Loyalhanna Care Center

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 protected from neglect, resulting in a fall with a fractured hip. The resident, who was cognitively intact and required substantial to maximum assistance for transfers due to chronic obstructive pulmonary disease and other diagnoses, had a care plan and physician's orders specifying that two staff members were required for all transfers using a wheeled walker. Despite these orders and care plan interventions, a nurse aide assisted the resident alone during a transfer after showering, without a second staff member present. During this process, the nurse aide slipped on water on the floor, causing both herself and the resident to fall. The resident sustained a visibly shortened and externally rotated right leg, and was subsequently diagnosed with a hip fracture requiring surgery. Documentation revealed that the nurse aide was unaware of the change in the resident's transfer status to a two-person assist, despite having received prior education on abuse and neglect. The nurse aide's failure to follow the care plan and physician's orders directly led to the resident's fall and injury. The incident was confirmed through review of clinical records, staff interviews, and investigative documents.

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 an environment free from accident hazards for a resident at risk for falls, resulting in a fall with a hip fracture. The resident, who was cognitively intact but required substantial to maximum assistance for transfers and used a walker, had a care plan and physician's orders specifying that two staff members were required for all transfers. Despite these orders, a nurse aide assisted the resident alone during a transfer after a shower. During this process, the nurse aide slipped on water on the floor, causing both herself and the resident to fall. The resident sustained a hip fracture that required surgical intervention. Documentation revealed that the nurse aide was unaware of the updated transfer status requiring two-person assistance. The incident occurred when the resident was standing at the bars and the aide attempted to assist her alone, contrary to the care plan and physician's orders. The event was confirmed through staff interviews and review of clinical records, which indicated that the required level of supervision and adherence to fall prevention protocols were not maintained at the time of the incident.

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 food in the proper consistency as ordered by the physician for a resident with a history of stroke and swallowing difficulties. The resident was prescribed a mechanically altered diet, later changed to a pureed texture, but was served food items inconsistent with these orders on multiple occasions. On one occasion, the resident was served a piece of chicken that was not ground as required, leading to a choking incident that resulted in hypoxia, aspiration, and hospital admission. Documentation shows that the nurse aide delivered the meal tray without verifying the correct diet texture, and the resident's husband had to cut the chicken into small pieces before the resident began choking. Subsequently, the resident experienced another choking episode after being served Brussel sprouts, which are not permitted on a mechanical soft diet due to their tough texture. Despite recent staff education on appropriate diet modifications, the dietary manager confirmed that Brussel sprouts were served to the resident, contrary to guidelines. The resident reported that these incidents were frightening and that she avoids certain foods due to a history of choking. These events demonstrate a failure by both dietary and nursing staff to ensure that prescribed diet textures were consistently provided, resulting in significant adverse outcomes for the resident.

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 adhere to physician's orders for medication administration for three residents. Resident 1, who was cognitively intact and diagnosed with diabetes, was ordered to receive 16 units of Humalog insulin only if she consumed more than 50% of her meal. However, records show that the insulin was administered on multiple occasions despite her meal intake being below the required threshold. This was confirmed by the Director of Nursing during an interview. Resident 21, who was cognitively impaired and had hypertension, was ordered to have her blood pressure and heart rate checked before administering Metoprolol Succinate. The facility did not document these vital signs before medication administration from the time the order was given. Similarly, Resident 75, who had heart failure and diabetes, was given Metoprolol Succinate despite having blood pressure readings below the threshold specified in the physician's order. The Director of Nursing confirmed that the medication should have been withheld on these occasions.

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 adhere to its policy on intravenous therapy, which requires flushing a peripherally-inserted central catheter (PICC) or midline catheter with saline solution before and after medication administration. This deficiency was identified for two residents. Resident 1, who was cognitively intact and required substantial assistance with care needs, had a PICC/midline catheter for intravenous administration of Vancomycin. Despite physician orders for the medication, there was no documented evidence that the catheter was flushed with saline solution as required by the facility's policy. Similarly, Resident 283, who was cognitively intact and independent with daily care needs, had a PICC/midline catheter for the administration of Cefepime due to a diagnosis of sepsis. The facility's records showed no evidence of catheter flushing with saline solution before and after medication administration, as per the physician's orders. Interviews with the Director of Nursing confirmed the lack of documentation for both residents, indicating a failure to follow the established protocol for safe intravenous therapy.

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 adhere to its medication labeling and storage policies, resulting in several deficiencies. An opened Humalog insulin Kwik pen for a resident was not discarded after the recommended 28 days, as it was labeled as opened on February 3, 2025. Additionally, a Novolin 70/30 insulin Kwik pen for another resident was opened but not dated, contrary to the facility's policy that requires dating upon opening. These actions were confirmed by an LPN during an observation of the medication cart on the North Hall. Furthermore, the facility did not provide a separately-locked, permanently-affixed compartment in the refrigerator for the storage of controlled drugs. During an observation, an unlocked box containing two unopened stock bottles of Ativan was found in the North Hall medication room refrigerator. The LPN confirmed the box was broken and could not be locked. The Director of Nursing acknowledged these issues, confirming the Humalog pen should have been discarded, the Novolin pen should have been dated, and the Ativan box should have been locked.

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 honor a resident's right to self-determination regarding diet consistency. Resident 8, who is cognitively intact and has a diagnosis of Multiple Sclerosis, expressed dissatisfaction with her prescribed mechanical soft, ground meat texture diet. Despite her ability to eat regular food without issues, the facility continued to provide the mechanical diet based on a physician's order from December 2023. The resident's concerns were noted in a speech therapy note from August 2024, which indicated that the resident had been unhappy with her diet textures for the past 10 months. Although the speech therapist expressed safety concerns about changing the diet, they acknowledged that the resident's quality of life could be improved by allowing her to choose her diet. The Medical Director required a waiver form or a modified barium swallow (MBS) study before considering a diet change. The MBS, initially scheduled for October 2024, was rescheduled to December 2024, and the results suggested that a soft diet with thin liquids might be appropriate. However, there was no documented evidence that the resident was offered the option to sign a waiver. Interviews with the Therapy Director and the Director of Nursing revealed that the facility's new ownership did not use waivers, and the Medical Director was reluctant to change the diet order. Despite the Director of Nursing's belief that the resident should have the diet she wanted, the facility did not take action to honor the resident's choice, resulting in a failure to support resident self-determination.

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 individualized care plans for three residents, leading to deficiencies in addressing their specific medical needs. Resident 12, who was cognitively intact and required assistance with care needs, had a history of thrombosis and embolism and was on an anticoagulant medication. However, there was no documented care plan to address these conditions and the need for anticoagulant therapy. The Director of Nursing confirmed the absence of such a care plan. Resident 21, who was cognitively impaired and had a history of falls, did not have a perimeter mattress on her bed as required by her fall care plan. This was confirmed by observations and an interview with the Director of Nursing. Additionally, Resident 75, who was cognitively intact and had an indwelling foley catheter, lacked a care plan addressing the catheter care and the use of smokeless tobacco, despite having smokeless tobacco on his bedside table. The Director of Nursing confirmed the absence of a care plan for these needs.

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 update the care plan of a resident, identified as Resident 46, to reflect specific care needs following an incident. The resident, who was moderately cognitively impaired and required staff assistance, had a colostomy and a history of placing silverware into her vagina and rectum. A quarterly Minimum Data Set (MDS) assessment indicated these needs, and physician's orders required a colostomy bag and wafer every shift. However, after an incident on February 8, 2025, where the resident was found digging at her stoma with silverware, resulting in an open area with bright red, bloody drainage, the care plan was not updated to include interventions to prevent such behavior. The deficiency was confirmed during an interview with the Director of Nursing on March 20, 2025, who acknowledged that the care plan had not been revised following the incident. The facility's policy, dated January 13, 2025, required that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, which was not adhered to in this case.

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 clarify physician's orders for a resident who was cognitively impaired and required assistance for personal care needs. This resident had a gastrostomy and was ordered to be NPO, yet the medications were incorrectly transcribed to be administered orally instead of through the feeding tube. The Director of Nursing confirmed the transcription error, which did not align with the professional standards of medication administration. Additionally, a registered nurse administered the wrong medications to another resident who was cognitively intact and required assistance for daily care needs. The nurse entered the wrong room and gave the resident a series of medications intended for another individual. This error was identified when the resident reported feeling lightheaded, and the blood pressure was found to be low. The resident was subsequently transferred to the emergency room for evaluation. The Director of Nursing confirmed that the nurse did not follow the facility's medication administration policy.

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 gastrostomy tube care as ordered by the physician for a resident with significant cognitive impairment and anoxic brain injury. The resident was dependent on staff for daily care and had a physician's order for the gastrostomy tube to be flushed every four hours with 130 mL of free water. However, the clinical records for February and March 2025 revealed multiple instances where the tube was either not flushed at all or flushed with incorrect amounts of water. Specific discrepancies included instances where the tube was flushed with only 60 mL or 180 mL of water instead of the prescribed 130 mL, and occasions where the tube was not flushed at all. These deviations from the physician's orders were confirmed by the Director of Nursing during an interview, indicating a failure to adhere to the prescribed care plan for the resident's gastrostomy tube management.

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 clarify a resident's continuous oxygen order when it was not in use, which was identified during a review of facility policies, clinical records, observations, and staff interviews. The facility's policy on oxygen therapy required that oxygen be administered to residents in need, consistent with professional standards, care plans, and resident preferences, with documentation of assessments and responses to therapy. Resident 1, who was cognitively intact and had a diagnosis of congestive heart failure, had a physician's order for continuous oxygen at a flow rate of 0-4 liters per minute to maintain blood oxygen levels above 89 percent. Observations on March 17 and 18, 2025, revealed that Resident 1's oxygen concentrator was turned off, and she was not receiving oxygen, despite the continuous order. A nursing note indicated that the resident's respirations were even and unlabored while on supplemental oxygen, but the medication administration record showed documentation of oxygen administration at different flow rates on March 17, 2025. An interview with the Director of Nursing confirmed that the continuous oxygen order was not being followed and should have been clarified.

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 accountability for controlled medications for one resident. The facility's policy required staff to sign the Medication Administration Record (MAR) after administering medications. An admission Minimum Data Set (MDS) assessment for the resident revealed moderate cognitive impairment and frequent pain, for which the resident received pain medication as needed, including an opioid. Physician's orders included 50 mg of Tramadol every six hours as needed for moderate pain. However, the controlled drug accountability record showed that Tramadol was signed out on several occasions, but there was no documented evidence in the MAR that the medication was administered to the resident. The Director of Nursing confirmed the lack of documentation for the administration of Tramadol to the resident.

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 timely physician responses to pharmacy recommendations for four residents. The facility's policy required a monthly comprehensive medication regimen review by a consultant pharmacist, with recommendations to be acted upon by the prescriber. However, for Resident 2, who was cognitively impaired and on antidepressant and antipsychotic medications, there was no documented evidence that the physician responded to a recommendation to evaluate the necessity of the current medication dosage. Similarly, for Resident 23, who had congestive heart failure, the physician did not respond to a recommendation to discontinue a medication due to nonuse. Additionally, Resident 66, who was cognitively impaired and diagnosed with cancer, had a recommendation to discontinue a medication due to nonuse, which also lacked a physician's response. Resident 68, with chronic obstructive pulmonary disease, had a recommendation to document the necessity of a medication or attempt a dosage reduction, but again, there was no documented physician response. Interviews with the Director of Nursing confirmed the absence of documented responses to these recommendations, indicating a failure in the facility's process for addressing pharmacy recommendations.

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 obtain laboratory studies as ordered by the physician for a resident, identified as Resident 53. The facility's policy, dated January 13, 2025, mandates that laboratory services be provided or obtained when ordered by a physician or other qualified practitioners. Resident 53, who was cognitively intact and received dialysis services, had physician's orders for several laboratory tests to be conducted every three months, including a complete blood count with differential, complete metabolic panel, Hemoglobin A1C, lipid panel, and levetiracetam level. These orders were dated September 5, 2021. However, there was no documented evidence that the facility obtained the required laboratory tests for Resident 53 after August 2024. This deficiency was confirmed during an interview with the Director of Nursing on March 19, 2025, who acknowledged the lack of evidence for the ordered laboratory studies. The resident's medical history included seizures and kidney failure, and they were receiving an anticonvulsant medication, levetiracetam, as part of their treatment plan.

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's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated issues identified in a survey ending March 20, 2025. These deficiencies included failures in developing comprehensive person-centered care plans, care plan timing and revision, and ensuring services met professional standards. Additionally, the facility did not follow physician's orders, manage tube feeding properly, or provide oxygen therapy as ordered. There were also issues with the accountability of controlled medications, labeling and storing drugs and biologicals, and maintaining proper infection control practices. The facility had previously developed plans of correction for these deficiencies, which included completing audits and reporting results to the QAPI committee. However, the current survey revealed that these plans were not effectively implemented, as the same deficiencies were cited again. The QAPI committee's ineffectiveness in correcting these practices indicates a failure to maintain compliance with nursing home regulations, as evidenced by the repeated citations under various F-tags.

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 adhere to infection control guidelines from CMS and CDC, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Resident 6, who had an indwelling urinary catheter, was observed without any signage or notification of being on EBP, and no PPE was available in or around the resident's room. Interviews with staff, including a Registered Nurse and the Director of Nursing, confirmed that Resident 6 should have been on EBP due to the presence of the catheter. Similarly, Resident 75, who also had an indwelling Foley catheter, was found without EBP signage or PPE in their room. Staff interviews confirmed the oversight. Additionally, Resident 283, with a midline catheter and a diagnosis of sepsis due to pseudomonas, was observed without EBP signage or PPE. The Director of Nursing confirmed that EBP should have been implemented for Resident 283 as well. These deficiencies indicate a failure to follow established infection control protocols for residents with indwelling medical devices.

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 follow physician's orders regarding bowel management for a resident who was cognitively intact and occasionally incontinent of bowel. According to the physician's orders, the resident was to receive 30 mL of Milk of Magnesia (MOM) as needed for constipation if no bowel movement occurred by the third day, followed by a Bisacodyl suppository if MOM was ineffective, and then a Fleets enema if there was still no result. Clinical records showed that the resident went without a bowel movement for seven days on one occasion and eleven days on another, with staff only administering MOM and a Bisacodyl suppository late in each episode. Review of the Medication Administration Record (MAR) confirmed that the prescribed sequence and timing of interventions were not followed as ordered. The Nursing Home Administrator acknowledged that the physician's orders for bowel medications were not adhered to for this resident. This failure was identified through clinical record review and staff interviews.

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 timely notification of the dietitian and physician regarding significant weight loss and decreased fluid intake for two residents, resulting in a delay in treatment. According to facility policy, any resident with a weight change of five percent or more should have their weight rechecked and, if confirmed, the dietitian and physician must be notified immediately. For one resident, a significant weight loss of 6.9 percent (10.5 pounds) in one month was confirmed, but there was no documented evidence that the physician was notified as required by the care plan. Another resident, who was at risk for fluid volume deficit due to diuretic use and had a history of swallowing difficulties, experienced a decline in daily fluid intake over several days, with intake consistently below the recommended amount. Despite laboratory results indicating worsening dehydration and electrolyte imbalances, there was no documentation that the physician was notified of the low fluid intake or that the care plan was updated with new interventions to address the issue. The resident also experienced a 9.6 percent weight loss over two months, but neither the physician nor the dietitian was notified until a supplement was ordered. Interviews with the Director of Nursing confirmed that the required notifications to the physician and dietitian regarding significant weight loss and decreased fluid intake were not made in a timely manner for both residents. This lack of timely communication resulted in delays in implementing appropriate interventions for the affected residents.

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

Loyalhanna Care Center was found to be non-compliant with federal and state regulations regarding accident hazards and supervision. The facility failed to maintain a safe environment by not adhering to its policy on water temperature control. The policy, dated January 13, 2025, required water temperatures to be set at no more than 110 degrees Fahrenheit, with weekly checks and documentation of water temperatures in all hot water circuits. However, during a complaint survey, it was observed that water temperatures in several resident rooms exceeded this limit, with temperatures recorded at 125, 121.6, and 119.4 degrees Fahrenheit. Interviews with Maintenance Worker 1 revealed a lack of adherence to the policy, as he admitted to not completing water temperature logs in the past week and was unable to provide documentation of weekly checks. The Nursing Home Administrator confirmed the absence of documented evidence for these checks and acknowledged that the water temperatures should not have been as high as observed. This failure to monitor and document water temperatures as per policy resulted in the facility's non-compliance with the requirements to ensure a safe environment for residents.

Plan Of Correction

Plan of Correction: In preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. IDENTIFIED: Residents identified were not in any immediate harm. Residents have been checked for any skin issues; no skin issues identified. LIKE: No other residents have been identified to have any issues. SYSTEM CORRECTION AND EDUCATION: The Nursing Home Administrator has educated the maintenance staff on the weekly water temp checks to include a sample of resident rooms. Any issues will be reported and handled accordingly. They have also been educated on the Safe Water Temperatures Policy and F689. Water temperature audits will be done weekly x 2 weeks and then monthly x 2 months. Results of audits will be reviewed at the facility's Quality Assurance Performance Improvement (QAPI) meetings. Date of Compliance: 26 March 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

Loyalhanna Care Center was found to be non-compliant with the requirements for providing a safe, clean, comfortable, and homelike environment as per 42 CFR Part 483, Subpart B. Observations made during a complaint survey revealed several deficiencies in the facility's environment. The floors in the South hallways were noted to have scattered dirt, debris, and clumps of brown dust, along with black markings identified as floor glue. The carpeting in Corridor A had varying amounts of dust and debris, and the wallpaper was peeling, with tape attempting to hold it in place. Additionally, a brown, clumpy substance was observed on the wall above a kiosk. Transition strips in the doorways of rooms 114, 111, and 220 were missing pieces, and the shower in the North hall had a pink substance in the grout. Interviews with the Environmental Services Director and the Maintenance Director confirmed these observations. The Environmental Services Director acknowledged the presence of dirt and debris, the difficulty in removing floor glue, and the inappropriate presence of a pink substance in the shower, which is typically removed weekly with bleach. The Maintenance Director confirmed the broken transition strips, the persistent floor glue, and the peeling wallpaper, all contributing to the facility's unkempt appearance. These findings indicate a failure to maintain a clean and homelike environment for the residents, as required by federal and state regulations.

Plan Of Correction

In preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F584 All items identified during visit have been addressed. Environmental rounds are on-going weekly in order to identify any further issues to be addressed in a timely manner. Education provided by administrator to the maintenance director and environmental services director F584 with a focus on ensuring that residents have a clean and homelike environment. Environmental audits will be completed by administrator/designee weekly X2 weeks and then monthly x2 months. Results of audits will be reviewed at the facility's Quality Assurance Performance Improvement (QAPI) meetings.

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, who was unable to carry out activities of daily living independently, received the necessary services to maintain personal hygiene. Specifically, the facility did not provide showers or baths as scheduled for a resident who required assistance due to dementia. The resident was cognitively intact and had a care plan that included receiving showers every Sunday and Wednesday evening. However, there was no documented evidence that the resident was offered or refused a shower on multiple occasions between December 2024 and January 2025. This was confirmed by the Nursing Home Administrator during an interview, indicating a lapse in adhering to the resident's care plan and preferences.

Plan Of Correction

R2 was interviewed by a registered nurse (RN) and verbalized she does refuse showers. Educated on benefits vs. risks. Skin assessment complete and no concerns identified. Shower was provided once R2 agreed. Resident preferences for showers/bathing reviewed and tasks in point of care updated to reflect preferences for all current residents and is completed upon admission for new admissions with interdisciplinary team follow up in clinical meetings. Re-education on F677 with nursing staff on F677 with a focus on providing residents with showers/baths as scheduled and proper documentation for refusals. Audits to be completed by director of nursing/designee weekly x 2 weeks, then monthly x 2 months. Results of audits will be reviewed at the facility's Quality Assurance Performance Improvement (QAPI) meetings.

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 make ongoing efforts to resolve grievances for the residents, as evidenced by the review of clinical records, Resident Council meeting minutes, and grievance records, along with staff interviews. The facility's grievance policy, dated October 28, 2024, stated that the facility would support each resident's right to voice grievances and make prompt efforts to resolve them. However, the Resident Council meeting minutes from September 11, October 16, and November 5, 2024, revealed that residents reported staff were slow in answering call bells, indicating a lack of prompt resolution to their grievances. Interviews with the Director of Nursing and the Clinical Coordinator on December 6, 2024, confirmed that there was no documented evidence of prompt efforts to resolve the residents' grievances following the Resident Council meetings on September 11 and October 16, 2024. The Clinical Coordinator further confirmed that there were no prompt efforts to resolve the residents' grievance regarding the response to call bells to their satisfaction until November 5, 2024, which should have been addressed sooner. The deficiency was cited as past non-compliance, indicating that the facility did not adhere to its grievance policy and failed to ensure that residents' grievances were promptly addressed and resolved. This lack of action in addressing the grievances related to the slow response to call bells contributed to the deficiency finding.

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 food items at appetizing temperatures, as evidenced by observations during a lunch meal service. The facility's policy, dated October 28, 2024, mandates that all hot food items must be cooked, held, and served at a temperature of at least 135 degrees Fahrenheit, while cold food items must be stored and served at 41 degrees Fahrenheit or below. During the observation on December 6, 2024, a test tray from the second North unit cart was found to have food items not meeting these temperature requirements. Specifically, the iced tea was at 60 degrees Fahrenheit, the Mandarin oranges at 50 degrees Fahrenheit, the bratwurst on a bun at 134.6 degrees Fahrenheit, the green beans at 145.5 degrees Fahrenheit, and the steak fries at 55 degrees Fahrenheit. The steak fries were notably cold and not at a palatable or appetizing temperature, a fact confirmed by the Dietary Director during the observation.

Plan Of Correction

No residents reported that the steak fries were cold and not at a palatable or appetizing temperature. Test trays include different types of fried potato dishes to determine proper temperatures that are palatable. Education with dietary staff by the administrator on F804 with a focus on serving food at an appetizing/palatable temperature. Audits will be completed 3 X week by the Dietary Director/Designee X4 weeks then weekly X4 weeks. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time substantial compliance has been met.

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 a clean, comfortable, and homelike environment for three residents, as evidenced by issues with water temperature during showers. The facility's policy requires maintaining a comfortable and safe temperature range, but residents reported discomfort due to inadequate water temperature. Resident 1, who is cognitively intact and requires assistance with daily care, reported that the water temperature during her scheduled showers was not warm enough, making her uncomfortable. Similarly, Resident 2, also cognitively intact and needing assistance, experienced fluctuating water temperatures during her showers, which were not comfortable. Resident 3 expressed a desire for warmer water during her showers. Observations in the North side shower room confirmed that the water temperature did not exceed 80°F, which is below the facility's policy range of 100-110°F. Interviews with nurse aides revealed that they often had to offer bed baths due to the cooler water temperature, but residents preferred their scheduled showers. The Maintenance Director explained that the water temperature is regulated by a valve, but if the hot water is insufficient, the desired temperature range is not achieved. The Nursing Home Administrator acknowledged that the water temperature should be within the normal limits to ensure a comfortable environment for residents.

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 clean and homelike environment in the rooms of 10 out of 14 residents reviewed. The facility's policy, dated April 10, 2024, required daily dust mopping and inspections by housekeepers to ensure cleanliness. However, observations on July 25, 2024, revealed significant dust and debris accumulation in multiple residents' rooms, including under beds and near doorways. Specific findings included empty plastic cracker wrappers, crumbs, dust, and paper debris in various rooms, indicating a lack of adherence to the cleaning policy. Interviews with staff, including the Director of Environmental Services, confirmed that the rooms were supposed to be cleaned daily and deep cleaned monthly. However, the Director acknowledged that the rooms needed cleaning and that staff should report when additional cleaning is necessary. The Director also mentioned that a deep clean was delayed due to other work responsibilities, such as laundry duties, further contributing to the deficiency in maintaining a clean environment.

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 residents were provided with showers as scheduled, affecting two residents. Resident 2, who has dementia and requires assistance with showering, was scheduled to receive showers every Monday and Thursday during the morning shift. However, records from June 26, 2024, to July 25, 2024, show that the resident only received three showers in that 30-day period, with no documentation of showers being offered and refused. This indicates a failure to adhere to the resident's care plan, which specified a preference for morning showers. Similarly, Resident 5, who has an artificial left shoulder and requires assistance due to fatigue and limited range of motion, was scheduled to receive showers every Tuesday and Friday during the p.m. shift. The records for June and July 2024 show no documented evidence of showers being provided or offered and refused on several scheduled days, including June 28, July 5, 9, 12, 19, and 23. An interview with the Director of Nursing confirmed the lack of documentation explaining why the showers were not provided as scheduled for both residents.

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 protect residents from neglect, as evidenced by the case of Resident 1, who was severely cognitively impaired and required extensive assistance with all care needs. On May 19, 2024, Resident 1's daughter observed that her mother had not received care since the previous evening, as indicated by a six-inch indentation from the urinary catheter tubing, red and mushy heels, and a bruise on her arm. Despite the daughter's complaints and the observations made by the Director of Nursing, the facility's investigation concluded that there was no neglect, citing that night shift staff chart care once per shift and may provide care later without additional charting. Additionally, the facility failed to administer medications as ordered by the physician for Residents 2, 3, and 4. On May 11, 2024, Resident 2 reported not receiving her nighttime medications, which was confirmed by the discovery of empty medication packets and whole pills in the garbage. Similarly, Residents 3 and 4 also reported not receiving their medications, and further investigation revealed that their medication packets were found in the trash, with some medications still intact. Despite the MAR indicating that the medications were administered, the Nursing Home Administrator confirmed that the residents did not receive their medications as ordered. The facility's failure to ensure proper care and medication administration resulted in neglect for the residents involved. The investigation into these incidents revealed discrepancies in care documentation and medication administration, highlighting a lack of adherence to the facility's abuse policy, which mandates that residents be free from neglect. The facility's management and nursing services were found to be deficient in ensuring the residents' rights and well-being, as outlined in the relevant state codes.

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 registered nurse administered medications as ordered by the physician for three residents. This deficiency was identified through a review of Pennsylvania's Nursing Practice Act, job descriptions, clinical records, and staff interviews. The registered nurse was responsible for supervising day-to-day nursing activities, including monitoring medication passes and treatment schedules to ensure medications were administered as ordered. However, it was found that medications were not administered to Residents 2, 3, and 4 as per the physician's orders. Resident 2, who had multiple diagnoses including hypertension, end-stage renal disease, and diabetes, reported not receiving her nighttime medications. The medications included Melatonin, Rosuvastatin, Trazodone, Ronpinirole, Cranberry, and Mirtazapine, which were signed off as administered by Registered Nurse 4. However, upon investigation, it was discovered that the medication packets were empty, and some medications were found discarded in the garbage. Similarly, Resident 3, with a history of coronary artery disease and atrial fibrillation, did not receive her Metoprolol, as evidenced by the packet found in the trash, despite it being signed off as administered. Resident 4, diagnosed with cancer, atrial fibrillation, and schizophrenia, also reported not receiving her nighttime medications, which included Atorvastatin, Divalproex, Apixaban, and Metoprolol. The investigation revealed that the medications were not administered as ordered, and there was no documentation of refusal or inability to take the medications. The Nursing Home Administrator confirmed that the medications were not administered as ordered, and Registered Nurse 4 had incorrectly signed them off as given.

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 administer medications as ordered by the physician for three residents. On May 11, 2024, a Licensed Practical Nurse overheard a resident expressing concerns about not receiving her nighttime medications. Upon investigation, it was discovered that the medication packs for the evening administration were missing, and the computer system falsely indicated that the medications had been administered. Further investigation revealed that other residents also reported not receiving their medications. The investigation uncovered that empty medication packets and random pills were found in various garbage bins, including a medication cup with crushed medications labeled for a specific room. The Medication Administration Records (MAR) falsely indicated that the medications had been administered, despite evidence to the contrary. Interviews with the residents confirmed that they did not receive their medications as scheduled. The residents involved had significant medical histories, including conditions such as hypertension, diabetes, coronary artery disease, and schizophrenia. The failure to administer medications as ordered could have serious implications for their health. The Nursing Home Administrator confirmed that the medications were not administered as required, and the responsible nurse had inaccurately documented the administration of these medications.

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 clinical records were complete and accurately documented for three residents. On May 11, 2024, a Licensed Practical Nurse (LPN) overheard a resident expressing concerns about not receiving her nighttime medications. Upon investigation, it was discovered that the medication packs for the evening administration were missing, and the computer system falsely indicated that the medications had been administered. Further investigation revealed that other residents also reported not receiving their medications. The investigation uncovered that empty medication packets and random pills were found in various garbage bins, including a medication cup with crushed medications labeled for a specific room. This indicated that the medications were not administered as recorded. The Medication Administration Record (MAR) falsely showed that the medications were given, despite evidence to the contrary. Interviews with the residents confirmed that they did not receive their medications as prescribed. The residents involved had significant medical conditions, including hypertension, diabetes, and coronary artery disease, which required consistent medication management. The failure to administer medications as ordered and the inaccurate documentation of medication administration were confirmed by the Nursing Home Administrator. This deficiency violated the accepted professional standards for maintaining accurate clinical records and safeguarding resident-identifiable information.

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 comprehensive care plans that included specific and individualized interventions to address the specialized care needs of a resident. The resident, who was cognitively intact and dependent on staff for care needs, was administered opioid medication and had a physician's order for an x-ray due to increased knee pain, which revealed moderate to severe tricompartmental osteoporosis. Despite these findings and a physician's order for Tramadol to manage the resident's pain, the facility did not create a care plan to address the resident's pain management needs. This deficiency was confirmed during an interview with the Registered Nurse Assessment Coordinator.

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's care plan was updated to reflect the resolution of a urinary tract infection (UTI) and the completion of antibiotic therapy. The facility's policy requires care plans to be reviewed and revised as necessary when residents experience a status change. However, for one resident, the care plan was not updated even after the UTI was resolved and the antibiotic course was completed. The resident was initially prescribed Keflex for a UTI, which was later changed to Cipro based on culture results. The course of Cipro was completed, but the care plan still indicated ongoing antibiotic therapy for the UTI. An interview with the Registered Nurse Assessment Coordinator confirmed that the care plan should have been updated to reflect the resolution of the UTI and the completion of the antibiotic therapy. This oversight was identified during a review of the resident's clinical records and facility policy, as well as staff interviews. The deficiency was noted for failing to update the care plan in accordance with the facility's policy and regulatory requirements.

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 clarify a physician's order for a resident receiving hemodialysis. The resident, who was cognitively intact and required assistance with daily care, had a diagnosis of End-Stage Renal Disease, kidney transplant failure, and cardiomyopathy. The physician's orders initially scheduled the resident to receive Bumetanide on non-dialysis days, but when the dialysis schedule changed, the Bumetanide order was not updated accordingly. This oversight was confirmed by the Director of Nursing during an interview. The facility's policy for hemodialysis, as well as the Pennsylvania Nursing Practice Act, requires that care and services be consistent with professional standards. However, the failure to update the Bumetanide order when the dialysis schedule changed indicates a lapse in following these standards. This deficiency was identified through a review of facility policies, clinical records, and staff interviews, highlighting the need for better communication and adherence to professional standards in managing physician orders for residents undergoing hemodialysis.

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 suprapubic urinary catheter care as ordered by the physician for a resident. The resident, who was cognitively intact and required extensive assistance with daily care needs, had an indwelling suprapubic catheter and received hospice services. Physician's orders specified a 16 French catheter with a 30 ml balloon, and the care plan was revised to reflect this. However, nursing notes indicated that the catheter was changed using the correct size on specific dates, but an observation revealed that the resident had an 18 French catheter in place instead of the ordered 16 French catheter. The resident confirmed this and showed the surveyor and LPN the box of 18 French catheters on her dresser. Interviews with the LPN and the Nursing Home Administrator confirmed that the catheter size should match the physician's order and care plan. The discrepancy was noted during an observation, and it was confirmed that the resident had an 18 French catheter instead of the ordered 16 French catheter. This failure to follow the physician's orders and care plan constitutes a deficiency in the facility's provision of care.

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 gastrostomy tube care was provided as ordered by the physician for one resident. The facility's policy required gastrostomy flushes to be provided as ordered, but a review of the clinical record for a cognitively impaired resident with an anoxic brain injury revealed that the gastrostomy tube was not flushed as ordered on multiple occasions. Specifically, there was no documented evidence of the required flushes on February 18, March 8, and April 5, 2024. The Director of Nursing confirmed the lack of documentation for these dates and times.

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 oxygen therapy as ordered for Resident 51. The resident, who was cognitively intact and had diagnoses including cardiomyopathy and non-ST-elevation myocardial infarction, was supposed to receive supplemental oxygen at a flow rate of 2-6 liters via nasal cannula continuously every shift to maintain a pulse oximetry reading greater than 89 percent. However, the Treatment Administration Record for April 2024 revealed multiple instances where the resident did not have his supplemental oxygen on as ordered, including on April 1, 2, 3, 6, and 9 for various shifts. Observations on April 8 and 9 confirmed that the resident was in bed without the supplemental oxygen in place. Interviews with the resident, a Registered Nurse Supervisor, and the Director of Nursing confirmed that the resident did not use the supplemental oxygen continuously as ordered and that the oxygen should have been applied as per the physician's orders. The facility's policy for oxygen administration was not followed, leading to this deficiency.

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 verify the registry status of two newly hired nurse aides before allowing them to work. The facility's abuse policy required verification with the Pennsylvania Nurse Aide Registry prior to hiring any nurse aides. However, the personnel files for Nurse Aide 3 and Nurse Aide 4 showed that they were hired on February 14, 2024, and January 18, 2024, respectively, but their registry status was not verified until April 10, 2024. This deficiency was confirmed by the Nursing Home Administrator during an interview on April 11, 2024.

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 accountability for controlled medications for two residents. For Resident 51, who was cognitively intact and required assistance with daily care needs, there were discrepancies in the administration of Percocet. The controlled drug record indicated that doses of Percocet were signed out on three separate occasions, but there was no documented evidence in the Medication Administration Record (MAR) or nursing notes that these doses were administered to the resident. This was confirmed by the Director of Nursing and the Nursing Home Administrator during an interview. Similarly, for Resident 61, who was also cognitively intact and dependent on staff for care needs, there were discrepancies in the administration of Tramadol. The controlled drug record showed that doses of Tramadol were signed out on two occasions, but there was no documented evidence in the MAR or nursing notes that these doses were administered to the resident. This was confirmed by the Director of Nursing during an interview. The facility's failure to document the administration of these controlled medications is a violation of their own policy and state 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 properly maintain the freezers in two medication rooms (North and South) and did not discard expired medical supplies in the South medication room. Observations revealed a large buildup of ice on the roof of the freezers in both medication rooms, with water dripping onto medication bags in the North medication room. This was confirmed by interviews with the Registered Nurse Supervisor and the Assistant Director of Nursing. Additionally, three expired intravenous catheters were found in the South medication room, which was confirmed by a Registered Nurse. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that the freezers should not have a large buildup of ice and that water should not be dripping onto stored medications. They also confirmed that the expired intravenous catheters should have been discarded. The facility's policy on medication storage indicated that all medications and equipment should be maintained to ensure proper sanitation, temperature, moisture control, and function, which was not adhered to in this case.

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's Quality Assurance Performance Improvement (QAPI) committee failed to correct recurring quality deficiencies and ensure that plans to improve the delivery of care and services were effectively implemented. The deficiencies identified in the current survey included issues related to care plan timing and revision, services provided to meet professional standards, gastrostomy tube maintenance, and the labeling and storage of drugs and biologicals. These deficiencies were previously cited in surveys ending May 3, 2023, July 14, 2023, and January 26, 2024, indicating a pattern of non-compliance and ineffective corrective actions by the QAPI committee. Specifically, the facility's plans of correction for deficiencies regarding care plan timing and revision, services provided to meet professional standards, tube feeding management, and the labeling and storage of drugs and biologicals included completing audits and reporting the results to the QAPI committee for review. However, the current survey revealed that the QAPI committee failed to successfully implement these plans, resulting in repeated citations under F657, F658, F693, and F761. This ongoing failure to address and correct deficiencies highlights significant issues in the facility's quality assurance processes.

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 staff followed proper infection control practices during wound care for one of the residents reviewed. The resident, who was cognitively impaired and dependent on staff for all daily care, had a Stage III pressure ulcer on the right buttocks. The physician's orders required the wound to be cleansed with normal saline, followed by the application of Medihoney, calcium alginate, and an abdominal pad. During an observation of the wound care, the LPN did not remove her gloves and perform hand hygiene between dirty to clean tasks, which is against the facility's policy and accepted standards of practice. The LPN, while wearing gloves, a gown, an N-95 mask, and eye protection, removed the dirty dressing, cleansed the wound, applied Medihoney, and covered the wound without changing gloves or performing hand hygiene between these steps. This was confirmed during an interview with the LPN, who stated that she considered it an all-inclusive dressing change. The Staff Development and Infection Preventionist RN also confirmed that hand hygiene should have been performed between dirty to clean tasks during wound care, as per accepted standards of practice.

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 food items at palatable temperatures during the lunch meal service. According to the facility's policy, cold foods should be kept at 41 degrees Fahrenheit or less, and hot foods should be held at 135 degrees Fahrenheit or higher. Observations revealed that a test tray left the main kitchen at 12:06 p.m. and arrived at the South 200 Hall at 12:07 p.m. The last resident was served at 12:22 p.m., and the test tray was checked at 12:23 p.m. The temperatures recorded were 48.1 degrees Fahrenheit for chocolate milk, 17 degrees Fahrenheit for ice cream, 102 degrees Fahrenheit for hot tea, 121 degrees Fahrenheit for mixed vegetables, and 113 degrees Fahrenheit for beef and noodles with Stroganoff gravy. These temperatures were confirmed by the Dietary Supervisor to be below the required 140 degrees Fahrenheit for hot foods, resulting in lukewarm and unappetizing meals for the residents.

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 environment for Resident 1 remained as free from accident hazards as possible and did not develop and implement effective interventions to prevent falls. Resident 1, who was cognitively intact and had a history of falls, sustained multiple unwitnessed falls in his room despite having a care plan in place. The care plan included interventions such as educating the resident to use the call light for assistance and ensuring the call light was within reach. However, these interventions were repeated without developing new individualized strategies to address the recurrent falls. The facility's investigation documents and nursing notes revealed that Resident 1 fell on several occasions, with each incident resulting in similar care-planned interventions that were not effective in preventing further falls. Interviews with the Registered Nurse Assessment Coordinator and the Registered Nurse Clinical Consultant confirmed that the interventions were repetitive and that new individualized care plans should have been developed to prevent the recurrent falls. The facility's failure to implement effective fall prevention measures for Resident 1 led to multiple incidents of unwitnessed falls, indicating a deficiency in maintaining a safe environment for the resident.

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 care-planned interventions for advanced directives were consistently implemented for one resident. The facility's policy required the interdisciplinary care planning team to review advance directives with the resident during quarterly care planning sessions. However, for Resident 3, who had a code status of do not resuscitate (DNR) and a physician's order for life-sustaining treatment (POLST), there was no documented evidence that the POLST was reviewed quarterly or upon a significant change in the resident's condition. This was despite the resident being discharged from hospice services and continuing as a long-term care resident, which should have triggered a review of the POLST as per the care plan. The deficiency was confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged that Resident 3's POLST was not reviewed as required. The resident's quarterly Minimum Data Set (MDS) assessment indicated severe cognitive impairment and dependency on staff for various activities of daily living. The failure to review the POLST as stipulated in the care plan and facility policy represents a lapse in ensuring that the resident's advanced directives were up-to-date and accurately reflected their current medical status and preferences.

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 treatments performed were documented by the nurse who performed the treatment for one of six residents reviewed. Specifically, for Resident 4, who had a pigtail catheter to drain pleural fluid, the documentation in the Medication Administration Record (MAR) was inaccurately signed by Licensed Practical Nurses (LPNs) instead of the Registered Nurses (RNs) who actually performed the procedure. This discrepancy was noted on multiple dates where the nursing notes indicated that RNs performed the catheter drainage, but the MAR was signed by LPNs. Interviews with the nursing staff and the Director of Nursing confirmed that only RNs were authorized and educated to perform the care related to Resident 4's pigtail catheter. However, the LPNs were signing the MAR based on instructions from the RNs. This practice was against the facility's policy and the Pennsylvania Code, which mandates accurate documentation by the individual performing the treatment. The Director of Nursing acknowledged the issue and confirmed that the LPNs had signed the MAR on the dates in question.

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 Resident 2's clinical records were complete and accurately documented. According to the facility's policy on charting and documentation, important information such as objective observations, changes in condition, treatments, and incidents should be recorded in the resident's medical record. However, there was no documented evidence that Resident 2 was assessed by a registered nurse or that a skin assessment was completed after an incident where the resident was left on a bed pan for four hours. This incident was reported by the resident's family member and noted in a social service note, but the necessary medical documentation was missing. An interview with the Assistant Director of Nursing revealed that an assessment was conducted with the supervisor on duty, but it was not documented in the medical record. This lack of documentation is a violation of the facility's policy and state regulations, specifically 28 Pa. Code 211.5(f) Clinical Records and 28 Pa. Code 211.12(d)(5) Nursing Services. The failure to document the assessment and skin condition of Resident 2 after the incident constitutes a deficiency in maintaining accurate and complete clinical records.