Chapel Manor

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately document a medical diagnosis in the clinical record for one of three residents reviewed, resulting in a discrepancy between prescribed medications and recorded diagnoses. The resident was admitted with diagnoses of essential tremor and major depressive disorder. Subsequent physician orders included Depakote 250 mg once daily by mouth for seizures, dated January 2, 2024, and Primidone 50 mg, 0.5 tablet by mouth at bedtime for seizures, dated January 3, 2024. Review of the resident’s clinical record showed no documented diagnosis of seizures despite these seizure-related medication orders. The facility’s Medication Monitoring policy, dated January 2024, states that the Medication Regimen Review (MRR) should include review of the medical record to prevent, identify, report, and resolve medication-related problems and irregularities. During an interview, the Nursing Home Administrator confirmed the findings that the seizure diagnosis was not documented in the resident’s record. This deficiency was cited under 28 Pa. Code 211.12(d)(3)(5) related to nursing services.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with moderate cognitive impairment, as indicated by a BIMS score of 12, was identified as being at risk for elopement and was care planned to wear a wander guard device. The care plan intervention for the wander guard was initiated due to the resident's impaired cognition and previous elopement risk assessments. However, a subsequent elopement evaluation showed the resident was no longer considered at risk, and staff discontinued 15-minute safety checks. Despite the change in risk status, the resident was able to leave the building unattended and was found outside the facility, expressing a desire to go to the police department. Facility investigation revealed that the resident's wander guard device was not functioning properly at the time of the incident, which contributed to the resident's unsupervised exit from the building.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident who required continuous 1:1 supervision due to severe cognitive impairment, restlessness, agitation, and dependence on staff for transfers and toileting, was left unsupervised. The resident had a history of falls and had recently undergone a left hip replacement following a previous fall. Physician notes and care plans consistently indicated the need for 1:1 supervision and fall precautions due to the resident's high risk for accidents. Despite these documented needs, on the night in question, the nurse aide assigned to provide 1:1 supervision left the resident unattended to provide care to another resident without notifying anyone or obtaining coverage. The aide reported that the resident was restless throughout the night and did not have non-skid footwear on, as the resident had removed them. During the period the resident was left alone, the resident attempted to get out of bed and suffered an unwitnessed fall, resulting in lacerations, abrasions, and a traumatic brain injury, including a subarachnoid hemorrhage and cerebral contusion, as confirmed by hospital imaging. Interviews and facility documentation revealed that staffing issues contributed to the failure to maintain continuous supervision, with aides being rotated and dividing their time between 1:1 supervision and care for other residents. The nursing home administrator confirmed that the resident, who was identified as needing 1:1 observation, was not provided with the required close staff supervision at all times. This lapse in supervision directly led to the resident's fall and subsequent serious injuries.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate nursing staff to meet the needs of a resident who required 1:1 supervision as ordered by the physician. The resident, who had diagnoses including restlessness, agitation, lack of coordination, and difficulty walking, was assessed as severely cognitively impaired and dependent on staff for transfers and toileting. Despite documented orders and care plans for continuous 1:1 supervision due to safety concerns and increased behaviors, staffing records showed the facility was short-staffed during the relevant night shift, providing fewer nurse aide and LPN hours than required for the census and resident needs. On the night in question, the nurse aide assigned to provide 1:1 supervision for the resident left the room to attend to another resident's personal hygiene needs without notifying anyone, leaving the resident unsupervised. During this period, the resident, who was restless and had removed non-skid footwear, fell from the bed. The incident was discovered when the nurse aide heard a noise and found the resident on the floor with lacerations and abrasions. The resident was unable to recall the incident or report pain, and a neurological assessment was performed. Following the fall, the resident was transferred to the hospital, where diagnostic imaging confirmed traumatic brain injury, including subdural hematomas and subarachnoid hemorrhage. Facility documentation and staff interviews confirmed that the required 1:1 supervision was not maintained due to inadequate staffing, directly resulting in the resident being left unsupervised and sustaining actual harm.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure complete documentation of Medication Administration Records (MAR) for two residents. For one resident with end stage renal disease, heart failure, and type 2 diabetes, there were instances where Oxycodone was signed out on the narcotic record but not documented on the MAR as administered. Specifically, on two occasions, the narcotic was signed out but there was no evidence in the MAR that the medication was given. The Director of Nursing confirmed the absence of documentation in the MAR for these instances. For another resident with chronic kidney failure, cerebral infarction, and heart failure, multiple instances were identified where Oxycodone was signed out on the narcotic record but not documented on the MAR. The resident was cognitively intact and reported adequate pain management. The Director of Nursing also confirmed the lack of documentation in the MAR for these occasions. Additionally, although the Director of Nursing is responsible for periodic, randomized checks to ensure proper medication administration, there was no documented evidence that these checks were performed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient supplies of linen, specifically wash clothes, for the bathing and toileting care needs of all 12 residents reviewed. Observations in the laundry department and throughout the nursing units revealed that there was no periodic automatic replacement (PAR) of wash clothes and that no wash clothes were in stock. Nursing staff reported that they frequently ran out of wash clothes on a daily basis over the past three months and had to use disposable wipes and large towels as substitutes. Interviews with eleven alert and oriented residents confirmed the ongoing shortage of wash clothes for bathing and hygiene care. These findings demonstrate that the facility did not reasonably accommodate the needs and preferences of each resident regarding personal hygiene supplies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Essential equipment for the mechanical preparation of ice was not maintained in a safe operating condition, as evidenced by interviews and observations. The facility had two ice machines intended to serve the nursing units and dietary department, but one was inoperable and the other was not functioning at full capacity, resulting in insufficient ice production. Staff interviews revealed that the malfunctioning ice machines had been an issue since at least May 20, 2025, and that the facility had to order ice from an outside vendor to meet demand. The maintenance director confirmed that one machine was awaiting a repair quote and the other was deemed unrepairable and required replacement. Multiple residents and staff reported that the supply of ice was inadequate, with residents stating that the available ice machine could not keep up with the need for drinking water. Nursing and dietary staff corroborated that ice production was low and that they were resorting to purchasing ice from a nearby convenience store for both residents and staff. Observations confirmed that one ice machine was not functioning and the other was not producing ice at the manufacturer's intended volume.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Chapel Manor was found to be non-compliant with the requirement to ensure residents are free from neglect, as outlined in 42 CFR Part 483, Subpart B. The deficiency was identified following an incident involving a resident, who was left in an unsafe position after receiving care. The resident, who had severe cognitive impairment and was at risk for falls, was left in a bed that was not lowered to a safe position, resulting in a fall that caused significant injuries. The resident, admitted with conditions including COPD, osteoporosis, and dementia, was assessed as having a high risk of falls. The care plan specified that the resident's bed should be kept in the lowest position to prevent falls. However, after morning care, a nurse aide left the resident's bed in a raised position while retrieving a wheelchair, during which time the resident rolled out of bed, sustaining a subdural hematoma and a fracture of the left femur. Interviews with staff confirmed that the bed was left in a high position contrary to the care plan's instructions. The Director of Nursing acknowledged that the bed should have been lowered to prevent such incidents. The facility's failure to adhere to the care plan and ensure the resident's safety resulted in actual harm, highlighting a lapse in following established safety protocols.

Plan Of Correction

The facility cannot retroactively correct the cited deficient practice. An initial observation of care will be conducted of 5 residents receiving care on each shift to verify residents' beds are placed in a safe position after the completion of care. The NPE or designee will re-inservice nursing staff on the Safe Resident Handling policy with the focus on placing residents' beds in a safe position after the completion of care. The NPE or designee will re-inservice nursing staff on the Abuse policy. The DON or designee will conduct random observations of 5 residents receiving care weekly x 4, then monthly x 2 to verify residents' beds are placed in a safe position after the completion of care. Results of the audits will be presented at the QAPI meetings for review. Date of compliance May 6, 2025

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to permit a resident to return after hospitalization, in violation of its own bed-hold and discharge policies. The resident, who had a history of traumatic brain injury and epilepsy, was transferred to a hospital following threatening and erratic behavior, and subsequently to a psychiatric hospital. Documentation shows that the facility did not assist the resident or family in finding an appropriate placement and did not assess the resident for safety or review clinical records when the resident was cleared for discharge and ready to return. The psychiatric hospital and admission staff confirmed that the resident was medically cleared and the facility was contacted for readmission, but the facility refused to accept the resident back. Interviews with facility staff, including the Social Service Director and Administrator, confirmed that the resident was expected to return after acute transfers and that there was no safe discharge available during the resident's stay. The facility's own policies require that residents transferred for acute care be permitted to return unless specific discharge criteria are met, which was not documented in this case. There was also no evidence that the facility provided the required support or documentation for discharge planning, and the resident's family member stated they could not provide care post-discharge.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement an effective discharge planning process for a resident, as required by its own policies and regulatory standards. The review of clinical records and facility policies revealed that the discharge planning process did not focus on the resident's discharge goals, did not adequately prepare the resident or their representative for transition to post-discharge care, and did not address factors that could lead to preventable readmissions. Specifically, the facility did not update the resident's comprehensive care plan and discharge plan in a timely manner, nor did it document the evaluation of the resident's discharge needs as required. The resident in question was admitted from the hospital with diagnoses including traumatic brain injury, epilepsy with medication non-compliance, and altered mental status. The care plan indicated a potential for discharge and included interventions such as identifying and documenting the resident's desires, evaluating discharge planning needs, and making referrals to community-based agencies. However, there was no documented evidence that these interventions were carried out or that a discharge plan with all relevant information was created to facilitate the resident's transition or avoid unnecessary delays. Additionally, the facility did not document or incorporate input from the resident's family member, who had communicated an inability to provide support and a preference for long-term care placement. Despite discussions with the family regarding discharge planning and the need for appropriate placement, the clinical record lacked evidence that these concerns were considered in the discharge planning process. This resulted in a failure to ensure that the discharge plan was consistent with the resident's needs and goals, as required by facility policy and regulatory standards.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report the complete investigation of an allegation of abuse within the required time frames. A resident, who had been admitted with diagnoses including rectal cancer, pain, cellulitis, and anxiety, alleged that the Nursing Home Administrator physically abused him by pushing him in the chest. The incident was reported to the State Event Reporting System the following day, and the investigation was deemed unsubstantiated. However, the required PB-22 form, which documents allegations of abuse with an identified alleged perpetrator, was not completed and submitted within the mandated five-day period. This delay was confirmed by the Assistant Nursing Home Administrator during an interview.

Plan Of Correction

The PB-22 form has been completed and submitted. Employee E2 was re-educated on the importance of following proper protocol and timeframes for completing and submitting the PB-22 form within five days of an abuse allegation. NHA/designee will complete an audit reviewing the past 30 days to ensure all PB-22 forms have been completed. Then weekly x4 audits to review the timely submission of PB-22 forms for any future abuse allegations. Audit results will be reviewed by the Director of Nursing or designated supervisor. Findings will be reported to QAPI monthly x3.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain and inspect emergency lighting as required, affecting the entire facility. During a document review on December 23, 2024, it was found that the facility could not provide documentation for monthly 30-second testing and annual 90-minute testing of emergency lighting. This deficiency was confirmed during an exit interview with the Assistant Administrator and the Maintenance Director.

Plan Of Correction

Monthly 30 second testing and annual 90 minute testing Emergency lighting system has been inspected and documentation is kept in equipment maintenance binder. Maintenance Dir/designee will re-educate maintenance staff on timely inspection of emergency lighting system monthly and annually. Maintenance dir/designee will complete monthly x3. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain proper exit signage as required by NFPA 101 standards, affecting the entire facility. During a document review on December 23, 2024, it was discovered that the facility lacked documentation of monthly exit sign testing after March 2024. This deficiency was confirmed during an exit interview with the Assistant Administrator and the Maintenance Director, who acknowledged the absence of the necessary documentation.

Plan Of Correction

The monthly Exit signage inspection have been completed. NPE/designee will re-educate maintenance staff on maintaining the monthly inspection documentation. NHA/designee will complete monthly audits to ensure compliance. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain and inspect portable fire extinguishers in accordance with NFPA 10, affecting the entire facility. During a document review on December 23, 2024, it was found that the facility could not provide documentation for the annual maintenance and inspection of portable fire extinguishers, nor could they provide certification of the inspector who conducted the annual inspection. Additionally, an observation in the Basement Electrical/Data Room revealed that the portable fire extinguisher had not undergone monthly inspections since September 2024. These findings were confirmed during an exit interview with the Assistant Administrator and the Maintenance Director.

Plan Of Correction

Annual portable fire extinguisher inspection has been completed. Certification of the inspector has been placed in the life safety book. Portable fire extinguisher in the basement electrical/data room has been completed. Maintenance Dir/designee will re-educate maintenance staff on maintaining monthly and annual inspection of portable fire extinguisher. NHA/designee will complete monthly audits to ensure compliance. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain and inspect its emergency generator, which is crucial for the safety and operation of the entire facility. During a document review on December 23, 2024, it was found that the facility could not provide documentation for several required tests and inspections. These included weekly visual inspections, weekly battery electrolyte level or battery voltage checks, an annual 90-minute load bank test, a 3-year 4-hour load test, and an annual fuel quality test. An exit interview with the Assistant Administrator and the Maintenance Director confirmed the absence of these critical documents. This lack of documentation indicates that the facility did not adhere to the necessary maintenance and testing protocols for its emergency generator, as outlined by NFPA standards. This deficiency affects the entire facility, as the generator is essential for maintaining power during emergencies.

Plan Of Correction

The generator will be visually inspected weekly. Battery voltage will be weekly inspected. Annual 90 min load bank and fuel quality has been completed. 3 year, 4 hour load test will be completed timely. Maintenance Dir/designee will re-educate maintenance staff on proper maintenance of the generator. NHA/designee will complete weekly audits x 3 and monthly audits x 1 to ensure compliance. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain and inspect the kitchen hood suppression system, which affected one of the three levels. During a document review on December 23, 2024, it was found that the facility could not provide documentation of a semi-annual kitchen exhaust hood/duct cleaning since December 17, 2023. This was confirmed during an exit interview with the Assistant Administrator and the Maintenance Director. Additionally, an observation on the same day revealed that the kitchen hood suppression system in the Basement Kitchen lacked monthly inspections. This was also confirmed during the exit interview with the Assistant Administrator and the Maintenance Director.

Plan Of Correction

Documentation for the semi-annual kitchen exhaust hood/duct has been completed and placed in the life safety book. Maintenance Dir/designee will re-educate maintenance staff on maintaining the monthly inspection documentation on kitchen hood/exhaust. NHA/designee will complete monthly audits to ensure compliance. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain and inspect the sprinkler system as required, affecting one of four quarters. During a document review on December 23, 2024, at 8:30 a.m., it was revealed that the facility could not provide documentation of a quarterly sprinkler inspection for the third quarter. This deficiency was confirmed during an exit interview with the Assistant Administrator and the Maintenance Director on the same day at 11:00 a.m.

Plan Of Correction

Documentation for the quarterly sprinkler inspection has been completed and placed in the life safety book. Maintenance Dir/designee will re-educate maintenance staff on maintaining quarterly inspection documentation on sprinkler system. NHA/designee will complete monthly audits to ensure compliance. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain and protect electrical wiring in accordance with NFPA 70, the National Electric Code. During an observation on December 23, 2024, at 10:40 a.m., it was noted that in the Basement's Elevator Machine Room, the covers were not mounted on the elevator control panels. This deficiency was confirmed during an exit interview with the Assistant Administrator and the Maintenance Director at 11:00 a.m. on the same day.

Plan Of Correction

Electrical wiring in the elevator room has been repaired. Maintenance Dir/designee will re-educate maintenance staff on maintaining wiring are not exposed. Maintenance dir/designee will complete initial audit to ensure electrical wires are not exposed. NHA/designee will complete weekly audits x3 and monthly x 1 to ensure compliance. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly document required fire drills, affecting three of twelve shifts. During a document review on December 23, 2024, it was revealed that the facility did not document fire drills for the 2nd quarter, 3rd shift, and the 4th quarter, 1st and 2nd shifts. This deficiency was confirmed during an exit interview with the Assistant Administrator and the Maintenance Director on the same day.

Plan Of Correction

Fire drills will be conducted monthly for all three shifts quarterly. Maintenance Dir/designee will re-educate maintenance staff on conducting fire drills on every shift quarterly. NHA/designee will complete monthly audits to ensure compliance. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comply with regulations regarding the use of power strips and electrical extension cords, as observed during a survey. On December 23, 2024, between 10:09 a.m. and 10:27 a.m., surveyors noted two specific instances of non-compliance. On the first floor, in the Nurse Manager Office, a coffee pot was plugged into an outlet strip. Additionally, in the Basement Manager of Center Scheduling office, a refrigerator was plugged into an outlet strip. These observations were confirmed during an exit interview with the Assistant Administrator and the Maintenance Director, indicating a breach of the facility's electrical safety protocols.

Plan Of Correction

Electrical power strips/extension cords have been removed from 1st floor nurses station and Scheduler's office. Maintenance Dir/designee will re-educate staff to refrain from using power strips/extension cords. Maintenance Dir/designee will complete initial audits to ensure no power strips/extension cords are being used. Maintenance will conduct random weekly audits of 5 offices/rooms to ensure no power strips/extension are being used. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Chapel Manor was found to have a deficiency related to its Emergency Preparedness Plan during an Emergency Preparedness Survey conducted on December 23, 2024. The survey revealed that the facility failed to review and update its Emergency Preparedness Plan at least annually, as required by federal regulations under 42 CFR 483.73(a). This deficiency was identified through a documentation review conducted at 8:30 a.m. on the day of the survey. An exit interview with the Assistant Administrator and the Maintenance Director confirmed that the Emergency Preparedness Plan had not been reviewed and updated as required. This oversight affects the entire facility, as the plan is a critical component of the facility's ability to respond effectively to emergencies. The lack of annual review and updates to the plan constitutes a failure to comply with the necessary emergency preparedness requirements, which are designed to ensure the safety and well-being of all residents and staff in the facility.

Plan Of Correction

Emergency preparedness plan has been reviewed and updated for 2024-2025. Maintenance Dir/designee will re-educate maintenance staff on timely updates and to keep the EPP book in one location. NHA/designee will complete quarterly audits to ensure EPP manual is updated and its proper location. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that its Emergency Preparedness Plan included comprehensive policies and procedures addressing the patient population, specifically focusing on persons at-risk. The plan was also required to outline the types of services the facility could provide during an emergency and ensure continuity of operations, including delegations of authority and succession plans. However, upon document review, it was found that the plan did not adequately address these critical components, particularly the aspect concerning persons at-risk. During an exit interview with the Assistant Administrator and the Maintenance Director, it was confirmed that there was a lack of documentation supporting the inclusion of these necessary elements in the Emergency Preparedness Plan. This deficiency affects the entire facility, as the absence of these policies and procedures could potentially impact the facility's ability to effectively manage emergencies and ensure the safety and well-being of its residents.

Plan Of Correction

Emergency preparedness plan has been reviewed and updated to include policies and procedures for person at risk has been reviewed and updated in the manual. NPE/designee will re-educate maintenance staff on timely updates and to keep the EPP book in the maintenance office. NHA/designee will complete weekly audits to ensure EPP manual is updated and its proper location. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found deficient in its emergency preparedness policies and procedures, specifically in the development of arrangements with other facilities and providers. During a documentation review, it was revealed that the facility failed to establish necessary agreements to ensure the continuity of services to patients in the event of limitations or cessation of operations. This deficiency affects the entire component of the facility's emergency preparedness plan. An exit interview with the Assistant Administrator and the Maintenance Director confirmed the lack of arrangements with other facilities. This oversight indicates a failure to comply with the regulatory requirement to maintain continuity of care for patients during emergencies, as outlined in the relevant sections of the federal regulations. The deficiency was identified during a survey conducted on December 23, 2024.

Plan Of Correction

Emergency preparedness plan has been reviewed and updated to include facility has made arrangements with other facilities and providers to receive residents in event of an emergency. NPE/designee will re-educate maintenance staff on timely updates for policies and procedures relating to arrangements for residents in the event of an emergency. NHA/designee will complete weekly audits to ensure EPP manual is updated and facility has made arrangements with other facilities and providers to receive residents in event of an emergency. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain and update an emergency preparedness communication plan that includes a method for sharing information from the emergency plan with residents and their families or representatives. During a document review and interview conducted on December 23, 2024, at 8:30 a.m., it was revealed that the emergency communications plan lacked a method for disseminating information to residents and their families or representatives. This deficiency affected the entire facility. An exit interview with the Assistant Administrator and the Maintenance Director confirmed the absence of the necessary documentation.

Plan Of Correction

Emergency preparedness plan has been reviewed and updated to include communication/notification to residents/representatives in an emergency situation. Maintenance Dir/designee will re-educate maintenance staff on timely updates for policies and procedures relating to communication/notification to residents/representatives in an emergency situation. NHA/designee will complete weekly audits x1 and monthly x2 to ensure EPP manual is updated. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found to be deficient in developing and maintaining an emergency preparedness training and testing program based on its emergency preparedness plan. During a document review on December 23, 2024, it was revealed that the facility had not established a training and testing program that aligns with the emergency plan, risk assessment, policies and procedures, and communication plan as required. This deficiency affects the entire facility, indicating a lack of compliance with the annual review and update requirement for the training and testing program. An exit interview with the Assistant Administrator and the Maintenance Director confirmed the absence of a comprehensive training and testing program. The failure to implement such a program suggests that the facility did not adhere to the regulatory requirements for emergency preparedness, which mandates an annual review and update. This oversight was identified through documentation review and interviews, highlighting a significant gap in the facility's emergency preparedness efforts.

Plan Of Correction

Emergency preparedness plan has been reviewed and updated to include the EPP training and testing staff based on the emergency plan. Maintenance Dir/designee will re-educate maintenance staff on timely updates for policies and procedures relating to training and testing staff based on the emergency plan. NHA/designee will complete weekly audits x1 and monthly x2 to ensure compliance. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the emergency preparedness requirements as outlined in the regulations. Specifically, the facility did not conduct the required annual full-scale exercise or an accepted substitution, nor did it conduct the additional exercise or an accepted substitution within the previous 12 months. This deficiency affects the entire facility, indicating a lapse in maintaining readiness for emergency situations. During a document review on December 23, 2024, it was revealed that the facility had not conducted these mandatory exercises. The regulations require that long-term care facilities participate in a full-scale exercise that is community-based annually or conduct an individual, facility-based functional exercise if a community-based exercise is not accessible. Additionally, an extra exercise, such as a mock disaster drill or a tabletop exercise, should be conducted annually. The facility's failure to perform these exercises suggests a significant oversight in adhering to emergency preparedness protocols. The deficiency was confirmed during an exit interview with the Assistant Administrator and the Maintenance Director on the same day. They acknowledged the lack of emergency preparedness exercises, which is a critical component of ensuring the safety and well-being of residents and staff in the event of an actual emergency. This oversight highlights the need for the facility to reassess its emergency preparedness strategies and ensure compliance with federal regulations.

Plan Of Correction

Emergency preparedness plan has been reviewed and updated to include an annual full scale/table to review exercise. Maintenance Dir/designee will re-educate maintenance staff on timely updates for policies and procedures relating to annual full scale/table to review exercise. NHA/designee will complete weekly audits x1 and monthly x2 to ensure annual full scale/table to review exercise. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found deficient in updating its policies in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act. During a document review on December 23, 2024, it was discovered that the facility did not have a carbon monoxide alarm evacuation plan in place. This deficiency affects the entire facility. The lack of documentation was confirmed during an exit interview with the Assistant Administrator and the Maintenance Director.

Plan Of Correction

Carbon monoxide alarm evacuation plan has been completed. NPE/designee will re-educate maintenance staff on timely completion of carbon monoxide evacuation. Maintenance dir/designee will complete monthly x3 to ensure annual full scale/table to review exercise. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide evidence of yearly performance evaluations for three out of five nurse aides reviewed, specifically employees E20, E21, and E22. This deficiency was identified during a review of facility-provided documentation and interviews with staff. On December 18th, 2024, an email was sent to the facility's Director of Nursing, employee E1, requesting evidence of these evaluations. A follow-up verbal request was made later that day. Despite these requests, the facility was unable to provide the necessary documentation, a finding that was confirmed with the facility's administrator and Director of Nursing. This failure to conduct and document annual performance evaluations is a violation of the Pennsylvania Code 28 Pa Code 211.12(d)(1) and 28 Pa Code 211.12(d)(5) related to nursing services.

Plan Of Correction

Employees E20, E21 and E22 nurse aides have received their yearly performance evaluations. HR/DON/Designee to complete initial audit of nursing aides to ensure a yearly performance evaluation is completed. HR/Designee to re-educate nursing administration to ensure nurse aides receive a yearly performance evaluation. HR/Designee to complete monthly audits X 3 to ensure ongoing nurse aide yearly performance evaluations are completed. HR/Designee will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that nurse staffing information was posted daily in a prominent and accessible location for residents on both the first and second floors. On December 15, 2024, at 10:00 am, it was observed that the required nurse staffing data was not posted in a clear and readable format on these floors. Instead, an assignment sheet was found in the facility's lobby area, which lacked essential details such as the facility name, total number and actual hours worked by registered nurses, licensed practical nurses, nurse aides, and the resident census. These deficiencies were confirmed with the facility's administrator and a supervisor on December 18, 2024.

Plan Of Correction

Daily Nurse staffing data is posted in the lobby, 1st and 2nd floor. NPE / Designee to re-educate facility scheduler and nursing administration regarding posting of the daily nurse staffing data in lobby, 1st and 2nd floors. Scheduler / Designee will complete weekly audits X 4 then monthly X 2 on 3 random days per week to ensure daily nurse staffing data is posted in the lobby, 1st and 2nd floors. Scheduler / Designee will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a tour of the main kitchen, it was observed that cans of food and fresh bread in the dry storage room were not labeled and dated. In the walk-in refrigerator, food items, including pizza intended for dinner, were not wrapped or covered and lacked labeling with dates. Additionally, a pie dessert was found plated without covers or plastic wrap and was not labeled or dated on the cookie trays. During lunch in the second-floor dining room, dessert pie was served without cover or wrap. Further observations in the kitchen revealed employees plating canned pears into bowls without covers or wrap. The food service director confirmed that these items needed to be wrapped or covered, labeled, and dated, as per the facility's policy.

Plan Of Correction

Food is being served in accordance with professional standards for food service safety. The dietary manager will re-educate all dietary staff on proper dating, labeling, serving, and storing foods. The NHA/designee will conduct daily audits for 3 weeks and weekly audits for 3 weeks to ensure compliance. The dietary manager will report the findings of the audit to the QAPI Committee for 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the accuracy and completeness of resident medical records for two residents. For Resident R98, the clinical documentation inaccurately included a diagnosis of gastrostomy status, which was not applicable. Observations and interviews with staff confirmed that Resident R98 did not have a gastrostomy and was on a pureed diet, eating by mouth. The error was attributed to a mix-up with another resident who had a similar last name and did have a gastrostomy. This discrepancy in the medical record was not addressed or corrected, leading to inaccurate documentation. For Resident R40, the facility did not ensure proper documentation and follow-up on a consultant pharmacist's recommendation regarding the use of the antipsychotic agent Quetiapine. The recommendation noted the absence of an allowable diagnosis to support the medication's use, yet there was no evidence of physician agreement or disagreement with the recommendation, as the form was unsigned. Additionally, the facility failed to provide original copies of the consultant pharmacist's form, indicating a lack of proper record-keeping and follow-up on medication management.

Plan Of Correction

Resident R98 gastrostomy diagnosis has been removed from the medical record. Medical Records will conduct an initial audit with a look back of 30 days to ensure accuracy of gastrostomy tube documentation. Medical Records to complete weekly audits X 4 then monthly X 2 on 5 random residents diagnoses to ensure accuracy of gastrostomy tube documentation. Resident R40 pharmacy recommendation has been approved by the provider and appropriate diagnosis for Quetiapine has been added to the medical record. DON / Designee will complete an initial audit of pharmacy recommendations in the past 30 days to ensure recommendations for appropriate diagnosis for Quetiapine are updated and signed by the physician. DON / Designee to complete weekly audits X 4 then monthly X 2 to ensure recommendations for appropriate diagnosis for Quetiapine are updated and signed by the physician. NPE/DON/Designee to re-educate facility physicians, Advanced Practice Providers regarding accuracy of diagnosis in the medical record. DON/Designee will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe, functional, sanitary, and comfortable environment across all four nursing units observed, namely A-Wing, B-Wing, C-Wing, and D-Wing. Observations revealed that in the D-Wing, the wall trim behind a resident's bed was falling off, and wallpaper was peeling away in multiple rooms on both the D-Wing and C-Wing. These conditions were confirmed by staff interviews, indicating a lack of maintenance and attention to the physical environment of the residents' rooms. Additionally, the nurses' stations across all wings were found to have broken chairs, which were uncomfortable and difficult for staff to use for essential tasks such as charting and phone calls. The C-Wing nurses' station also had phones that were either broken or had worn-out numbers, making communication challenging. Staff interviews corroborated these findings, highlighting the discomfort and difficulty in performing their duties due to the poor condition of the furniture and equipment.

Plan Of Correction

Room 216 D wing wall trim has been repaired. Room 214 D wing wall has been repaired. Room 215 C wing wall paper has been repaired. Office chairs have been ordered for all of the wings. C wing phones have been replaced. Maintenance will complete an initial audit of all the rooms for needed repairs to the walls. Maintenance will audit all of the office chairs in the nursing units and order replacement for the damaged/broken chairs. NPE will re-educate staff to add all repair needs to TELS system. NHA/designee will conduct weekly audits x2 and monthly x1 to ensure compliance. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that corridors had firmly secured handrails on three of four nursing units observed, specifically on the B-Wing, C-Wing, and D-Wing nursing units. On the D-Wing nursing unit, several handrails were missing or broken, with tape covering the broken brackets, and one handrail next to the center stairwell door was broken. On the C-Wing nursing unit, the end cover on a handrail was missing, exposing rough and sharp edges, and another handrail was missing between a resident room and the nurses station. On the B-Wing, the handrail beside the nurses station was missing, leaving exposed posts with sharp corners. These observations were confirmed by licensed nurses, Employee E8 and Employee E17, who acknowledged the missing and broken handrails and the potential hazard they posed.

Plan Of Correction

Hand rails have been securely mounted on B, C, and D wing. Hand rails between room 215 and 213 have been replaced. Hand rails between the center stairwell have been replaced and securely mounted. Maintenance will complete an initial audit of all nursing units and order replacement for the damaged/broken hand rails. Maintenance will complete weekly audits x 2 and monthly x 1 to ensure handrails are secured and damage-free. NPE will re-educate staff to add all repair needs to the TELS system. NHA/designee will conduct weekly audits x 2 and monthly x 1 to ensure compliance. Maintenance Director will report the findings of the audits to the QAPI Committee x 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately complete MDS assessments for two residents, leading to discrepancies in their medical records. For one resident, the Quarterly MDS indicated the use of physical restraints daily, despite no physician orders or care plans supporting this, and no restraints were observed during a facility visit. A licensed nurse confirmed that the MDS assessment was coded in error. For another resident, the Discharge MDS inaccurately documented the discharge destination. The resident was discharged to a short-term general hospital, contrary to the discharge plan and progress notes indicating the resident's intention to go home with family. A licensed nurse acknowledged that the discharge MDS assessment was also coded in error.

Plan Of Correction

Resident R96 Quarterly MDS has been revised to remove use of physical restraints. Resident R187 Quarterly MDS has been revised to reflect discharge to home. MDS Coordinator / Designee to conduct an initial audit of residents in past 30 days with Quarterly MDSs for accuracy of physical restraints and discharge disposition. NPE / DON / Designee to re-educate MDS Coordinators regarding accuracy of Quarterly MDS submissions. MDS Coordinator / Designee to complete weekly audits X 4 then monthly X 2 for residents with Quarterly MDSs to ensure accuracy of submissions for physical restraints and discharge disposition. MDS Coordinator will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to revise the care plan for a resident, identified as R124, specifically concerning Feeding-Related Care. The resident was admitted to the facility with several diagnoses, including Dementia, Severe Protein-Calorie Malnutrition, Adult Failure to Thrive, and Muscle Wasting and Atrophy. These conditions necessitate careful management of nutritional intake and hydration. A physician's order dated November 19, 2024, specified an automatic water flush of 55 ml/hr via PEG tube for 12 hours while enteral feed runs, totaling 660 ml over 24 hours, with an additional flush of 50 ml after each feeding. On December 17, 2024, it was observed that the care plan for Resident R124 had not been updated to reflect these specific hydration orders. This oversight was confirmed during an interview with the charge nurse, identified as employee E19. The failure to update the care plan to include the ordered volume of water flush represents a deficiency in the facility's compliance with the care planning requirements, as outlined in 28 Pa Code 211.11(d) Resident Care Plan.

Plan Of Correction

Resident R124 Care plan has been updated to reflect the goal and interventions with the ordered volume of water flush. DON / Designee to conduct an initial audit of current residents with physician orders for water flushes via tube to ensure care plan reflects volume of water flush. NPE / DON / Designee to re-educate professional nurses regarding updating care plan to reflect volume of water flush. DON / Designee to complete weekly audits X 4 then monthly X 2 for residents with orders for water flushes via tube to ensure care plan reflects volume of water flush. DON/Designee will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement timely interventions for weight management for a resident diagnosed with Gastro-Esophageal Reflux Disease with Esophagitis and Abnormal Weight Loss. Upon admission, the resident's weight was recorded at 135.1 lbs, but over the following months, the resident experienced a significant weight loss, dropping to 113.4 lbs by December. A Nutrition Assessment Note by the Registered Dietitian on October 2, 2024, highlighted the significant weight loss and recommended weekly weight monitoring and a daily house shake to support oral intake. However, the facility did not conduct or record the recommended weekly weights for the resident, as confirmed by an interview with the Registered Dietitian.

Plan Of Correction

Resident R181 weekly weights obtained and recorded. Dietician to conduct initial audit on residents recommended for weekly weights in the past 30 days to ensure weekly weights obtained and recorded. NPE / DON / Designee to re-educate professional nurses on obtaining and recording weekly weights per dietician recommendations. Dietician to conduct weekly audits X 4 then monthly X 2 on residents recommended for weekly weights to ensure weights taken and recorded. Dietician will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate respiratory care and services for a resident diagnosed with Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease (COPD), and Atelectasis. The resident was ordered to receive oxygen at 2 Liters/Min via nasal cannula as needed. However, on two separate occasions, the resident was observed receiving oxygen at 3 Liters/Min, which was not in accordance with the physician's order. This discrepancy was confirmed by a Licensed Nurse at the time of the findings.

Plan Of Correction

Resident R158 is receiving her PRN oxygen at 2L/minute per physician orders. DoN / Designee to conduct initial audit on residents receiving oxygen therapy to ensure accurate liters/minute per physician orders. NPE/DON/Designee to re-educate professional nurses to ensure physician orders followed for liters/minute for residents receiving oxygen therapy. DON / Designee to conduct weekly audits X 4 then monthly X 2 on 5 random residents receiving oxygen to ensure accurate liters/minute per physician orders. DON/Designee will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure accurate completion of physician notes regarding the assessment and gastrostomy status of a resident, identified as R98. The resident was admitted with diagnoses including Alzheimer's disease, dysphagia, and gastric ulcer. However, the physician's notes inaccurately documented the presence of a gastrostomy and the need to monitor gastrostomy feeding over several months. Upon review, there were no physician orders for enteral feeds or gastrostomy care, and observations confirmed the absence of any gastrostomy equipment or site. Interviews with the resident's care nurse and the attending physician revealed that the resident never had a feeding tube and was on a pureed diet. The physician admitted to an error in documentation, confusing the resident with another patient who had a similar last name and a gastrostomy. This error led to incorrect documentation in the resident's clinical records, violating the requirement for accurate and complete clinical records as per 28 Pa. Code 211.5(f).

Plan Of Correction

Resident R98 physician notes have been corrected to reflect no gastrostomy tube. NPE / DON / Designee to re-educate facility physicians and Advanced Practice Providers regarding accuracy of documentation and diagnosis in physician/provider notes. Medical Records to complete weekly audits X 4 then monthly X 2 on 5 random residents physician notes and diagnoses to ensure accuracy of gastrostomy tube documentation. Medical Records will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was free from unnecessary medications, specifically in the case of a resident with a complex medical history including Bipolar Disorder, PTSD, ADHD, and Anxiety Disorder. The resident was prescribed Olanzapine, an antipsychotic medication, for Bipolar Disorder. A pharmacist's evaluation recommended that movement tests such as the Abnormal Involuntary Movement Scale (AIMS) or DISCUSS be performed initially within 30 days and then at least every six months to monitor for potential side effects like Tardive Dyskinesia, a movement disorder associated with antipsychotic medications. However, a review of the clinical records revealed that these recommended assessments were not conducted for the resident. This oversight was confirmed during an interview with the Nursing Supervisor, a Registered Nurse, who acknowledged the findings. The lack of these assessments indicates a failure by the facility to adhere to the pharmacist's recommendations, thereby not ensuring the resident's drug regimen was free from unnecessary medications.

Plan Of Correction

Resident R50 Abnormal Involuntary Movement Scale (AIMS) assessment has been completed per pharmacist recommendation. DON / Designee will complete an initial audit of residents receiving an antipsychotic to ensure an AIMS assessment is completed. NPE/DON/Designee to re-educate professional nurses to ensure an AIMS assessment is completed for residents receiving antipsychotics. DON / Designee to complete weekly audits X 4 then monthly X 2 for residents receiving an antipsychotic to ensure an AIMS assessment is completed. DON/Designee will report the findings of the audits to the QAPI Committee X 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective infection control program related to Transmission Based Precautions for one resident, identified as Resident R49. The facility's policy on Enhanced Barrier Precautions, revised in December 2024, outlines the use of targeted personal protective equipment (PPE) to reduce the transmission of Multi-Drug Resistant Organisms (MDROs), including ESBL-producing Enterobacterales. Resident R49 was listed under Enhanced Barrier Precautions due to an ESBL infection, and a physician order dated April 17, 2024, confirmed the need for infection precautions. On December 15, 2024, an observation revealed that a Nurse Aide, identified as Employee E16, was providing cleaning care to Resident R49 without wearing the required PPE, despite the resident being on Enhanced Barrier Precautions. The lack of PPE use was confirmed with Employee E16 at the time of the observation. This failure to adhere to the facility's infection control policy represents a deficiency in maintaining an effective infection prevention and control program.

Plan Of Correction

NPE / DON / Designee will re-educate nursing staff on appropriate PPE based on identified Enhanced Barrier Precautions. Infection Prevention Nurse / Designee to complete weekly audits X 4 then monthly X 2 on 5 random residents on Enhanced Barrier Precautions to ensure staff are utilizing appropriate PPE. DON / Designee will report the findings of the audits to the QAPI Committee X 3 months. Resident R49 remains on Enhanced Barrier Precautions with staff utilizing appropriate PPE with provision of direct care. Infection Prevention Nurse / Designee to complete an initial audit of residents on Enhanced Barrier Precautions to ensure nursing staff utilizing appropriate PPE.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the call bell systems functioned properly on the C-Wing nursing unit. During an observation, it was noted that although the call bell system was activated, no lights above the residents' rooms or at the nurses' station control panel were illuminated to indicate which room had activated the call bell. Employee E6, a licensed nurse, confirmed that she could hear the call bell but was unable to determine the source, leading her to walk up and down the halls and eventually go room by room to locate the activated call bell. It was determined that the call bell in resident room [ROOM NUMBER]A had been activated, but neither the light above the room nor the control panel light was illuminated during the activation.

Plan Of Correction

The malfunction part in the call bell system has been replaced and C wing call bell is functioning properly. Maintenance/designee will complete an initial audit on all call bell systems on each unit. Maintenance/designee will complete weekly audits x 4 then monthly x 2 to ensure the call bell system is functioning properly. Maintenance Director will report the findings of the audits to the QAPI Committee x 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the required staffing levels for nurse aides across multiple shifts, as evidenced by a review of nursing time schedules and interviews with staff. The regulation mandates a minimum of one nurse aide per 10 residents during the day, one per 11 residents during the evening, and one per 15 residents overnight. However, the facility consistently fell short of these requirements over a series of 59 out of 63 shifts reviewed. On several specific dates, the facility's census data indicated a need for a certain number of nurse aides based on the number of residents. For instance, on September 1, 2024, with a census of 191 residents, the facility required 19.10 nurse aides during the day shift but only provided 16.39. Similarly, on the night shift of the same day, 12.73 nurse aides were needed, but only 10.61 were available. This pattern of understaffing was repeated on numerous other dates, including September 2, 3, 4, and 5, 2024, where the number of nurse aides fell short of the required numbers for both day and night shifts. The deficiency was not limited to a single period but was observed over several months, including May, September, and December 2024. On December 15, 2024, for example, the facility had a census of 183 residents, requiring 18.30 nurse aides during the day shift, but only 14.00 were provided. The consistent lack of adequate staffing levels indicates a systemic issue in meeting the regulatory requirements for nurse aide staffing, with no additional higher-level staff available to compensate for the deficiencies.

Plan Of Correction

There were no adverse effects to the residents in the center as a result of the CNA ratios for the night shift staffing during the months of May, September or December 2024. Chapel Manor will continue to use recruiters, our website, recruitment websites and social media to advertise our current open positions and interview immediately. Staffing meetings are held two times a day Monday-Friday to review staffing ratios from the previous day, the current day, and the upcoming week to ensure appropriate staffing levels. Staff has been educated on the attendance policy. The Scheduling Coordinator, Nursing Supervisors and Director of Nursing were re-educated on maintaining a CNAs per 10 residents on day shift, 11 residents on evening shift, and 15 residents on night shift. Administrator or designee to audit licensed nurse ratios for random all shifts weekly for 6 weeks. Findings will be reviewed in QAPI.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the regulatory requirements for staffing Licensed Practical Nurses (LPNs) across multiple shifts. The regulation mandates a minimum of one LPN per 25 residents during the day, one LPN per 30 residents during the evening, and one LPN per 40 residents overnight. However, the review of nursing schedules and staff interviews revealed that the facility did not comply with these staffing ratios for 57 out of 63 shifts reviewed. On specific dates, the facility's census data indicated a need for a certain number of LPNs based on the number of residents, but the actual staffing levels fell short. For instance, on 09/03/2024, the evening shift required 7.76 LPNs for a census of 194 residents, but only 7.30 LPNs were scheduled. Similarly, on 12/13/2024, the night shift required 4.58 LPNs for a census of 183 residents, but only 3.00 LPNs were available. In each instance, there were no additional higher-level staff available to compensate for the deficiency. The consistent shortfall in LPN staffing across various shifts and dates indicates a systemic issue in maintaining the required staffing levels. This deficiency was observed over several months, affecting both day and night shifts, and was not mitigated by the presence of additional higher-level staff. The lack of adequate staffing could potentially impact the quality of care provided to the residents, although the report does not specify any direct consequences or risks resulting from the staffing deficiencies.

Plan Of Correction

There were no adverse effects to the residents in the center as a result of the Licensed Practical Nurse ratios for the night shift staffing during the months of May, September and December 2024. Chapel Manor will continue to use recruiters, our website, recruitment websites and social media to advertise our current open positions and interview immediately. Staffing meetings are held two times a day Monday-Friday to review staffing ratios from the previous day, the current day, and the upcoming week to ensure appropriate staffing levels. Staff has been educated on the attendance policy. The Scheduling Coordinator, Nursing Supervisors and Director of Nursing were re-educated on maintaining a licensed nurse ratio of one licensed nurse per 25 residents on day shift, 30 residents on evening shift, and 40 residents on night shift. Administrator or designee to audit licensed nurse ratios for random all shifts weekly for 6 weeks. Findings will be reviewed in QAPI.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the regulatory requirement of providing a minimum of one registered nurse (RN) per 250 residents during all shifts. This deficiency was identified through a review of nursing schedules and staff interviews, revealing that on four separate days, the facility did not have the required RN coverage. Specifically, on 09/02/2024, with a census of 192 residents, only 0.79 RN was available during the day shift. On 05/23/2024, with a census of 198 residents, the facility provided 0.99 RN during the evening shift and 0.96 RN during the night shift. Additionally, on 05/24/2024, with a census of 195 residents, only 0.95 RN was available during the night shift. In all instances, there were no additional higher-level staff available to compensate for the RN shortfall.

Plan Of Correction

There were no adverse effects to the residents in the center as a result of the Registered Nurse ratios for the night shift staffing during the months of May, September and December 2024. Chapel Manor will continue to use recruiters, our website, recruitment websites and social media to advertise our current open positions and interview immediately. Staffing meetings are held two times a day Monday-Friday to review staffing ratios from the previous day, the current day, and the upcoming week to ensure appropriate staffing levels. Staff has been educated on the attendance policy. The Scheduling Coordinator, Nursing Supervisors and Director of Nursing were re-educated on maintaining a licensed nurse ratio of one licensed nurse per 250 residents on each shift. Administrator or designee to audit licensed nurse ratios for random all shifts weekly for 6 weeks. Findings will be reviewed in QAPI.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. This deficiency was identified through a review of nursing time schedules and staff interviews, which revealed that the facility did not provide the required hours of care on 16 out of 21 days reviewed during September and December 2024. Specific instances of non-compliance included days where the facility census ranged from 182 to 194 residents, yet the hours of direct nursing care provided per resident fell short, with figures as low as 2.61 hours on certain days. The deficiency was consistent across multiple days, indicating a systemic issue in staffing or scheduling that prevented the facility from meeting the mandated care hours. The shortfall in nursing care hours was documented on specific dates, such as September 1st through 7th and December 11th through 17th, where the care hours ranged from 2.61 to 3.12, all below the required 3.2 hours. This failure to provide adequate nursing care hours could potentially impact the quality of care and well-being of the residents, although the report does not specify any direct consequences or risks that arose from this deficiency.

Plan Of Correction

There were no adverse effects to the residents in the center as a result of less than 3.2 direct care for each resident were provided during the months of September and December 2024. Chapel Manor will continue to use recruiters, our website, recruitment websites, and social media to advertise our current open positions and interview immediately. Staffing meetings are held two times a day Monday-Friday to review staffing ratios from the previous day, the current day, and the upcoming week to ensure appropriate staffing levels. Staff has been educated on the attendance policy. The Scheduling Coordinator, Nursing Supervisors, and Director of Nursing were re-educated on maintaining a minimum of 3.2 direct resident care for each resident. Administrator or designee to complete random audits weekly for 6 weeks for licensed nurse ratios for all shifts to ensure 3.2 PPD is maintained. Findings will be reviewed in QAPI. Findings will be reviewed in QAPI.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to serve foods that were palatable and at proper temperatures on one of its nursing floors, specifically Unit D. This deficiency was identified through a review of meal tray test results, facility policy, and interviews with residents and staff. The facility's policy, revised in September 2017, mandates that hot foods be held at temperatures greater than 135 degrees Fahrenheit and cold foods at less than 41 degrees Fahrenheit. However, during a test tray observation on Unit D, the recorded temperatures for various food items did not meet these standards. For instance, mashed potatoes were at 104 degrees Fahrenheit, and a cheeseburger was at 124 degrees Fahrenheit, both below the required temperature for hot foods. Similarly, cold items like apple juice and a peach cup were above the required temperature for cold foods. Interviews with residents further highlighted the issue, with one resident stating that the hot food was consistently cold and unpalatable, while another resident reported feeling sick after consuming the food and noted that complaints to the staff did not result in any changes. An interview with a dietary staff member confirmed that the test tray food temperatures did not meet the facility's standards. This deficiency is a violation of resident rights and dietary services regulations as outlined in 28 Pa. Code 201.29(j) and 28 Pa. Code 211.6(c).

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to equip corridors with safe handrails on each side in the Second Floor Nursing D Unit. During an observation on October 3, 2024, at 11:45 p.m., it was noted that the handrail by room [ROOM NUMBER]-unit D was broken and hanging off, and the handrail by room 215-unit D was missing. An interview with the second floor unit manager, an LPN identified as Employee E4, confirmed that the handrails were not secured. The Nursing Home Administrator acknowledged the issue and mentioned that a work order for the handrails would be sent.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide care and services as ordered by the physician for Resident R2. During an interview, the resident stated that he was supposed to receive ACE wraps for his lower extremity swelling, as recommended by his physician after finding compression stockings uncomfortable. However, the staff did not assist him in applying the ACE wraps. An observation confirmed that the resident was not wearing ACE wraps or compression stockings, and while ACE wraps were found in his bedside drawer, no compression stockings were available in his room. The physician's order from July 23, 2024, specified the use of compression stockings for edema, and the Treatment Administration Record indicated that the order was signed as administered from August 2 to August 12, 2024. A licensed nurse confirmed the absence of both ACE wraps and compression stockings, as ordered by the physician.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to serve foods that were palatable and at proper temperatures on one of its nursing floors, specifically Unit A. The deficiency was identified through a review of meal tray test results, facility policy, and interviews with residents and staff. The Resident Tray Assessment Report outlined specific temperature standards for food items, which were not met during a test tray observation. The test tray temperatures recorded by Dietary staff, Employee E4, showed that cold food items such as a ham and cheese sandwich, coleslaw, and a fruit cup were served at temperatures above the acceptable range, while hot coffee was served below the required temperature. Interviews with residents revealed dissatisfaction with the food service. One resident mentioned that hot food was sometimes served hot, but the taste was often bad. Another resident reported that hot food was not served hot and that complaints to the staff did not result in any changes. The test tray observation confirmed these issues, as the recorded temperatures did not meet the facility's standards for hot food. This failure to adhere to temperature standards and ensure palatable food constitutes a violation of resident rights and dietary services regulations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to schedule an appointment for outside services in a timely manner for a resident who was experiencing severe shoulder pain. The resident, who had been receiving cortisone shots for shoulder pain prior to admission, reported excruciating pain rated at 10/10 and expressed a need to see an outside provider for treatment. Despite the resident's request and the physician's recommendation for follow-up with an orthopedic provider, no appointment was made. The resident's clinical record showed a history of muscle weakness, osteoarthritis, and pain in both upper arms, and a previous hospital record indicated a need for orthopedic follow-up. Interviews with facility staff revealed a lack of action in scheduling the necessary appointment. The unit clerk stated that she was waiting for the facility administration to respond to make the appointment, while the Director of Nursing could not provide a reason for the delay, citing the high demand for services among residents. The deficiency was identified as a failure to employ or obtain outside professional resources to provide necessary services when the facility did not have a qualified professional available.