Pennsylvania Department of Health
CRANBERRY PLACE
Patient Care Inspection Results

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CRANBERRY PLACE
Inspection Results For:

There are  117 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.
CRANBERRY PLACE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and a Civil Rights Compliance survey, completed on February 1, 2024, it was determined that Cranberry Place was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.10(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 facility policy, observations, and resident and staff interviews, it was determined that the facility failed to provide a homelike environment for three of three nursing units (North Wing, East Wing, and South Wing).

Findings include:

Review of facility policy "Resident Rights", reviewed 1/2/24, indicated that residents have the right to a safe, clean, comfortable and homelike environment.

During a group interview on 1/30/24, at 1:10 p.m., it was noted that the Dining Room has not been open for residents to eat in since COVID 19 started in 2020.

During an observation at lunchtime on 1/29/24, 1/30/24, 1/31/24, and 2/1/24, no residents were present in the Dining Room.

During an interview on 1/31/24 at 2:40 pm. Nursing Home Administrator (NHA) confirmed that the facility had one Dining Room that was to accomodate residents from all three unit, but had not been open regularly since COVID 19 and that it was only "open briefly in 2023 for a very short time". NHA confirmed that the facility failed to provide a homelike environment for residents in three of three nursing units (North Wing, East Wing, South Wing).

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


 Plan of Correction - To be completed: 03/13/2024

The facility dining room was reopened on 2/5/24.



All residents have been updated and offered the dining space for meals. Staff will assist residents to the dining room as indicated to ensure the facility is providing homelike environment for residents. Residents will be reminded that the dining room is opened at the February Resident Council meeting.



Dietary manager and supervisors will be reeducated by the NHA regarding the need to keep the dining room open to ensure the facility is providing homelike environment for residents.



Dining room availability will be audited by the NHA/designee weekly x 4 weeks then monthly to ensure the facility is providing homelike environment for residents.



Results will be reviewed at the quarterly QAPI.
483.25(l) REQUIREMENT Dialysis:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.25(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 facility policy, clinical record review, and staff interviews, it was determined that the facility failed to maintain ongoing communication with the dialysis (a machine filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for three of three residents receiving dialysis (Resident R46, R216, and R218).

Findings include:

Review of facility policy "Hemodialysis Coordination of Care" dated 1/2/24, indicated the facility staff are responsible for communicating resident's medical condition and pretreatment vital signs to the dialysis center staff before treatment as ordered.

Review of the clinical record indicated Resident R46 was admitted to the facility on 1/5/24.

Review of Resident R46's Minimum Data Set (MDS - a period assessment of care needs) dated 1/11/24, indicated diagnoses of high blood pressure, end stage renal disease (ESRD - an inability of the kidneys to filter the blood), and hip fracture. Section O, Question O0110 indicated Resident R46 received dialysis while a resident.

Review of a physician's order dated 1/5/24, indicated Resident R46 received dialysis treatments three times a week on Monday, Wednesday, and Friday.

Review of Resident R46's "Dialysis Communication Forms" failed to reveal facility staff provided communication to the dialysis facility for 11 of 11 days on 1/8/24, 1/10/24, 1/12/24, 1/15/24, 1/17/24, 1/19/24, 1/22/24, 1/24/24, 1/26/24, 1/29/24, and 1/31/24.

Review of clinical record indicated Resident R216 was admitted to the facility on 1/19/24.

Review of Resident R216's MDS dated 1/23/24, indicated diagnoses of high blood pressure, ESRD , and muscle wasting. Section O, Question O0110 indicated Resident R216 received dialysis while a resident.

Review of a physician's order dated 1/19/24, indicated Resident R216 received dialysis treatments three times a week on Monday, Wednesday, and Friday.

Review of Resident R216's "Dialysis Communication Forms" failed to reveal facility staff provided communication to the dialysis facility for three of three days on 1/22/24, 1/24/24, and 1/29/24.

Review of clinical record indicated Resident R218 was admitted to the facility on 1/25/24.

Review of Resident R218's MDS dated 1/31/24, indicated diagnoses of high blood pressure, ESRD , and diabetes.

Review of a physician's order dated 1/26/24, indicated Resident R218 received dialysis treatments three times a week on Monday, Wednesday, and Friday.

Review of Resident R218's "Dialysis Communication Forms" failed to reveal facility staff provided communication to the dialysis facility for two of two days on 1/29/24, and 1/31/24.

During an interview on 2/1/24, at 9:31 a.m. the Director of Nursing (DON) stated that the "Dialysis Communication Forms" are filled out by the dialysis clinic staff and that the facility staff do not complete the forms.

During an interview on 2/1/24, at 9:41 a.m. the DON stated, "The Regional Director of Nursing said that we do not do pre and post dialysis assessments."

During an interview on 2/1/24, at 9:41 a.m. the DON confirmed that the facility failed to maintain ongoing communication with the dialysis center for three of three residents receiving dialysis (Resident R46, R216, and R218).

28 Pa. Code 211.10(c)(d) Resident Care Policies
28 Pa. Code 211.12 (d)(2) Nursing Services
28 Pa. Code 211.12(d)(1)(5) Nursing Services
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1) Management.


 Plan of Correction - To be completed: 03/13/2024

A communication log/binder has been implemented for resident R46, R216 and R218 to facilitate coordination of care as indicated between the facility and the dialysis provider. The binder will be used to place communication notes as needed by either the facility or the dialysis provider. The plan of care has been updated as indicated. The Hemodialysis Coordination of Care policy has been revised.

All residents have been evaluated for the need of a dialysis communication binder / log to facilitate communication with the dialysis provider as indicated.

RNs and LPNs will be educated by the Director of Nursing and /or designee. Education will review the communication binder and the importance of sending the communication binder /log with the resident to dialysis to facilitate on-going communication between the facility and the dialysis provider to ensure coordination of care.

We will audit to ensure the communication binder is implemented as a means to facilitate communication between the facility and the dialysis provider. Audits will be completed two times per week for one month, and weekly thereafter. Audits will continue for 3 months or until substantial compliance is achieved.



Results will be reviewed at the Quarterly QA meeting.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response: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(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:

Based on review of facility policy, Resident Group interviews, Resident Council meeting minutes, grievances, and staff interview it was determined the facility failed to consider the views of a resident and/or family and act promptly on grievances and recommendations concerning issues of resident care and life in the facility for nine of twelve months (January, February, March, April, May, June, July, August and September 2023).

Findings include:

Review of facility policy titled "Resident Rights-Grievance", last reviewed 1/2/24, indicated prompt efforts to resolve grievances. The intent of the grievance process is to support each resident's right to voice grievances and to assure that after receiving a complaint/grievance the facility actively seeks a resolution and keeps the resident appropriately apprised of its process toward a resolution.

During a Resident Group meeting held on 1/30/24, eight of eleven members voiced concerns over not receiving resolutions to their concerns during resident council meetings.

Review of Resident Council meeting minutes on the following dates revealed facility concerns
1/12/23, 2/9/23, 3/9/23, 4/13/23, 5/11/23, 6/8/23, 7/13/23, 8/10/23, 9/14/23, 10/12/23, 11/9/23, 12/14/23.

Review of the facility concern log revealed that January 2023-September 2023, did not have corresponding concern forms.

The facility could not provide documentation that the facility investigated and provided a resolution to the Resident Council concerns January- September 2023.

Interview with Resident R503 1/31/24, at 2:24 p.m. stated she never received any follow up concern form resolutions.

During an interview on 1/31/24, at 11:00 a.m. the Director of Nursing confirmed the facility did not follow up on the resident council concerns for months January-September 2023 .


28 Pa. Code: 201.18(e)(4) Management
28 Pa. Code: 201.29(i) Resident Rights
28 Pa. Code: 211.12(d)(3) Nursing Services


 Plan of Correction - To be completed: 03/13/2024





R503's was followed up with regarding her concerns as indicated. Resident Council minutes from the January-September 2023 were reviewed and concerns were investigated and followed up on as indicated. An additional resident council meeting has been scheduled 2/12/24 to review previously shared concerns and provide resolution as indicated.



Resident Council minutes will be recorded and reviewed by the Administrator and/or designee following each meeting to determine concerns and follow up to be documented as indicated. Individual resident concerns will be investigated and documented on the Concern log by the Grievance Officer and follow up as indicated.



RNs, LPN, CNA, Housekeeping, Social Services, Activities staff will be educated by the NHA/designee regarding the need to provide timely follow up on concerns voiced at Resident Council.



The grievance log will be reviewed weekly times one month and then monthly thereafter until substantial compliance is achieved to ensure timely follow up. Resident council minutes will be audited at the end of each month to determine if concerns were identified and followed up as indicated and reported back to the council the next month.



Results will be reviewed at the quarterly QAPI meeting.
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 clinical record review, staff interview and observations it was determined the facility failed to ensure the privacy of the resident while providing care for two of four residents observed (Resident R26, and R108).

Findings Include:

Review of facility policy "Personal Care and Privacy" dated 1/2/24, indicated to maintain privacy and dignity during personal hygiene and/or procedures.

Review of the admission record indicated Resident R26 was admitted to the facility on 10/5/23.

Review of Resident R26's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/8/23, indicated the diagnoses of diabetes (too much sugar), high blood pressure, and coronary artery disease (narrow arteries decreasing blood flow to the heart).

Review of Resident R26's physician order dated 1/5/24, indicated to inject Lantus insulin (medication shot to regulate sugar) every morning.

Observation on 1/31/24, at 8:25 a.m. Resident R26 was lying in bed in a night gown. Registered Nurse (RN) Employee E2 pulled up the residents gown and gave the shot in the abdomen without pulling the privacy curtain or shutting the door allowing any passerby to view her exposed.

Review of the admission record indicated Resident R108 was admitted to the facility on 12/29/23.

Review of Resident R108's MDS dated 1/28/24, indicated the diagnoses of rectal cancer, anxiety, and hyperlipidemia (high levels of fat in the blood).

Review of Resident R108's physician order dated 1/28/24, indicated to inject octreotide (medication shot that treats diarrhea in certain types of cancer) three times a day.

Observation on 1/31/24, at 8:40 a.m. Resident R108 was lying in bed in a night gown and pair of shorts. RN Employee E2 lifted her gown and gave the shot in the left upper arm without pulling the privacy curtain or shutting the door allowing any passerby to view her exposed.

Interview on 1/31/24, at 8:45 a.m. with RN Employee E2 confirmed the privacy curtain was not pulled and the door was not shut for Residents R26 and Resident R108 during care.

Interview own 2/1/24, at 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to ensure the privacy of the resident while providing care for two of four residents observed (Resident R26, and R108).

28 Pa. Code: 211.12(d)(1)(3)(5)Nursing services.
28 Pa. Code: 201.29(b)(d)(j) Resident rights.
28 Pa. Code 211.10(c)(d) Resident care policies.


 Plan of Correction - To be completed: 03/13/2024



E2 was reeducated at the time of the finding by the DON regarding the need to ensure privacy by closing the door or pulling the privacy curtain as indicated when providing care.



All staff on duty at the time of the finding were verbally reeducated regarding the need to ensure privacy by closing the door or pulling the privacy curtain as indicated when providing care.



RNs/LPNs/CNAs will be reeducated by the DON/designee regarding the need to ensure privacy when administering injections and during care.



10 random audits of staff providing care will be observed per week for 4 weeks then 10 audits biweekly for one month, then 10 audits monthly thereafter until substantial compliance is achieved to ensure resident privacy by closing the door or pulling the privacy curtain as indicated when providing care.



Results will be reviewed at the quarterly QAPI.
483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(b) The facility must develop and implement written policies and procedures that:

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

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

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

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

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

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

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

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to implement the facility abuse policy for one of three abuse allegations (Resident R62).

Findings include:

Based on review of facility policy, clinical record review, reports submitted to the State, and staff interview, it was determined that the facility failed to report an allegation of verbal abuse in the required timeframe for one of three residents (Resident R62).

Findings include:

Review of facility policy "Abuse Neglect Exploitation" dated 1/2/24, indicated the facility shall provide a safe environment where residents are protected from all forms of abuse and strive to achieve a culture that treats every resident with dignity and respect. Through seven major elements of screening, training, prevention, identification, investigation, protection, and reporting, the facilities act to prevent abuse. In the event an incident that meets or has the potential to meet one of the definitions stated in the policy on abuse or neglect of a resident is reported to the Administrator or designee, an investigation of the incident will be commenced immediately. The Administrator and/or Director of Nursing will ensure that all alleged or suspected violations involving mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of elder property are investigated and reported immediately, via that Pennsylvania Department of Health (PA DOH) Electronic Reporting System (ERS).

Review of Title 42 Code of Federal Regulations (CFR) states in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

Review of the clinical record indicated Resident R62 was admitted to the facility on 10/27/23.

Review of Resident R62's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/25/24, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and depression (a constant feeling of sadness and loss of interest).

During an interview on 1/29/24, at 11:24 a.m. Resident R62 stated, "I don't feel safe here. I don't like having to share a bathroom with a roommate. I asked someone what am I supposed to do if I have to use the bathroom and my roommate is in there? They told me to just shit my pants. I think it was an aide. I told the person in charge here that someone said that to me."

During an interview on 1/29/24, at 11:59 a.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware by the state surveyor of the allegation of verbal abuse that Resident R62 had made during an interview on 1/29/24, at 11:24 a.m.

A review of incidents submitted to the State on 1/30/24, at 12:45 p.m. did not include the verbal abuse allegation involving Resident R62.

During an interview on 1/30/24, at 1:06 p.m. the NHA stated, "We did not do an investigation into the allegation, we are starting an investigation now and will look back a week."

During an interview on 1/31/24, at 1:24 p.m. the DON stated, "A report was submitted yesterday by the Unit Manager, we are obtaining statements from staff who worked on the 24th through the 30th, the investigation is ongoing."

During an interview on 1/31/24, at 1:24 p.m. the DON confirmed that the facility failed to report an allegation of verbal abuse in the required timeframe and failed to implement the facility abuse policy for one of three abuse allegations (Resident R62).

28 Pa Code: 201.14 (a) Responsibility of Management
28 Pa Code: 201.18 (e )(1) Management.


 Plan of Correction - To be completed: 03/13/2024

R62's report of verbal abuse was reported via the Electronic Reporting System (ERS).



Nurses and the Director of Nursing on duty at the time of the finding were re-educated on the facility's Abuse Neglect and Exploitation policy and the need to identify and report verbal abuse within the required timeframe.



The Director of Nursing and Unit managers will be re-educated by the Administrator and / or designee on the facility Abuse Neglect and Exploitation policy and the need to recognize and report allegations of verbal abuse whether confirmed or not confirmed via ERS as indicated and within the required timeframe.

The Director of Nursing and/or designee will interview staff regarding the facility's Abuse Neglect and Exploitation policy, to affirm understanding and the need to identify and report verbal abuse as indicated. Fifteen (15) employee interviews will be conducted weekly for one month and then monthly thereafter or until substantial compliance is achieved.

Results will be reviewed at the quarterly QAPI meeting.


483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on review of facility policy, clinical record review, reports submitted to the State, and staff interview, it was determined that the facility failed to report an allegation of verbal abuse in the required timeframe for one of three residents (Resident R62).

Findings include:

Review of facility policy "Abuse Neglect Exploitation" dated 1/2/24, indicated the facility shall immediately report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes. In the event an incident that meets or has the potential to meet one of the definitions stated in the policy on abuse or neglect of a resident is reported to the Administrator or designee, an investigation of the incident will be commenced immediately. The Administrator and/or Director of Nursing will ensure that all alleged or suspected violations involving mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of elder property are investigated and reported immediately, via that Pennsylvania Department of Health (PA DOH) Electronic Reporting System (ERS).

Review of Title 42 Code of Federal Regulations (CFR) states in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

Review of the clinical record indicated Resident R62 was admitted to the facility on 10/27/23.

Review of Resident R62's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/25/24, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and depression (a constant feeling of sadness and loss of interest).

During an interview on 1/29/24, at 11:24 a.m. Resident R62 stated, "I don't feel safe here. I don't like having to share a bathroom with a roommate. I asked someone what am I supposed to do if I have to use the bathroom and my roommate is in there? They told me to just shit my pants. I think it was an aide. I told the person in charge here that someone said that to me."

During an interview on 1/29/24, at 11:59 a.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware by the state surveyor of the allegation of verbal abuse that Resident R62 had made during an interview on 1/29/24, at 11:24 a.m.

A review of incidents submitted to the State on 1/30/24, at 12:45 p.m. did not include the verbal abuse allegation involving Resident R62.

During an interview on 1/30/24, at 1:06 p.m. the NHA stated, "We did not do an investigation into the allegation, we are starting an investigation now and will look back a week."

During an interview on 1/31/24, at 1:24 p.m. the DON stated, "A report was submitted yesterday by the Unit Manager, we are obtaining statements from staff who worked on the 24th through the 30th, the investigation is ongoing."

During an interview on 1/31/24, at 1:24 p.m. the DON confirmed that the facility failed to report an allegation of verbal abuse in the required timeframe for one of three residents (Resident R62).

28 Pa Code: 201.14 (a) Responsibility of Management

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


 Plan of Correction - To be completed: 03/13/2024

R62's report of verbal abuse was reported via the Electronic Reporting System (ERS).



All residents and/ or their resident representative will be interviewed by the Administrator and / or designee to ensure all concerns of verbal abuse have been identified and reported as indicated.



The Director of Nursing and Unit managers will be educated by the Administrator and / or designee regarding the need to recognize and report allegations of verbal abuse whether confirmed or not confirmed via ERS as indicated and within the required timeframe.

The Director of Nursing and / or designee will interview residents regarding their care to ensure allegations of verbal abuse are identified and reported within the required timeframe as indicated. Fifteen (15) resident interviews will be conducted weekly for one month and then monthly thereafter or until substantial compliance is achieved.

Results will be reviewed at the quarterly QAPI meeting.


483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on review of facility policy, clinical record review, investigation documentations, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out neglect for one of three residents (Resident R46).

Findings include:

Review of facility policy "Accidents and Incidents" dated 1/2/24, indicated all accidents and incidents involving residents will be reported and investigated as indicated. When a resident incident/accident occurs the resident will be assessed by a Nurse. The Charge Nurse or designee will complete an assessment noting witnesses, if applicable, and that the family and physician were notified.

Review of facility policy "Abuse Neglect Exploitation" dated 1/2/24, indicated incidents in which a resident has been injured or had the potential for injury and the cause of the incident is unknown should be promptly investigated. The following individuals may be considered when interviewing/investigating: the person making the report, individuals alleged to have been involved in the incident, the resident, if able and willing to be interviewed, staff on duty working on the unit during the time of the alleged incidents, and staff on duty working on the unit during the time of the alleged incidents.

Review of the clinical record indicated Resident R46 was admitted to the facility on 1/5/24.

Review of Resident R46's Minimum Data Set (MDS - a period assessment of care needs) dated 1/11/24, indicated diagnoses of high blood pressure, end stage renal disease (ESRD - an inability of the kidneys to filter the blood), and hip fracture.

Review of a progress note completed by a Licensed Practical Nurse on 1/15/24, at 7:00 a.m. stated, "Resident told nighttime aide that the evening aides that were taking care of him was trying to transfer him to his wheelchair, and they lost their footing and fell with him falling on his bed and the aides falling to the floor. Resident stated he did not get injured but wanted to make it a point to tell staff and dialysis nurse. Resident was not exactly positive as to what time incident occurred. Appropriate parties notified and resident is his own POA (power of attorney)."

Review of the clinical record failed to reveal a progress note from the 1/14/24, 3 p.m. to 11 p.m. evening shift detailing the incident or documented vital signs after the incident.

Review of the facility "Incident/Accident Follow-Up" documentation dated 1/16/24, indicated that the incident occurred on 1/14/24, at 9:00 p.m. No vital signs were documented on the incident report.

Review of a witness statement completed by Nurse Aide (NA) Employee E4, dated 1/16/24, stated, "When cleaning up Resident R46 this morning for dialysis he stated that the evening aides both lifted him up and they tripped landing him on the bed and they fell to the floor. He said he was afraid because he almost got his head whacked against the footboard on his bed and almost landed on the floor."

During an interview on 2/1/24, at 11:29 a.m. the Director of Nursing (DON) confirmed that the statement obtained from the nightshift NA on 1/14/24, was the only statement that was obtained for the incident investigation.

During an interview on 2/1/24, at 12:26 p.m. the DON confirmed the clinical record did not indicate that Resident R46 was assessed by a licensed nurse after the fall, vital signs were obtained after the fall, and a progress note was completed after the fall. The DON also confirmed that the facility did not identify or obtain statements from the staff members who were on duty at the time of the fall.

During an interview on 2/1/24, at 12:26 p.m. the Nursing Home Administrator and DON confirmed that the facility failed to conduct a thorough investigation to rule out neglect for one of three residents (Resident R46).

28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 201.14 (c)(e) Responsibility of licensee.
28 Pa. Code: 201.18 (e)(1) Management.


 Plan of Correction - To be completed: 03/13/2024

A retrospective review of the incident involving R46 has been conducted. A follow-up assessment of the resident was also completed including vital signs,



A retrospective review of incidents that occurred over the last 3 months was conducted to ensure the appropriate steps were taken when investigating an incident and accident such as statements and / or interviews of the staff responsible for oversight and any staff that may have knowledge of the incident and / or accident.



All RNs and LPNs will be reeducated by the DON/designee regarding the requirement to complete an incident report including vital signs and the need to ensure details regarding an incident are documented and that witness statements for all residents and / or employees involved with or having knowledge of an incident are completed and maintained as part of the investigation as indicated.

The Director of Nursing will review all incidents with the Administrator 3 times per week for 1 month, and weekly thereafter for 3 months or until substantial compliance is achieved to ensure all incidents include a complete report with vital signs, assessment, and statements as indicated.

Results will be reviewed at the quarterly QAPI meeting.
483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to develop a plan of care to include a focus and interventions for one of three residents' tube feeding (R102), and one of two residents' (R108) parenteral feeding in order to maintain a resident's highest practicable physical well-being as required.

Findings include:

Review of facility policy "Resident Centered Care Plan", dated 1/2/24, indicated that the care plan process defines clinical care goals and expectations for each resident, including identification of specific programs appropriate for the resident such as restorative or rehabilitation care. The care plan will be individualized for each resident based upon all available resident specific information including, but not limited to identified clinical and functional goals, approaches and interventions, and physician's orders

Review of the clinical record revealed that Resident R102 was admitted to the facility on 11/14/23.

Review of Resident 102's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/21/23, indicated diagnoses of intracranial hemorrhage (brain bleed), high blood pressure, and dysphagia (difficulty swallowing). Section K0520B indicated that resident received nutrition through a feeding tube (a device use to provide nutrition to people who cannot obtain nutrition by mouth) while a resident. Section K0710A indicated that resident received 51% or more of total calories through the tube feeding.

Review of Resident R102's physician order dated 11/14/23, indicated to check feeding tube placement, and residuals (the volume of fluid remaining in the stomach at a point in time during the feeding) three times per day.

Review of Resident R102's physician order dated 12/5/23, indicated to provide 325 milliliters (ml) of Osmolite 1.5 (a type of tube feeding supplement) four times a day (12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m.) with 125 ml of free water flush before and after each feeding.

Review of Resident R102's clinical record on 2/1/24, failed to reveal a resident centered plan of care with goals and interventions related to her tube feed.

Review of the clinical record revealed that Resident R108 was admitted to the facility on 12/29/23, and readmitted on 1/22/24.

Review of Resident 108's MDS dated 1/28/24, indicated diagnoses of cancer of the rectum (part of the large intestine), intestinal fistula (an abnormal connection between two body parts), and malnutrition (lack of sufficient nutrients in the body) . Section K0520A indicated that resident received parenteral feeding (receiving nutrition in the veins (IV) to bypass the intestine) on admission, while a resident, and while not a resident. Section K0710A indicated that resident received 51% or more of total calories through the parenteral feeding.

Review of Resident R108's physician order dated 1/22/24, indicated to provide TPN (total parenteral nutrition- a feeding supplement that is entered into the veins) at 1900 mls (milliliters) per day for 16 hours per day, and flush IV with ten mls of normal saline (a solution of water and electrolytes) before and after TPN administration.

Review of Resident R108's clinical record on 2/1/24, failed to reveal a resident centered plan of care with goals and interventions related to her parenteral feeding.

During an interview on 2/1/24, at 11:16 a.m., Registered Nurse Assessment Coordinator (RNAC), Employee E3 confirmed the facility failed to develop a care plan to include a focus and interventions for Resident R102's tube feeding, and R108's parenteral feeding.

28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: Resident care policies.


 Plan of Correction - To be completed: 03/13/2024



A care plan for resident R102 has been implemented to address tube feedings. A care plan for resident R108 has been implemented to address parenteral feedings.



All resident care plans have been reviewed and updated as indicated to ensure tube feeding and parental feedings needs are addressed as indicated.



The Dietitian and the RNACs will be educated by the Director of Nursing /designee regarding the need to ensure the plan of care addresses tube feeding and parental feedings needs as indicated.



DON/designee will audit 10 resident care plans per week for one month and then monthly thereafter or until substantial compliance is achieved to ensure tube feeding and parental feeding needs are addressed as indicated.



Results will be reviewed at the quarterly QAPI.
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 review of facility policy, clinical record review, and staff interviews, it was determined that the facility staff failed to follow physician's orders for one of two residents (Resident R62) with a ventricular assist device (VAD - a device that provides support for cardiac circulation, either partially or completely replacing the function of a failing heart).

Findings include:

Review of facility policy "Care of Resident with Ventricular Assist Device" dated 1/2/24, indicated care of the patient may include details such as assessment of the patient cardiac status by obtaining a blood pressure with a doppler, respirations, temperature, edema, weight, redness, draining, or foul odor at the driveline site (insertion site of the device into the body), pain and anxiety. Monitor Device Flows (Cardiac Output). Upon admission, follow all basic care protocols as ordered for residents with a VAD.

Review of the clinical record indicated Resident R62 was admitted to the facility on 10/27/23.

Review of Resident R62's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/25/24, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and depression (a constant feeling of sadness and loss of interest).

Review of an active physician's order dated 10/27/23, indicated to obtain vital signs twice a day during the day and evening shifts. Notify the physician if blood pressure is greater than 90 mmHg (millimeters of mercury) or less than 70 for three consecutive days.

Review of an active physician's order dated 10/27/23, indicated to chart VAD controller parameters three times daily during the day, evening, and night shifts.

Review of Resident R62's December 2023 Treatment Administration Record (TAR) indicated that vital signs were not documented during the day shift on 12/16/23, the day shift on 12/17/23, and the evening shift on 12/20/23.

Review of Resident R62's January 2024 TAR indicated that vital signs were not documented during the day shift on 1/1/24, and VAD controller parameters were not documented during the night shift on 1/10/24, and the evening shift on 1/21/24.

During an interview on 1/31/24, at 1:24 p.m. the Director of Nursing confirmed that the facility staff failed to follow physician's orders for one of two residents (Resident R62) with a ventricular assist device.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(a)(b)(3) Management.
28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.


 Plan of Correction - To be completed: 03/13/2024



R62 Vital signs and VAD controller parameters have been reviewed with the provider.

All residents with VAD orders have been reviewed to ensure VS and VAD controller parameters have been documented as indicated.

RN/LPNs will be educated by DON/Designee regarding the requirement to obtain vital signs three times daily on the day, evening, and night shift and VAD parameters for those ordered and to document this in the clinical record.

The DON/designee will audit VAD residents 3x/week for one month then weekly times one month to ensure all orders for vitals and parameters were documented as ordered.

Results will be reviewed at the quarterly QAPI meeting.
483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide a safe environment resulting in a fall during a transfer for one of three residents (Resident R46).

Findings include:

Review of facility policy "Accidents and Incidents" dated 1/2/24, indicated all accidents and incidents involving residents will be reported and investigated as indicated. The purpose is to promote a safe environment for all residents, report occurrences appropriately and review and analyze for the opportunity for preventive measures. When a resident incident/accident occurs the resident will be assessed by a Nurse. The Charge Nurse or designee will complete an assessment noting witnesses, if applicable, and that the family and physician were notified.

Review of the clinical record indicated Resident R46 was admitted to the facility on 1/5/24.

Review of Resident R46's Minimum Data Set (MDS - a period assessment of care needs) dated 1/11/24, indicated diagnoses of high blood pressure, end stage renal disease (ESRD - an inability of the kidneys to filter the blood), and hip fracture.

Review of a progress note completed by a Licensed Practical Nurse on 1/15/24, at 7:00 a.m. stated, "Resident told nighttime aide that the evening aides that were taking care of him was trying to transfer him to his wheelchair, and they lost their footing and fell with him falling on his bed and the aides falling to the floor. Resident stated he did not get injured but wanted to make it a point to tell staff and dialysis nurse. Resident was not exactly positive as to what time incident occurred. Appropriate parties notified and resident is his own POA (power of attorney)."

Review of the facility "Incident/Accident Follow-Up" documentation dated 1/16/24, indicated that the incident occurred on 1/14/24, at 9:00 p.m. The incident report failed to include Resident R46's transfer status at the time of the fall and any indication of the facility staff members involved.

Review of a witness statement completed by Nurse Aide (NA) Employee E4, dated 1/16/24, stated, "When cleaning up Resident R46 this morning for dialysis he stated that the evening aides both lifted him up and they tripped landing him on the bed and they fell to the floor. He said he was afraid because he almost got his head whacked against the footboard on his bed and almost landed on the floor."

During an interview on 2/1/24, at 11:29 a.m. the Director of Nursing (DON) confirmed that the statement obtained from the nightshift NA on 1/14/24, was the only statement that was obtained for the incident investigation.

During an interview on 2/1/24, at 12:11 p.m. Physical Therapist Employee E5 stated Resident R46 required moderate staff assistance of one with a wheeled walker at the time of the fall on 1/14/24.

During an interview on 2/1/24, at 12:26 p.m. the DON confirmed that the facility did not identify or obtain statements from the staff members who were on duty at the time of the fall.

During an interview on 2/1/24, at 12:26 p.m. the DON confirmed that the facility failed to provide a safe environment resulting in a fall during a transfer for one of three residents (Resident R46).

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 211.11(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(5) Nursing services.


 Plan of Correction - To be completed: 03/13/2024

A retrospective review of R46s fall event on 1/14/24 has been completed and investigation completed as indicated.



A three month retrospective review of fall events will be completed to ensure all falls are documented and investigated including statements to ensure a safe environment has been maintained.



All RNs and LPNs will be reeducated by the DON/designee regarding the requirement to complete an incident report to ensure details regarding an incident are documented and that witness statements for all residents and / or employees involved with or having knowledge of an incident are completed and maintained as part of the investigation as indicated.

The Director of Nursing will review all incidents with the Administrator 3 times per week for 1 month, and weekly thereafter for 3 months or until substantial compliance is achieved to ensure all incidents include a complete report including statements as indicated.

Results will be reviewed at the quarterly QAPI
483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing 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.
§483.35 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 a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to assure that licensed nurses displayed the appropriate competencies and skills necessary to provide care to two of two residents (Resident R62 and R81) with a ventricular assist device (VAD - a device that provides support for cardiac circulation, either partially or completely replacing the function of a failing heart).

Findings include:

Review of facility policy "Care of Resident With Ventricular Assist Device" dated 1/12/24, indicated for each resident with a VAD, coordination with the Artificial Heart Program is required and includes facility staff education, specifics of resident's care and equipment, specifics for notification of Artificial Health Team, including contact numbers, and additional information specific to resident and/or device. Care of the patient may include details such as assessment of the patient cardiac status by obtaining a blood pressure with a doppler, respirations, temperature, edema, weight, redness, draining, or foul odor at the driveline site (insertion site of the device into the body), pain and anxiety. Upon referral for admission of resident with a VAD, assure that facility can meeting requirements for acceptance: arrange for staff education, as indicated.

Review of the clinical record indicated Resident R62 was admitted to the facility on 10/27/23.

Review of Resident R62's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/25/24, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and depression (a constant feeling of sadness and loss of interest).

During an interview on 1/29/24, at 11:27 a.m. Resident R62 stated, "I don't feel safe here, no one knows how to take care of my LVAD (left ventricular assist device). I went a whole week without having my blood pressure checked. None of the nurses know how to take my blood pressure with a doppler, I have to show them how to do it. My driveline dressing was falling off and no one knew how to change it. They had to go find someone, I think they pulled someone off of the street to do it."

Review of the clinical record indicated Resident R81 was admitted to the facility on 9/29/22.

Review of Resident R81's MDS dated 11/2/23, indicated diagnoses of heart failure, diabetes mellitus (too much sugar in the blood), and presence of heart assist device.

During an interview on 1/29/24, at 1:09 p.m. Resident R81 stated, "The staff do pretty good with my LVAD, most are getting LVAD trained."

During an interview on 1/29/24, at 1:03 p.m. the Director of Nursing (DON) provided the survey team with copies of certificates for facility staff members who had taken and passed the specialty skilled competency class. The DON confirmed at this time that these certificates were the only ones that the facility was able to locate.

During an interview on 1/29/24, at 2:00 p.m. Licensed Practical Nurse (LPN) Employee E7 stated that she has not taken the VAD class yet but has been assigned to take care of residents who have a VAD in the facility. LPN Employee E7 stated that she asks someone who is certified for help.

During an interview on 1/29/24, at 3:14 p.m. Registered Nurse (RN) Employee E8 stated that she has taken the VAD class and feels comfortable taking care of residents with a VAD, is able to troubleshoot alarms, and knows how to take a blood pressure with a doppler. RN Employee E8 stated, "If a nurse is taking care of a VAD resident and isn't properly trained, they know to reference the VAD binder at the desk. There is also a number that they can call to ask the VAD Team at the hospital if they are unsure of something."

A review of the staffing deployment sheet for 1/29/24, indicated that RN Employee E8 was scheduled to work 7 a.m. to 5 p.m. and RN Employee E11 was scheduled to work 11 p.m. to 7 a.m. on 1/29/24, into 1/30/24. Review of the 1/29/24, deployment sheet for the 3 p.m. to 11 p.m. shift revealed RN Employee E8 was the only staff member schedule who had taken and passed the VAD class. No staff members scheduled to work from 5 p.m. to 11 p.m. on 1/29/24, had taken and passed the VAD class.

During an interview on 1/29/24, at 3:05 p.m. the Nursing Home Administrator and DON confirmed that no staff members that had taken and passed the VAD class were scheduled to work from 5 p.m. to 11 p.m. on 1/29/24.

During an interview on 1/29/24, at 3:20 p.m. the DON stated that Staff Educator RN Employee E12 would be staying and working until RN Employee E11 arrived at 11 p.m.

Review of the daily staffing deployment sheets for 1/17/24, through 1/30/24, revealed no staff members who had taken and passed the VAD class were scheduled to work on 1/20/24, from 7 p.m. to 11 p.m.

During an interview on 2/1/24, at 12:06 p.m. the NHA confirmed no VAD competent licensed nurses were scheduled to work on 1/20/24, from 7 p.m. to 11 p.m. and that that the facility failed to assure that licensed nurses displayed the appropriate competencies and skills necessary to provide care to two of two residents (Resident R62 and R81) with a ventricular assist device.

28 Pa. Code: 201.14(1) Responsibility of licensee.
28 Pa. Code: 201.18(a)(3) Management.


 Plan of Correction - To be completed: 03/13/2024

At the time of the findings, certified Ventricular Assisted Device (VAD) nurse coverage each shift was confirmed for the dates of 1/29/24 through 2/14/24 to ensure the staff on duty to care for resident R62 and R81 had the appropriate skills and competencies to provide care to resident R62 and R81.



At the time of the finding, an expedited VAD certification class was coordinated and scheduled for 2/7/24 to ensure staff had the appropriate skills and competencies to provide VAD care.



The Staff Development Coordinator and the Director of Nursing will be reeducated by the Administrator regarding the need to have competent staff scheduled on each shift and assigned to the residents as indicated to ensure staff have the necessary competencies and skills to provide VAD care.



The Administrator /designee will audit staff training/competency records and the schedule to ensure staff are scheduled on each shift and assigned to the residents as indicated to assure staff have the necessary competencies and skills to provide VAD care. Audits will be conducted 5x/week for 4 weeks then weekly x 4 weeks and then monthly thereafter or until substantial compliance is achieved.



Results will be reviewed at the quarterly QAPI meeting.
483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.
Observations:

Based on review of facility policy, observation, clinical record and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of four residents (Resident R108).

Findings include:

Review of the policy "SRC-Pharmacy-12.8 Medication Administration: General" dated 1/2/24, indicated the facility will provide a safe, effective medication administration process and verify the medication order for the right resident, right drug, right dose, right route, and right time.

Review of the policy "SRC-Pharmacy-12.10 Medication Administration: Injectables" dated 1/2/24, indicated to administer an IM (intra-muscular) injection, the deltoid muscle may be used for a small volume injection two milliliters or less. Position the syringe at a 90 degree angle to the skin surface with the needle a couple inches from the skin. Quickly and firmly thrust the needle through the skin deep into the muscle. Pull back the plunger slightly to check for blood return.

Review of the admission record indicated Resident R108 was admitted to the facility on 12/29/23.

Review of Resident R108's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/28/24, indicated the diagnoses of rectal cancer, anxiety, and hyperlipidemia (high levels of fat in the blood).

Review of Resident R108's physician order dated 1/28/24, indicated to inject octreotide one milliliter (medication shot that treats diarrhea in certain types of cancer) IM three times a day.

Observation on 1/31/24, at 8:40 a.m. of Resident R108's medication administration, Registered Nurse (RN) Employee E2 prepared the injection with an intradermal needle (for injections only one eighth of an inch below the skin). RN Employee E2 was prepared to enter the resident's room.

Survey Agency (SA) questioned RN Employee E2, outside the resident room and asked if the needle was large enough to reach Resident R108's muscle.

Interview on 1/31/24, at 8:41 a.m. RN Employee E2 indicated the needle was not large enough for an IM injection and selected an appropriate IM needle prior to administering the medication.

During the observation RN Employee E2 chose the left deltoid for the injection site. Quickly thrusted the needle through the skin deep into the muscle. RN Employee E2 failed to pull back the plunger slightly to check for blood return as required.

Interview on 1/31/24, at 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that residents are free of significant medication errors for one of four residents (Resident R108).


28 Pa. Code: 211.12(d)(1)(3)(5)Nursing services.
28 Pa. Code: 201.29(b)(d)(j) Resident rights.
28 Pa. Code 211.10(c)(d) Resident care policies.


 Plan of Correction - To be completed: 03/13/2024

At the time of the finding, employee E2 was verbally re-educated on the proper technique for giving an intramuscular (IM) injection and needle size for injections.

At the time of the finding all RN/LPNs on duty were re-educated on the proper technique for giving IM injections and needle size for injections.

The Director of Nursing and/or designee will educate and complete return demonstration with all RNs and LPNs on the proper technique for giving IM injections and proper needle size needed for IM injections.

The Director of Nursing and/ or designee will conduct IM injection observations/audits to ensure the proper technique for giving IM injections and proper needle sizes are being used. Ten (10) observations will be conducted per week for 4 weeks, and then 10 observations per month will be conducted thereafter or until substantial compliance is achieved.

Results will be reviewed at the quarterly QAPI meeting.


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

§483.45(h) Storage of Drugs and Biologicals

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

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

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to label open medications with a date in one of four medication carts (West Back Hall).

Findings include:

Review of facility policy "Medication Storage" dated 1/2/24, indicated all medications are maintained under strict conditions according to accepted standards of practice.

An observation on 1/31/24, at 9:02 a.m. of the West Back Hall medication cart revealed the following medications not dated upon opening:
- Resident R12's Advair (inhaled medication used to treat shortness of breath) inhaler.
- Resident R14's Combivent (inhaled medication used to treat shortness of breath) inhaler.
- Resident R15's NovoLog pen (prefilled pen to inject rapid-acting insulin under the skin).
- Resident R15's Tresiba pen (prefilled pen to inject long-acting insulin under the skin).
- Resident R81's Lantus pen (prefilled pen to inject long-acting insulin under the skin).

During an interview on 1/31/24, at 9:08 a.m. Registered Nurse Employee E1 confirmed the findings noted above.

During an interview on 1/31/24, at 3:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to label open medications with a date in one of four medication carts (West Back Hall).

28 Pa. Code: 211.9(a)(1)(h)(k)(l)(1) Pharmacy services.
28 Pa. Code:211.12(d)(1)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 03/13/2024

The medications that were found unlabeled and opened were immediately discarded.



At the time of the finding, all medication carts were checked for unlabeled and opened items.



At the time of the finding, all staff on duty at the time were verbally reminded about the need to label medications when opened.



All RNs, and LPNs will be educated by the Director of Nursing and/or designee regarding the need to label medication with the date opened.



The Director of Nursing or designee will audit medication carts to ensure all items are labeled with the date opened as indicated, audits will be completed weekly for one month, bi-weekly for one month and then monthly thereafter or until substantial compliance is achieved.



Results will be reviewed at the Quarterly QA Meeting.
483.70(e)(1)-(3) REQUIREMENT Facility Assessment: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(e) Facility assessment.
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include:

§483.70(e)(1) The facility's resident population, including, but not limited to,
(i) Both the number of residents and the facility's resident capacity;
(ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population;
(iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population;
(iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and
(v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

§483.70(e)(2) The facility's resources, including but not limited to,
(i) All buildings and/or other physical structures and vehicles;
(ii) Equipment (medical and non- medical);
(iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies;
(iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;
(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
(vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

§483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.
Observations:

Based on staff interviews and a review of the facility's assessment and resident census and condition it was determined that the facility failed to implement and document a complete facility wide assessment, which identified the specific resources necessary to care for its specific resident population.

Findings include:

Review of the policy "SRC-Administration-Facility Assessment" dated 1/2/24, indicated the facility assessment must address or include:
- The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population.
-The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population.

Review of the admission record indicated Resident R91 was admitted to the facility on 6/16/23.

Review of Resident R91's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/24/23, indicated the diagnoses of cardiomyopathy (a disease of the heart muscle), congestive heart failure (the heart doesn ' t pump blood as well as it should), and renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids).

Review of Resident R91's physician orders dated 5/4/23, indicated the following:
-Remove battery from Life Vest (a wearable defibrillator for residents at risk of sudden cardiac death)v to turn it off while showering on scheduled shower days. Replace battery after showering. Staff member to stay with resident while showering.
-Transmission. Make sure Life Vest phone is attached to the charger in order to transmit information each night during the night shift. Must be after 12:01 a.m.
-Change Life Vest garment every three days and wash old garment. Lay out flat to dry or in dryer. Avoid hanging to dry as this will stretch the garment. Do not use bleach due to silver in pockets. Take battery out to turn off vest while changing garment.
-Change Life Vest battery daily. Place old battery on the charger.

Observation on 1/29/24, at 10:00 a.m. indicated Resident R91 walking in the hallway with a Life Vest on.

Interview with Resident R91 on 1/29/24, at 10:00 a.m. indicated he had the Life Vest for heart failure.

Review of the Facility Assessment dated 1/2/24, failed to include the use of a Life Vest as a condition that requires complex medical care and management routinely cared for in the facility.

Interview on 1/30/24, at 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to implement and document a complete facility wide assessment, which identified the specific resources necessary to care for its specific resident population.

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


 Plan of Correction - To be completed: 03/13/2024

R91 remains at the facility and all needs are met. Facility Assessment has been updated to include the ability to accept residents with Life Vest.

All resident conditions have been reviewed to ensure Facility Assessment identified the specific resources necessary to care for its specific resident population during day to day operations and emergencies.



The Administrator was reeducated by the UPMC Senior Director of Quality regarding the need to review the facility assessment quarterly and as necessary with resident's census and conditions and updating it as indicated to ensure specific resources are in place to care for specific resident population.



The Administrator will review 10 residents' conditions weekly x 4 weeks then monthly thereafter until substantial compliance is achieved to ensure current resident conditions align with the facility assessment to ensure specific resources are in place to care for the specific resident population.



Results will be reviewed at the quarterly QAPI meeting.
483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities:This is a less serious (but not lowest level) deficiency and 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.
§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

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

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

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

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

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

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

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

§483.75(e) Program activities.

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

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

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

§483.75(g) Quality assessment and assurance.

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

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

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

Findings include:

Review of the facility policy "Quality Assessment/Performance Improvement", dated 1/2/24, indicated that the facility will utilize a QAPI program to comprehensively address systems of care and management practices to provide safe and high quality care utilizing data and the best available evidence to define and measure goals. QAPI activities are designed to systematically monitor and evaluate the quality and appropriateness of resident care and services. The QAPI committee is responsible for making recommendations for improvement when negative trends or problems are identified. The facility implements systems to monitor care and services from multiple sources including clinical outcome results, input from staff, residents, families, and others, performance indicators used to monitor a wide range of care processes and outcomes, reviewing findings against benchmarks established for performance, e.g. CMS (Center for Medicare and Medicaid Services) quality measures.

The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending 2/2/23, revealed that the facility would maintain compliance with cited nursing home regulations.

The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending 2/2/23, identified a deficiency related to not maintaining ongoing communicating with the dialysis (a machine that filters waste, salts, and fluid from the blood when kidneys can no longer do this work adequately) center.

The facility's plan of correction for the survey ending 2/2/23, indicated that it would implement a binder that will be used to place communication notes by either the facility or dialysis provider. It also indicated that staff would be educated on the process and that audits will be completed and reviewed in quarterly Quality Assurance meetings.

The results of the current survey ending 2/1/24, identified repeated deficiency related to not maintaining ongoing communication with the dialysis center.

During an interview on 2/1/24, at 1:10 p.m. the Nursing Home Administrator confirmed the facility failed to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively addressed recurring deficiencies

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


 Plan of Correction - To be completed: 03/13/2024

The plan to improve communication related to dialysis was added to the quarterly QAPI agenda to ensure plans to improve the delivery of care and services effectively addressed prior deficiencies.

A retrospective review of the last 2 years for survey deficiencies and approved plans of correction will be reviewed to ensure those plans to improve delivery of care and services effectively addressed prior deficiencies and are included in the quarterly QAPI agenda as indicated.

The Administrator was reeducated by the UPMC Senior Director of Quality on the requirement to maintain a list of plans of correction and audits to ensure that plans to improve the delivery of care and services are effectively addressed prior deficiencies to ensure compliance.

The Administrator and/or designee will audit the QAPI agenda monthly for three months and then quarterly thereafter or until substantial compliance is achieved to ensure past and future plans of correction and audits to improve the delivery of care and services are effectively addressed prior deficiencies to ensure compliance.

Results will be reviewed at the quarterly QAPI meeting.

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