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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 70 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.


PENNYPACK NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey, completed on August 26, 2024, it was determined that Pennypack Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations, as they relate to the Health portion of the survey.

Plan of Correction:

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:

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.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to notify the representative of the Office of the State Long Term Care Ombudsman for two of 16 resident records reviewed (Residents R2, R36).

Finding include:

Review of Resident R2's clinical record revealed that the resident was admitted to the facility on March 5, 2024, diagnosed with neuromuscular dysfunction of the blader and infection and inflammatory reaction due to indwelling urethral catheter.

Review of Resident R2's nursing progress note dated May 21, 2024, revealed the resident was transferred to the hospital when there was a complaint of severe abdominal pain and blood noted in urine. Further review of the resident's record revealed the resident was transferred to the hospital on June 6, 2024, due to acute kidney failure.

Resident R36 was admitted to the facility on March 13, 2024, for aftercare following a joint replacement. Review of Resident R36's nursing progress notes dated July 13, 8 and 7, 2024 indicated the resident was transferred to the hospital due to a change in condition.

Interview on August 23, 2024, at 2:00 p.m. the Nursing Hone Administrator confirmed that there were no written notices of the hospital transfers given to the State Long Term Care Ombudsman upon transfer out of the facility for Resident R2, and Resident R36.
.

28 Pa. Code 201.29(h) Resident rights

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

1.R2 and R36 hospital transfers were updated on LTC Ombudsman log.

2. The social services department will review hospital transfers for the last 30 days to ensure discharges are placed on Ombudsman log.

3. The Administrator/designee will re-inservice the social services department on completing the ombudsman log and process of notifying the ombudsman. The ombudsman log will be reviewed during the clinical meeting.

4. The admin/designee will complete random audits on the ombudsman log for accuracy weekly x 4weeks. Audits will be reviewed by the QAPI committee and will determine the need for further audits.

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

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

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

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

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

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

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

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

Observations:

Based on observation, review of facility policy and procedures and interview with staff, it was determined that the facility failed to maintain an effective infection control program related to the transportation, sorting, washing, and drying of soiled resident clothing and the storage of clean linens and residents' clothing in the laundry room.

Findings include:

Review of facility Policy on Infection prevention and control program revealed that infection prevention and control program (IPCP) was established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
Review of facility document entitled "Clean Linen Storage and Handling" revealed; sort, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens, or other soiled items.

Observation on August 20, 2024 at 10:20 AM in the presence of the Food Service Director and the Director of Housekeeping revealed that the facility's outside dumpster area contained large blue containers filled with dirty hospital gowns. The Director of Housekeeping indicated the facility used a laundry service and the gowns were waiting to be picked up tomorrow for their services.

Observation of the laundry room located in the basement conducted on August 26, 2024, at 10:48 a.m. revealed that the basement was accessible from inside the facility through a door leading to a wooden staircase, which was covered with dust and particles of stains.

Further observation revealed that to reach the laundry room, used for the laundry service of the personal clothing of the residents, multiple congested areas, filled with various obsolete- looking pieces of gadgets had to be walked behind, and there was only one door to the laundry area. The laundry room measured approximately 18 x 15 feet in size. In the laundry room, there were three dryers (non-commercial). There were two washing machines (non-commercial) adjacent to the wall facing the door. On the corner of the room, near the entrance wall, and near the washing machines and the dryers, were a big pile of clear plastic bags of clothing on the floor reaching to the same height as the washing machines. Continued observation of the laundry area revealed that to the left of the room (left wall) was a desk with computer and printer, and further down the left wall was kept, housekeeping supplies, and tools seems like scrubbing pads for floor stripping machines, and mop heads.

Further, observation of the Laundry room revealed that there was a large pile of sweeper mop cloths. Additional observation revealed that the floor of the Laundry room was dirty with black colored sticky particles, peeled paintings, rusted metal parts. Also observed that the laundry room was congested with gadgets like materials, clean and soiled items, personal clothes, and mop heads which were not sufficiently separated.

Interview with Housekeeping staff, Employee E6 confirmed that the pile of sweeper mop cloths were items that had already been washed.

Observation of the laundry room revealed that there were no clear designated area for soiled items, and clean items.

Additionally, the congested space in which the soiled clothing and other soiled items were transported, delivered, sorted, washed, dried, folded and stored, did not allow for the prevention of contamination of the clean clothing by the soiled items.

Observation of the shower room, located near the resident room B6, conducted on August 26, 2024, at 11:23 a.m., revealed that clean linens were stored in racks without doors, but with covering drapes. Further observation revealed that soiled lines were stored in the same shower room, in plastic bags. At the time of the finding, it was confirmed with the Housekeeping Director, Employee E6.

Observation of the shower room, located near the resident room A10, conducted on August 26, 2024, at 11:33 a.m., revealed that clean linens were stored in racks without doors, but with covering drapes. Further observation revealed that soiled lines were stored in the same shower room, in plastic bags.

At the time of the finding, it was confirmed with the Housekeeping Director, Employee E6.

28 Pa. Code 201.14(a) Responsibility of licensee

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

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

1. Soiled linen in outside blue bins was placed in bags and stored for pick up by contracted laundry service, Staircase steps were cleaned. Laundry room cleaned. Soiled and clean mop heads were separated. Clean and soiled clothing were separated. Linen racks with clean linen covered. Soiled linen was bagged and placed in outside blue bins.

2. Blue bins, laundry room, basement , and shower rooms were checked for cleanliness, clutter , and proper storage of soiled and clean linen

3. Director of Housekeeping/designee will be re-in-service housekeeping staff on cleaning and laundry policies and procedures.

4. The admin/designee will complete random audits of the laundry area and stairwells will be performed weekly x4weeks. Audits will be reviewed by the QAPI committee and will determine the need for further audits.

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, facility documentation, and interviews with staff, it was determined that the facility failed to issue the resident/resident representative a Notice of Medicare Non-Coverage (NOMNC) prior to termination of Medicare A services, as required, for one of three residents' records reviewed (Resident R25).

Findings include:

Review of Facility policy on " Medicare Advance Beneficiary and Medicare Non-coverage Notices", indicated that if the resident's Medicare covered Part A stay or when all of Part B therapies are ending, a Notice of Medicare Non-coverage (CMS form 10123) is issued to the resident at least two calendar days before benefits end.

Review of the clinical record for Resident R25 revealed that the resident was admitted to the facility on April 10, 2019, with Medicare insurance coverage for skilled nursing care. Further review of the record revealed that Resident R25's Last Covered Day of Part A Service was June 28, 2024. Review of clinical records revealed that the Notice of Medicare Non-Coverage (NOMNC - written notice to the resident, beneficiary, or resident representative, of the right to an expedited review of a Medicare service termination) was issued to Resident R25 or the resident's representative only on July 17, 2024.

Interview with the Nursing Home Administrator on August 26, 2018, at 12:30 p.m., confirmed that the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to Resident R25 prior to the termination of the Medicare A service.

The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) prior to termination of Medicare A services, as required.

28 Pa. Code 201.29(f) Resident rights

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

1. R25 received the corrected NOMNC.

2. NOMNCs presented in the last 30 days will be reviewed for completion.

3. The DON/designee will re-inservice social services on the completion of the NOMNC. NOMNC's will be reviewed during the clinical meeting to ensure completion.

4. The RNAC/designee will complete random audits of the NOMNCs provided to residents for completion and accuracy weekly x 4 weeks. Audits will be reviewed by the QAPI committee and will determine the need for further audits.

483.20(k)(1)-(3) REQUIREMENT PASARR Screening for MD & ID:

§483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability.

§483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with:
(i) Mental disorder as defined in paragraph (k)(3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission,
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
(B) If the individual requires such level of services, whether the individual requires specialized services; or
(ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission-
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
(B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability.

§483.20(k)(2) Exceptions. For purposes of this section-
(i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital.
(ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual-
(A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital,
(B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and
(C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services.

§483.20(k)(3) Definition. For purposes of this section-
(i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1).
(ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b)(3) or is a person with a related condition as described in 435.1010 of this chapter.

Observations:

Based on clinical record review and staff interview, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed for one of 24 residents reviewed (Resident R16).

Findings include:

The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability. The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility.

Review of Resident R16's clinical record revealed the resident was admitted to the facility on December 6, 2018, with a diagnosis to include Major Depressive Disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Post-Traumatic Stress Disorder (A disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), Schizoaffective Disorder (Schizoaffective disorder is a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder), and Anxiety Disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).

Review of Resident R16's clinical record revealed a Pennsylvania Preadmission Screening Resident Review Identification Level I Form (PASRR) which indicated; for section VIII- PASRR LEVEL I Screening Outcome, the resident was not checked off for the outcomes that may or may not lead to chronic disability.

Interview on August 26, 2024, at 11:30 a.m., with the Director of Nursing, confirmed the finding.

28 Pa Code 211.5(f) Clinical records

28 Pa Code 211.16(a) Social services

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

1.R16's PASRR has been completed.

2. Current resident PASRR's will be reviewed for accuracy by the social services department.

3. The Administrator/ designee will re-service the social service department on the completion of the PASRR.

4. The administrator/designee will complete random audits on the PASRR's to ensure completion weekly x 4weeks. Audits will be reviewed by the QAPI
committee and will determine the need for further audits.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on observations, clinical record review, review of facility documents and staff interviews, it was determined that the facility failed to revise the care plan for fall prevention, for one of 24 residents reviewed (Resident R25).

Findings include:

Review of Resident R25's clinical record revealed that the Resident was admitted in the facility on April 10, 2019. R25's diagnoses included, Unspecified Dementia (Dementia is a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), Anxiety Disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), Unspecified Glaucoma (A condition in which there is a build-up of fluid in the eye, which presses on the retina and the optic nerve. The retina is the layer of nerve tissue inside the eye that senses light and sends images along the optic nerve to the brain. Glaucoma can damage the optic nerve and cause loss of vision or blindness), Muscle Wasting and Atrophy (Muscular Atrophy is the decrease in size and wasting of muscle tissue), Unspecified Lack of Coordination (Lack of Coordination can be due to damage to brain, nerves, or muscles).

Review of Clinical Nursing Progress Note, dated April 3, 2024, for R25, indicated that Resident fell at about 11:35 a.m., outside of another resident's room, resident found lying on her left side, it was observed during assessment that resident had hematoma on left-side of forehead, and per physician-order Resident R25 was sent to the hospital for evaluation and treatment. Resident R25 was readmitted from the hospital on April 8, 2024.

Further review of clinical progress notes dated April 8, 2024, indicated the Fall Risk Evaluation for Resident R25, resulted in Fall Risk Score of 21.0.

Review of the care plan for Resident R25, indicated that the resident's fall- prevention- care plan, initiated on January 5, 2023, with the target date of April 2, 2024, was not updated, or revised, to reflect the interventional status, based on the fall risk evaluation or the fall occurred on April 3, 2024.

On August 26, 2024, at 1:17 p.m., the Director of Nursing, confirmed that the findings regarding the lack of revision and updating of the care plan for Resident R25, related with the fall was accurate.

28 Pa Code 211.5(f) Clinical records

28 Pa Code 211.11(d) Resident Care Plan

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

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

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

1. R25's fall care plan has been updated to include current interventions.

2. Current residents with falls in the last 30 days will be reviewed to ensure the care plans are reviewed for fall interventions.

3. The DON/designee will inservice licensed staff on updating the careplan with fall interventions. Careplans will be reviewed during the morning clinical meeting.

4. The DON/designee will complete random audits of new fall risk management reports to ensure interventions are care planned weekly x 4 weeks. Audits will be reviewed by the QAPI committee and will determine the need for further audits.

483.25(k) REQUIREMENT Pain Management:

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on observation, review of resident's records, facility's policies and interviews with staff, it was determined that the facility failed to ensure adequate pain management was provided for one resident documented with severe pain of 16 resident records reviewed (Resident R38).

Findings include:

Review of the facility's policy for "Pain Assessment and Management" revised on October 2022, states that pain management is a process that includes assessing the resident for potential pain, recognizing the presence of pain, developing and implementing interventions for pain, monitoring the resident to determine if the resident's pain is being adequately controlled, and to assess the effectiveness of the resident's level of comfort overtime. The same policy states to contact the physician immediately if the resident's pain or medication are not adequately controlled.

Review of Resident R38's clinical record revealed an initial admission date of May 1, 2024 diagnosed with a cerebral infarction (stroke), and following the stroke diagnosed with Aphasia (inability to understand or express speech) and dysphagia (swallowing difficulties) with severe malnutrition (lack of proper nutrition), In addition the resident was diagnosed with Parkinson's disease (a progressive nervous system disorder), bipolar (a mental disorder that causes extreme mood swings) dementia (loss of intellectual function), bilateral knee contractures, multiple pressure ulcers, osteomyelitis (bone infection from the pressure ulcers), urethral fistula (a tunnel that connects to the genital area, causing urine to enter the rectum, and feces to enter the bladder) and used a gastrostomy ( a surgical feeding tube place through the skin into the stomach allowing direct access of fluids and nutrients).

Review of Resident R38's admission MDS (Minimum Data Set, an assessment of resident's needs) dated May 5, 2024, assessed the resident as severely, cognitively impaired, with physical impairments to both sides of the upper and lower body, and was incontinent of bowel and bladder. The resident was assessed as completely dependent on staff for bed mobility, transfers, personal hygiene, toileting and bathing, The same MDS indicated the resident was on a scheduled pain medication regimen, receiving pain medication when needed, noting the resident did not receive non-medication interventions for pain. The resident was assessed with one (1), Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, slough may be present but does not obscure the depth of the tissue loss that may include undermining and tunneling) and two (2) Stage IV Pressure Ulcers (full thickness tissue loss with exposed bone, tendon, or muscle, slough or eschar may be present and often includes undermining and tunneling, and five unstageable pressure ulcers (depth unknown due to the wounds covered by slough and/or eschar).

On August 20, 2024, at 12:00 p.m. Resident R38 was observed in bed with her eyes closed not acknowledging the presence of the surveyor when name was repeatedly called. On August 23, 2024, at 10:00 a.m. the surveyor observed the resident in bed with her eyes closed. The resident did not respond when the surveyor called out her name. When surveyor asked if she had pain, the resident's eyes opened looking in the direction of the surveyor unable to verbalize her needs.

Review of Resident R38's physician orders revealed an order for Tramadol 50 mg starting on May 1, 2024, until August 2, 2024, that instructed to give a half a tablet every eight hours for pain (the severity or type of pain was not specified) and to indicate the level of pain 0 to 10 (10 being the worst pain).

Review of Resident R38's care plan for pain management dated May 6, 2024 included intervention to monitor/record/report any signs and symptoms of non-verbal pain and to report these occurrences to the physician.

Resident R38's pain assessment dated May 24, 2024, indicated the resident's pain, "Frequently limited the resident's participation in rehabilitation", the pain "Almost constantly" limited the resident's day to day activities, the pain intensity was assessed at a "9" with the resident's verbal descriptor scale as severe, with indicators of pain that included non-verbal sounds, verbal complaints of pain, and facial expressions of pain. The pain location was documented at the resident's left hip, right hip, coccyx, right elbow, left and right heel,

Review of Resident R38's electronic medication administration record (EMAR) during the time the pain medication was given for the months of May, June, and July, 2024 revealed the resident was documented as frequently experiencing very strong, to the worst pain possible (8-10). Further review of the MAR for May, June, and July 2024 revealed no evidence of further assessments or appropriate monitoring for the effectiveness of the pain medication once it was administered.

Interview with the Regional Registered Nurse Employee E8 and Licensed Registered Nurse Employee R7 on August 23, 2024, at 10:30 a.m. stated on August 2, 2024 the resident was experiencing pain on night shift and the resident's pain regimen changed to Percocet (a medication for pain) given as needed. The facility could not show evidence prior to this change that they responded appropriately when documentation revealed Resident R38's was experiencing severe pain.

28 Pa. Code 211.12(c) Nursing services

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

28 Pa. Code 211.12(d)(2) Nursing services

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

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

1. R 38's pain management has been updated by MD.

2. Current residents receiving PRN pain management will be reviewed to ensure PRN pain medications are given per MD orders.

3. The DON/designee will re-inservice the licensed staff on the pain management policy and procedure and pain management. PRN pain medications will be reviewed during the clinical meeting and follow up to the MD if necessary.

4. The DON/designee will complete random audits on administered PRN pain medication to ensure correct administration and MD follow up if needed weekly x4 weeks. Audits will be reviewed by the QAPI committee and will determine the need for further audits.

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

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

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

Observations:

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for three of four residents observed during medication administration (Resident R31, R48, and R49).

Findings include:

On August 21, 2024, 9:02 a.m., observed that Employee E3, a Licensed Nurse, administered to Resident R49, the medicine, Aspirin 81 mg, Chewable tablet, one tablet by mouth; when asked the Licensed Nurse to double check the medicine, the nurse stated it was Aspirin 81 mg, Chewable tablet.

Review of physician order for Resident R49, dated August 17, 2024, revealed an order to administer Aspirin Enteric-Coated (EC) Tablet Delayed Release 81 MG (Aspirin), Give 1 tablet by mouth one time a day for Thrombocytosis.

Review of literature revealed that Aspirin comes in enteric-coated and non-enteric (regular) forms. Regular Aspirin is absorbed in the stomach, while Enteric-Coated aspirin is absorbed in the small intestine.

At the time of the observation, interview with Licensed nurse Employee E3, confirmed the above findings.

On August 21, 2024, 9:16 a.m., observed that Employee E4, a Licensed Nurse, administered to Resident R31, the medicine Calcium with Vitamin D 600 mg/10 mcg ( 400 IU), by mouth.
Review of physician order for Resident R31, dated February 28, 2022, revealed an order to administer Calcium-Vitamin D3 Tablet 500-400 MG-UNIT (Calcium Carb-Cholecalciferol), Give 1 tablet by mouth two times a day for Supplement With breakfast and lunch.

At the time of the observation, interview with Licensed nurse Employee E4, confirmed the above findings.

Review of physician order for Resident R48, dated August 8, 2024, revealed an order to administer Senna Oral Tablet 8.6 MG (Sennosides), Give 1 tablet by mouth in the morning for constipation.

On August 21, 2024, 9:32 a.m., observed that Employee E4, a Licensed Nurse, was going to administer to Resident R48, the medicine named Senna Plus tablet, by mouth, but was prevented the administration of Senna Plus tablet.

Review of literature indicated that Senna Plus is used to treat constipation. It contains two medications: Sennosides and docusate. Sennosides are known as stimulant laxatives. They work by keeping water in the intestines, which helps to cause movement of the intestines. Docusate is known as a stool softener. It helps increase the amount of water in the stool, making it softer and easier to pass. Review of literature specified that Sennosides are known as stimulant laxatives. They work by keeping water in the intestines, which causes movement of the intestines.

At the time of the observation, interview with Licensed nurse Employee E4, confirmed the above findings.

The facility incurred a medication error rate of 11.54%.

Pa Code:211.12(d)(1)(2)(5) Nursing Services.

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

1. R39, R31, and R48 receive their medications per physician orders.

2. Medication carts will be reviewed to ensure OTC medications are available.

3. The DON/designee re-in serviced E2 and E4 on the medication pass policy and procedure and current licensed nurses will receive medication administration policy and procedure education.

4.Random medication pass audits will be conducted by the DON/designee to ensure complete medication administration weekly x4 weeks. Audits will be
reviewed by the QAPI committee and will determine the need for further audits

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