Pennsylvania Department of Health
ALLIED SERVICES CENTER CITY SKILLED NURSING
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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ALLIED SERVICES CENTER CITY SKILLED NURSING - 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 completed on March 7, 2024, it was determined that Allied Services Center City Skilled Nursing 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(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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

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

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

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

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

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

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

Observations:

Based on observation, a review of clinical records, and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by three of the five residents attending a group meeting (Residents 1, 7, and 23) and two out of the 17 residents sampled (Residents 13 and 23).

Findings include:

A clinical record review revealed that Resident 13 had diagnoses, which included congestive heart failure (a chronic condition in which the heart does not pump enough blood). A review of the resident's annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 22, 2024, indicated that Resident 13 is moderately cognitively impaired with a BIMS score of 10 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired).

An observation of Resident 13's room on March 7, 2024, at 10:45 AM revealed that the nurse call light above Resident 13's door was lit indicating that the resident's call bell was activated. Observation at this time of the call bell alert system located at the nurses station revealed that the call bell began ringing at 10:29 AM (16 minutes).

An interview with Resident 13 during the observation revealed that her call bell had not yet been answered and that she needed staff assistance to be toileted. Resident 13 stated that it often takes staff between 20 and 45 minutes for the call bell to be answered and assistance provided because the staff are busy. Following this interview, and the surveyor informed Employee 3, LPN, of the resident's unmet toileting need and at that this time staff assistance was provided.

A clinical record review revealed that Resident 23 was admitted to the facility on September 7, 2023, with diagnoses that included lumbar vertebra fracture and heart failure. A review of a quarterly Minimum Data Set assessment dated December 15, 2023, revealed that Resident 23 is cognitively intact with a BIMS score of 15.

During an interview on March 5, 2024, at 12:00 PM, Resident 23 indicated that she experiences long wait times for staff after ringing her call bell for assistance. She explained that she sometimes waits for 20 minutes before staff respond.

During a resident group interview with residents on March 6, 2024, at 10:00 AM, three of the five residents in attendance (Residents 1, 7, and 23) stated that they have experienced long wait times for staff to respond to their call bells and requests for assistance.

During the resident group interview on March 6, 2024, Resident 1 stated that she frequently experienced long waits for staff to respond to her requests for assistance via the nurse call bell system. She explained that it is a problem when she needs to go to the bathroom because she is unable to remain continent when she feels the urge to go. Resident 1 stated that she has waited 35 to 40 minutes for staff to respond to requests for assistance. Resident 1 also stated that after staff assist her to the toilet, it may take another 35-40 minutes for them to come back to assist her from the toilet. She explained that staff response is the worst during the day shift of nursing duty.

During the resident group interview on March 6, 2024, Resident 7 stated that she waits 25 to 30 minutes for staff assistance after ringing her call bell. Resident 7 explained that she experiences the longest wait times on the night shift.

During the resident group interview on March 6, 2024, Resident 23 stated that she experiences long waits for staff to respond to her call bell and provide needed assistance. She explained that she sometimes waits for 20 minutes before staff respond to her call bell and the longest wait times occur on the night shift.

During an interview on March 7, 2024, at 12:00 PM, the Director of Nursing (DON) verified that all residents at the facility should be treated with dignity and respect, including timely response to their requests for assistance.. The DON was unable to explain why multiple residents are reporting untimely staff responses to residents' requests for assistance, which is negatively affecting their quality of life in the facility.

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

28 Pa. Code 211.12 (c)(d)(4)(5) Nursing services

Plan of Correction - To be completed: 04/16/2024

1. The facility cannot retroactively correct the deficiency as it relates to Residents 1, 7, 23, and 13.
2. To identify residents with the potential to be affected by this deficient practice random call bell audits will be completed on each shift.
3. The DON/designee will educate current staff on timely response to call bells per revised policy developed in Resident Council Meeting.
4. The DON/designee will review 5 random call bell audits encompassing day, evening and night shifts detailing response times per week for 4 weeks and monthly for 2 months to ensure substantial compliance. The SSD/designee will conduct 5 resident interviews per week for 4 weeks and monthly for 2 months to ensure response time satisfaction. The results of the audits will be reviewed at the facility's monthly QAPI Meeting.

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

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

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

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

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

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

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

Plan of Correction - To be completed: 04/16/2024

1. The facility is unable to retroactively correct the controlled substance signature sheets for three medication carts or Resident 57's controlled substance record.
2. To identify residents with the potential to be affected the facility will conduct an audit of current controlled substance signature sheets to ensure Nursing staff verified count of controlled drugs in their respective medication carts. The facility will conduct an audit of discharges over the past 30 days to ensure individual resident's controlled substance record reflects the disposition of the amount and doses remaining upon the resident's discharge.
3. The DON/designee will provide education to licensed nursing staff on the process for completing controlled substance signature sheets and controlled substance records.
4. The DON/designee will audit 5 controlled substance signature sheets and records weekly for 4 weeks and monthly for 2 months to ensure substantial compliance. The results of the audits will be reviewed at the facility's monthly QAPI Meeting.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

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

Observations:

Based on observations and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean environment on one of two nursing units (Nursing Unit 2).

Findings include:

An observation in resident room #207 on March 5, 2024, at 10:26 AM revealed a 2-inch brown/tan stain on the wall in the resident's bathroom, near the call bell and several brown/tan substance droplets on the wall to the left of the call bell. Brown/red stains were observed on the floor to the left of the toilet. A buildup of dirt and debris was observed along the edge of the bathroom floor.

An observation in resident room #212 on March 5, 2024, at 10:35 AM revealed tan discolored rings on two ceiling blocks with and a black and gray substance on one ceiling block

An observation in resident room #201 on March 5, 2024, at 10:40 AM revealed tan discolored stains on nine ceiling blocks.

An observation in resident room #200 on March 5, 2024, at 10:55 AM revealed tan discolored stains on three ceiling blocks and two ceiling blocks stained with a black and gray substance.

An observation in resident room #202 on March 5, 2024, at 11:00 AM revealed brown stains on the window blinds.

An observation in the Unit 2 resident shower and bathing room on March 5, 2024, at 11:48 AM revealed strands of white and black hair were observed in the drain in the large white bathtub. Multiple strands of hair and debris were also observed in the tub basin. A light gray pool of water and debris was observed on the shower floor. Hair strands were observed in the first shower floor drain. A clump of hair and a tan piece of paper were observed in a second shower floor drain. Dark hair strands were also observed on the tile shower floor.

An observation of resident room #203 on March 5, 2024, at 11:55 AM revealed dark tan discolored stain rings on five ceiling blocks

During an interview on March 6, 2024, at approximately 11:15 AM, the Facility Maintenance Manager explained that the ceiling tiles were discolored and stained due to condensation on the piping above the residents' rooms that was dripping onto the ceiling tiles.

During an interview on March 7, 2024, at approximately 12:00 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the facility should be maintained in a clean and sanitary manner.

28 Pa. Code 201.18 (e)(2.1) Management

Plan of Correction - To be completed: 04/16/2024

1. The bathroom in resident room 207 was cleaned. The discolored ceiling tiles in resident rooms 212, 201, 200, and 203 were replaced. Unit 2 resident shower room was cleaned.
2. Environmental rounds will be completed to ensure no new areas of concern are identified.
3. The EVS Director/designee will educate Housekeeping staff on cleaning protocol in direct resident care areas. The Facilities Maintenance Manager/designee will educate Maintenance staff on identifying and replacing ceiling tiles when concerns are noted.
4. The NHA will review 5 resident room bathrooms, the Unit 2 resident shower room, and ceiling tiles in 5 resident rooms per week for 4 weeks and monthly for 2 months to ensure substantial compliance. The results of the audits will be reviewed at the facility's monthly QAPI Meeting.

483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements:

§483.15(c) Transfer and discharge-
§483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i) Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

Observations:

Based on a review of clinical records and a staff interview, it was determined that the facility failed to ensure necessary resident information was communicated to the receiving health care provider for four transferred residents out of five sampled residents (Residents 11, 13, 36, and 45).

Findings include:

A review of Resident 36's clinical record revealed that the resident was transferred to the hospital on September 16, 2023, and returned to the facility on September 17, 2023.

A review of Resident 11's clinical record revealed that the resident was transferred and admitted to the hospital on September 19, 2023, and returned to the facility on September 22, 2023.

A review of Resident 13's clinical record revealed the resident was transferred from the facility and admitted to the hospital on January 10, 2024, and returned to the facility on January 15, 2024.

A review of Resident 45's clinical record revealed the resident was transferred from the facility and admitted to the hospital on February 5, 2024, and returned to the facility on February 8, 2024.

Further review of the above clinical records revealed no documented evidence of the information communicated to the receiving health care facility upon the residents' transfer to the hospital.

An interview with the director of nursing on March 6, 2024, at 9:00 AM, confirmed that the facility was unable to provide documented evidence that all special instructions or precautions for ongoing care, as appropriate, and comprehensive care plan goals were communicated to the receiving health care facility.

28 Pa. Code 211.5 (f) Medical records

Plan of Correction - To be completed: 04/16/2024

1. The facility cannot retroactively correct the deficiency as it relates to Residents 11, 13, 36, and 45.
2. The facility will complete an audit of residents transferred within the past 30 days to ensure necessary documentation was present during transfer.
3. The NHA/designee will educate Social Services and Nursing Departments on sending the documentation required upon transfer of a resident.
4. The NHA/designee will review sampled resident transfers per week for 4 weeks and monthly for 2 months to ensure substantial compliance. The results of the audits will be reviewed at the facility's monthly QAPI Meeting.

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

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

Observations:

Based on observation, review of clinical records and select incident reports and resident and staff interviews it was determined that the facility failed to timely and effectively monitor a resident's use of a therapeutic device to preserve skin integrity and prevent pressure sore development, which resulted in the development of an avoidable pressure sore by one resident out of three reviewed (Resident 53).

Findings:

According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk.

The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair.

A review of Resident 53's clinical record revealed she was admitted to the facility on January 5, 2024, with diagnoses of included motor vehicle collision, fractures of the nasal bone, multiple right sided rib fractures, left thumb, patella (knee), right bimalleolar (ankle) fractures.

An admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 12, 2024, revealed that the resident was cognitively intact, had impairment on both lower extremities with functional range of motion, and was dependent on staff for toileting, lower body dressing, and putting on/taking off footwear.

The resident's care plan indicated she was at risk for potential for or actual skin breakdown related to alteration in mobility, initiated January 5, 2024, with a goal that the resident will comply with therapeutic regimen, including preventative measures and nutritional interventions through next review, with a target date of April 18, 2024. Planned interventions included pressure redistribution cushion to chair as ordered, pressure redistribution mattress to bed, turn and re-position per schedule, employ good transfer technique to avoid friction, and skin checks at least weekly on scheduled bathing days, date initiated, January 5, 2024.

The resident's care plan also indicated that a skin breakdown or interference with structural integrity of layers of skin on left inner heel, caused by pressure from device worn by resident initiated January 11, 2024, and resolved on February 21, 2024. The goal was that the area will improve with no signs of infection by April 18, 2024, resolved on February 21, 2024. Planned interventions, included suspected deep tissue injury (DTI) left inner heel with treatment as ordered, remove immobilizer left lower extremity for skin check, initiated January 11, 2024, and treatment to area, which will provide padding and protect area until healed initiated January 12, 2024.

A review of a "Braden Scale" (a tool used to determine/predict pressure sore development) dated January 5, 2024, revealed that the resident scored a 19, indicating the resident was very low or no risk for pressure sore development.

A review of a nursing note, a late entry by a CRNP, dated January 9, 2024, 5:48 PM, reflecting an admission visit with the resident indicated that the resident has a brace LLE (left lower extremity) and a soft cast to the right ankle. The entry noted that the resident required assistance with activities of daily living.

A nursing note dated January 10, 2024, 2:31 PM, revealed that during routine wound rounds by nurse, the resident complained of a burning feeling to the left heel. The immobilizer was removed for a skin check and the nurse found a discolored area to the left inner heel.

A physician order dated January 10, 2024, was noted for staff to remove the immobilizer left lower extremity for skin check every shift. Cleanse left inner heel with soap water, pat dry, apply skin prep and dry dressing daily and as needed for soiling or dressing displacement.

An incident report dated January 10, 2024, at 2:25 PM, revealed that the resident was complaining of burning feeling to left heel. Immobilizer removed for skin check, discolored area noted left inner heel. Immobilizer removed and deep tissue injury (DTI) was noted to the inner aspect of her heel. New treatment order received. The facility noted, however, that the pressure area was "unavoidable" as the "immobilizer necessary for bone healing." New treatment will provide padding and protect area while immobilizer is in place.

Review of witness statement, "pressure injury/MASD" by Employee 4 (Licensed Practical Nurse - LPN), dated January 11, 2024, revealing that vascular checks had been performed, and no area noted at time. The witness statement pre-typed question asked: did you see anything in the environment that could have contributed to the area? If yes, explain: "immobilizer."

A review of the resident's Treatment Administration Record (TAR), for January 2024, revealed the task of removing the left lower extremity (LLE) immobilizer for skin checks, was not initiated until January 10, 2024, five days after the resident's admission and the day the resident's pressure sore was discovered.

A review of facility "wound-skin healing record", dated February 14, 2024, indicated that the resident's pressure injury, DTI, left inner heel, measured 4.0 (cm) x 2.0 cm x 0 cm. No exudate (drainage), no odor, no s/s infection. Two small areas of intact purple/maroon discolored skin separated by flesh tone skin edges, normal in appearance, surrounding skin normal in temp.

A review of a wound consultant note dated February 20, 2024, indicated the resident's left heel pressure sore was s now resolved.

Interview with Employee 5 (Registered Nurse, Assistant Director of Nursing) on March 7, 2024, at approximately 9:50 AM, confirmed the resident's January 2024 TAR failed to identify the removal of the left lower extremity immobilizer, to check the integrity of the resident's skin to prevent pressure sore development, until after the pressure ulcer/injury was identified.

Interview with Resident 53 on March 7, 2024, at approximately 11:05 AM, indicated she had been experiencing discomfort in her left heel, for a brief period of time, so she alerted staff.

Observation of the left inner heel on March 7, 2024, at approximately 11:10 AM, with the resident's approval, and in the presence of Employee 6 (LPN), revealed an intact, slightly reddened, small, circular area. The area measured 1 cm x 1.5 cm (as measured by Employee 6 LPN). During the observation the resident displayed and vocalized no pain and or discomfort.

The facility was unable to provide documented evidence that staff had timely and consistently conducted skin integrity checks under the brace prior to the development of this unstageable DTI to promptly identify declines in skin integrity and prevent the development of the deep tissue injury.

During an interview with the Director of Nursing (DON) on March 7, 2024, at approximately 10:15 AM, confirmed that the facility was unable to demonstrate that staff had timely implemented consistent removal of the immobilizer to conduct checks the integrity of the resident's skin and there was no evidence that this task was completed until after the pressure ulcer/injury was identified.

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

Plan of Correction - To be completed: 04/16/2024

1. Resident 53 still resides in the facility. Her pressure injury is healed.
2. To identify residents with the potential to be affected the facility will complete an audit of residents with orthopedic devices to bilateral lower extremities to validate current physician orders that do not include removal of device with ordering physician to see if he/she wants facility clinical staff to check for skin breakdown periodically. Residents with orthopedic devices to bilateral lower extremities will have pain assessments completed to ensure no new areas are noted until scheduled follow up appointment with ordering physician.
3. The DON/designee will educate current licensed Nursing staff on clarifying orders for residents with orthopedic devices to bilateral lower extremities that do not include removal of device with ordering physician to see if he/she wants facility clinical staff to check for skin breakdown periodically. The DON/designee will educate current licensed Nursing staff on completing pain assessments on residents with devices to bilateral lower extremities whose orders do not include removal of device to help identify potential pressure ulcer development and report positive pain assessments to physician at time of discovery.
4. The DON/designee will audit the physician orders and pain assessments of sampled residents with orthopedic devices to bilateral lower extremities per week for 4 weeks and monthly for 2 months to ensure substantial compliance. The results of the audits will be reviewed at the facility's monthly QAPI Meeting.

483.90(e)(1)(iv)(v) REQUIREMENT Bedrooms Assure Full Visual Privacy:

§483.90(e)(1)(iv) Be designed or equipped to assure full visual privacy for each resident;

§483.90(e)(1)(v) In facilities initially certified after March 31, 1992, except in private rooms, each bed must have ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains.

Observations:

Based on a review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to ensure each resident room is designed and equipped to assure full visual privacy for two out of the 17 residents sampled (Resident 15; Resident Room #202, Resident 13 Room #218).

Findings include:

A clinical record review revealed that Resident 15 was admitted to the facility on January 18, 2024, with diagnoses to include encephalopathy (dysfunction in brain processes including attention, cognition, and consciousness) and pneumonia.

A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 25, 2024, revealed that Resident 15 is severely cognitively impaired with a BIMS score of 7 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 severe cognitive impairment.

Observation on March 5, 2024, at 11 AM revealed that Resident 15 did not have a roommate and resided in resident room #202.

During an interview and observation on March 5, 2024, at 11:00 AM, Resident 15 stated that she was worried that people could see in through her room window at night and when staff were assisting her with clothing changes or providing personal care. She explained that she was concerned that her window blinds would not close completely.

An observation at the time of the interview in resident room #202 revealed a window that measured approximately 5.0 feet tall x 10.0 feet wide, covered by multiple 3-inch vertically hanging blinds. When in the closed position, some of the blind slats remained open, creating a line of sight into and out of the room. A courtyard and other facility windows were visible through the opening in the blinds. Further observation revealed that the window blinds were missing slats.

During an additional observation on March 7, 2024, at 8:35 AM, Employee 2, Licensed Practical Nurse, confirmed that the vertical blinds in resident room #202 would not fully close allowing for a line of sight into and out of the room.

Observation of Resident Room 218 on March 6, 2024, at approximately 10:00 AM revealed that the vertical window blinds were partially opened and one of the slats was twisted. Observation at this time also revealed that when the blinds were fully closed the middle slat was missing. Interview with Resident 13 at this time revealed that the middle slat has been missing for a while. Resident 13 stated that the missing slat prevented her from having full privacy (from the outside) when the blinds are closed.

During an interview on March 7, 2024, at 9:00 AM, the Director of Nursing (DON) confirmed that each resident room should be designed and equipped to assure privacy. The DON indicated that action would be taken to ensure Resident 15 and Resident 13's room window blinds were functioning properly and providing full privacy.

28 Pa Code 201.18 (e)(2.1) Management

Plan of Correction - To be completed: 04/16/2024

1. The window blinds in rooms 202 and 218 were immediately replaced.
2. To identify residents with the potential to be affected the facility will conduct an audit of resident room window blinds to ensure total visual privacy is provided.
3. The NHA/designee will provide education to Clinical and Maintenance staff on the requirement for window blinds to endure total visual privacy.
4. The NHA/designee will audit 5 resident room blinds weekly for 4 weeks and monthly for 2 months to ensure substantial compliance. The results of the audits will be reviewed at the facility's monthly QAPI Meeting.

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

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

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

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

Observations:

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide restorative nursing services to maintain the mobility and functional abilities of one of the 17 residents sampled (Resident 15).

Findings included:

A clinical record review revealed that Resident 15 was admitted to the facility on January 18, 2024, with diagnoses to include encephalopathy (dysfunction in brain processes including attention, cognition, and consciousness) and pneumonia.

A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care, dated January 25, 2024, revealed that Resident 15 is severely cognitively impaired with a BIMS score of 7 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 severe cognitive impairment.

During an interview on March 5, 2024, at 11:00 AM, Resident 15 stated that she was not currently receiving restorative nursing services.

A clinical record review revealed a Physical Therapy (PT) Discharge Summary dated February 22, 2024, which indicates that Resident 15 was discharged from skilled physical therapy at this time because her highest practical level of functioning was achieved. The PT discharge summary indicated that Resident 15 was provided skilled services to improve the resident's ability to transfer, balance, ambulate, and improve her overall functional status. The PT discharge summary further noted that to maintain Resident 15's current level of performance and to prevent decline, development of, and instruction in an ambulation restorative nursing program, was completed with the resident's interdisciplinary team.

Further review of the resident's clinical record, conducted during the survey ending March 7, 2024, revealed no documented evidence that restorative nursing program was developed and implemented for Resident 15 following discharge from skilled therapy.

During an interview on March 7, 2024, at 12:00 PM, the Director of Nursing (DON) confirmed that the failed to provide restorative nursing services to Resident 15 as recommended upon discharge from skilled therapy.

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

Plan of Correction - To be completed: 04/16/2024

1. Resident 15 was placed on a RNP for ambulation.
2. To identify resident with the potential to be affected the facility will complete an audit of therapy discharges for the past 30 days to ensure recommendations for restorative nursing were implemented.
3. The DOR/designee will educate Therapy staff on communicating discharge recommendations for restorative nursing services during clinical morning meeting. The DON/designee will educate clinical nursing staff on education of discharge recommendations received during clinical morning meeting.
4. The DON/designee will audit sampled therapy discharges weekly for 4 weeks and monthly for 2 months to ensure substantial compliance. The results of the audits will be reviewed at the facility's monthly QAPI Meeting.

483.70(q)(1)-(5) REQUIREMENT Payroll Based Journal:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

§483.70(q) Mandatory submission of staffing information based on payroll data in a uniform format.
Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

§483.70(q)(1) Direct Care Staff.
Direct Care Staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Direct care staff does not include individuals whose primary duty is maintaining the physical environment of the long term care facility (for example, housekeeping).

§483.70(q)(2) Submission requirements.
The facility must electronically submit to CMS complete and accurate direct care staffing information, including the following:
(i) The category of work for each person on direct care staff (including, but not limited to, whether the individual is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS);
(ii) Resident census data; and
(iii) Information on direct care staff turnover and tenure, and on the hours of care provided by each category of staff per resident per day (including, but not limited to, start date, end date (as applicable), and hours worked for each individual).

§483.70(q)(3) Distinguishing employee from agency and contract staff.
When reporting information about direct care staff, the facility must specify whether the individual is an employee of the facility, or is engaged by the facility under contract or through an agency.

§483.70(q)(4) Data format.
The facility must submit direct care staffing information in the uniform format specified by CMS.

§483.70(q)(5) Submission schedule.
The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly.

Observations:

Based on record review and interview, it was determined that the facility failed to submit accurate staffing information in the Payroll-Based Journal (PBJ) system for two of the four quarters reviewed (October 1, 2023, through December 31, 2023, and July 1, 2023, through September 30, 2023).

Findings include:

A review of the Payroll-Based Journal (PBJ) Staffing Data Report Certification and Survey Provider Enhanced Reports (CASPER) Report 1705D for fiscal year quarter 4 2023 (July 1 - September 30) revealed that the facility's data triggered for no registered nurse (RN) hours on August, 5, 2023, August 6, 2023, August 27, 2023, September 2, 2023 and September 4. 2023.

A review of the Payroll-Based Journal (PBJ) Staffing Data Report Certification and Survey Provider Enhanced Reports (CASPER) Report 1705D for fiscal year quarter 1 2024 (October 1 - December 31) revealed that the facility's data triggered for no registered nurse (RN) hours on October 1, 2023, October 14, 2023, November 18, 2023, November 19, 2023, November 23, 2023, and November 25, 2023.

A review of staffing time sheets and daily nurse assignment sheets revealed that the facility had RN staffing working on each date that triggered for no RN hours on the PBJ Staffing Data Reports.

During an interview on March 7, 2024, at approximately 10:00 AM, the facility Vice President of Skilled Nursing Operations indicated that the PBJ trigger for no RN hours was due to a coding error that occurred when the facility updated their system to identify charge nurses. He explained that charge nurses were added to the facility's reporting system in July of 2023, but the facility failed to code the charge nurses as registered nurses for submissions through the PBJ system.

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

Plan of Correction - To be completed: 04/16/2024

1. The facility cannot correct the data submitted for calendar Q3 2023, and calendar Q4, 2023, as the CMS submission / correction deadlines have passed.
2. A system wide audit was completed for all positions currently in the payroll system, to ensure all positions are coded properly to the PBJ table for accurate staffing information data submission to PBJ.
3. Payroll representatives, human resources personnel, and IT staff involved in the coding of staffing data, and the creation of PBJ files for submission, have been re-educated on proper coding of positions for accurate reporting.
4. Prior to each quarterly submission, the facility will audit the payroll system and PBJ lookup table, to ensure all positions are coded properly for accurate staffing information to be submitted to PBJ.

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