Kinzua Nursing And Rehab

Penalty

Fine: $223,355

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 the facility’s failure to follow nursing standards of practice and accurately transcribe and implement admission medication orders for a newly admitted resident, resulting in the omission of a prescribed psychotropic medication. Pennsylvania Code Title 49 requires RNs to carry out nursing care actions that promote, maintain, and restore well-being and to be fully responsible and accountable for the quality of care delivered. Facility policies required clarification and transcription of newly prescribed medications onto the MAR or into the electronic MAR, implementation of written transfer orders unless unclear or incomplete, and acting upon and documenting pharmacist recommendations. The RN job description required delivery of care using the nursing process while maintaining professional standards. The resident, admitted with schizoaffective disorder bipolar type, Parkinson’s disease, and major depressive disorder, had transfer orders that included lithium carbonate 300 mg extended-release orally with no stop date. On admission, the facility’s physician orders dated the same day did not include the lithium carbonate 300 mg order, and the resident’s MARs for the subsequent period showed no evidence that this medication was ordered or administered. A pharmacy admission medication review identified a potential clinically significant irregularity, noting that the lithium carbonate 150 mg dose fell below the recommended daily dose and was potentially subtherapeutic, but there was no evidence that this review was addressed by facility staff or the physician. Documentation from the resident’s last behavioral health visit prior to admission showed active orders for both lithium carbonate 150 mg daily and 300 mg daily, indicating that the higher dose should have been part of the resident’s regimen. Following admission, the resident’s clinical record documented escalating behavioral and psychiatric symptoms over multiple days, including pacing, wandering, screaming, yelling, loud and unusual religious statements, hitting staff, increased anxiety, arguments with other residents, and repeated administration of anti-anxiety medications. Progress notes described manic behavior, flight of ideas, talking to self and to people not present, delusional thoughts, agitation, disruptive behavior in common areas, lack of sleep, and the need for one-on-one care due to mania. The resident experienced falls and was noted to be confused, disoriented, and in a manic state. Laboratory results showed a lithium level of 0.14 mmol/L, below the referenced normal range of 0.60–1.20 mmol/L, and a neurology progress note stated that the resident’s lithium doses were not correctly dosed and that the resident was showing signs of active psychosis. In interviews, the DON confirmed that the lithium carbonate 300 mg order from the transfer orders was not transcribed into the facility medication record and that the pharmacy admission medication review identifying a potential clinically significant irregularity was not addressed by facility staff or the physician. The resident’s care plans included a plan for risk of adverse effects related to antipsychotic medication, with a goal of no side effects, and a plan for risk of behavioral symptoms related to schizoaffective disorder with an intervention to administer medications per physician order. Despite these care plans, the lithium carbonate 300 mg order was not implemented because it was never transcribed into the electronic medical record or MAR, and the pharmacy’s alert about a potentially subtherapeutic lithium dose was not acted upon. The facility’s failure to accurately transcribe the admission medication orders and to respond to the pharmacist’s identified irregularity created a situation that surveyors determined placed the resident in Immediate Jeopardy of the likelihood of serious bodily injury, harm, or death.

Removal Plan

• All Registered Nurses will receive education regarding the proper process for entering physician orders for new admissions, including thorough review of hospital discharge orders, accurate entry of orders into the electronic health record, and the required process for transcription and clarification to ensure accuracy within the medical record.
• Nursing staff will utilize a standard Medication Transcription/Clarification Tool during the admission process to ensure all medication orders are completely and accurately transcribed.
• Any discrepancies identified will be clarified with the physician prior to implementation, and physicians will be notified promptly of any transcription error or clarification needs.
• Implement a revised admission process requiring use of the Medication Transcription/Clarification Tool to validate that medication orders are accurately entered into the electronic health record and appropriately populate in the electronic medication administration record.
• Director of Nursing or designee will audit admissions to verify accuracy of order transcription and clarification.
• Admission audits will be conducted until sustained compliance is achieved.
• Audit results will be reviewed at the Quality Assurance Performance Improvement meetings and additional corrective action or re-education will be implemented as indicated by audit findings.

Penalty

Fine: $223,355

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

Surveyors identified that the facility failed to ensure a resident was free from significant medication errors related to a psychotropic medication. Pennsylvania Code Title 49, Section 21.11, which outlines RN responsibilities for promoting, maintaining, and restoring well-being and being accountable for the quality of care delivered, was cited. Facility policies titled "Medication and Treatment Orders" and "Medication Errors" required that newly prescribed medications, including written transfer orders from other health care facilities, be clarified if unclear and transcribed onto the Medication Administration Record (MAR) or electronic MAR, and that medications be administered according to physician orders. Review of the clinical record for Resident R1, admitted on 1/8/26 with schizoaffective disorder bipolar type, Parkinson’s disease, and major depressive disorder, showed that the facility’s physician orders dated 1/8/26 did not include an order for lithium 300 mg extended-release orally, despite this medication being present on the transfer orders. As a result, the resident did not receive lithium carbonate 300 mg from 1/8/26 through 2/8/26. During an interview, the DON confirmed that the lithium order from the transfer documentation was not transcribed into the resident’s medication record, was not clarified with the physician, and therefore was not administered as ordered.

Penalty

Fine: $223,355

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 the failure of the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to effectively manage the facility so that admission medications are transcribed accurately. Review of facility records and job descriptions showed that the NHA’s primary purpose is to supervise clinical and administrative affairs, including overseeing staff, personal and financial matters, medical care, medical supplies, and facilities, while the DON’s primary purpose is to plan, organize, develop, and direct the overall operations of the clinical department in accordance with regulatory standards to ensure quality care. Despite these defined responsibilities, survey findings identified that the facility failed to ensure accurate transcription of admission medications, demonstrating that the NHA and DON did not fulfill their essential job duties to ensure compliance with Federal and State guidelines and regulations, including 28 Pa. Code 201.14(a), 201.18(b)(1)(3)(e)(1), and 211.12(d)(1)(3)(5).

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 accurate and complete documentation in the medical records of four out of twelve residents reviewed. Specifically, for one resident who passed away, the clinical record did not include required details such as the date and time of death, the name and title of the individual pronouncing death, and the name of the person removing the deceased from the facility, as mandated by facility policy. The Director of Nursing confirmed these omissions during an interview. Additionally, three other residents with complex medical conditions, including brain cancer, stroke, diabetes, pressure ulcers, and amputations, had incomplete documentation of wound treatments and other ordered care. Multiple entries in their treatment administration records were left blank, indicating that the completion of prescribed treatments was not consistently recorded. The Director of Nursing also confirmed these gaps in documentation, which were contrary to the facility's policies requiring timely and accurate recording of all treatments and care provided.

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 necessary assistance with bathing and personal hygiene for two residents who were dependent on staff for activities of daily living. According to facility policy and physician orders, one resident was to receive showers every Wednesday and Saturday, while another was to receive showers every Tuesday and Friday. Documentation and interviews revealed that both residents missed multiple scheduled showers, and their clinical records confirmed their need for assistance with personal care. During interviews, one resident expressed distress over not receiving showers as expected, noting greasy hair and feeling unkempt. Observations confirmed that both residents had greasy and unkempt hair at the time of the survey. The Director of Nursing acknowledged that the residents had not received showers as ordered and confirmed their unkempt appearance. The facility's own policy required documentation of the date, time, and staff involved in providing showers or bed baths, but records showed missed care events. The deficiency was identified through review of clinical records, staff and resident interviews, and direct observation, demonstrating a failure to provide necessary services to maintain personal hygiene for residents unable to perform these activities independently.

Plan Of Correction

1) Resident 3 and Resident 4 were showered, and shower documentation was completed. 2) Director of nursing or designee audited current residents to ensure showers are ordered correctly and documentation complete. 3) Director of nursing or designee educated current direct care staff on shower policy and documentation of showers. 4) Director of nursing or designee will audit 5 residents 3x per week for 2 weeks and then monthly to ensure shower offered/provided until compliance is met. Results of audits will be reviewed in QAPI each month until compliance is met. **UPDATE:** Audits will include documentation if refusal or change in schedule. Cognitively impaired residents will be visualized for cleanliness: hair, nails, general appearance.

Penalty

No penalty information released

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

Summary

A deficiency occurred when the facility failed to take timely and appropriate action to obtain and administer a prescribed medication for a resident. The facility's policies required that medications be administered safely and promptly as prescribed, and that medications be received from the pharmacy in a timely manner. Despite these policies, a resident who returned from the hospital with an order for morphine for pain and dyspnea did not receive the medication as needed upon readmission. The resident, who had diagnoses including palliative care, hypertension, and dementia, was documented as having significant pain and respiratory distress upon return to the facility. Nursing documentation indicated that the resident was non-responsive, had agonal breathing, and had received morphine prior to leaving the hospital. Pain assessments conducted after readmission showed observable signs of pain, including labored breathing and facial grimacing, with pain scores indicating moderate pain on two separate occasions. Despite the physician's order for morphine to be given as needed, the medication was not administered until the following morning, several hours after the resident's return. Staff interviews revealed that delays in obtaining a pull code for the controlled medication from the dispensing unit contributed to the delay, as the process required communication between the physician and pharmacist. The DON confirmed that the medication was not available or administered as ordered, despite documented pain and the resident's need for comfort measures.

Plan Of Correction

1) R1 received medication. 2) Director of nursing or designee audited current new residents admitted within the last 30 days with controlled substance orders to ensure no delay in medication administration and medication availability. 3) Director of nursing or designee educated Registered Nurses to receive pull code for controlled substances upon admission of new residents with narcotics. 4) Director of nursing or designee will audit new controlled substance orders for availability by either receiving pull code from emergency kit, having pharmacy perform stat run or utilizing a local back-up pharmacy to obtain medications, weekly for 2 weeks and then monthly until compliance is met. Results of audits will be reviewed in QAPI each month until compliance is 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 ensure that medication was obtained and provided as ordered by the physician for one resident. Specifically, a review of the clinical record for a resident with diagnoses including diabetes, hypertension, and gastroesophageal reflux disease showed a physician's order for caladryl external lotion to be applied topically to a rash twice daily for seven days. However, the treatment record for the relevant months did not contain evidence that the caladryl lotion was applied as ordered. Nursing documentation indicated that the facility was waiting for delivery of the caladryl lotion from the pharmacy, and there was no documentation that the medication was received or administered. The Director of Nursing confirmed that there was no evidence of receipt or application of the medication per the physician's order. Facility policies required medications to be administered according to prescriber orders and for the prescriber to be contacted if medication delivery would be delayed, but there was no documentation that these procedures were followed.

Plan Of Correction

1) Medical Director was made aware of R2 order and missed administration. Medical Director did not wish to order Caladryl based on current clinical presentation. 2) Director of nursing or designee audited not administered medication pass of current residents to ensure current medications are available to be administered, with no delay in medication administration. 3) Director of nursing or designee educated licensed staff on policy for ordering medications from pharmacy. 4) The Director of nursing or designee will audit medication administration records for missed doses, ensuring availability of medication 5 times per week for 2 weeks, and then monthly until compliance is met. Results of audits will be reviewed in QAPI each month until compliance is met. UPDATE: Education will include the path to follow if a medication is not available: Make RN aware, check MedBank, contact pharmacy, notify physician, follow physician orders, document, and notify family if applicable. Pharmacy does notify if a medication is unavailable.

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 nurse aide (NA) to resident ratios on several occasions during the review period. Specifically, for the day shift, the facility did not provide the mandated one NA per 10 residents on four days, as staffing records showed fewer NAs scheduled than required based on the census. For the evening shift, the facility did not meet the one NA per 11 residents requirement on two days, again scheduling fewer NAs than needed. These findings were confirmed through a review of staffing documents and an interview with the Nursing Home Administrator, who acknowledged the shortfalls on the identified dates and shifts. No information regarding the medical history or condition of individual residents at the time of the deficiency was provided in the report.

Plan Of Correction

The facility will provide staff to ensure the needs of residents are met. The facility will produce a daily schedule to meet the required nurse aide to resident ratios on all shifts. The Director of Nursing or designee will provide re-education on minimum nurse aide staffing ratios to Registered Nurse Supervisors and Human Resources/Scheduling, who are responsible for maintaining adequate nurse aide staffing and nurse aide staffing ratios. The Director of Nursing or designee will educate HR/Scheduler and RN supervisors on protocols for replacing staff related to call-offs, including mandating staff when replacement staff are unable to be found. The Director of Nursing or designee will meet 5 times per week for 4 weeks to audit the daily deployment sheet for accuracy to ensure the daily schedule meets nurse aide ratios. The Director of Nursing or designee will audit the hours worked to ensure that the minimum number of nurse aide staff to resident ratios have been met, using the Department of Health staffing grid for 4 weeks. The Director of Nursing or designee will audit weekly that protocols were followed when a call-off occurred. This includes asking staff to stay, posting needs, posting needs with agencies, offering bonuses, and mandating staff when needed. The facility has ads posted on Indeed and recently increased our shift differential for nurse aides on second and third shifts, resulting in an increase in applications over the last two weeks. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.

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 ratios for Licensed Practical Nurses (LPNs) across multiple shifts and days, as mandated by regulation effective July 1, 2023. Specifically, the facility did not provide the required number of LPNs per resident on the day shift for 11 out of 21 days reviewed, on the evening shift for one day, and on the overnight shift for four days. Staffing documents showed that on these dates, the number of LPNs scheduled and worked was consistently below the calculated requirement based on the facility's census for each shift. The deficiency was confirmed through a review of nursing staffing documents and an interview with the Nursing Home Administrator, who acknowledged the shortfalls. The report details the specific census numbers and the corresponding LPN staffing levels for each deficient shift, demonstrating that the facility did not meet the mandated LPN-to-resident ratios on multiple occasions during the review period.

Plan Of Correction

The facility will provide staff to ensure the needs of residents are met. The facility will produce a daily schedule to meet the required licensed practical nurse to resident ratios on all shifts. The Director of Nursing or designee will provide re-education on minimum licensed practical nurse staffing ratios to Registered Nurse Supervisors and Human Resources/Scheduling, who are responsible for maintaining adequate staffing and licensed practical nurse staffing ratios. The Director of Nursing or designee will educate HR/Scheduler and RN supervisors on protocols for replacing staff related to call-offs, including mandating staff when replacement staff are unable to be found. The Director of Nursing or designee will meet 5 days per week for 4 weeks to audit the daily deployment sheet for accuracy to ensure the daily schedule meets licensed practical nurse ratio. The Director of Nursing or designee will audit the hours worked to ensure that the minimum number of licensed practical nurse staff to resident ratios have been met, using the Department of Health staffing grid for 4 weeks. The Director of Nursing or designee will audit weekly that protocols were followed when a call-off occurred. This includes asking staff to stay, posting need, posting need with agencies, offering bonus, and mandating when needed. The facility has ads posted on Indeed and has recently advertised our shift differential for licensed practical nurses on second and third shifts, with an increase in applications over the last two weeks. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.

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 the required minimum of 3.2 hours of direct resident care per resident per day over a 24-hour period on three specific days during the review period. Review of nursing staffing documents showed that on these dates, the provided hours of care per patient day (PPD) were 3.16, 3.19, and 3.17, all below the regulatory minimum. This deficiency was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the facility did not meet the mandated staffing levels on the identified dates. No additional information regarding the medical history or condition of specific residents was provided in the report.

Plan Of Correction

The facility will provide staff to ensure the needs of residents are met. The facility will produce a daily schedule to at least meet the required 3.2 minimum general nursing care per patient day hour requirement. The Director of Nursing or designee will provide re-education on minimum general nursing care staffing hours to Registered Nurse Supervisors and Human Resources/Scheduling who are responsible to maintain adequate general nursing care staffing hours. The Director of Nursing or designee will educate HR/Scheduler and RN supervisors of protocols for replacing staff related to call offs, including mandating staff when replacement staff are unable to be found. The Director of Nursing or designee will meet 5 days per week for 4 weeks to audit the daily deployment sheet for accuracy to ensure the daily schedule meets minimum general nursing care staffing PPD. The Director of Nursing or designee will audit the hours worked to ensure that the minimum number of general nursing care staff hours have been met using the Department of Health staffing grid for 4 weeks. The Director of Nursing or designee will audit weekly that protocols were followed when a call off occurred. This includes asking staff to stay, posting need, posting need with agencies, offering bonus, and mandating when needed. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.

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 employ a full-time qualified dietitian or ensure that the employee designated as the director of food and nutrition services received frequent consultations from a qualified dietitian. Review of the director's credentials revealed a lack of appropriate competencies and skills, including the absence of certification for food service management, a relevant degree, or sufficient experience and completed coursework in food safety and management. There was no evidence of a dietitian functioning as a consultant for the director. Interviews with the DON and NHA confirmed that the facility has not had a dietitian on a full-time, part-time, or consulting basis since the change in ownership.

Penalty

No penalty information released

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

Summary

The facility failed to accurately and consistently assess the nutritional status of residents upon admission and as needed thereafter, as required by its own policy and regulatory standards. Specifically, the facility did not complete comprehensive nutritional assessments for 27 out of 85 residents reviewed, all of whom were identified as being at risk for unplanned weight loss or compromised nutritional status. The facility's policy required a dietitian to complete a comprehensive nutritional assessment within seventy-two hours of admission, annually, and upon significant change in condition, but there was no evidence that these assessments were performed for the identified residents. Clinical records for multiple residents showed a lack of documented nutritional assessments both at admission and during their stay, despite the presence of significant medical conditions such as high blood pressure, pneumonia, pressure ulcers, COPD, diabetes, dementia, and other serious diagnoses. For example, one resident experienced a significant weight loss and developed new pressure ulcers, yet there was no evidence of a nutritional assessment being completed at any point. This pattern was consistent across all identified residents, regardless of their specific medical histories or changes in condition. Interviews with facility staff, including the DON and the NHA, confirmed that the facility had been without a dietitian on a full-time, part-time, or consulting basis since a specific date. As a result, no nutritional assessments were completed for any residents from that time forward. The lack of a dietitian and the absence of required assessments directly contributed to the deficiency, as the facility was unable to ensure that residents' nutritional needs were being properly evaluated and addressed.

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 a comprehensive care plan for a resident who was admitted with multiple diagnoses, including high blood pressure, pneumonia, and unstageable pressure ulcers on the right heel and sacrum. The facility's policy requires that a comprehensive assessment be conducted to assist in developing person-centered care plans, identifying current interventions and treatments, and linking these to the problems and diagnoses being treated. Despite the presence of physician orders for wound treatments and weekly wound care consultant assessments, there was no evidence in the clinical record that a care plan addressing the resident's skin integrity impairment and pressure ulcers had been developed. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that a care plan for the resident's pressure ulcers had not been created. The lack of a care plan was identified through a review of the clinical record, facility policy, and staff interviews, and was found to be non-compliant with state regulations regarding the responsibility of the licensee and 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 review and/or revise care plans within the required timeframes for seven out of fifteen residents reviewed. Facility policy requires that comprehensive assessments and care plans be developed, reviewed, and revised by a team of health professionals, with interventions monitored and adjusted as needed. However, clinical record reviews revealed that multiple residents had care plans with outstanding target dates, indicating they were not updated as required. For example, one resident had 37 out of 39 care plans with overdue target dates, and another had all 15 care plans overdue. Interviews with the DON and RN Assessment Coordinator confirmed these care plans were not reviewed or revised within the mandated periods. Additionally, deficiencies were found in the content of the care plans themselves. Some care plans lacked essential components such as goals and interventions. For instance, one resident's care plans for actual skin breakdown and safety had no goals, while another resident had four care plans with no goals or interventions, covering areas such as discharge potential and infection. Another resident's care plan for enhanced barrier precautions lacked any interventions. These omissions were confirmed by staff interviews. The residents affected had a range of complex medical conditions, including diabetes, high blood pressure, anxiety, COPD, osteoporosis, osteomyelitis, metabolic encephalopathy, respiratory failure, DVT, urinary tract infection, and dementia. The failure to timely review, revise, and complete care plans for these residents was identified through record review and staff interviews, and was cited under state regulations for responsibility of the licensee and 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 meet the required nurse aide (NA) staffing ratios during the overnight shift on one of the 21 days reviewed. Specifically, on January 13, 2025, the facility had a census of 74 residents, which required 4.93 NAs to meet the mandated ratio of one NA per 15 residents. However, only 4.53 NAs were on duty, resulting in a staffing shortage. This deficiency was confirmed during an interview with the Nursing Home Administrator on February 3, 2025, who acknowledged that the facility did not meet the minimum NA ratio for the specified date and shift.

Plan Of Correction

The facility will provide staff to ensure the needs of residents are met. The facility will produce a daily schedule to meet the required nurse aide to resident ratios on all shifts. The facility will also utilize licensed staff when needed to fulfill the aide need. The Director of Nursing or designee will provide re-education on minimum nurse aide staffing ratios to Registered Nurse Supervisors and Human Resources/Scheduling who are responsible for maintaining adequate nurse aide staffing and nurse aide staffing ratios. The Director of Nursing or designee will educate HR/Scheduler and RN supervisors of protocols for replacing staff related to call-offs, including mandating staff when replacement staff are unable to be found. The facility shall also utilize licensed staff to help fill the CNA openings when able. The Director of Nursing or designee will meet 5x per week for 4 weeks to audit the daily deployment sheet for accuracy to ensure the daily schedule meets nurse aide ratios. The Director of Nursing or designee will audit the hours worked to ensure that the minimum number of nurse aide staff to resident ratios have been met using the Department of Health staffing grid for 4 weeks. The Director of Nursing or designee will audit weekly that protocols were followed when a call-off occurred. This includes asking staff to stay, asking licensed staff to stay, posting need, posting need with agencies, offering bonuses, and mandating when needed. The facility has ads posted on Indeed and recently increased our shift differential for nurse aides on second and third shifts, resulting in an increase in applications over the last six weeks. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.

Penalty

No penalty information released

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

Summary

The facility failed to implement adequate safety measures related to wheelchair transport and fall precautions for two residents. Resident R13, who had a history of stroke, Parkinson's Disease, and required assistance to propel a wheelchair, was involved in an incident where they were being pushed in a wheelchair without footrests attached. This led to the resident losing balance, falling, and sustaining an injury that required hospital admission. The facility did not have a policy for staff on the safe use of footrests during wheelchair transport, contributing to the incident. Resident R14, diagnosed with prostate and bone cancer and cognitive communication deficit, had a physician's order for a pressure alarm when in bed. However, during an incident, the pressure alarm was not plugged in, resulting in the resident falling, sustaining a head injury, and becoming unresponsive. The lack of a functioning alarm system meant that staff were not alerted in time to prevent the fall. These deficiencies highlight the facility's failure to ensure proper safety measures and supervision to prevent accidents.

Plan Of Correction

R13 and R14 have both returned to us from the hospital. Resident 13's wheelchair has wheelchair footrests. Resident 14 has orders for a bed alarm to check placement and function every shift. Current residents that utilized a wheelchair for mobility were verified that they have wheelchair footrests. Current residents that have bed or chair alarms orders were verified that they have current orders for check placement and function of alarms every shift. A wheelchair mobility procedure was developed for resident transportation. The Director of Nursing or designee will educate staff, including agency staff, on footrest usage with transporting residents in wheelchairs, as well as checking that all bed/chair alarms are plugged in and active prior to leaving a resident's room. Staff will be educated that residents will have orders for alarms, and staff will also check placement and function every shift, as well as verifying the alarm is active prior to leaving the resident unsupervised. Audits will be completed to ensure all residents being transferred in a wheelchair have footrests in use when assisting residents with mobility, as well as audits to ensure alarms in use are plugged in and active. These audits will be completed on 5 residents, 3 times a week for 2 weeks, and then monthly until cleared by Quality Assurance.

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 notify the Pennsylvania Department of Health (DOH) field office of reportable incidents/accidents involving four residents. Resident R9, admitted with a stroke and left-sided paralysis, rolled out of bed and was sent to the emergency room for a hip evaluation. Resident R13, with a history of stroke and Parkinson's Disease, fell while being pushed in a wheelchair, resulting in a hospital admission. Resident R14, diagnosed with prostate and bone cancer, fell and was found unresponsive with a head injury, necessitating emergency department evaluation. Resident R15, suffering from dementia and Alzheimer's Disease, sustained a head injury from a fall in the dining room and was also sent to the emergency room. The facility's documentation and clinical records lacked evidence of these incidents being reported to the DOH field office, as required by regulation 51.3 (g)(1-14). During an interview, the Nursing Home Administrator confirmed the failure to report these incidents. This oversight represents a deficiency in the facility's compliance with state notification requirements, potentially compromising patient safety and quality assurance.

Plan Of Correction

The incidents involving R9, R13, R14, and R15 will be reported to Pennsylvania Department of Health Electronic Reporting system. The Director of Nursing or designee will conduct a look back of past 30 day transfers, and if any transfer is identified as a result of an incident or accident, it will be reported to the Department of Health electronic reporting system. Education was provided to the Director of Nursing and the Nursing Home Administrator on reportable events and criteria for reporting by the Regional Director of Clinical Services. All incidents will be reviewed in the Morning Meeting to determine if they meet the requirements for reporting to the Department of Health. Audits will be conducted to determine if an incident is a Department of Health reportable incident by the Director of Nursing or the Nursing Home Administrator on all incidents for 2 weeks, and then 5 incidents weekly until cleared by Quality Assurance.

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 corridor doors as required by regulations, specifically for one of over fifty corridor doors. During an observation on December 10, 2024, at 11:35 a.m., it was noted that the door to resident room 505 on the first floor did not have positive latching. This deficiency was identified through direct observation by the surveyors. The maintenance supervisor confirmed the deficiency during an interview conducted at the same time as the observation. The lack of positive latching on the corridor door is a violation of the requirements that ensure doors resist the passage of smoke and maintain safety standards within the facility.

Plan Of Correction

The door to room 505 was fixed immediately. All doors on A hall were checked and all passed. Education provided to maintenance as well as all staff on the importance of checking doors latching and process to report if it does not. Maintenance director or designee will audit 5 doors a week times 2 weeks and then weekly until cleared by quality assurance.

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 comprehensively address the formulation of advance directives for two residents, leading to a deficiency in honoring residents' rights to make informed decisions about their medical care. Resident R36, who was admitted with diagnoses including pervasive developmental disorder, unspecified psychosis, difficulty speaking, and dementia with agitation, was identified as a Full Code. However, the facility did not have evidence of a POLST or advance directive in the resident's clinical record, nor was there documentation of discussions or assistance offered regarding advance directives. Interviews with nursing staff confirmed the absence of these critical documents in the resident's record. Similarly, Resident R4, admitted with diagnoses of dementia, hyperlipidemia, and chronic obstructive pulmonary disease, had an order for Do Not Resuscitate (DNR) but lacked evidence of being provided with written information or assistance in formulating advance directives. The Director of Nursing confirmed the absence of such documentation in Resident R4's clinical record. These findings indicate a failure to adhere to the facility's policy on advance directives, which requires providing residents with information and assistance in formulating their medical care preferences.

Plan Of Correction

1. Resident 36 and Resident 4 responsible parties were notified and reviewed Advance directive option. Physician Orders for Life-Sustaining Treatment (POLST) were completed for both residents and physician and families notified. 2. Current resident records were reviewed to ensure that current residents have a code status and a current POLST of their wishes for healthcare. 3. Director of Nursing or designee will provide education to licensed nurses and the social worker on the advance directive policy and the completion of advanced directives on admission. 4. Director of Nursing will audit admissions to ensure that current residents have a code status including a current POLST. Audits will be completed 3 times weekly for 2 weeks then Monthly until compliance is met. Audits will be reviewed at Quality Assurance meetings monthly until compliance is 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 follow physician's orders for three residents, leading to deficiencies in care. Resident R69, who had a history of stroke, breast cancer, and high blood pressure, was observed multiple times without the prescribed left arm sling and soft cervical collar, which were ordered to be worn at all times except for specific activities. The Regional Nurse Consultant confirmed the non-compliance with the physician's orders during an interview. Resident R17, diagnosed with hypothyroidism and hyperlipidemia, did not have a scheduled dermatology appointment as ordered by the physician for a skin rash. The appointment was canceled due to COVID, and there was no evidence of rescheduling. The Director of Nursing confirmed the failure to schedule the Telederm appointment. Additionally, Resident R65, with hemiplegia and hypertension, was observed without the required contracture boot on the right foot/ankle on several occasions, despite physician orders and care plan interventions. The Director of Nursing confirmed the absence of the boot, acknowledging the failure to adhere to the physician's orders.

Plan Of Correction

1. Resident R69 was addressed immediately to ensure sling and collar were on and Dr. notified. R17 order for the telehealth visit was discontinued as per physician. R65 order for boot was discontinued after consultation with therapy as it was deemed it was no longer necessary for the patient. 2. Director of Nursing or designee will audit 5 residents weekly for three weeks to review physician orders are being followed. Redline process, review of all new orders, discontinued orders, labs and appointments, will be put into place for third shift supervisor to review all new orders and discontinued orders daily. 3. Director of Nursing or designee will educate Licensed staff and certified nursing aids on Verbal physician care orders and physician orders. Reviewed with staff on where to see orders/tasks for residents and to ensure those measures are in place for each resident. 4. Audits of 5 residents per week x 3 weeks on care orders and appointments to ensure they are active and in place. Audits will be completed 5 residents per week x 3 weeks and monthly until cleared by quality assurance meeting.

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 with limited range of motion received the necessary treatment and services to prevent further decline. Resident R65, who has hemiplegia, was observed multiple times without the prescribed resting hand splint on their left hand, despite a sign in the room indicating it should be worn during the day. The resident and their significant other confirmed that the splint was not being applied, and the resident expressed discomfort due to their fingers pushing into their hand. Interviews with the Director of Rehab and the Director of Nursing revealed that the resident was discharged from therapy with a goal to wear the hand splint for eight hours daily. However, the process to incorporate these goals into the resident's care plan was not effectively followed, as evidenced by the repeated observations of the resident without the splint. The Director of Nursing confirmed the oversight, acknowledging that the splint should have been applied daily.

Plan Of Correction

1. Resident #65 had therapy eval completed to ensure that resident required hand splint. Physician and family were updated with recommendations. 2. Current residents with hand splints were reviewed to ensure that orders were current and equipment available and staff were applying the splint. 3. Director of Nursing or designee will educate licensed staff and certified nurse aides on splints/adaptive equipment. Reviewed with staff on where to see orders/tasks for residents with splints/adaptive equipment. 4. Audits of residents with hand splints will be completed to ensure that residents have the splints on as per ordered and proper documentation supporting the wearing of those splints. Audits will be completed 3x weekly for 2 weeks then monthly until compliance is met. Audits will be reviewed at quality assurance meetings monthly until compliance is 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 appropriate care for residents with urinary catheters, as evidenced by deficiencies in catheter maintenance and infection control practices. For one resident with a suprapubic catheter, the facility did not document the required monthly catheter and bag changes in April, June, and November 2024, as ordered by the physician. This lack of documentation was confirmed by the Regional Nurse Consultant, indicating a failure to adhere to physician orders and facility policy regarding catheter care. Additionally, two other residents with foley catheters were observed with improper catheter management. One resident's urinary drainage bag was found lying on the floor without a cover, with the drainage valve touching the floor, which was confirmed by the Registered Nurse Assessment Coordinator (RNAC) as inappropriate. Another resident's foley catheter drainage bag was observed hanging off the wheelchair armrest, positioned higher than the bladder, which was also confirmed by the RNAC as incorrect placement. These observations highlight a failure to maintain unobstructed urine flow and proper infection control measures as per facility policy.

Plan Of Correction

1. Resident #1 suprapubic catheter was last changed on 10/11/2024. Physician was notified that suprapubic catheter was not changed as per order in April, June, and November. No ill effects occurred due to catheter not being changed. Resident #5 foley was immediately put in a basin so it didn't touch the floor. Resident #11 foley was repositioned to ensure it was positioned below the bladder. 2. Current residents with foley/suprapubic catheters were reviewed to ensure that catheters were being changed as per physician orders, that catheter bags were not on the floor, and to ensure that catheter bags were positioned below the bladder to prevent back flow of urine. 3. Director of Nursing or designee will provide education to Licensed staff and Certified Nurse Aides on Catheter care policy and the Supra pubic catheter policy. She will educate on following physician orders for catheter changes, ensuring that the catheter bags are not on the floor, and that the staff must position the catheter below the bladder to prevent back flow of urine. 4. The Director of Nursing or designee will audit to ensure that all catheters are changed per physician order, the foley is not on the floor, and that the catheter bag is positioned appropriately. Audits will be completed on all catheters 3x weekly for 2 weeks then monthly until compliance is met. Audits will be reviewed at quality assurance meetings monthly until compliance is 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 properly label and manage multi-dose containers of insulin and Tuberculin solution, leading to deficiencies in medication storage and expiration management. Observations revealed that insulin pens and vials on the Gold and Red Units' medication carts were not labeled with the date they were opened, making it impossible to determine their discard dates. Additionally, an opened multi-dose vial of insulin was found to be expired by five days. Staff interviews confirmed that these items should have been labeled with the opened date to ensure proper discard timing. Further observations in the Red Unit medication room identified an opened multi-dose vial of Tuberculin solution that was expired by seven days. Staff confirmed that this vial should have been discarded according to the facility's policy, which requires opened vials to be labeled with the date opened and a new expiration date. The failure to adhere to these policies resulted in the presence of expired medications in the facility, which was confirmed by staff interviews.

Plan Of Correction

Medication carts were immediately audited to ensure that any multidose vials of insulin, insulin pens, or Tuberculin solutions were dated with open date and that they had not expired since open per manufacturer guidelines. The Director of nursing or designee will educate licensed staff on medication storage policy and insulin policy to ensure that staff understands they have to date multidose insulin vials, insulin pens, and Tuberculin solutions when opened and they have to follow manufacturer guidelines of when it expires and not to be used after that date. The Director of Nursing or designee will audit all medication carts to ensure that insulin vials, insulin pens, and TB solution is dated with an open date and not used beyond expire date. Audits will be completed on 1 cart a day 3x weekly for 2 weeks then monthly until compliance is met. Audits will be reviewed at quality assurance meetings monthly until compliance is 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 maintain sanitary operations and food safety standards in the main kitchen and a pantry, as observed during a survey. In the main kitchen, a metal container with cake-like squares was found without labels or dates, and the heating units' vents had a thick layer of gray fuzzy substance. Additionally, the food disposal under the sink was covered with a thick layer of dry brown substance. The Dietary Manager confirmed these observations, acknowledging that the cake-like items should have been labeled and dated, and the vents and food disposal should have been clean. In the Gold Pantry, a refrigerator contained food items on a paper plate and in a ziplock bag without names or dates, and an open bottle of Pepsi also lacked labeling. The freezer contained an open half-gallon container of ice cream without a name or date, and ice packs used for resident treatments were stored with food. Temperature logs for the refrigerator and freezer were incomplete, missing entries for several days in November and entirely for December. The Assistant Director of Nursing confirmed these deficiencies, noting that food items should be labeled and dated, ice packs should not be stored with food, and temperatures should be logged daily.

Plan Of Correction

1. All items found without dates were immediately disposed of. All other pantries/refrigerators were checked for undated items as well as non-dietary items. The heating unit vents were inspected and cleaned the same day. The food disposal under the sink was cleaned the same day. The pantry refrigerator was cleaned of all items that were not labeled and dated. All refrigerators were temped and new temperature logs were put in place. 2. All refrigerators have been checked for temperature logs as well as proper labeling. 3. Nursing Home Administrator or designee will educate whole house on Food Labeling and Dating, Foods Brought by Family/Visitors, and Cleaning and Disinfection of Environmental Surfaces. Education also includes that the dietary manager or designee will temp and log all refrigerator temps daily. 4. Nursing Home Administrator or designee will audit to ensure the heater vents and disposal to ensure clean as well as all refrigerators, in the kitchen and the pantries, to ensure food is labeled including date. These will also be audited to ensure no non-dietary items are in the refrigerators. Refrigerator temperature logs will also be audited. The kitchen will be audited to ensure all unrefrigerated items are labeled and dated as well. These audits will be performed 1 refrigerator and the kitchen a day 3 times a week for 2 weeks then monthly until compliance is met. Audits will be reviewed at quality assurance meetings monthly until compliance is 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 maintain a clean and homelike environment in one resident room and failed to provide clean equipment for one resident. Observations in room 520 revealed multiple instances of food items and empty beverage bottles on the floor, which were confirmed by a visitor and the Nursing Home Administrator (NHA) as inappropriate. The facility's policy on maintaining a homelike environment requires a clean, sanitary, and orderly setting, which was not adhered to in this case. Additionally, Resident R37 was observed sitting in a wheelchair with food-like substances stuck to the cushion and frame over several days. The NHA confirmed the presence of these substances and acknowledged that the wheelchair and cushion should have been clean. Resident R37's clinical record indicated diagnoses of anxiety, hyperlipidemia, and hypertension, but the report focused on the cleanliness of the resident's equipment rather than their medical conditions.

Plan Of Correction

1. Room 520 was picked up at the time of notification and was cleaned the same day. R37's wheelchair was cleaned the same day. 2. Nursing Home Administrator or designee will educate all housekeeping staff to ensure the policy and procedure is followed when cleaning resident rooms and wheelchairs. 3. Nursing Home Administrator or designee will educate all housekeeping staff on "Daily Resident/Patient Room Cleaning" and "Quality of Life-Homelike Environment." Staff will date and sign the task checklist daily. 4. The Administrator or designee will audit 5 resident rooms and wheelchairs for cleanliness and signed daily task checklists 3 x week x 2 weeks, 2 x week x 2 weeks, and weekly x 2 weeks. Findings will be discussed at our monthly Quality Assurance meeting and changes will be made if necessary.

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 a physician's order for the provision of oxygen therapy for a resident with chronic obstructive pulmonary disease (COPD), dementia, and high blood pressure. The resident was observed using an oxygen nasal cannula connected to an oxygen concentrator delivering 2 liters per minute on multiple occasions. The clinical records indicated the resident utilized oxygen on several dates, but there was no evidence of a physician's order for this therapy. A Licensed Practical Nurse confirmed the absence of a physician's order during an interview.

Plan Of Correction

1. Obtained an order for oxygen for resident #26. Oxygen at 2 liter as needed. Responsible party was notified of order. 2. Current residents that are using oxygen were reviewed to determine they had orders for oxygen therapy in electronic medical record. 3. Director of Nursing or designee educated License staff on the respiratory policy. Nurses educated that residents must have an order for oxygen therapy. 4. Director of Nursing or designee will audit all residents to ensure that residents using oxygen therapy have orders for oxygen in electronic medical record. Audits will be completed 3 x weekly for 2 weeks then monthly until compliance is met. Audits will be reviewed at quality assurance meeting monthly until compliance is 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 written notice of the bed-hold policy to residents or their representatives upon or within twenty-four hours of transfer to a hospital. This deficiency was identified for two residents, R52 and R72, during a review of facility policy, clinical records, and staff interviews. The facility's policy, titled "Bed-Hold Notification - Pennsylvania," requires that residents or their responsible parties be offered the choice to hold the resident's bed when a transfer to the hospital is necessary. Resident R52, who was admitted with chronic obstructive pulmonary disease, dementia, and high blood pressure, was transferred to the hospital, but there was no evidence in the clinical record that the bed-hold policy was provided. Similarly, Resident R72, with diagnoses including dementia, prostate cancer, and high blood pressure, was also transferred to the hospital without evidence of receiving the bed-hold policy. Interviews with the Regional Nurse Consultant confirmed the lack of documentation 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 ensure the completion of a discharge summary for a resident, identified as CR72, who was discharged from the facility. Resident CR72 was admitted on 3/12/24 with diagnoses including dementia, prostate cancer, and high blood pressure. On 10/08/24, the resident's spouse informed the facility that Resident CR72 would not be returning. However, upon review of the closed clinical record, it was found that there was no discharge summary documenting the resident's stay and course of treatment. This deficiency was confirmed during an interview with the Regional Nurse Consultant on 12/05/24.

Plan Of Correction

1. Resident R72's discharge summary was opened and completed. 2. The last 10 closed charts will be audited for discharge summaries. All closed charts will be reviewed going forward to ensure discharge summary is in the closed file. 3. Nursing Home Administrator or designee will educate Interdisciplinary Team, which includes medical records, on discharge summaries to ensure that staff understands they have to be completed on all discharged residents and in the file prior to closing. 4. Nursing Home Administrator or designee will audit to ensure discharge summaries are included in closed charts. Audits will be completed on all discharged residents for 2 weeks then monthly until compliance is met. Audits will be reviewed at quality assurance meetings monthly until compliance is 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 meet the required nurse aide (NA) staffing ratios as mandated by the regulation effective July 1, 2024. Specifically, the facility did not maintain the required NA-to-resident ratios on several occasions across different shifts. During the day shift, the facility was understaffed on two days, with fewer NAs working than required for the resident census. On November 5, 2024, with a census of 78 residents, only 6.86 NAs worked when 7.80 were required. Similarly, on December 1, 2024, with a census of 77 residents, 7.20 NAs worked when 7.70 were required. The evening and overnight shifts also experienced staffing shortages. On November 29, 2024, during the evening shift, the facility had a census of 76 residents but only 4.80 NAs worked when 6.91 were required. The overnight shift was particularly affected, with staffing shortages on 11 out of 21 days reviewed. For instance, on November 8, 2024, with a census of 76 residents, only 4.26 NAs worked when 5.07 were required. These deficiencies were confirmed during an interview with the Nursing Home Administrator on December 5, 2024.

Plan Of Correction

The facility will provide staff to ensure the needs of residents are met. The facility will produce a daily schedule to meet the required nurse aide to resident ratios on all shifts. The Director of Nursing or designee will provide re-education on minimum nurse aide staffing ratios to Registered Nurse Supervisors and Human Resources/Scheduling who are responsible to maintain adequate nurse aide staffing and nurse aide staffing ratios. The Director of Nursing or designee will educate HR/Scheduler and RN supervisors of protocols for replacing staff related to call offs, including mandating staff when replacement staff are unable to be found. The Director of Nursing or designee will meet 5x per week for 4 weeks to audit the daily deployment sheet for accuracy to ensure the daily schedule meets nurse aide ratios. The Director of Nursing or designee will audit the hours worked to ensure that the minimum number of nurse aide staff to resident ratios have been met using the Department of Health staffing grid for 4 weeks. The Director of Nursing or designee will audit weekly that protocols were followed when a call off occurred. This includes asking staff to stay, posting need, posting need with agencies, offering bonuses, and mandating when needed. The facility has ads posted on Indeed and recently increased our shift differential for nurse aides on second and third shift, resulting in an increase in applications over the last two weeks. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.

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 Licensed Practical Nurse (LPN) staffing ratio on the day shift for one of the 21 days reviewed. Specifically, on December 1, 2024, the facility had a census of 77 residents but only staffed 3.00 LPNs, whereas 3.80 LPNs were required to meet the regulatory ratio of one LPN per 25 residents. This deficiency was identified through a review of the facility's nursing staffing documents covering several time periods, and it was confirmed during an interview with the Nursing Home Administrator on December 5, 2024, at 9:10 a.m.

Plan Of Correction

The facility will provide staff to ensure the needs of residents are met. The facility will produce a daily schedule to meet the required licensed practical nurse to resident ratios on all shifts. The Director of Nursing or designee will provide re-education on minimum licensed practical nurse staffing ratios to Registered Nurse Supervisors and Human Resources/Scheduling who are responsible to maintain adequate staffing and licensed practical nurse staffing ratios. The Director of Nursing or designee will educate HR/Scheduler and RN supervisors of protocols for replacing staff related to call offs, including mandating staff when replacement staff are unable to be found. The Director of Nursing or designee will meet 5 days per week for 4 weeks to audit the daily deployment sheet for accuracy to ensure the daily schedule meets the licensed practical nurse ratio. The Director of Nursing or designee will audit the hours worked to ensure that the minimum number of licensed practical nurse staff to resident ratios have been met using the Department of Health staffing grid for 4 weeks. The Director of Nursing or designee will audit weekly that protocols were followed when a call off occurred. This includes asking staff to stay, posting need, posting need with agencies, offering bonuses, and mandating when needed. The facility has ads posted on Indeed and is recently advertising our shift differential for licensed practical nurses on second and third shift, with an increase in applications over the last two weeks. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.

Penalty

No penalty information released

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

Summary

The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day over a 24-hour period. This deficiency was identified during a review of the facility's nursing staffing documents and confirmed through staff interviews. Specifically, on three separate days, the facility's nursing care hours fell below the required minimum: 2.84 hours on one day, 2.98 hours on another, and 3.19 hours on a third day. The Nursing Home Administrator acknowledged the shortfall in meeting the mandated nursing care hours on these dates.

Plan Of Correction

The facility will provide staff to ensure the needs of residents are met. The facility will produce a daily schedule to at least meet the required 3.2 minimum general nursing care Per Patient Day hour requirement. The Director of Nursing or designee will provide re-education on minimum general nursing care staffing hours to Registered Nurse Supervisors and Human Resources/Scheduling who are responsible to maintain adequate general nursing care staffing hours. The Director of Nursing or designee will educate HR/Scheduler and RN supervisors of protocols for replacing staff related to call offs, including mandating staff when replacement staff are unable to be found. The Director of Nursing or designee will meet 5 days per week for 4 weeks to audit the daily deployment sheet for accuracy to ensure the daily schedule meets minimum general nursing care staffing PPD. The Director of Nursing or designee will audit the hours worked to ensure that the minimum number of general nursing care staff hours have been met using the Department of Health staffing grid for 4 weeks. The Director of Nursing or designee will audit weekly that protocols were followed when a call off occurred. This includes asking staff to stay, posting need, posting need with agencies, offering bonus, and mandating when needed. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.

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 sanitary environment in one of its two shower rooms, specifically the Red shower room. During an observation, a black substance was found between the white ceramic tiles, and a gray substance was covering the surface of the tiles closest to the floor. The facility's policy on cleaning, dated 1/16/24, outlines a procedure for cleaning ceramic tile walls, which includes using a quaternary disinfectant and scrubbing the tiles and grout. However, during an interview, a housekeeper was unable to confirm when the shower room was last cleaned, and the facility could not provide evidence of the last cleaning date. The Nursing Home Administrator confirmed the presence of the substances and acknowledged that they should not be present on the tiles.