Pennsylvania Department of Health
GREENFIELD HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GREENFIELD HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  149 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.
GREENFIELD HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey, and an Abbreviated Complaint Survey completed on 2/02/2024, it was determined that Greenfield Healthcare and Rebabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.
Observations:

Based on observations, review of facility records and staff interviews, it was determined that the facility failed to maintain kitchen equipment (one of two food steamers, and one of one walk-in coolers) in safe, operating condition.

Findings include:

A facility policy entitled "Equipment-Facility Repair/Maintenance Needs" dated 9/14/23, indicated that the facility will ensure timely attention to any facility equipment or items that require attention, repair, or replacement.

Observations on 1/30/24, 11:20 a.m. in the main kitchen revealed the walk-in cooler temperature log posted on door as "out of order" beginning 1/01/24, and one of two food steamers with an "out of order" sign posted on the front, and Dietary Employee E4 waiting for room in the food steamer to keep food hot.

Review of facility records revealed the walk-in cooler has been "out of service" since the beginning of December 2023, a work order dated 1/19/24, to repair/replace the food steamer and walk-in cooler, lacked signatures indicating acceptance of the estimates.

During an interview on 1/31/24, at 11:00 a.m. Dietary Employee E3, and the Dietary Manager confirmed that staff must carry boxes of food up two flights of stairs from the ground floor or push boxes of food on a cart outside around the building.

During an interview on 2/01/24, 11:33 a.m. the Dietary Manager and Dietary Employee E3 confirmed that the steamer has been out of order since November 2023, when it caught fire.

During an interview on 2/02/24, 9:52 a.m. Dietary Employees E3, E4, and E5 confirmed; that having one working food steamer impacts the quality of food and that certain foods (eggs, pureed meats) get a burnt crust on top in the oven and needs to be in steamer; there is the potential for meals to be late due to using one food steamer to prepare two food steamers worth of food. Dietary Employees E3, E4, and E5 also confirmed that the lack of the walk-in cooler requires that staff have to go down to the basement to get milk, juices, etc. which increases the chance of cold foods not holding proper temperatures in the kitchen; negatively affects efficiency and productivity due to staff must to run down stairs to get individual resident food/beverage requests.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(3) Administrator's responsibility






 Plan of Correction - To be completed: 03/28/2024

To ensure that the Steamer and Walk-in Cooler are in proper operating condition within the dietary department the following will occur:
Education will be provided to the Maintenance Director February 22, 2024 regarding maintaining of equipment. Education will be provided by the Administrator.

Dietary staff will be educated by the Maintenance director regarding timely reporting of equipment not being operational.


Updated estimates for the walk-in cooler and steamer will be obtained no later than February 28, 2024. Securing updated information will be the responsibility of the Maintenance Director and monitored by the Administrator.
Once updated estimates are obtained, the facility will act accordingly regarding the repair/replacement of equipment.

Education will be provided to the Dietary staff to ensure that all food temperatures are always appropriate. Education for Dietary staff will be provided by the Dietary Manager or Designee and will be completed no later than March 1, 2024.

An audit will be completed 3 times a week for 2 weeks, 2 times a week for 2 weeks then weekly ongoing to ensure that equipment is reported and repaired in a timely manner and will be the responsibility of the Maintenance Director and monitored by the Administrator.

Results of the audit will be presented at the monthly Quality Assurance Meeting and recommendations will be implemented.
483.10(c)(2)(3) REQUIREMENT Right to Participate in Planning Care: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(c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:
(i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.
(ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
(iii) The right to be informed, in advance, of changes to the plan of care.
(iv) The right to receive the services and/or items included in the plan of care.
(v) The right to see the care plan, including the right to sign after significant changes to the plan of care.

§483.10(c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-
(i) Facilitate the inclusion of the resident and/or resident representative.
(ii) Include an assessment of the resident's strengths and needs.
(iii) Incorporate the resident's personal and cultural preferences in developing goals of care.
Observations:


Based on review of facility policy and clinical records, and resident and staff interviews, it was determined that the facility failed to ensure that residents and their responsible parties were afforded the opportunity to participate in the care planning process for three of 23 residents reviewed (Residents R44, R56, and R71).

Findings include:

Review of the facility policy entitled "Care Plan-Interdisciplinary Team" dated 09/14/23, revealed that "The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan."

During an interview on 1/30/24, at 1:16 p.m. Resident R44 indicated that he/she didn't remember being invited to or participating in care plan meetings.

Resident R44's clinical record revealed an admission date of 01/03/23, that he/she is alert and oriented and had diagnoses that included acute and chronic respiratory failure, chronic pain syndrome, and iron deficiency. The clinical record lacked evidence that Resident R44 was invited to participate at care plan meetings and/or participated in a care plan meeting.

During an interview on 2/02/24, at 11:10 a.m. the Social Worker confirmed the clinical record lacked evidence of Resident R44 being invited to or participating in the care planning process.


During an interview on 1/30/24, at 1:30 p.m. Resident R56 indicated that he/she has not been invited and/or participated in a care plan meeting.

Review of Resident R56's clinical record revealed an admission date of 5/11/22, that he/she is alert and oriented and had diagnoses that included hypertension (high blood pressure), calculus of gallbladder (gall stones), and Vitamin D deficiency (low Vitamin D levels).

Resident R56's clinical record lacked evidence that Resident R56 was invited to and/or participated in a care plan meeting.

During an interview on 2/01/24, at 1:55 p.m. the Social Worker confirmed the clinical record lacked evidence of Resident R56 being invited to or participated in the care planning process.


Resident R71's clinical record revealed an admission date of 9/23/23, with diagnoses that included dementia, mood disturbance and anxiety, left lower leg wound, irregular heartbeat, heart block, and high blood pressure.

Resident R71's most recent Quarterly MDS with an ARD date 12/20/23, Section C0100 indicated he/she is rarely/never understood, and that a Brief Interview for Mental Status (BIMS- performance-based standardized cognitive assessment primarily utilized in nursing homes) should not be conducted. The clinical record lacked evidence that the resident and/or representative had been invited to or participated in a care plan conference.

During an interview 1/30/24, at 12:28 p.m. Resident R71's legal representative confirmed that his/her resident was admitted in September, and they have not been invited to a care plan meeting.

During an interview 2/01/24, at 1:55 p.m. the Social Worker confirmed there was no evidence that Resident R71 and/or representative had been invited to or participated in a care plan conferences.

28 Pa. Code 201.29(a) Resident rights

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

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



 Plan of Correction - To be completed: 03/14/2024

For resident R44, R56, R71 and all residents of the facility, the following action plan will be initiated.
Care Plan meetings for residents R44, R56 and R71 will be held February 22, 2024.
All residents/resident representatives will be invited to attend their plan of care meetings no less than quarterly.
To ensure that an invitation was extended/sent to the resident/resident representative to attend a care plan meeting the following process will be utilized:
Social Service will present the resident with a written invitation as well as personally invite residents to their scheduled care plan meeting. Evidence of the conversation to invite the resident will be documented in the resident's medical record along with a copy of the invitation. If the invitation is sent to the resident representative a copy of the invitation and stamped envelope will be placed in the resident's medical record.

Education was provided to the Interdisciplinary Team regarding the invitation of resident/resident representatives to care plan meetings February 2, 2024, by the Administrator.
An audit will be developed to ensure that an invitation was extended/sent to the resident/resident representative to attend a care plan meeting. This audit will be completed for each care plan date as it is set and with any additional meeting. The audit will be completed by the Administrator or Designee.
Results of the audit will be presented at the monthly Quality Assurance Meeting and recommendations will be implemented.


483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to accurately code the Minimum Data Set (MDS-periodic assessment of resident care needs) for four of 23 residents reviewed (Residents R2, R5, R37, and R72).

Findings include:

Review of a facility policy entitled, "Certifying Accuracy of the Resident Assessment" dated 9/14/23, indicated that "Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. The information captured on the assessment reflects the status of the resident during the observation period for that assessment."

Resident R2's clinical record revealed an admission date of 10/30/99, with diagnoses that included Type 2 diabetes (disorder of improper blood sugar usage in the body), muscle weakness, and traumatic brain injury.

Resident R2's order summary revealed that a Victoza injection (an antihyperglycemic injection used to help control blood sugar, which is not classified as an insulin) was ordered 05/20/22 and discontinued on 1/23/24. The Victoza injection was replaced with a Trulicity injection (an antihyperglycemic injection used to help control blood sugar, which is not classified as an insulin) with an order to start on 1/24/24.

The Quarterly MDS dated 1/23/24, Medications Section N0350A indicated that Resident R2 received insulin seven times during the seven day look back period.

During an interview on 2/01/24, at 2:21 p.m. the Director of Nursing (DON) confirmed that the MDS Section N was coded incorrectly for insulin and should have been zero days for Resident R2.


Resident R5's clinical record revealed an admission date of 1/08/24, with diagnoses that included end stage renal disease, Type 2 diabetes, and benign prosthetic hyperplasia (BPH- a noncancerous enlargement of the prostate gland). The clinical record also revealed a physician's order dated 12/24/23, for dialysis (mechanical removal of toxins from the blood) on Monday, Wednesday, and Friday.

An Admission and 5-Day MDS dated 1/15/24, revealed under "Special Treatments, Procedures, and Programs" Section OJ1, indicated that Resident R5 did not receive dialysis treatments.

During an interview on 2/01/24, at 2:21 p.m. the DON confirmed that Resident R5's Admission and 5-Day MDS Section OJ1 was incorrectly coded and should have been marked for receiving dialysis treatments.


Resident R37's clinical record revealed an admission date of 10/02/23, with diagnoses that included end stage renal disease, dependance on renal dialysis, and Type 2 diabetes.

Resident R37's care plan revealed Resident R37 received offsite dialysis Mondays, Wednesdays, and Fridays with an initiation date of 10/09/23.

The Quarterly MDS dated 12/16/23, under section "Special Treatments, Procedures, and Programs" Section OJ1 indicated that Resident R37 did not receive dialysis treatments.


Resident R72's clinical record revealed an admission date of 10/13/23, with diagnoses that included dementia, alcohol abuse and age related cognitive decline.

Resident R72's clinical record revealed that Resident R72 was sent to the hospital for chest pains on 11/16/23, and was readmitted to the facility on 11/18/23. The MDS lacked evidence that Resident R72 was discharged with return anticipated and also lacked evidence of entry on 11/18/23.

During an interview on 2/01/24, at 2:21 p.m. the DON confirmed that Resident R72 was sent out to the hospital on 11/16/23, and returned on 11/18/23, and the MDS did not reflect that hospital admission.


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





 Plan of Correction - To be completed: 03/14/2024

To ensure that the residents Minimum Data Set is accurately coded the following will be initiated:
Education was provided to the RNAC by the Director of Nursing on February 16, 2024.
For residents R2, R5, R37 and R72, corrections will be made to their Minimum Data Set, no later than February 20, 2024, to accurately reflect the resident's status.
An initial audit will be completed for residents receiving antihyperglycemic injections, going to dialysis, and/admitted to the hospital/return as well as discharge/entry MDS's to the facility to ensure MDS's were coded accurately or completed when needed.

For all residents of the facility, an audit of residents receiving antihyperglycemic injections, going to dialysis, and/admitted to the hospital/return as well as discharge/entry MDS's to the facility, will be completed 3 times a week for 2 weeks, 2 times a week for 2 weeks then weekly for 3 months. The audit will be completed by the Director of Nursing or Designee and will be monitored by the Administrator.
Results of the audit will be presented at the monthly Quality Assurance Meeting and recommendations will be implemented.





483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice: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)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:


Based on review of clinical records and facility documents and staff interview, it was determined that the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) Form 10123 as required for two of three residents reviewed for beneficiary notices (Residents R70 and R279).

Findings include:

The Skilled Nursing Facility (SNF) Beneficiary Notification Review revealed that Resident R70 began receiving skilled services on 9/18/23, that the last covered day of Part A Services was 10/31/23, and that the facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Documentation indicated that Resident R70 remained in the facility following the last day covered, and that a NOMNC CMS Form 10123 was not issued.

The SNF Beneficiary Notification Review revealed that Resident R279 began receiving skilled services on 10/26/23, that the last covered day of Part A Services was 11/6/23, and that the facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Documentation indicated that Resident R279 was discharged 11/6/23, from the facility following the last covered day, and that a NOMNC CMS Form 10123 was not issued.

During an interview on 1/31/24, at 10:43 a.m. the Nursing Home Administrator confirmed that the NOMNC Form 10123 was not provided to Residents R70 and R279 and/or their resident representatives as required. He/she also confirmed that Resident R70 and R279 should have been given a NOMNC before Medicare Part A coverage ended.

28 Pa. Code 201.18(b)(2)(e)(1) Management

28 Pa. Code 201.29(a) Resident rights






 Plan of Correction - To be completed: 03/14/2024

To ensure that all Beneficiary Notices are given to all residents of the facility per CMS guidelines, the following will occur.
For residents R70 and R270, the facility cannot retroactively correct the deficient practice.
Residents who have been recently cut from MC A with days remaining have received a Beneficiary Notice. A copy of this notice has been placed in the resident's medical record.
Social Service will be responsible for issuing the Beneficiary Notice.


Education was provided February 2, 2024, to the Interdisciplinary Team regarding the CMS guidelines for issuing the Beneficiary Notice. This education was provided by the Administrator.
An audit will be developed to track resident eligibility days to determine when to provide the Beneficiary Notice for the resident. The audit will be conducted no less than 48 hours prior to the last covered day of service for those residents who will be discharged from skilled services. The audit will be conducted by the Administrator or Designee
Results of the audit will be presented at the monthly Quality Assurance Meeting and recommendations will be implemented.







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 policy, clinical record review, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for one of 23 residents reviewed (Resident R37).

Findings include:

A facility policy entitled, "Care Plan-Baseline" dated 9/14/23, indicated, "The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following:

a.The stated goals and objectives of the resident;
b.A summary of the resident's medications and dietary instructions;
c.Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and
d.Any updated information based on the details of the comprehensive care plan, as necessary."

Resident R37's clinical record revealed an admission date of 10/02/23, with diagnoses that included end stage renal disease, dependance on renal dialysis, and type 2 diabetes (disorder of improper blood sugar usage in the body).

R37's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R37 and/or his/her representative.

During an interview on 2/01/24, at 2:00 p.m. the Social Worker confirmed that the clinical record for Resident R37 lacked evidence that a written summary of the baseline care plan and order summary was provided to the Resident and/or his/her representative upon admission to the facility.

28 Pa. Code 211.10(c) Resident care policies









 Plan of Correction - To be completed: 03/14/2024

For resident R37 and all residents of the facility, the following will be initiated:
For resident R37 a Baseline Care Plan and Order Summary was provided February 22, 2024
The facility will check admissions for the past 30 days to ensure that they have been provided copies of their baseline care plan and order summary.

A Baseline Care Plan will be developed, and an order summary will be provided to the resident and or resident's responsible party.
Education will be provided to the Inter Disciplinary Team no later than February 16, 2024, by the Administrator regarding the completion and presentation of a Baseline Care Plan and order summary to the resident and or resident representative.
An audit will be completed by the Administrator or Designee for all newly admitted residents and re-admissions to ensure a copy of a care plan and order summary signed by the resident and or resident representative will be placed in the resident's medical record.
This audit will be conducted by the Administrator or Designee.

Results of the audit will be presented at the monthly Quality Assurance Meeting and recommendations will be implemented.







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 and clinical records, observations, and staff interview, it was determined that the facility failed to develop comprehensive care plans for two of 23 residents reviewed (Residents R14 and R72).

Findings include:

Review of a facility policy entitled "Care Plans, Comprehensive Person-Centered" dated 9/14/23, indicated that an interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.

Review of a facility policy entitled "Wanderguard" dated 9/14/23, indicated that a physcian's order must be obtained and a careplan will be implemented once a wanderguard (alarming device attached to a resident to alert staff of their leaving a designated area/facility) is placed on a resident.

Resident R72's clinical record revealed an admission date of 10/13/23, with diagnoses that included dementia, alcohol abuse and age related cognitive decline.

Resident R72's clinical record revealed Resident R72 was sent to the hospital for chest pains on 11/16/23, and was readmitted to the facility on 11/18/23. A Wandering Risk Assessment dated 11/21/23, revealed that Resident R72 was at high risk for wandering.

Observations on 1/30/24, at 3:30 p.m., and 1/31/24, at 11:30 a.m. revealed that Resident R72 was laying in bed and had a wanderguard bracelet on his/her right wrist.

Resident R72 clinical record lacked evidence of a careplan for the wanderguard bracelet.

During an interview on 1/31/24, at 11:45 a.m. the Director of Nursing confirmed that Resident R72 had a wanderguard bracelet placed upon return from his/her hospital admission on 11/18/23, a period of 75 days and lacked a comprehensive care plan during that time to reflect the use of the wanderguard.


Resident R14's clinical record revealed an admission date of 1/05/24, with diagnoses that included Type 2 diabetes (condition that affects how the body uses glucose (blood sugar)), left below the knee amputation, high blood pressure, and asthma.

Observations on 1/30/24, and 1/31/24, revealed Resident R14 lying in bed with a Continuous Positive Airway Pressure (CPAP- a machine that uses mild air pressure to keep breathing airways open while you sleep) mask on his/her face.

Review of Resident R14's clinical record revealed there was no evidence of a care plan for the CPAP machine.

During an interview on 2/01/24, at 9:01 a.m. the DON confirmed that the CPAP was not addressed in Resident R14's care plans.

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






 Plan of Correction - To be completed: 03/14/2024

For resident R72 and R14 and all residents of the facility a Comprehensive Care Plan will be developed and updated accordingly.
The Care Plan for R72 and R14 has been updated.
The facility has completed a check of all current residents who have orders for a wander guard or CPAP to ensure a care plan was present.

Education related to the completion of a Comprehensive Care Plan was provided to the RNAC February 1, 2024, by the Director of Nursing. An admission audit will be completed by the Assistant Director of Nursing for all residents with new orders or newly admitted to the facility with orders for a wander guard or CPAP to ensure a care plan is present. In addition, an audit for all residents of the order summary report will be completed. These audits will occur 3 times a week for 2 weeks, 2 times a week for 2 weeks and then weekly ongoing. The audit will be monitored by the Director of Nursing.
Results of the audit will be presented at the monthly Quality Assurance Meeting and recommendations will be implemented.





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

Based on review of Pennsylvania Code Title 49 Professional and Vocational Standards, clinical records, and facility documentation, and staff interviews, it was determined that the facility failed to follow nursing standards of practice related to medical diagnosing for one of 23 residents reviewed (Resident R21).

Findings include:

Review of Pennsylvania Code Title 49. Professional and Vocational Standards 21.11. General functions. (c) stated: "The registered nurse may not engage in areas of highly specialized practice without adequate knowledge of and skills in the practice areas involved."

Resident R21's clinical record revealed an admission date of 1/04/23, with diagnoses including right hip fracture, Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), Paranoid Schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves - paranoia commonly happens with schizophrenia), and unspecified dementia. The clinical record also revealed a physician's orders dated 5/23/23, for Nuplazid (atypical antipsychotic-medication to treat mental disorders) for Parkinson's Disease, and dated 6/21/23, for Asenapine patch (atypical antipsychotic) for Paranoid Schizophrenia. The clinical record lacked evidence of a physician's diagnosis of Paranoid Schizophrenia.

Resident R21's Pennsylvania Readmission Screening Resident Review (PASRR- assessment that helps decide if a nursing facility is the best place for a person with a behavioral, intellectual, or developmental disability) dated 12/27/22, lacked evidence of a diagnosis of Paranoid Schizophrenia.

Resident R21's psychiatric evaluations dated 2/09/23, and 3/30/23, lacked evidence of diagnosis of Paranoid Schizophrenia.

Resident R21's Minimum Data Sets (MDS- period evaluation/assessment of a resident's medical condition and capabilities), Section I6000 dated 1/12/23, and 4/11/23, lacked an active diagnosis of Paranoid Schizophrenia, and MDS's Section I6000 dated 6/23/23, 7/12/23, 8/04/23, and 11/03/23, indicated an active diagnosis of Paranoid Schizophrenia.

An interview on 2/01/24, at 9:37 a.m. with the Social Worker confirmed there was no evidence of previous diagnosis on Resident R21's clinical record prior to 6/21/23.

During an interview on 2/01/24, at 12:41 p.m. the Social Worker and Director of Nursing confirmed that Resident R21 did not have a diagnosis of Schizophrenia, and that the staff nurse assigned the diagnosis for administering the Asenapine patch, and that he/she was not qualified to do so.

28 Pa. Code 201.14(a) Responsibility of licensee

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








 Plan of Correction - To be completed: 03/14/2024

For resident R21 and all residents of the facility, each diagnosis requires the certification of a Physician. The Schizophrenia diagnosis for resident R21 was removed as there was no evidence of a Physician certification for the diagnosis.
Licensed Nursing staff will be educated regarding the need to have a Physician certification to document a diagnosis. This education will be completed by the Assistant Director of Nursing and will occur no later than February 23, 2024.
An audit will be completed by the Assistant Director of Nursing to ensure that all current residents with a diagnosis or Schizophrenia have physician documentation of that diagnosis. This audit will be monitored by the Director of Nursing.
For all new/readmitted residents having a diagnosis of Schizophrenia an audit will be completed by the Assistant Director of Nursing or Designee to ensure that the residents with a diagnosis of Schizophrenia have physician documentation of that diagnosis. The audit will be monitored by the Director of Nursing. This audit will be completed 3 times a week for 2 weeks, 2 times a week for 2 weeks then weekly ongoing including off shifts.
Results of the audit will be presented at the monthly Quality Assurance Meeting and recommendations will be implemented.





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 and clinical records, observations, and staff interviews it was determined that the facility failed to obtain a physician's order for the application of a wanderguard bracelet for one of five residents reviewed for their usage (Resident R72) and failed to obtain a physician's order for the application of a Continuous Positive Airway Pressure (CPAP- a machine that uses mild air pressure to keep breathing airways open while you sleep) for one of 23 residents reviewed (Resident R14).

Findings include:

Review of a facility policy entitled "Wanderguard" dated 9/14/23, indicated that a physcian's order must be obtained and a careplan will be implemented once a wanderguard (alarming device attached to a resident to alert staff of their leaving a designated area/facility) is placed on a resident.

Review of a facility policy entitled "Medication and Treatment Orders" dated 9/14/23, indicated that orders for medications and treatments will be consistent with principles of safe and effective order writing.

Resident R72's clinical record revealed an admission date of 10/13/23, with diagnoses that included dementia, alcohol abuse and age related cognitive decline.

Resident R72's clinical record revealed Resident R72 was sent to the hospital for chest pains on 11/16/23, and was readmitted to the facility on 11/18/23. A Wandering Risk Assessment dated 11/21/23, revealed that Resident R72 was at high risk for wandering.

Observations on 1/30/24, at 3:30 p.m., and 1/31/24, at 11:30 a.m. revealed that Resident R72 was laying in bed and had a wanderguard bracelet on his/her right wrist.

Resident R72 clinical record lacked evidence of a physician's order for the wanderguard bracelet.

During an interview on 1/31/24, at 11:45 a.m. the Director of Nursing confirmed that Resident R72 had a wanderguard bracelet placed upon return from his/her hospital admission on 11/18/23, a period of 75 days and lacked any physician's orders for its usage.


Resident R14's clinical record revealed an admission date of 1/05/24, with diagnoses including Type 2 diabetes (condition that affects how the body uses glucose (blood sugar)), left below the knee amputation, high blood pressure, and asthma, and lacked a physcian's order for a CPAP.

Further review of Resident R14's clinical record revealed a "Care of Valuables Acknowledgement" dated 1/05/24, that identified the presence of a CPAP machine.

Observations on 1/30/24, and 1/31/24, Resident R14 lying in bed with a CPAP mask on his/her face.

Review of Resident R14's clinical record revealed a lack of lack of evidence of a physician's order for the CPAP machine.

During an an interview on 2/01/24, 9:01 a.m. the DON confirmed that the CPAP was not included in Resident R14's physcian's orders.

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




 Plan of Correction - To be completed: 03/14/2024

For residents R72 and R14 and all residents of the facility a physician's order must be obtained prior to the application or use of equipment. For resident R72 a physician order was obtained for a wander guard and for resident R14 a physician order was obtained for the use of a CPAP.

A check of all current residents utilizing a C-Pap or having a wander guard was completed to ensure physician orders are present.

Education will be provided by the Assistant Director of Nursing no later than February 23, 2024 for all licensed nursing staff related to the need for physician orders prior to the application or use of equipment.
An audit will be developed by the Assistant Director of Nursing that will review all order summaries and 24-hour reports and will be completed 3 times a week for 2 weeks, 2 times a week for 2 weeks and weekly ongoing, to ensure that a physician order is received prior to the application or use of equipment. This audit will be monitored by the Director of Nursing.

Results of the audit will be presented at the monthly Quality Assurance Meeting and recommendations will be implemented.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

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

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


Based on observations, review of clinical records and facility policy, and staff interviews, it was determined the facility failed to ensure that a resident with limited range of motion received physician ordered treatment and services to prevent further decrease in range of motion for one of one residents reviewed for range of motion (Resident R36).

Findings include:

Review of facility policy entitled "Splints" dated 9/14/23, indicated that "Caregivers will apply the splint to the affected area, at the times scheduled by therapy." and "Splinting will be charted ..."

Review of Resident R36's clinical record revealed and admission date of 9/25/22, with diagnoses that included joint contracture (a condition when there is loss of joint mobility/movement), hypertension (high blood pressure), bradycardia (a condition when the heart beats slow), and atrial fibrillation (a condition when the heartbeat is irregular)

Review of Resident R36's clinical record revealed a physician's order dated 9/20/23, for a left knee brace to be donned (put on) during the day, taken off at night, and skin checks every two hours. Further review of the clinical record lacked evidence that the brace was applied as ordered.

Review of physical therapy discharge summary dated 8/24/23, through 9/21/23, revealed, patient and caregiver training for passive stretching and application/wearing time of orthotic (knee brace).

Observations on 1/31/24, at 9:47 a.m. and 12:44 p.m. revealed resident R36 laying in his/her bed without a brace on his/her left knee. Additional observation on 2/1/24, at 9:50 a.m. revealed Resident R36 seated in his/her wheelchair in the hallway without a brace on his/her left knee.

During an interview on 2/01/24, at 10:35 a.m. the Director of Nursing confirmed that Resident R36 did not have a brace on his/her left knee. He/she also confirmed that the brace should be applied and removed from Resident R36's left knee according to the physician's orders.

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

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








 Plan of Correction - To be completed: 03/14/2024

For resident R36 and all residents of the facility who require the use of a Splint application will be followed per Physician Order.
Resident R36's brace was applied at the time the facility became aware of absence. There were no negative effects as a result. In addition, an initial check of all residents with splint/brace orders was completed to ensure that they were being applied as ordered.
Nursing Staff will be educated no later than February 23, 2024 regarding the application of splints per Physician Order. Education will be provided by the Assistant Director of Nursing.
An audit will be developed and completed for all residents with splints by the Assistant Director of Nursing or Designee to ensure that all Splints are applied per Physician Order. The audit will be conducted 3 times a week for 2 weeks, 2 times a week for 2 weeks, then weekly on going including off shifts and will be the responsibility of the Assistant Director of Nursing or Designee. This audit will be monitored by the Director of Nursing.
Results of the audit will be presented at the monthly Quality Assurance Meeting and recommendations will be implemented.


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 observations, review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment according to physician's orders for two of two residents reviewed for oxygen usage (Residents R42 and R14).

Finding include:

Review of facility policy entitled "Treatments - Oxygen Concentrators (machine that uses the air in the atmosphere, filters it, and gives you air that is 90%-95% oxygen)" dated 9/14/23, indicated "Maintenance: Daily/Weekly: Condenser filters: removed weekly ... place filter in unit washing machine ... put clean backup filter on concentrator" and "Change the oxygen tubing and filter every other week."

Review of a facility policy entitled "CPAP/BiPAP (Continuous Positive Airway Pressure machine that uses mild air pressure to keep breathing airways open while you sleep/Bilevel Positive Airway Pressure machine that provides non-invasive ventilation therapy used to help you breathe) Support" dated 9/14/23, revealed machine cleaning involved; wiping the machine with warm, soapy water and rinse at least once a week; rinse the washable filter under running water once a week to remove dust and debris; masks, nasal pillows and tubing are cleaned daily in warm, soapy water and soaking/agitating for five minutes, rinse with warm water and allow to air dry.

Review of Resident R42's clinical record revealed an admission date of 12/20/23, with diagnoses that included Tracheostomy status (a surgical procedure that creates an opening in the neck which allows air to enter the lungs), Quadriplegia (a condition where a person is paralyzed and unable to move their body from the neck down), and Gastro-Esophageal Reflux Disease (heart burn or acid reflux).

Review of Resident R42's clinical record revealed physician orders to change oxygen tubing every night shift every Sunday and Clean Oxygen concentrator filter every night shift every Sunday.

Review of Resident R42's treatment record revealed a lack of evidence that the oxygen tubing and oxygen filter were changed as ordered on Sunday 1/21/24, and Sunday 1/28/24.

Observation on 1/31/24, at 9:49 a.m. revealed an oxygen concentrator with filters on both sides of the concentrator with a large amount of a white substance covering the entire filter. Observation also revealed an oxygen tube (a soft tube that delivers oxygen) connected to the concentrator and attached to Resident R42's tracheostomy (artificial opening through the neck into the trachea) that lacked a date on which it was changed.

During an interview on 1/31/24, at 9:54 a.m. the Director of Nursing confirmed that the tubing should have been dated, and the filter should have been cleaned weekly and also confirmed that when the tubing and filter are changed, there should be documentation in the clinical record.


Resident R14's clinical record revealed an admission date of 1/05/24, with diagnoses including Type 2 diabetes (condition that affects how the body uses glucose (blood sugar)), left below the knee amputation, high blood pressure, and asthma.

Observations on 1/30/24, and 1/31/24, revealed Resident R14 lying in bed with a mask on his/her face, and the tubing from the concentrator attached to her CPAP machine lacked a date indicating when it was last changed, and the CPAP machine casing was noted to have a build-up of dirt/dust where the exit tubing (large bore tubing leading from the machine to the face mask) was connected to the machine.

During an interview on 1/31/24, at 10:00 a.m. Licensed Practical Nurse Employee E2 confirmed that the tubing to and from the CPAP machine was not dated and should have been; that the machine casing was dirty; that there was a build-up of dirt/dust where the exit tubing was connected to the machine; and that he/she did not know who was responsible for cleaning the machine.

Further review of Resident R14's clinical record revealed a "Care of Valuables Acknowledgement" dated 1/05/24, that identified the presence of a CPAP machine. There was no physician's order or a care plan for Resident R14's CPAP machine.

During an interview on 2/01/24, at 9:01 a.m. the Director of Nursing confirmed that facility staff takes care of CPAP machines, and there was no order or care plan for the CPAP machine used by Resident R14.

28 Pa. Code 211.5(f)(viii) Medical records

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




 Plan of Correction - To be completed: 03/14/2024

For resident R42 and R14 and all residents of the facility, all oxygen tubing will be changed and labeled every night shift every Sunday as well as cleaning of the C-PAP and concentrator filters. Resident R42 and R14's oxygen tubing and or concentrator filters were cleaned immediately when identified.
Education will be provided no later than February 23, 2024, to all licensed nursing staff regarding the changing and labeling of all oxygen tubing as well as cleaning of C-PAP and concentrator filters.
An audit will be conducted to ensure that all oxygen tubing is changed and labeled as well as cleaning of concentrator filters and C-Paps per physician orders. The audit will be completed by the Assistant Director of Nursing or Designee 3 times a week for 2 weeks, 2 times a week for 2 weeks and then weekly ongoing and will be monitored by the Director of Nursing.

Results of the audits will be presented at the monthly Quality Assurance Meeting and recommendations will be implemented.

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, observations, and staff interview, it was determined that the facility failed to label a multi-dose injection pen of Lantus insulin (a long-acting insulin which is used to treat elevated blood sugar levels) with the date it was opened in one of two medication carts reviewed (West South Cart).

Findings include:

Review of a facility policy entitled, "Medication Labeling and Storage" dated 9/14/23, indicated that "multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial."

Observation on 01/31/24, at 7:53 a.m. of the West South Cart revealed an opened multi-dose injection pen of Lantus insulin without an open date and instructions from the pharmacy on the storage bag to discard the medication 28 days after it is opened.

At the time of the observation, Licensed Practical Nurse Employee E1 confirmed that the multi-dose injection pen of Lantus insulin did not have an open date.

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

28 Pa. Code 211.9(a)(1) Pharmacy services

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







 Plan of Correction - To be completed: 03/14/2024

All multi-dose medications once opened must be dated. January 31, 2024 a multi-dose injection pen of Lantus insulin was reordered from Pharmacy to ensure proper labeling and date.

An initial check of all other medication carts in the facility to ensure there were no other insulin vials/pens not dated was completed.

Education will be provided for all Licensed Nursing Staff regarding the proper storage of medications. Education will be provided by the Assistant Director of Nursing and will be completed no later than February 23, 2024.
An audit will be developed by the Assistant Director of Nursing and will be conducted 3 times a week for 2 weeks, 2 times a week for 2 weeks and weekly ongoing including off shifts for all medication carts. The audit will be the responsibility of the Assistant Director of Nursing or Designee and will be monitored by the Director of Nursing.
Results of the audit will be presented at the monthly Quality Assurance Meeting and recommendations will be implemented.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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

Based on observations, review of facility policy, and staff interview, it was determined that the facility failed to prevent the potential for cross contamination (the spreading of germs/microorganisms from one surface to another) during wound care for one of five residents reviewed for wounds (Resident R16).

Findings include:

A facility policy entitled "Handwashing/Hand Hygiene" dated 9/14/23, indicated that staff are to perform hand hygiene after removing gloves.

A facility policy entitled "Dressing, Dry/Clean" dated 9/14/23, indicated that staff are to change gloves and/or perform hand hygiene after removing the soiled dressing, and after opening clean supplies.

Observation on 2/02/24, at 9:20 a.m. of wound care revealed Licensed Practical Nurse (LPN) Employee E6 removed the soiled wound dressing, changed his/her gloves, and failed to perform hand hygiene prior to donning (put on) clean gloves. LPN Employee E6 cleansed the wound, changed his/her gloves, and failed to perform hand hygiene prior to donning clean gloves.

During an interview at that time LPN Employee E6 confirmed that he/she should have performed hand hygiene after removing the gloves.

During an interview on 2/02/24, at 9:25 a.m. the Director of Nursing confirmed that staff are expected to perform hand hygiene after removing their gloves.

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

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



 Plan of Correction - To be completed: 03/14/2024

For Employee E6 and all Licensed Nursing Staff education will be provided by the Assistant Director of Nursing no later than February 23, 2024 to ensure that proper hand hygiene is performed after removing gloves during dressing changes.
There were no adverse effects due to the infection control issue.
An audit of 10% of all dressing changes will be observed to include off shifts by the Assistant Director of Nursing
or Designee 3 times a week for 2 weeks, 2 times a week for 2 weeks and weekly ongoing to ensure proper technique is maintained and will be monitored by the Director of Nursing.

The results of the audit will be reviewed by the monthly Quality Assurance meeting and recommendations will be instituted.

§ 201.19(4) LICENSURE Personnel policies and procedures.:State only Deficiency.
(4) A determination by a health care practitioner that the employee, as of the employee's start date, is free from the communicable diseases or conditions listed in § 27.155 (relating to restrictions on health care practitioners).

Observations:


Based on review of employee personnel records and staff interview, it was determined that the facility failed to ensure personnel records included verification of employee's health status for two of five employees reviewed (Maintenance Director Employee E7, and Activities Manager Employee E8).

Findings include:

Review of Maintenance Director Employee E7's personnel file revealed the date of hire was 12/1/23.

Review of Maintenance Director Employee E7's personnel file lacked evidence of documentation by a licensed practitioner of verification that Maintenance Director Employee E7 was free from communicable disease or conditions.

Review of Activities Manager Employee E8's personnel file revealed the date of hire was 12/19/23.

Review of Activities Manager Employee E8's personnel file lacked evidence of documentation by a licensed practitioner of verification that Activities Manager Employee E8 was free from communicable disease or conditions.

During an interview on 2/2/24, at 11:50 a.m., the Nursing Home Administrator confirmed that the facility lacked evidence of verification of health status for two of five employees.




 Plan of Correction - To be completed: 03/14/2024

For Employee E7, E8 and all employees a verification of employee's health status stating that they are free of communicable disease or conditions will be documented in the employee's personnel file.

A complete audit of all current personal files was completed to ensure documentation was present.
Education was provided to Human Resource 2/2/24 regarding the presence of documentation required within the employee personal file.

A check list will be utilized by Human Resource and completed during the employee onboarding process to ensure that a verification of employee's health status stating that they are free of communicable disease, or conditions will be documented in the employee's personnel file.
An audit will be developed and will be completed by the Administrator or Designee prior to the employee's first scheduled day of employment to ensure that employee's health status is present in the employee's personnel file.
The results of the audit will be presented at the monthly Quality Assurance meeting and recommendations will be instituted.

§ 211.5(f)(i)-(xi) LICENSURE Medical records.:State only Deficiency.
(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a resident ' s medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death.

Observations:


Based on a review of closed clinical records and staff interview, it was determined that the facility failed to ensure that a discharge summary, with the physician's final diagnosis, was completed for one of four discharged residents reviewed (Closed Record Resident CR76).

Findings include:

A review of Resident CR76's closed clinical record revealed that the resident was admitted to the facility on 4/5/13, with diagnoses that included diabetes, hyperlipidemia (high cholesterol), and dementia (a disease that affects short term memory and the ability to think logically).

A nursing progress note dated 11/4/23, revealed that Resident CR76 had ceased to breath (passed away).

Review of Resident CR76's closed clinical record lacked evidence of a physician's discharge summary with resident's final diagnosis.

During an interview on 2/2/24, at 12:15 p.m. the Director of Nursing (DON) confirmed the facility could not provide documentation of a physician discharge summary completed for Resident CR76. The DON also confirmed that Resident CR76 should have had a discharge summary completed.




 Plan of Correction - To be completed: 03/14/2024

For resident CR76 and all residents of the facility closed clinical records will contain a discharge summary with the physician's final diagnosis.
Resident CR76 physician's discharge summary with final diagnosis was obtained February 2, 2024 and added to the resident's closed clinical record.
All medical records of recent discharges/deaths were reviewed to ensure a discharge summary was completed.

An audit will be completed by Medical Records prior to the closing of the resident clinical record to ensure a discharge summary with the physician's final diagnosis. The audit will be the responsibility of the Administrator or Designee.
The results of the audit will be presented at the monthly Quality Assurance meeting and recommendations will be instituted.

§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:


Based on review of facility nursing staffing documentation and staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 20 residents on the overnight shift, for 11 of 21 days reviewed for staffing ratios (8/31/23, 9/1/23, 11/18/23-11/20/23, 11/22/23, 11/24/23, 1/25/24, 1/26/24, 1/28/24, and 1/29/24) .

Findings include:

Review of facility census and nursing staffing documentation revealed that the facility failed to meet the minimum NA ratio for the following dates for the overnight shift:.

8/31/23, facility census of 69 residents, three NA scheduled and 3.45 were required.

9/1/23, facility census of 71 residents, three NA scheduled and 3.55 were required.

11/18/23, facility census of 64 residents, three NA scheduled and 3.20 were required.

11/19/23, facility census of 64 residents, three NA scheduled and 3.20 were required.

11/20/23, facility census of 65 residents, two NA scheduled and 3.25 were required.

11/22/23, facility census of 64 residents, three NA scheduled and 3.20 were required.

11/24/23, facility census of 64 residents, three NA scheduled and 3.20 were required.

1/25/24, facility census of 77 residents, 3.5 NA scheduled and 3.85 were required.

1/26/24, facility census of 80 residents, 2.5 NA scheduled and four were required.

1/28/24, facility census of 78 residents, 3.5 NA scheduled and 3.9 were required.

1/29/24, facility census of 77 residents, 3.5 NA scheduled and 3.85 were required.

During an interview on 2/2/24, at 11:50 a.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to meet the minimum NA ratio requirements on the above dates and shift.





 Plan of Correction - To be completed: 03/14/2024

The facility must maintain the minimum of one Nurse Aide for every 20 residents on the overnight shift. To ensure that this regulatory requirement is met the following action plan will be implemented:
Education was provided to the scheduler February 2, 2024 and will be provided to the Assistant Director of Nursing to ensure that they understand the regulatory staffing requirements for nursing assistants as they are the 2 staff members who cover call off scheduling on the off shifts and weekends.
The nursing assistant schedule will be reviewed by the scheduler and Director of Nursing to ensure that nursing assistant ratios are met prior to posting of the schedule.
In the event of call-offs by staff, all other staff/agency will be contacted to cover any open shifts to ensure ratios are met.
An audit will be developed and completed by the Director of Nursing or Designee daily for 4 weeks, then 3 times a week for 3 weeks, then 2 times a week for 2 weeks then weekly ongoing, to ensure that nursing assistant ratios are met for the overnight shifts. The audit will be monitored by the Administrator.
Results of the audit will be presented at the Quality Assurance monthly meeting and recommendations will be implemented.




§ 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 review of facility nursing staffing documentation and staff interviews, it was determined that the facility failed to ensure a minimum of one Licensed Practical Nurse (LPN) per 25 residents on day shift for four of 21 days reviewed (8/31/23, 11/22/23, 1/27/24, and 1/28/24), failed to ensure a minimum of one LPN per 30 residents on the evening shift for four of 21 days reviewed (8/31/23, 11/22/23, 11/23/23, and 11/24/23), and failed to ensure one LPN per 40 residents on the overnight shift for one of 21 days reviewed (11/18/23).


Findings include:

Review of facility census and nursing staffing documentation revealed that the facility failed to meet the minimum LPN ratio for the following dates for the day shift:.


8/31/23, facility census of 69 residents, two LPN scheduled and 2.76 were required.

11/22/23, facility census of 64 residents, two LPN scheduled and 2.56 were required.

1/27/24, facility census of 79 residents, three LPN scheduled and 3.16 were required.

1/28/24, facility census of 78 residents, three LPN scheduled and 3.12 were required.


Review of facility census and nursing staffing documentation revealed that the facility failed to meet the minimum LPN ratio for the following dates for the evening shift:.


8/31/23, facility census of 69 residents, two LPN scheduled and 2.30 were required.

11/22/23, facility census of 64 residents, two LPN scheduled and 2.13 were required.

11/23/23, facility census of 64 residents, two LPN scheduled and 2.13 were required.

11/24/23, facility census of 64 residents, two LPN scheduled and 2.13 were required.


Review of facility census and nursing staffing documentation revealed that the facility failed to meet the minimum LPN ratio for the following dates for the overnight shift:.

11/18/23, facility census of 64 residents, one LPN scheduled and 1.60 were required.

During an interview on 2/2/24, at 11:50 a.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to meet the minimum LPN ratio requirements on the above dates and shifts.





 Plan of Correction - To be completed: 03/14/2024

The facility must maintain the minimum of one Licensed Practical Nurse (LPN) per 25 residents on the day shift, and 1 LPN per 30 residents on the evening shift and one LPN for every 40 residents on the overnight shift. To ensure that this regulatory requirement is met the following action plan will be implemented:
Education was provided to the scheduler February 2, 2024 and will be presented to the Assistant Director of Nursing to ensure that they understand the regulatory staffing requirements for Licensed Practical Nurses.
The LPN schedule will be reviewed by the scheduler and Director of Nursing to ensure that LPN ratios are met prior to posting of the schedule.
In the event of call-offs by staff, all other staff/agency will be contacted to cover any open shifts to ensure ratios are met. The Assistant Director of Nursing and or the Scheduler are responsible for handling call offs on the off shifts and weekends.
An audit will be developed and completed by the Director of Nursing or Designee daily for 4 weeks, then 3 times a week for 3 weeks, then 2 times a week for 2 weeks then weekly ongoing, to ensure that LPN ratios are met for the day, evening and overnight shifts. The audit will be monitored by the Administrator or Designee.
Results of the audit will be presented at the Quality Assurance monthly meeting and recommendations will be implemented.



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