Pleasant Acres Rehabilitation And Nursing 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 deficiency involves failure to store and serve food and beverages in accordance with professional food safety standards and the facility’s own policies on personal hygiene and dress code. The facility’s policies required facial hair to be covered with a beard guard, nails to be trimmed, clean, and unpolished, and disposable gloves to be single-use and changed between tasks. Surveyors observed the Food Service Director removing gloves, using a cell phone, then donning new gloves and resuming food preparation without performing hand hygiene, while also having one-inch long fingernails with nail polish. Another dietary employee with a full beard was observed walking through the kitchen without a beard covering. Additional observations showed multiple dietary staff handling food and kitchen equipment without changing gloves or performing hand hygiene between tasks. One dietary aide, while wearing the same pair of gloves, retrieved a large can of pudding, dished salad, opened both reach-in and walk-in refrigerators, touched her face, hair, pants, and sweater, opened a bag of grated cheese, handled the cheese, and then topped the salad. Another dietary aide emptied lettuce into a bowl, moved a cardboard box from the counter to the floor, added shredded cabbage, tossed the salad, and portioned it into bowls without changing gloves or washing hands. A cook opened frozen cauliflower, handled hot pans from the oven with a hot pad, then topped chicken with grated cheese and delivered it to the steam table using the same gloves. Another dietary aide operated the elevator controls and doors and then, with the same gloved hands, retrieved grilled cheese sandwiches from a food warmer and placed them on a plate on the tray line, again without glove changes or hand hygiene.

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 pest control program in the dish room, as evidenced by unsanitary environmental conditions and the presence of pests. During an observation in the dish room, surveyors noted a musty odor and standing water on the floor behind the dish machine. Approximately 40 floor tiles had a black substance that could not be removed with a broom, and the cover to the sump pump on the floor contained food debris and food wrappers. A dustpan on the floor near the sump pump also contained food wrappers and food particles. Under the right end of the food trough on the dirty side of the dish machine, a blue trash can was found filled with water, and the exhaust unit from the top of the dish machine to the exterior wall was dripping water onto the floor. A dead roach was observed on the floor near the clean side of the dish machine under a wall shelf. Interviews with dietary aides confirmed that they had observed bugs in the dish room. A subsequent observation in the dish room with the Maintenance Director showed that the conditions remained unchanged, including the dead roach still on the floor. Review of the pest control service reports showed that the facility received weekly pest control services, including treatment of the kitchen and basement or dish room, with roaches listed as a targeted pest. However, one report documented that treatment could not be applied in the dish room because the floor was wet. During an interview with the NHA and Assistant NHA, it was acknowledged that there should not be standing water or food debris on the dish room floor. These findings demonstrated that the facility did not maintain the dish room environment in a manner that supported an effective pest control program and kept the area free from pests.

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 a resident from abuse, resulting in actual harm. A resident with diagnoses including tremors, insomnia, disorientation, Parkinsonism, and dementia was found with multiple bruises and swelling on the right side of the face, both legs, and both hands. The injuries were discovered in the morning and were not present the previous evening, as confirmed by staff. The resident, who primarily speaks Vietnamese and has impaired cognitive function, was unable to fully communicate the incident to staff without assistance from a multi-lingual visitor and later a translation service. Through translation, the resident reported that a large female staff member entered his room at night, instructed him to straighten his legs, and then struck him multiple times with a shoehorn on his legs, face, hands, and thigh. The resident did not call out or attempt to report the incident at the time. Staff interviews and clinical record reviews confirmed that the injuries were consistent with the resident's account and were not observed prior to the alleged incident. The resident later identified the staff member involved from photographs, and the facility's investigation substantiated the abuse. Witness statements from multiple staff members, including LPNs and NAs, indicated that no injuries were observed on the resident during their shifts prior to the morning the injuries were discovered. The shoehorn used in the incident belonged to the resident and was found in his room. No other residents reported abuse by the implicated staff member. The incident resulted in mental anguish and physical harm to the resident, as evidenced by the documented injuries and the resident's emotional response during subsequent 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

Pleasant Acres Rehabilitation and Nursing Center was found to be non-compliant with resident rights and dignity requirements as per 42 CFR Part 483 Subpart B. The facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for five residents. One resident, diagnosed with Alzheimer's disease and secondary parkinsonism, was observed without a bra, exposing her breasts through a thin shirt. Despite being documented as fully dependent on staff for dressing, her care plan did not reflect a preference for not wearing undergarments. The Director of Nursing acknowledged the oversight when it was brought to her attention. Another incident involved a housekeeper entering a resident's room while on a personal phone call, ignoring the resident's inquiry about cleaning the bathroom. This behavior was reported as disrespectful by another resident, who noted that staff often answered call bells while on personal calls. The Nursing Home Administrator expressed an expectation for staff to treat residents with dignity and respect, which was not upheld in these instances. Additionally, two residents in the dementia care unit were examined by a physician in a common dining area without being asked for permission, compromising their privacy. The Director of Nursing stated that residents should be provided privacy during examinations, which was not observed in this case. These findings indicate a failure to uphold resident dignity and privacy as required by regulations.

Plan Of Correction

This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Resident 75 had a bra put on once identified. Employee 10 was educated on the "Proper use of earbud and phone in resident care areas" for speaking on the phone in residents' 150 room. Employee 13 was educated on providing privacy while performing examinations on all residents including 180 and 310. Staff were educated on the "Proper use of earbud and phone in resident care areas" due to concerns by resident 195. 2. To identify other residents that have the potential to be affected, the NHA/designee completed an observational audit on all floors to ensure staff are not using their phones or earbuds in resident care areas, to ensure female residents are dressed appropriately and to ensure physicians are providing privacy when examining residents. 3. Staff will be educated by staff development/designee on the facility "Cellphone Policy". Staff will be educated on dignity and residents rights in regards to residents dressing appropriately. Physicians will be educated by staff development/designee on dignity and resident rights in regards to providing privacy to residents while performing examinations. 4. The NHA/designee will conduct an observational audit 2x a week for 4 weeks on all floors on female residents to ensure they are dressed appropriately and dignified, that staff are not using cellphones and earbuds in resident care areas and lastly to ensure physicians are providing privacy when performing examinations on residents. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.

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, clean, comfortable, and homelike environment on two of its nursing units, specifically the Main 1 and fifth floor units. Observations revealed several deficiencies, including a black plastic fan in a resident's room that was covered in a dark grey fuzzy substance, which remained uncleaned despite being reported to housekeeping. Additionally, multiple chairs in the Main 1 TV lounge and dining room were found with dried liquid spills, debris, and some had cracked or ripped cushions. A medical pump and pole in a resident's room were covered in a dried liquid substance, and the resident's wheelchair had an accumulation of dried food and debris. Further observations noted that another resident's bedroom floor was dusty and had a dark buildup around the edges, and a dresser in a resident's room had labels with names that did not match any current residents. Interviews with staff, including the Assistant Nursing Home Administrator and the Director of Nursing, confirmed awareness of these issues and acknowledged that the conditions did not meet the facility's expectations for cleanliness and maintenance.

Plan Of Correction

This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Resident 338 had her fan cleaned of all dark grey fuzzy substances. M1 TV Room had all chairs cleaned so all spill stains and any debris on cushions and frames were removed. Three chairs were also removed off the unit because the cushions were cracked or ripped. Resident 178 had her medical pump and pole removed from the room and the feet of the pole was cleaned. M1 Dining Room chairs were cleaned and are free of any spills, stains and debris from the cushions and the frames. Resident 178 wheelchair was cleaned and is free of any dried food and debris. Resident 47 wheelchair was cleaned and is free of any dried food and debris. Resident 120 floor in their room was cleaned from dust/grit and is now free of any dark build up on the edges of the walls and furniture. Resident 327 dresser had all labels removed from the drawers that did not bear the name of the resident. 2. To identify other residents that have the potential to be affected, the NHA/designee completed an observational audit on all floors to ensure the following: a. TV and Dining Room chairs are free from cracks and tears as well as to ensure the chair cushions and frames are free of spills, stains or debris. b. Resident floors are free of dust and grit and that wall edges and furniture is free of dark spots. c. Resident rooms do not have unused medical poles in them and that the medical pole are clean. d. Resident wheelchairs are free of dried food and debris. e. Resident dressers are free of any labels that are not of the residents in the room. f. Resident personal fans are free of any fuzzy substances. 3. Staff will be educated by staff development/ designee on a clean and safe environment, wheel chair cleaning, general housekeeping and medical equipment cleaning. 4. The NHA/designee will conduct an observational audit on a random floor for 1x a week for five weeks to ensure: a. Resident fans are cleaned b. Chairs are clean and not damaged in the TV lounges and dining rooms c. That resident wheelchairs are cleaned of any dried food and debris d. Medical equipment that is not used is removed from room and clean e. Resident dressers do not have old resident labels on them and lastly to ensure resident floors are clean of any dust and debris as well as any dark spots on the wall edges and furniture. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.

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 comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their specific medical needs. Resident 144, diagnosed with dementia and anxiety disorder, did not have a care plan for dementia until it was identified during the survey. The Director of Nursing initially believed that existing care plans for other conditions were sufficient. Resident 161, who had a cerebral vascular accident and peripheral vascular disease, was observed with enabler bars on his bed, but these were not documented in his care plan or physician orders after returning from the hospital. The Director of Nursing acknowledged that the care plan should have been updated to reflect the use of enabler bars. Resident 221, with heart failure and a history of falls, also had enabler bars attached to the bed, but no care plan was developed for their use. Similarly, Resident 265, who had impaired visual function and received eye injections for macular edema, lacked a care plan addressing her visual needs and treatment by an ophthalmologist. These omissions indicate a failure to ensure that care plans were comprehensive and reflective of the residents' current medical conditions and needs.

Plan Of Correction

This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Resident 144's care plan was updated with a dementia diagnosis. Resident 161's current physician orders and care plan have been updated for enabler bars. Resident 221's care plan has been updated for having bilateral enabler bars. Resident 265's care plan has been updated to include a vision care plan. 2. To identify other residents that have the potential to be affected, the DON/designee completed an audit on residents with enabler bars to ensure residents have current orders and care plans in place. The DON/designee completed an audit on residents with a vision diagnosis to ensure they have a vision care plan. The DON/designee completed an audit on residents who have a dementia diagnosis to ensure they have an accompanying care plan for dementia. 3. Nursing staff and social service staff will be educated by staff development/designee on developing/implementing comprehensive care plans. 4. The DON/designee will conduct an audit 1x a week for 4 weeks on new admissions and current residents that have a dementia diagnosis, ordered enabler bars, and a vision diagnosis to ensure they have a care plan developed/implemented for dementia, enabler bars, and vision. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.

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 the regulatory requirements for the administration of psychotropic medications, specifically regarding the extension of PRN orders beyond 14 days without proper documentation. The deficiency was identified in the case of a resident diagnosed with anxiety disorder and depression, who had a physician's order for Lorazepam gel every 2 hours as needed for agitation/anxiety. This order, which began on January 28, 2025, did not include an end date, and the physician did not provide a rationale for extending the PRN order beyond the 14-day limit as required by the facility's policy and federal regulations. A review of the resident's electronic medical record revealed a pharmacist's recommendation for a gradual dose reduction of psychoactive medications, which the physician declined without providing a documented rationale. The lack of a documented rationale and duration for the extended PRN order was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the expectation was for the physician to provide such documentation. This oversight resulted in the facility's non-compliance with the requirement to ensure that PRN psychotropic medications are appropriately justified and time-limited.

Plan Of Correction

This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Resident 92's physician gave an end date for the residents Lorazepam medication. 2. To identify other residents that have the potential to be affected, the DON/designee will audit psychoactive medications ordered by resident 92's physician to ensure they have an end date. 3. Physicians will be educated by DON/designee on the importance of including an end date on psychoactive medications. 4. The DON/designee will conduct an audit 1x a week for 4 weeks of any new admissions with psychoactive medications and current residents who receive a new order for psychoactive medications to ensure physicians ordered stop dates on these medications. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.

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 professional standards for food service safety, specifically regarding the operation of the dish machine in the kitchen. The facility's policy, revised on April 5, 2024, mandates that the dish machine's final rinse temperature should not be less than 180 degrees Fahrenheit, as established by the Food and Drug Administration. However, an observation on March 17, 2025, revealed that the final rinse temperature was only 176 degrees Fahrenheit. Additionally, a review of the dish machine temperature log from March 1st to 17th, 2025, showed that the final rinse temperature was consistently documented below the required 180 degrees Fahrenheit for all meals. Interviews with facility staff further confirmed the deficiency. The Food Service Director acknowledged that the final rinse temperature should be 180 degrees Fahrenheit and admitted that the documented temperatures were below this standard. The Assistant Nursing Home Administrator revealed that the facility's Maintenance Department is responsible for repairing the dish machine and that a request had been submitted to assess the final rinse temperature. It was also disclosed that the Dietary Department used an incorrect temperature log, which led to a failure in submitting a maintenance request to evaluate the final rinse temperature. The Maintenance Department eventually recalibrated the temperature for the final rinse cycle.

Plan Of Correction

This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. The dish machine final rinse temperature was adjusted by the maintenance department and the correct log is in place to correctly record final rinse temperatures. 2. The NHA/designee will audit final rinse temperature log from March 18th, 2025 until week 1 audits begin. 3. Dietary staff has been educated by staff development/designee on dishwashing machine temperatures. 4. The NHA/designee will conduct an audit 1x a week for 4 weeks on dishwashing final rinse temperatures to ensure temperatures are at 180 degrees F or higher. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.

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 of resident assessments for three residents. Resident 21's Minimum Data Set (MDS) inaccurately indicated that the resident had not received hospice services, despite a physician's order and care plan confirming hospice admission. This discrepancy was acknowledged by the Nursing Home Administrator during an interview. Resident 259's MDS did not reflect the physician's documentation that a gradual dose reduction of the antipsychotic medication was contraindicated, despite a pharmacy recommendation and physician's note. This error was confirmed by both the Registered Nurse Assessment Coordinator and the Assistant Nursing Home Administrator. Resident 351's discharge MDS inaccurately recorded the discharge status as being to a short-term general hospital, while the resident had actually left the facility against medical advice and returned home. This error was confirmed by the Nursing Home Administrator, who acknowledged that the discharge MDS was marked inaccurately. These inaccuracies in the MDS assessments highlight a failure in accurately reflecting the residents' statuses, as required by the regulations.

Plan Of Correction

This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Resident 21 MDS was corrected to reflect resident was receiving hospice services. Resident 259 MDS was corrected to reflect that the physician did document the gradual dose reduction was contradicted for the Seroquel ordered September 25th, 2024. Resident 351 MDS was corrected that showed the resident discharged from the facility AMA. 2. To identify other residents that have the potential to be affected, the NHA/designee conducted an audit on hospice residents to ensure MDS is properly coded. The NHA/designee will conduct an audit on residents with gradual dose reductions in past 30 days to ensure MDS is coded properly for physician responses. The NHA/designee conducted an audit on the past 30 days of discharges to ensure the MDS is coded properly. 3. MDS staff will be educated by staff development/ designee on the importance of accurately completing MDS assessments and documentation. 4. The NHA/designee will conduct an audit 1x a week for 4 weeks to ensure on residents on hospice services to ensure the MDS is coded properly. The NHA/designee will conduct an audit 1x a month for 3 months to ensure gradual dose reductions are coded properly based on physician documentation. The NHA/designee will conduct an audit 1x a week for 4 weeks on residents that discharge to ensure their MDS is coded properly on where they discharged. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.

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 review and revise the care plans of two residents to accurately reflect their current medical status. For Resident 161, the care plan inaccurately stated a 'full code' status, despite the resident's POLST, advance directive, and physician orders indicating a 'do not resuscitate' (DNR) status. This discrepancy was noted in the care plan created in September 2024, and although the code status was clarified to DNR in October 2024, the care plan was not updated accordingly. The Director of Nursing (DON) confirmed that the care plan should have matched the resident's documented code status. For Resident 327, the care plan did not include information regarding the presence or care of a loop recorder implant, which was ordered to be monitored and plugged in each shift starting February 2025. Despite the loop recorder monitor being observed on the resident's nightstand, the care plan lacked any mention of this device. The DON acknowledged that the care plan should have included details about the loop recorder implant, as per the physician's orders.

Plan Of Correction

This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Resident 161's care plan was updated to reflect residents choice to be a DNR. Residents 327's care plan was updated to reflect the information on the loop recorder monitor as well as the ordered care for the loop recorder implant. 2. To identify other residents that have the potential to be affected, the DON/designee conducted an audit on resident care plans to ensure they match the residents code status. The DON/designee conducted an audit on residents with a cardiac monitor device to ensure they have a care plan that includes the information on the device and the proper care/monitoring it requires. 3. Nursing staff and social service staff will be educated by staff development/designee on care plan revisions, updating code statuses in the care plan and implementing care plans on cardiac monitoring devices. 4. The DON/designee will conduct an audit 1x a week for 4 weeks on new admissions and any residents that updated their code status to ensure their care plan reflects their code status. The DON/designee will conduct an audit 1x a week for 4 weeks on new admissions that have a cardiac monitoring device to ensure their care plan identifies the device as well as the information how to care/monitor the device. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.

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 professional standards of practice in the transcription and administration of medication orders for a resident with a gastrostomy tube. The resident, who had a history of dysphagia following a nontraumatic subarachnoid hemorrhage, was on an NPO (Nothing by Mouth) diet, with all nutrition and medications to be administered via the gastrostomy tube. Despite this, several medications were ordered and documented to be administered orally (PO), and staff signed off on these orders as if they were administered by mouth. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), revealed that they were aware of the resident's gastrostomy status and that all medications were indeed administered via the gastrostomy tube. However, the orders were not corrected to reflect the appropriate route of administration, and the staff did not seek guidance to amend the orders, which is a requirement when care needs exceed the LPN's scope of practice. This oversight in ensuring the orders matched the resident's care needs led to the deficiency.

Plan Of Correction

This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Resident 144's orders were changed after contacting the physician to administer medications through gastrostomy tube. 2. To identify other residents that have the potential to be affected, the DON/designee conducted an audit on NPO residents to ensure physician orders are accurate for the method the resident is administered their medications. 3. Licensed staff will be educated by staff development/designee on accurately entering orders into the EMAR and medication administration. 4. The DON/designee will conduct an audit 1x a week for 4 weeks on new admitting NPO residents and any new medication orders for NPO residents to ensure the physician orders are correct in regards to the method the medication is administered to the resident. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.

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 adequate personal hygiene and grooming for a resident dependent on staff assistance for activities of daily living. Resident 120, who has diagnoses including dementia and muscle weakness, was observed with significant soiling on the soles of her feet while she was barefoot in bed. The floor in her room was noted to be dusty and gritty with a dark buildup around the edges. Staff interviews revealed that the resident frequently removes her footwear and prefers to walk barefoot, necessitating daily foot washing. The Director of Nursing confirmed that the resident disrobes and ambulates independently, and staff wash her feet as needed.

Plan Of Correction

This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Resident 120's feet were cleaned and ADL care was provided. 2. To identify other residents that have the potential to be affected, the DON/designee will audit residents that are care planned for removing footwear/walking barefoot and check their feet for black soiling. 3. Staff will be educated by staff development/designee on providing ADL care and providing podiatry care. 4. The DON/designee will conduct an audit 1x a week for 4 weeks on new admissions and residents with an updated care plan that has a focus on self-care deficit in regards to removing footwear/walking barefoot to ensure ADL care is provided to their feet and no black soiling is present. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.

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 and services were provided in accordance with physician orders for three residents. For Resident 121, there was a lack of documentation in the Medication Administration Record (MAR) for several medications, including Lantus, Levothyroxine Sodium, Melatonin, Acetaminophen, and blood sugar monitoring. The progress notes did not indicate whether these medications and monitoring were administered or provide a rationale for not following physician orders. Resident 221's Treatment Administration Record (TAR) showed that staff did not document care for the Foley catheter as per physician orders. The orders required emptying the Foley drainage bag every shift and recording output, as well as irrigating the catheter with sterile normal saline every shift. Documentation was missing for several shifts in January and February 2025, and the Director of Nursing confirmed that staff should have documented the catheter care. For Resident 338, the MAR lacked documentation for the administration of several medications, including Atorvastatin Calcium, Melatonin, Ativan, Baclofen, and Insulin Lispro on specific dates. The progress notes did not indicate whether these medications were administered or provide a rationale for not following physician orders. The Director of Nursing acknowledged that the MAR should be completed at the time of administration or resident refusal.

Plan Of Correction

This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Resident 121's physician was notified of the MAR blanks from January 19th, 2025 for the following medications: Lantus 15 units, Lantus 46 units, Levothyroxine Sodium, Melatonin 3 Milligrams, Acetaminophen 325 Milligrams. Resident 121's physician was also notified of the MAR blank on January 19th, 2025 in regards to monitoring blood sugar levels before bedtime. Resident 221's physician was notified of catheter care not documented on the TAR from the following shifts and dates: Evening shift of January 5th, 2025, day and night shift on January 9th, 2025, day shift on January 14th, 2025, evening shift of January 31st, 2025, evening shift of February 1st, 2025, day shift on February 5th, 2025, evening shift on February 14th, 2025, evening shift on February 15th, 2025 and evening shift on February 16th, 2025. Resident 221's physician was also notified of irrigation of the Foley was not documented on the TAR for the following shifts and dates: Evening shift on February 1st, 2025, day shift of February 5th, 2025, evening shift on February 14th, 2025, evening shift on February 15th, 2025 and evening shift on February 16th, 2025. Resident 338's physician was notified of the MAR blanks from January 19th, 2025 for the following medications: Atorvastatin Calcium 40MG, Melatonin Oral Tablet 3 MG, Ativan .5 MG, Baclofen Oral Tablet 10MG and Insulin Lispro. 2. To identify other residents that have the potential to be affected, the DON/designee will audit January 19th, 2025 MARS for residents that were assigned to the same nurse and/or nurses who were assigned to resident 121 and to resident 338 on that day. The DON/designee will audit MAR's and TAR's of residents that have a catheter to ensure catheter care and irrigation of their Foleys are being documented on. 3. Licensed and certified staff will be educated by staff development/designee on the importance of following physician orders in regards to medication administration, providing catheter care/Foley irrigation. 4. The DON/designee will conduct an audit 1x a week for 4 weeks on residents MARS to ensure there is no blanks on medication administration and blood sugar monitoring. The DON/designee will conduct an audit 1x a week for 4 weeks on residents with a catheter that catheter care is documented in the TAR and foley irrigation is documented in the TAR. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.

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 complete and accurate records related to dialysis communication for Resident 96, who required dialysis services. The facility's policy on Dialysis Management, revised in March 2024, mandates the exchange of necessary information for resident care, including the completion of a dialysis communication form by the dialysis center personnel and its subsequent review by the facility. However, the review of Resident 96's clinical records revealed that the dialysis communication sheets were not completed for multiple dates in January and March 2025. Additionally, the facility did not document the resident's post-dialysis dry weight as per physician orders on several occasions in January 2025. Resident 96 had multiple diagnoses, including congestive heart failure, diabetes mellitus, chronic kidney disease stage 5, and bipolar disorder, necessitating regular dialysis sessions. Despite the physician's orders for dialysis on specific days and the requirement to record the resident's dry weight post-dialysis, the facility failed to adhere to these orders. Interviews with the Director of Nursing (DON) confirmed the lapses in completing the dialysis communication sheets and obtaining the dry weight, acknowledging that the facility had contacted the dialysis center to address the issue of incomplete post-dialysis vital sign documentation.

Plan Of Correction

This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Resident 96's physician was notified that the dry weight per physician order was not documented on Monday evening shift on January 6th, 20th and 27th, 2025. Resident 96's physician and dialysis center was notified that communication sheets were not completed on the following dates in January 2025: 1st, 3rd, 8th, 10th, 13th, 15th, 17th, 20th, 22nd, 24th, 27th, 29th and the 31st. In March 2025: 12th and 14th. 2. To identify other residents that have the potential to be affected, the DON/designee will audit dialysis residents to ensure physician orders are being followed in regards to documenting resident's dry weight. The DON/designee will also audit dialysis resident's communication sheets to ensure they are completed. 3. Staff will be educated by staff development/designee on the importance of following physician orders in regards to taking dry weights. The DON/designee will contact dialysis centers and educate them on the importance of completing communication sheets. The DON/designee will educate licensed staff on contacting the dialysis center when communication sheets are not completed. 4. The DON/designee will conduct an audit 1x a week for 4 weeks on dialysis residents to ensure their dry weights are taken per physician orders as well as audit dialysis communication sheets to ensure they are completed by the dialysis center. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.

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 Medication Regimen Reviews were completed and responded to in a timely manner for two residents. For Resident 90, who has diagnoses including schizoaffective disorder and anxiety disorder, a pharmacist recommended a gradual dose reduction (GDR) for psychoactive medications. The attending physician disagreed with this recommendation but did not provide a rationale for the decision in the resident's medical record. An interview with the Director of Nursing (DON) confirmed the absence of documentation explaining the physician's disagreement with the GDR recommendation. Similarly, for Resident 144, who has diagnoses including depressive disorder and anxiety disorder, a pharmacist also recommended a GDR for psychoactive medications. The attending physician disagreed with the recommendation but again failed to provide a rationale or date the response. The DON confirmed that there was no documentation available to explain the physician's decision regarding the GDR recommendation for Resident 144. These deficiencies indicate a failure to comply with the requirement for documenting the rationale for not following a pharmacist's recommendation.

Plan Of Correction

This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Residents 90's physician has updated a rationale for not attempting a GDR on a pharmacist recommended GDR for resident 90's psychoactive medications. Resident 144's physician has updated a rationale and response for disagreeing on a pharmacist recommended GDR for resident 144's psychoactive medications. 2. To identify other residents that have the potential to be affected, the DON/designee will audit pharmacist recommended GDRs for past 30 days to ensure physicians document a response and rationale for disagreeing with GDR or not attempting the GDR. 3. Physicians will be educated by the DON/designee on the importance of providing documentation on a rationale and a response to pharmacy recommended GDR's. 4. The DON/designee will conduct an audit 1x a month for 3 months on pharmacy recommended GDR's on psychoactive medications to ensure physicians provide documentation of a response and rationale for either not attempting the GDR or disagreeing with it. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.

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 minimum staffing levels for nurse aides (NAs) on several occasions across different shifts. Specifically, during the day shift, the facility did not provide the necessary number of NAs per resident on five out of fourteen days reviewed. For instance, on December 20, 2024, with a resident census of 362, the facility was required to have 36.20 NA full-time equivalents (FTEs) but only provided 35.77. Similar shortfalls were noted on December 21 and 22, 2024, and March 15 and 16, 2025, with the facility consistently failing to meet the required NA FTEs based on the resident census. The evening and night shifts also experienced staffing deficiencies. On four out of fourteen days reviewed for the evening shift, the facility did not meet the required NA FTEs, with notable shortfalls on December 20 and 21, 2024, and March 13 and 14, 2025. Additionally, the night shift was understaffed on two out of seven days reviewed, specifically on March 15 and 16, 2025. These deficiencies were confirmed through an interview with the Nursing Home Administrator, who acknowledged the facility's failure to meet the minimum staffing requirements on the specified dates and shifts.

Plan Of Correction

This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. CNA staffing ratios for dayshift were not met on December 20th, 21st and 22nd, 2024; March 15th and 16th, 2025. CNA staffing ratios for evening shifts were not met on December 20th and 21st, 2024; March 13th and 14th, 2025. CNA staffing ratios were not met on the night shift on March 16th and 17th, 2025. The facility has robust retention and recruitment activities in place. Nursing leadership did all things reasonably possible to meet the required ratios through bonuses, day off on another day, split shifts, extra day pay. All unscheduled staff were contacted and supplemental staffing were contacted to send replacement staff with little avail. Ancillary staff were available and assisted in various tasks such as call bell attendant, delivery and removal of meal trays, delivery of water, bed making and performance of other tasks within their scope of practice. There were no negative outcomes to residents. The facility will continue to ensure schedule reflects the required staffing ratios and address call offs. Staff and supplemental staffing have been reminded of the importance of them reporting to work as assigned. 2. No residents were affected. 3. To prevent this from reoccurring, the NHA/designee completed education with the staffing coordinators on the Pennsylvania Regulation for CNA Staffing Ratios. Nursing supervisors will be educated to make phone calls to replace call offs and no shows. 4. To monitor and maintain ongoing compliance, the NHA/designee will audit 5 schedules weekly x 4 Weeks to ensure CNA ratios are being met every shift. Audit results will be reviewed with QAPI Committee meeting monthly to determine the need for further audits.

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 state-mandated minimum of 3.20 hours of direct nursing care per resident per day on three specific dates. On December 20 and 21, 2024, the facility provided 3.15 and 3.14 hours of direct care per resident, respectively. Additionally, on March 16, 2025, the facility provided only 2.81 hours of direct care per resident. These deficiencies were identified through a review of staffing information provided by the facility for the periods of December 16 - 22, 2024, and March 13 - 19, 2025. The Nursing Home Administrator confirmed the shortfall in direct care hours during an interview on March 20, 2025.

Plan Of Correction

This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Staffing PPD for December 20th and 21st, 2024; March 16th, 2025 were under the minimum staffing PPD of 3.20. The facility has robust retention and recruitment activities in place. Nursing leadership did all things reasonably possible to meet the required PPD through bonuses, day off on another day, split shifts, extra day pay. All unscheduled staff were contacted and supplemental staffing were contacted to send replacement staff with little avail. Ancillary staff were available and assisted in various tasks such as call bell attendant, delivery and removal of meal trays, delivery of water, bed making and performance of other tasks within their scope of practice. There were no negative outcomes to residents. The facility will continue to ensure schedule reflects the required PPD and address call offs. Staff and supplemental staffing have been reminded of the importance of them reporting to work as assigned. 2. No residents were affected. 3. To prevent this from reoccurring, the NHA/designee completed education with the staffing coordinators to schedule the staffing for 3.20 and above to maintain required PPD. Nursing supervisors will be educated to make phone calls to replace call offs and no shows. 4. To monitor and maintain ongoing compliance, the DON/designee will audit 5 schedules weekly x 2 Weeks to ensure staffing PPD is 3.20 or above. Audit results will be reviewed with QAPI Committee meeting monthly to determine the need for further audits.

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 the required 2-hour fire resistance rating of structural steel beams, which affected one of the 27 smoke compartments within the building. During an observation on March 5, 2025, at 11:15 AM, it was noted that approximately four inches of structural steel were exposed above the suspended ceiling in the 5th floor alcove near Resident Room 540. This exposure compromised the fire resistance rating of the structural steel member. The Facilities Manager confirmed the deficiency during an interview conducted at the same time.

Plan Of Correction

1. The four inch structural steel above resident room 540 was covered with Universal Fireproofing Patch that provides a minimum 2-hour fire resistance coating. 2. The maintenance department will be in-serviced by NHA/Designee on the importance of having the structural steel of the facility being coated with a minimum of a 2-hour fire resistant material. 3. Quarterly audits will be performed by the maintenance director/ designee in random locations to ensure there is a minimum 2-hour fire resistant protectant on the structural steel of the facility. 4. Results of the audit will be reviewed/reported to the QA committee to determine trends and compliance. QA committee will determine need for continuance of audits.

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 the automatic sprinkler protection system properly, as it was observed to be burdened with extraneous weight. This deficiency affected one of the 27 smoke compartments within the facility. The report indicates that the sprinkler system was not maintained in accordance with NFPA 25, which is the standard for the inspection, testing, and maintenance of water-based fire protection systems. The failure to adhere to these standards was determined through observation and interview, highlighting a lapse in the facility's maintenance protocols for its fire protection systems.

Plan Of Correction

1. The flexible ductwork within the 1st floor Old Receptionist Room was removed from the sprinkler pipe in the same area. 2. The maintenance department will be in-serviced by NHA/Designee on the importance of having the sprinkler pipe clear of any flexible ductwork. 3. Quarterly audits will be performed by the maintenance director/designee to ensure there is no flexible ductwork hanging from the sprinkler pipe. 4. Results of the audit will be reviewed/reported to the QA committee to determine trends and compliance. QA committee will determine need for continuance of audits.

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 have a deficiency related to the improper suspension of ductwork from the sprinkler system. On March 6, 2024, an observation was made at 10:46 AM, revealing that a length of flexible ductwork was suspended from the sprinkler piping above the suspended ceiling in the 1st floor Old Receptionist Room. This was confirmed through an interview with the Facilities Manager, who acknowledged the ductwork's suspension from the sprinkler system. This action compromises the integrity and functionality of the sprinkler system, which is critical for fire safety. Additionally, the facility failed to maintain the smoke resistance of corridor doors, which is essential for preventing the spread of smoke in the event of a fire. On March 6, 2025, at 11:08 AM, an observation revealed an unprotected penetration in the door to Room 102 on the 1st floor. This was confirmed in an interview with the Facilities Manager, who acknowledged the unprotected penetration. This deficiency affects one of the 27 smoke compartments within the facility, potentially compromising the safety of residents and staff in the event of a fire.

Plan Of Correction

1. The unprotected penetration on the first floor door to room 102 was filled with wood putty as this is a smoke door. 2. The maintenance department will be in-serviced by NHA/Designee on the importance of not having penetrations in doors within the facility. 3. Quarterly audits will be performed by the maintenance director/designee to ensure there are no penetrations in corridor doors. 4. Results of the audit will be reviewed/reported to the QA committee to determine trends and compliance. QA committee will determine need for continuance of audits.

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, comfortable, and homelike environment on the 5th floor, as observed on August 27, 2024. Debris and soiled areas were found under and around the bed of Resident 1, and a dried liquid spill was noted on the door of Resident 3's room. A vitals monitor in the hallway outside Resident 3's room had spots of debris, and the base of the stand had multiple dried soiled areas. Additionally, a dried liquid spill was present on the wall and baseboard in the hallway outside Resident 3's room. Multiple ants were gathered around a dropped piece of food next to Resident 4's bed, with dried spills on the bed's legs and debris on the fall mat. Debris was also present around and under Resident 2's bed. Soiled and/or rusty areas were observed on the leg of Resident 5's overbed table, and cobwebs were present in a window at the end of the west hallway. These observations were acknowledged by the Nursing Home Administrator and Director of Nursing during a tour.

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 a comprehensive person-centered care plan for three residents. Resident 220, who had diagnoses including muscle weakness and portal vein thrombosis, was prescribed Eliquis to reduce the risk of stroke and blood clots. However, the interdisciplinary plan of care did not address the use of this medication. The Director of Nursing (DON) acknowledged the lack of a care plan for this medication during an interview and subsequently provided an updated care plan. Resident 291, who had hemiplegia following a cerebral infarction, expressed a preference to smoke during an interview. Despite this, the resident's care plan did not document this preference until two days later. The DON confirmed that a smoking care plan should have been in place. Additionally, Resident 317, who had diagnoses including congestive heart failure and chronic kidney disease, reported issues with his hearing aids. His care plan did not document his hearing loss or the use of hearing aids until the day after the interview. The DON acknowledged that a care plan for hearing loss and hearing aids should have been developed.

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 medication regimen was free from unnecessary psychotropic medication. The resident, who had diagnoses including unspecified dementia and major depressive disorder, was prescribed Seroquel for anxiety and restlessness by hospice services. This prescription was accepted by the facility's physician and started without documented justification for the use of an antipsychotic medication. The resident was already on Buspar and Ativan for anxiety and agitation, and there were no documented incidents of anxious behaviors or psychotic symptoms in the months leading up to the addition of Seroquel. The facility's policy on psychotropic medication use requires that such medications be prescribed only when necessary to treat specific conditions, and that behavioral interventions be attempted first. However, the clinical record revealed no symptoms or justification for the use of Seroquel, and no documentation of negative behaviors or psychotic symptoms was found. Additionally, there was no screening or assessment for side effects of antipsychotic medications during the duration of Seroquel use, and the comprehensive plan of care did not include monitoring for target behaviors or side effects. Furthermore, the informed consent for the psychotropic medication was not conducted until almost five months after the start of the medication. During an interview, the Director of Nursing confirmed that there was no further information or documentation regarding the use of Seroquel for the resident. This lack of documentation and adherence to policy led to the deficiency cited in the report.

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 menu was followed during a lunch meal service, and did not meet the therapeutic diet needs of two residents. On April 24, 2024, the main meal for residents on a regular diet was supposed to include Italian sausage with peppers and onions, but observations revealed that the peppers and onions were not served. The Dietary Manager confirmed that the production sheets included peppers and onions, and they should have been followed. Additionally, two residents on therapeutic diets were not served double portions as required by their physician orders and care plans. Resident 121, who has a history of cerebral infarction, dysphagia, and iron deficiency anemia, was not given double portions of a pureed texture, honey thick liquids consistency meal. Similarly, Resident 338, diagnosed with gastroesophageal reflux disease and chronic obstructive pulmonary disease, was not served double portions of a mechanical soft-chopped texture, regular/thin liquids consistency meal. The Nursing Home Administrator was informed of these deficiencies during an interview on April 24, 2024. The Assistant Nursing Home Administrator verified that the production sheets for the lunch meal included the missing peppers and onions. The failure to follow the menu and provide the prescribed therapeutic diets for the two residents was confirmed through clinical record reviews, observations, and staff interviews. No further information was provided by the facility regarding these concerns.

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 residents were served food prepared in a form designed to meet their individual needs. Specifically, 13 residents who were on a chopped texture diet were served regular bowtie pasta instead of the prescribed pastina pasta during the lunch meal service. This discrepancy was observed in the main kitchen during tray line meal service. The Dietary Manager confirmed that the residents should have been served pastina pasta. The Nursing Home Administrator was informed of the issue but provided no further 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 ensure that care and services were provided in a manner that enhanced or maintained resident dignity for Resident 146. Resident 146, who has diagnoses including Alzheimer's disease and major depressive disorder, was observed ambulating in the hallway wearing a white knit shirt that was tucked tightly into her pants, causing the shirt collar to be pulled down and fit closely to her body. It was noted that Resident 146 was not wearing a bra, and her breasts were visible through the shirt. During an interview, a Nurse Aide revealed that she did not put on Resident 146's bra because the prongs were sticking out and the white knit shirt was the only one she could find. The Nurse Aide also mentioned that, in her experience, Resident 146 does not refuse to wear a bra. The Director of Nursing agreed that Resident 146 should have been dressed in a way that prevented her from being exposed.

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 needs were accommodated regarding call bell accessibility for two residents. Resident 39, who has diagnoses including morbid obesity, difficulty in walking, and muscle weakness, was observed in her room with her call bell on the floor during lunchtime and later after lunch. Her care plan, which included an intervention to ensure the call bell and personal items were within reach, was not followed as observed on April 22, 2024. Resident 271, who has diagnoses including muscle weakness and difficulty in walking, was observed in his room yelling for assistance to go to the bathroom with his call bell out of reach on two separate occasions. His care plan also included an intervention to ensure the call bell and personal items were within reach, which was not adhered to as observed on April 22 and April 24, 2024. The Nursing Home Administrator confirmed that residents should have access to their call bells.

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 personal privacy during medical treatment for Resident 93. The resident, who has diagnoses including peripheral artery disease and cerebrovascular disease, was observed sitting in her wheelchair in the hallway with five other residents present. Employee 5 approached Resident 93 in the hallway and informed her about the recommendation for an above-the-knee amputation of her right leg, based on a recent consultation. This conversation caused the resident to cry and wheel herself back to her room. The Director of Nursing confirmed that medical information should be kept confidential and acknowledged the revision of the resident's care plan to address her sadness and depression related to her condition.

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, clean, comfortable, and home-like environment for two residents. Resident 220's wheelchair had cracked and torn vinyl covering on the armrests, with foam stuffing protruding, which was not identified during periodic inspections. Resident 220 uses the wheelchair daily for mobility, and it belonged to the facility. Resident 258's overbed table was missing a piece of trim, had damaged veneer, and exposed inner wood, which was also not identified until later. Both deficiencies were acknowledged by the Nursing Home Administrator during 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 provide an appropriate rationale for continuing an antipsychotic medication, Seroquel, for a resident diagnosed with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and major depressive disorder. The medication was initially prescribed by Hospice services for anxiety and restlessness and was accepted by the facility's physician. However, a pharmacy medication review recommended including an appropriate diagnosis for the Seroquel order, noting that it is typically used for bipolar disorder and schizophrenia. The facility provider declined this recommendation, citing behaviors and a diagnosis of dementia with behaviors and psychosis, despite no documented occurrences of behaviors or psychosis in the resident's clinical record during the relevant months. The pharmacy provider did not further question the appropriateness of the medication for the undocumented indications. Subsequently, the Seroquel order was reordered with an indication of psychosis, agitation, and anxiety, even though there was no indication that the resident was experiencing symptoms of psychosis. During an interview, the Director of Nursing revealed that the facility was actively reviewing the application of psychotropic medications but had no further information regarding the resident's medication regimen review. This failure to provide an appropriate rationale for the medication and to document the necessary indications led to the 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 follow infection control standards during medication administration for two residents. During observations, an employee was seen dispensing medications from multidose containers directly into her bare hand before placing them into medicine cups. This occurred for Resident 281, who received a vitamin D tablet, and Resident 93, who received multiple medications including vitamin B12, Senna S, and a multivitamin. The facility's policy on medication administration, which includes infection control procedures such as hand hygiene and the use of gloves, was not adhered to during these instances. During an interview, the Director of Nursing confirmed that staff should not handle medications with their bare hands, indicating a breach in protocol. The observations and staff interview revealed that the facility did not comply with its own infection control standards, as outlined in their policy last reviewed in June 2023. This deficiency was identified under 28 Pa code 211.12(d)(1)(3)(5) 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

The facility failed to timely notify a resident's physician of a change in condition for two of four residents reviewed and failed to notify a resident's responsible party of a change in condition and/or treatment changes for four of four residents reviewed. The facility's policies on Change in Condition and Physician Notification were not adhered to, resulting in significant lapses in communication and documentation. For instance, Resident 1 experienced significant weight loss and elevated blood sugars, but there was no documentation that their physician or responsible party was notified of these changes or the new dietary and medication recommendations. Similarly, Resident 2 and Resident 3 were exposed to Influenza A and received new medication orders, but their responsible parties were not informed. Resident 3 also had multiple changes in condition, including a moist cough, red and swollen leg, and difficulty swallowing, none of which were communicated to their responsible party. Resident 4's case was particularly concerning. They exhibited symptoms such as purple and cold feet, low oxygen saturation, and poor oral intake over several days. Despite these significant changes, there was no documentation that a Registered Nurse assessed the resident, that the physician followed up in a timely manner, or that the responsible party was notified. The resident's condition deteriorated to the point of being unresponsive and septic upon arrival at the hospital, where they eventually passed away. The facility's failure to follow its own policies and ensure timely communication and documentation contributed to the inadequate care provided to these residents. The Director of Nursing and other staff members confirmed that the facility's procedures for notifying physicians and responsible parties were not followed. The facility did not provide any documentation to support that they were continuing to follow up with Resident 4's physician regarding their ongoing change in condition prior to the resident's transfer to the hospital. This lack of adherence to established protocols and poor communication among staff members led to significant deficiencies in the care provided to the residents, as evidenced by the detailed clinical record reviews and staff interviews conducted during the survey.

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 received adequate assistance to prevent accidents and did not conduct thorough investigations following falls. Resident 3, who had diagnoses including dementia, muscle weakness, and lack of coordination, was witnessed falling out of a chair in the TV room while sleeping, resulting in a bloody nose with bruising and deformity. The incident report for Resident 3 was incomplete, missing critical sections such as mental status and predisposing factors. Additionally, there was no evidence that the nurse aide monitoring the TV room sought help to assist Resident 3 back to bed, despite observing the resident leaning forward in the chair multiple times before the fall. Resident 4, also diagnosed with dementia, muscle weakness, and lack of coordination, was found on the floor next to their bed, confused and incontinent. The incident report and witness statements did not include information on when Resident 4 was last observed or when incontinence care was last provided. The DON confirmed that the fall occurred from the bed and that incontinence care was provided immediately after the fall. However, the investigation lacked details on the timing of the last observation and care provided to Resident 4. The facility's Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that thorough investigations were expected but not completed in these cases. The interdisciplinary team reviewed the falls and ruled out abuse and neglect, but the documentation was insufficient to determine the exact circumstances leading to the falls. The facility's policy on incident reporting and investigation was not fully adhered to, resulting in incomplete investigations and inadequate supervision to prevent accidents.

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 care and services were provided in accordance with professional standards for Resident 4, who had diagnoses including dementia and depression. On February 20, 2024, an LPN noted that Resident 4's feet were purple and cold to the touch, but there was no documentation that this condition was reported to or assessed by an RN. Later that day, another LPN noted the same condition and a low oxygen saturation rate, but again, there was no RN assessment or follow-up with the physician documented. The next day, an RN noted that Resident 4's feet were ice cold with negative pedal pulses and blue skin color, and the resident was eventually transferred to the hospital after the physician's assessment. Further review revealed that Resident 4 had a significant decline in meal and fluid intake from February 17-21, 2024, which was not reported by nurse aides, assessed by an RN, or communicated to the physician. On February 21, 2024, the physician noted that Resident 4 had poor oral intake, a mental status change, dehydration, and possible sepsis, and ordered the resident to be sent to the hospital. Resident 4 arrived at the hospital unresponsive and in acute distress, and was diagnosed with sepsis. The resident passed away later that day. The facility's documentation and staff interviews confirmed that changes in Resident 4's condition were not properly reported to or assessed by an RN, and there was a lack of follow-up with the physician. The facility's policy required that changes in a resident's condition be reported to an RN and that the RN complete necessary follow-up, which was not adhered to in this case. The facility did not provide any documentation to support that staff were continuing to follow up with Resident 4's physician prior to February 21, 2024.