

An interview on August 27, 2024, at 9:30 a.m. with Employee E4, Food Service Director (FSD), revealed that her responsibilities included oversight of ordering, receiving, storing, preparation and service of food. Further interview with the FSD confirmed that she was not currently a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; or had an associate's or higher degree in food service management or hospitality from an accredited institution; and that she had not received frequently scheduled consultations from a qualified dietitian.

A review of Employee E4's credentials revealed that Employee E4 did not meet the statutory qualifications of a director of food and nutrition services.

During an interview on August 30, 2024, at 10:30 a.m. with the Administrator, the FSD's personnel file was reviewed, and her qualifications were discussed which revealed she had been working at the facility for over a year and was not a Certified Dietary Manager or Certified Food Manager. The Administrator confirmed that the FSD had not completed these requirements.

The Nursing Home Administrator was unable to provide evidence that the FSD was Certified, and therefore unqualified to direct the dietary department.


28 Pa. Code 211.6(c)(d) Dietary services

28 Pa Code 201.18(e)(1)(6) Management




 Plan of Correction - To be completed: 10/14/2024

FSD will receive a CFM license
NHA/designee will audit monthly X2 to ensure that FSD has a CFM license.
Results will be reviewed in QAPI and determined if further auditing is necessary.
483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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.
§483.60(d) Food and drink
Each resident receives and the facility provides-

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

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

Based on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature for three of eight residents interviewed (Residents R52, R236 and R6).

Findings include:

A review of Test Tray form revealed that the standard temperature range for EntrStarch and Vegetable was 135F, and milk and cold beverage were 45F.

Interview on the second floor with Resident R52 on August 27, 2024, at 10:40 AM revealed that the food is not great, and not aways warm enough, and too many eggs, and has not been getting her milk.

Interview on the second floor with Resident R136 on August 27, 2024, at 10:45 AM, at 10:55 AM revealed that for the past four to five days he was not getting coffee, no milk and no ice cream listed on his ticket, and for breakfast he is only getting one yogurt, and the food is not always hot when he is served.

Interview on the second floor with Resident R77 on August 27, 2024, at 10:50 AM revealed that she does not like the food, it is of poor quality, no variety, that especially the vegetables are overcooked and mushy, and that the food is not always warm enough.

Interview on the second floor with Resident R132 on August 27, 2024, at 10:55 AM revealed that the resident had issues with meals and was tired of complaining, he also said that he should be getting double portions and that his food is not always warm.

Observations during a test tray conducted with Employee E3, Food Service Director, on August 28, 2024, at 12:20 PM revealed that the chicken was 116.8 degrees, the potatoes were 114.5 degrees, the broccoli was 108 degrees, the milk was 50 degrees, and the hot tea was 116.6 degrees. Tasting revealed that the hot food was too cool and the hot water was not warm enough to steep the tea.

An interview with the Dietary Staff, Employee E4, on August 28, 2024, at 12:20 PM confirmed that the hot foods and hot water were too cool to be palatable.

Interviews with residents during Resident Council on August 29, 2024 at 10:00 a.m. revealed residents had complaints about the food palatability at the facility. The following resident described the food as cold when it was supposed to be hot, having bad texture, and not being offered alternatives: Resident R1, R14, R44, R98.

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: 10/14/2024

FSD and staff will be educated to provide food and drink that was palatable and served at the proper temperature.

FSD/designee will do random audits 2X weekly X4 then monthly X2 to monitor.

Results will be reviewed in QAPI and determined if further review is necessary.
483.70(n)(2)(i)(ii)(3)-(5) REQUIREMENT Entering into Binding Arbitration Agreements: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.
§483.70(n) Binding Arbitration Agreements
If a facility chooses to ask a resident or his or her representative to enter into an agreement for binding arbitration, the facility must comply with all of the requirements in this section.

§483.70(n)(1) The facility must not require any resident or his or her representative to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility and must explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility.

§483.70(n)(2) The facility must ensure that:
(i) The agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands;
(ii) The resident or his or her representative acknowledges that he or she understands the agreement;

§483.70(n)(3) The agreement must explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it.

§483.70(n) (4) The agreement must explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility.

§483.70(n) (5) The agreement may not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman, in accordance with §483.10(k).
Observations:

Based on a review of facility documents and resident clinical records and interviews with staff and residents, it was determined that the facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for three of nine residents reviewed (Resident R56).

Findings include:

Review of Attachment 19, Binding Arbitration Agreement, found on page 72 of the facilities Admission Agreement revealed, "The Arbitration Agreement was explained to the Resident, his/her Resident Representative, or Guardian with legal authority to enter into the Arbitration Agreement in the case of a Resident without capacity signing below, in a form and manner that he or she understands, including in a language the Resident and his/her Resident Representative signing below understand.

Interview on August 29, 2024, at 1:15 p.m., with the Administrator, who was on the phone with the Admission Director, who was home on a medical leave, revealed that the Admission Director stated that all arbitration agreements were always signed as part of the admission agreement, and no resident had refused to sign the arbitration agreement.

Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment

Review of admission record indicated Resident R56 was admitted to the facility on May 8, 2023.

Review of Resident R56's Minimum Data Set (MDS - a periodic assessment of care needs) dated August 6, 2023, indicated the diagnoses of stroke and dementia (progressive degenerative disease of the brain). The resident was assessed with a BIMS (Brief Interview of Mental Status) score of 3 - severe impairment of cognition.

Review of Resident R56's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated that he signed the document (typed in script) on admission on May 15, 2023.

Interview on May 16, 2024, at 2:05 p.m. with the Nursing Home Administrator confirmed that this resident had a low BIMS score, indicating severe cognitive impairment, and should not have been signing admissions documents including the binding arbitration agreement as he did not have the capacity to understand the terms of a binding arbitration agreement.

28 Pa. Code: 201.14(a)(c)(d)(e) Responsibility of licensee.



 Plan of Correction - To be completed: 10/14/2024

Admissions director will be educated educated to ensure that residents have the capacity to understand the terms of a binding arbitration agreements.

Admissions director/designee will do random audits 1X weekly X4 then monthly X2 to monitor.

Results will be reviewed in QAPI and determined if further review is necessary.
§ 201.22(b) LICENSURE Prevention, control and surveillance of tuber:State only Deficiency.
(b) Recommendations of the Centers for Disease Control and Prevention (CDC), United States Department of Health and Human Services (HHS) shall be followed in screening, testing and surveillance for TB and in treating and managing persons with confirmed or suspected TB.

Observations:
Based on review of personnel records and interview with staff, it was determined that the facility failed to complete 2-step intradermal tuberculin skin testing for one of five employees reviewed (Employee E22)

Findings Include:

Review of the personnel file for employee E22 revealed that prior to employment on May 8, 2024, a one-step PPD test (a test to detect tuberculosis) had been administered. No evidence of a second step was noted.

During an interview with human resources director, employee E23, on August 29, 2024, at 01:00 p.m., she stated that, "this employee (employee E22) only received a one-step PPD test prior to employment" rather than the two step test as required.


 Plan of Correction - To be completed: 10/14/2024

Facility will ensure to complete 2-step intradermal tuberculin skin testing for the employee.

HR director will be educated to ensure employees complete a 2-step intradermal tuberculin skin testing.

HR/designee will do random audits 1X weekly X4 then monthly X2 to monitor.

Results will be reviewed in QAPI and determined if further review is necessary.
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:
Based on a review of nursing staffing hours and staff interview, it was determined that the facility did not ensure a minimum of one Licensed Practical Nurse (LPN) for every 40 residents during the night shift on one of 21 days reviewed (August 24, 2024).

Findings include:

Review of nursing staff care hours provided by the facility revealed the following LPN hours scheduled for the resident census:

Night shift (requires one LPN, or 8 LPN hours, per 40 residents)

August 24, 2024, 24.33 LPN hours, with a census of 142 residents, required 28.40 LPN hours.

Interview with the staffing coordinator, employee E24, on August 30, 2024, at 2:00 p.m., confirmed that the above staffing levels did not meet the required minimums for LPNs.



 Plan of Correction - To be completed: 10/14/2024

The staffing director will be educated to staff per DOH guidelines for LPN staffing ratios.

NHA/designee will do random audits weekly X4 then monthly X2 to ensure that facility is staffing per DOH LPN staffing ratios.

Results will be reviewed during the facilities monthly QAPI meeting to determine the need for further review.
§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:
Based on a review of nursing staffing hours and staff interview, it was determined that the facility did not ensure a minimum of 3.2 hours of direct care per patient, per day (PPD) was met for one day of 21 reviewed (August 24, 2024).

Findings include:

Review of nursing staff care hours provided by the facility revealed that on August 24, 2024, the PPD for the day was 3.13.

Interview with the staffing coordinator, employee E24, on August 30, 2024, at 2:00 p.m., confirmed that the above staffing level did not meet the required minimums for PPD hours.


 Plan of Correction - To be completed: 10/14/2024

The staffing director will be educated to staff per DOH guidelines for PPD staffing requirements.

NHA/designee will do random audits weekly X4 then monthly X2 to ensure that facility is staffing per DOH guidelines for PPD staffing requirements.

Results will be reviewed during the facilities monthly QAPI meeting to determine the need for further review.

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