Health inspection·August 15, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to comprehensively assess and monitor pressure ulcers within required timeframes for one of two residents with pressure ulcers reviewed (Resident R14). Residents Affected - Few Findings include: A facility policy dated 6/11/24, entitled Pressure Ulcer Assessment / Prevention indicated When a pressure ulcer is found, regardless if upon admission or after, it must be documented in the electronic medical record and The Wound Nurse/RN [Registered Nurse] will complete weekly skin rounds and measure pressure ulcers, arterial / vascular ulcers, and surgical incisions. The findings will be documented in the electronic medical record. Resident R14's clinical record revealed an admission date of 6/16/16, with diagnoses that included diabetes (a chronic condition that affects the way the body processes blood sugar), diverticulitis (inflammation of pouches in the wall of the large intestines, and venous thrombosis (blood clot in the deep vein most commonly located in the leg or pelvis). Resident R14's clinical record progress notes revealed that on 7/11/24, staff observed an open area to Resident R14's coccyx. The progress note lacked an initial assessment including description and measurement of the pressure area. Further review of clinical record progress notes revealed the coccyx pressure ulcer was assessed / measured on 7/12/24, and then not again until 7/22/24, a period of 10 days and then not again until 8/5/24, a period of 14 days. During an interview on 8/15/24, at 1:22 p.m. the Director of Nursing confirmed that Resident R14's coccyx pressure ulcer was not assessed / measured upon initial finding of the area or as frequently as required from 7/12/24, through 8/5/24. 28 Pa. Code 211.5(ii)(viii)(ix) Clinical records 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services Page 1 of 3 395626 395626 08/15/2024 Penn Highlands Jefferson Manor 417 Route 28 Brookville, PA 15825

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Based on review of Title 49. Professional and Vocational Standards, facility policy, and clinical records and staff interview, it was determined that the facility failed to assure that a Registered Nurse (RN) conducted initial and/or follow-up resident wound assessments for two of two residents reviewed with wounds (Residents R14 and R15). Findings include: Review of the Title 49. Professional and Vocational Standards, Department of State Chapter 21, State Board of Nursing, dated 5/25/24, indicated that under Responsibilities of the RN, 21.22, General Functions. (a) The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible, and (b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered. The 21.141 Definitions, Practice of practical nursing revealed The performance of selected nursing acts in the care of the ill, injured or infirm under the direction of a licensed professional nurse, a licensed physician or a licensed dentist, which do not require the specialized skill, judgement and knowledge required in professional nursing. The 21.145 Functions of the LPN [Licensed Practical Nurse], (a) . The LPN participates in the planning, implementation and evaluation of nursing care using the focused assessment in settings where nursing takes place. A facility policy dated 6/11/24, entitled Pressure Ulcer Assessment / Prevention indicated The Wound Nurse/RN will complete weekly skin rounds and measure pressure ulcers, arterial / vascular ulcers, and surgical incisions. The findings will be documented in the electronic medical record. Resident R14's clinical record revealed an admission date of 6/16/16, with diagnoses that included diabetes (a chronic condition that affects the way the body processed blood sugar), diverticulitis (inflammation of pouches in the wall of the large intestines, and venous thrombosis (blood clot in the deep vein most commonly located in the leg or pelvis). Resident R14's clinical record progress notes revealed that on 7/11/24, staff observed an open area to Resident R14's coccyx. Progress note dated 7/12/24, revealed an assessment of the coccyx wound that was completed by Licensed Practical Nurse (LPN) Employee E1. Progress notes dated 7/22/24, and 8/05/24, revealed an assessment of the coccyx wound that was completed by LPN Employee E2. Progress note dated 8/12/24, revealed an assessment of the coccyx wound that was completed by LPN Employee E3. There was no evidence that the comprehensive wound assessment was completed by an RN on 7/12/24, 7/22/24, 8/05/24, or 8/12/24. Resident R15's clinical record revealed an admission date of 2/04/22, with diagnoses that included dementia (a condition that affects a persons memory, thinking, and behaviors), osteoarthritis (degenerative joint disease that results from the breakdown of joint cartilage and bones), and peripheral vascular disease (disorder of the blood vessels outside the heart that can affect the brain, legs, feet, and other organs). Resident R15's clinical record progress notes dated 6/07/24, 6/14/24, 6/21/24, 6/28/24, 7/05/24, 7/12/24, 7/29/24, 7/26/24, 8/02/24, and 8/09/24, revealed an assessment of the right hip wound that was completed by LPN Employee E1. Progress note dated 8/06/24, revealed an assessment of the right hip 395626 Page 2 of 3 395626 08/15/2024 Penn Highlands Jefferson Manor 417 Route 28 Brookville, PA 15825

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wound that was completed by LPN Employee E2. Progress note dated 8/13/24, revealed an assessment of the right hip wound that was completed by LPN Employee E4. There was no evidence that the comprehensive wound assessment was completed by an RN on 6/07/24, 6/14/24, 6/21/24, 6/28/24, 7/05/24, 7/12/24, 7/29/24, 7/26/24, 8/02/24, 8/06/24, 8/09/24, or 8/13/24. During an interview on 8/14/24, at 1:27 p.m. the Nursing Home Administrator and Director of Nursing confirmed that wound assessments and documentation were conducted by an LPN, and not completed by an RN or completed with the oversight of an RN for Residents R14, and R15. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services 395626 Page 3 of 3