Pennsylvania Department of Health
SPIRITRUST LUTHERAN THE VILLAGE AT SPRENKLE DRIVE
Patient Care Inspection Results

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SPIRITRUST LUTHERAN THE VILLAGE AT SPRENKLE DRIVE
Inspection Results For:

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SPIRITRUST LUTHERAN THE VILLAGE AT SPRENKLE DRIVE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights survey completed on January 4, 2024, it was determined that SpiriTrust Lutheran-The Village at Sprenkle Drive was not in compliance with the following requirements of 42 CFR Part 483 Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 22 residents reviewed (Resident 12).

Findings Include:

Review of Resident 12's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and atrial fibrillation (A-fib- irregular heart rhythm).

Review of Resident 12's annual MDS assessment (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs), dated August 4, 2023, revealed that section C- Cognitive Patterns, and section D- Mood, were marked with dashes (-), meaning not assessed.

During an interview with the Nursing Home Administrator, Director of Nursing, and Employee 3 on January 4, 2024, at 10:29 AM, when asked about the dashes on Resident 12's MDS assessment, Employee 3 stated that it was missed.

28 Pa Code 211.12 (d)(3)(5) Nursing Services


 Plan of Correction - To be completed: 03/01/2024

1. The MDS assessment for resident 12 is unable to be corrected retroactively.

2. The facility will complete a full house audit to verify all current MDS assessments submitted in the past month were completed timely and in its entirety.

3. NHA will re-educate the interdisciplinary team on the Minimum Data Set Completion and Transmittal Standard.

4. Social Services director will complete daily audits of scheduled MDS assessments for timeliness of interview x8 weeks. Audits will be reviewed at the QAPI meeting for follow and additional recommendations.
483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for two of 22 residents reviewed (Residents 1 and 77).

Findings Include:

Review of Resident 1's clinical record documented diagnoses that included anxiety (a feeling of worry, nervousness, or unease), depression (feelings of severe despondency and dejection), dysphagia (difficulty swallowing), and dementia (a condition characterized by progressive loss of intellectual functioning, and impairment of memory and abstract thinking).

During an interview with Resident 1 on January 2, 2024, at 10:01 AM, it was revealed he wears dentures, his gums were sore at that time, and would like to see a dentist for his sore gums. Resident stated that when he bites down, it causes pain in his lower gum. Resident stated he hadn't been seen by a dentist while at the facility.

Observation on January 2, 2024, at 10:01 AM, Resident 1 was wearing full upper dentures, his bottom jaw was edentulous, and his gums were reddened.

Resident 1's December 2023 physician orders included Orajel Mouth/Throat Gel 10 % (Benzocaine (Dental)- topical pain killer) Give one application orally three times a day for Oral ulcers, start date December 1, 2023.

Resident 1's December 2023 Medication Administration Record (MAR - documentation of medication administered) documented Orajel was administered orally three times a day for oral ulcers, started December 1, 2023; and First-mouthwash BLM mouth/throat suspension (magic mouthwash- medication used to treat oral ulcers and mouth pain) was administered one time a day for mouth ulcer December 12, 2023, through December 18, 2023; administered as ordered.

Review of Resident 1's progress notes documented on December 1, 2023, revealed the Resident complained of oral pain/discomfort, nurse noted small red inflamed areas to upper and lower gums under denture lining, and the physician was made aware and ordered Orajel three times a day until healed.

Further review of progress notes documented on December 11, 2023, Certified Registered Nurse Practitioner ordered magic mouthwash for ulcers in Resident 1's mouth for seven days.

Review of nursing note on December 27, 2023 documented the Resident receiving Orajel for recent mouth sores.

Review of Resident 1 care plan on January 2, 2023, failed to include documentation of dentures and mouth pain/ulcers.

During an interview with the Director of Nursing (DON) on January 3, 2024, at 1:10 PM, it was revealed that Resident 1 has upper and lower dentures and is able to care for his dentures himself.

Further review of Resident 1's care plan on January 4, 2024, documented a focus area for dental health problems due to injury related to dentures with complaint of mouth pain, initiated on January 3, 2024; with interventions that included mouth inspections as needed, report changes to nurse, and to observe/document/report to provider signs or symptoms of dental problems.

During an interview with the DON on January 4, 2024, at 10:36 AM, it was revealed a dental care plan should've been initiated prior to January 3, 2024.

Review of Resident 77's clinical record revealed diagnoses that included gastro-esophageal reflux disease (GERD- acid reflux) and Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar).

Review of Resident 77's current physician orders, revealed an order dated September 21, 2023, for a hospice consult evaluation and treatment.

Review of Resident 77's progress notes revealed a note dated September 28, 2023, stating that Resident 77 is on hospice services as of September 28, 2023.

Review of Resident 77's significant change MDS (Minimum Data Set- an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs), dated October 11, 2023, revealed that Resident 77 was marked as receiving hospice services.

Review of Resident 77's current care plan failed to reveal a hospice care plan.

On January 3, 2024, at 1:13 PM, the DON provided a hospice care plan for Resident 77 that was initiated on January 3, 2024. At that time, the DON stated that the hospice care plan should have been initiated prior to this date.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services


 Plan of Correction - To be completed: 03/01/2024

1. The comprehensive care plan for Residents 1 and 77 were updated on January 3, 2024.

2. Audits will be completed for all residents on hospice and those with documented dental pain for care plan accuracy.

3. NHA/designee will re-educate the IDT team on the comprehensive care plan standard of practice.

4. Weekly audits of care plans for accuracy to occur in accordance with the care plan conference schedule x8 weeks. Audits will be reviewed at the QAPI meeting for follow and additional recommendations.
483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on staff interviews, record review, and facility policy review, it was determined that the facility failed to ensure that the comprehensive care plan was revised to include changes in the resident's status and plan of care for one of 19 residents reviewed (Resident 26).

Findings include:

Review of the facility policy, titled "Comprehensive Care Plan Standard", last reviewed July 2023, revealed that it requires the resident's care plan to be reviewed and revised, if applicable, by the interdisciplinary team after each annual and quarterly assessment.

Review of Resident 26's clinical record on January 2, 2024, revealed diagnoses that include diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) and hypertension (elevated blood pressure).

Review of the current care plan on January 3, 2024, at 10:30 AM, revealed a care plan for pain related to lower left leg cellulitis (bacterial skin infection). Resident 26 was admitted with a diagnosis of cellulitis on July 2, 2022, and the cellulitis was resolved after treatment with antibiotics. The cellulitis was never removed from the care plan.

During an interview with the Nursing Home Administrator and Clinical Consultant on January 4, 2024, at 10:30 AM, both were in agreement that the care plan should have been revised to remove the cellulitis diagnosis.

28 Pa. Code 211.12(d)(1)(3)Nursing services


 Plan of Correction - To be completed: 03/01/2024

1. Resident 26's care plan for cellulitis was resolved.

2. Audit of care plans in place for infections and cellulitis was completed. Care plans of resolved infections were removed from plan of care.

3. NHA/designee will reeducate the interdisciplinary team on the comprehensive care plan standard of practice.

4. Weekly audits of care plans for infections, cellulitis and antibiotics will be completed based on the care conference schedule x8 weeks. Audits will be reviewed at the QAPI meeting for follow and additional recommendations.
483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

§483.55(b) Nursing Facilities.
The facility-

§483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(g) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

§483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

§483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

§483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

§483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.
Observations:

Based on review of the facility's Dental Services policy, observations, staff and resident interviews, and record review, it was determined that the facility failed to provide routine and emergency dental services for one of 22 residents reviewed (Resident 1).

Findings:

Review of the facility's Dental Services policy, revised November 28, 2017, read, in part, the facility must assist residents in obtaining routine and emergency dental care. Routine services include an annual inspection of the oral cavity including fitting dentures. Emergency dental services includes treatment of acute pain of teeth or gums by a dentist.

Review of Resident 1's clinical record documented diagnoses that included anxiety (a feeling of worry, nervousness, or unease), depression (feelings of severe despondency and dejection), dysphagia (difficulty swallowing), and dementia (a condition characterized by progressive loss of intellectual functioning, and impairment of memory and abstract thinking).

During an interview with Resident 1 on January 2, 2024, at 10:01 AM, it was revealed he wears dentures, his gums were sore at that time, and would like to see a dentist for his sore gums. The Resident stated that when he bites down, it causes pain in his lower gum. Resident stated he hadn't been seen by a dentist while at the facility.

Observation on January 2, 2024, at 10:01 AM, revealed Resident 1 was wearing full upper dentures, his bottom jaw was edentulous, and his gums were reddened.

On January 2, 2024, review of Resident 1's clinical record revealed he was admitted to the facility on January 4, 2023, payor source as of October 14, 2023, was Community Heath Choices AmeriHealth caritas (Pennsylvania medical assistance managed care health plan), and was cognitively intact per Brief Interview For Mental Status (BIMS- a test to evaluate cognition) score of 14, completed on December 28, 2023.

Resident 1's December 2023 physician orders included: consult podiatry, vision, dental and audiology services as ordered (360Care Podiatry, vision, dental), start date February 3, 2023; and Orajel Mouth/Throat Gel 10 % (Benzocaine (Dental)- topical pain killer) Give one application orally three times a day for Oral ulcers, start date December 1, 2023.

Resident 1's December 2023 Medication Administration Record (documentation of medication administered) documented Orajel was administered orally three times a day for oral ulcers, started December 1, 2023; and First-mouthwash BLM mouth/throat suspension (magic mouthwash - medication used to treat oral ulcers and mouth pain) was administered one time a day for mouth ulcer December 12, 2023, through December 18, 2023; administered as ordered.

Review of Resident 1's progress notes documented on December 1, 2023, revealed the Resident complained of oral pain/discomfort, nurse noted small red inflamed areas to upper and lower gums under denture lining, physician was made aware and ordered Orajel three times a day until healed.

Further review of progress notes documented on December 11, 2023, Certified Registered Nurse Practitioner ordered magic mouthwash for ulcers in Resident 1's mouth for seven days.

Review of nursing note on December 27, 2023, documented the Resident receiving Orajel for recent mouth sores.

During an interview with the Nursing Home Administrator (NHA) on January 3, 2024, at 11:10 AM, it was revealed that, per 360Care, prepayment is needed before scheduling an appointment.

During an interview with the Director of Nursing (DON) on January 3, 2023, at 1:10 PM, it was revealed that Resident 1 has upper and lower dentures, and is able to care for his dentures himself. It was also revealed that the physician followed-up with Resident 1 regarding his pain in his lower jaw. DON stated that there wasn't a white patch on Resident 1's lower jaw. DON reiterated that the facility provided information stating 360Care required prepayment before scheduling an appointment.

Resident 1's lower gum line slightly erythematous with no open area. Recommendation made to keep lower denture out between meals, continue use of Orajel and follow-up with dentist to evaluate need for new dentures. this seems out of place or needs more info?

Interview with Corporate Nurse on January 3, 2024, at 2:40 PM, revealed that, with the new contract, 360Care does require prepayment for residents who are Medicaid pending.

Census documentation revealed Resident 1 was Medicaid pending September 16, 2022, through December 21, 2022, then was on skilled services October 22, 2022, through October 13, 2023, and was on Medicaid services as of October 14, 2023.

During an interview with NHA on January 3, 2024, at 2:40 PM, it was revealed that he wasn't aware that Resident 1 was in emergent need to see a dentist. Resident 1 is able to eat and has not lost weight. Resident 1's family opted for dental services to be on hold until Resident 1 was on Medicaid. The dentist requires prepayment for services for certain payor sources.

During an interview with the DON and Employee 7 (Unit Manager) on January 4, 2024, at 11:20 AM, it was revealed that Resident 1 wasn't on Medicaid until October 14, 2023, the family wasn't willing to prepay for routine dental services, and the family opted to wait until Resident 1 was on Medicaid services. It was also revealed that dental pain would not be considered need for emergent dental services, and the physician was managing and monitoring Resident's dental health. It was confirmed that the dentist is expected in the facility March 2024, the dental office should be aware that Resident 1's payor source was Medicaid, and should be scheduled for a routine dental visit; however, they weren't able to confirm that Resident 1 was on the dentist schedule to be seen March 2024.

During the interview with DON and Employee 7 on January 4, 2024, at 12:00 PM, revealed Resident 1 was not seen for routine dental due to having dentures without concerns and not being active on Medicaid. It was also revealed that Resident 1 is scheduled to be seen by the facility dentist on February 28, 2024, at 9:00 AM.

The facility failed to provide routine and emergent dental services in a timely manner as evidence by treatment for dental pain initiated December 1, 2023, with additional intervention December 11, 2023. Further, the facility failed to evaluate/monitor Resident 1's oral health and dental pain prior to surveyor questioning Resident 1's oral pain and, at that point, the physician did complete a follow-up visit on January 3, 2024, recommending Resident 1 be seen by a dentist.

28 Pa Code 211.15 Dental services


 Plan of Correction - To be completed: 03/01/2024

1. The physician evaluated Resident 1 on January 3, 2024 for lower jaw pain and dental appointment scheduled for February 28, 2024.

2. Facility will audit residents with signed 360 Care Dental consents for routine visits that have been completed and/or are scheduled.

3. NHA/designee will reeducate the nursing team on the Dental Services standard of practice.

4. Audits of IDT notes will be completed for residents with documented dental issues and appointments for dental consults x8 weeks. Audits will be reviewed at the QAPI meeting for follow and additional recommendations.

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