Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT MILLVILLE, THE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS AT MILLVILLE, THE
Inspection Results For:

There are  102 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
GARDENS AT MILLVILLE, THE - 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 Compliance Survey completed on March 1, 2019, it was determined that The Gardens at Millville 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:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on observation of the facility's food and nutrition services department and nursing unit pantry areas, and staff interview, it was determined that the facility failed to maintain sanitary practices for the storage and service of food to prevent the potential for microbial growth in food, which increased the risk of food-borne illness.

Findings include:

Observation of refrigerator in the East D wing resident area on February 26, 2019, at 11:00 AM revealed that the internal temperature was 46 degrees Fahrenheit (acceptable range is at or below 40 degrees Fahrenheit). The facility's environmental log on refrigerator noted that the refrigerator temperature was 40 degrees F. Observation of the same refrigerator on February 27, 2019, at 11:30 AM revealed that the temperature was 48 degrees Fahrenheit. The environmental log on refrigerator noted that the refrigerator temperature was 46 degrees F. The refrigerator was empty during both observations.

Observation of the refrigerator in the West A Wing lounge area on February 27, 2019, at 12:42 PM revealed one swollen quart of lactose-free milk with a sell by date of January 7, 2019; one six ounce yogurt with a sell by date of February 5, 2019, and a plastic soup bowl of applesauce marked "med pass" dated February 13, 2019 (fourteen days old). The freezer compartment of the refrigerator had a build-up of ice greater than four inches thick.

Observation of the refrigerator located in the activity area on the West B Wing on February 27, 2019, at 1:05 PM revealed an opened quart of liquid eggs with no initial open date. Instructions on the container noted that the product should be used within three days of opening.

Observation of the food and nutrition services department dishwasher area on March 1, 2019, at 11:00 AM revealed nine plastic dish racks and two silverware holders, which were visibly soiled with black colored stains.

Observation of the delivery area at this time revealed five boxes of paper products placed directly on the floor.

Interview with the food and nutrition services director on March 1, 2019, at 11:30 AM confirmed the above food safety and sanitation concerns.





28 Pa. Code 211.6(c)(d) Dietary services.

28 Pa. Code 207.2(a) Administrator's responsibility.
Previously cited 5/7/18













 Plan of Correction - To be completed: 04/09/2019

0812
-Refrigerator On East D wing was checked and the refrigerator was replaced.
-Outdated items were disposed of and the freezer defrosted in the West Side A wing Lounge Area refrigerator.
-The open carton of liquid eggs was removed from the West Side B-Wing Activities Area refrigerator.
-New dish racks and silverware holders were ordered for the Nutrition services department.
-Supplies brought into the delivery area of the nutrition service department will be kept on a cart till they are put away.
The Nutrition Services Director or designee will in-service Dietary Staff, Environment Services Staff, Maintenance Staff and Nursing Staff on appropriate temperature ranges and checking temps, labeling and dating, cleaning, and monthly defrost as needed.
- The Nutrition Services Director or designee will randomly audit checking and documenting of temps, labeling and dating, cleaning, and monthly defrosting as needed.
-Audits will be forwarded to the monthly QAPI meeting for review and any concerns will be addressed by the Nutrition Services Director or designee immediately.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observation and staff interview it was determined that the facility failed to maintain a clean and sanitary environment on two of two nursing units and failed to provide the necessary maintenance services to maintain a sanitary, orderly, and comfortable interior of one of two medication storage rooms.

Findings include:

Observation of the activity/dining room area located on the West B Unit on February 26, 2019, at 12:45 PM revealed a urine smell in the hallway located outside the bathroom. The cloth upholstery of one chair located in the area near the bathroom was visibly soiled and stained.

Observation of the facility's main dining room on February 26, 2019, at 1:00 PM revealed that the cloth upholstery on two chairs was visibly soiled and stained.

Observation of Resident 46's room on March 1, 2019, at 12:55 PM revealed that the interior surface of the resident's dresser drawers was visibly stained and in need of cleaning. The walls in the resident's room were gouged.

Interview with the director of nursing on March 1, 2019, at 1:00 PM confirmed that the environment was to be maintained in a clean and sanitary manner.

Observations during a tour of the medication room on East Wing on February 27, 2019, at 12:00 PM revealed that the base of the cabinet in the area beneath the sink in left corner of the room was falling apart, with wood crumbling from sides and an enlarged hole around piping in the floor in the right corner due to the rotting bottom of the cabinet exposing decayed building material waste in the left corner of the cabinet.

Interview with maintenance director on March 1, 2019, at 11:29 a.m. he confirmed the above observations.



28 Pa. Code 207.2 (a) Administrator's responsibility
previously cited 5/7/2018






 Plan of Correction - To be completed: 04/09/2019

0584
-The hallway outside of the bathrooms and bathrooms located in the activities room on the West Side of the facility floors have when striped, waxed.
-The cloth chair noted in the activities room near the bathroom hallway has been shampooed/cleaned due to being stained.
-The two chairs in the main dining room noted to be soiled/stained have been shampooed/cleaned.
-The interior surface of the dresser drawer in resident 46's room that was noted to be stained has been cleaned.
-The walls in resident 46's room has been repaired and painted.
-The base of the cabinet in the area beneath the sink in the left corner of the East Side Med Room has been repaired and well as the hole around the piping in the right corner of the cabinet and the cabinet bottom.
The Maintenance Director, Environment Services Director and facility Administrator with complete a tour of the facility and formulate a list or any repairs and/or cleaning that needs to be completed.
-The Nursing Home Administrator will complete random rounds/audits with the Director of Environmental Services and the Maintenance Director weekly for 4 weeks and then monthly for 2 months to verify any areas needing cleaning, odor control or repair is completed timely.
-All audited will be forwarded to the monthly QAPI meeting for review and any concerns will be addressed by the Administrator immediately.

483.60 REQUIREMENT Provided Diet Meets Needs of Each Resident:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
§483.60 Food and nutrition services.
The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.
Observations:

Based on observation, review of the facility's menus and staff interview, it was determined that the facility failed to ensure that 100% fruit juices were offered by the facility on the menu to meet the nutritional needs of the resident and resident choice and further failed to ensure residents are offered a varied diet to meet resident choice.

Findings include:

Observation of the beverage machine located near the trayline in the food and nutrition services department on February 28, 2019, at approximately 12:15 PM revealed that the product labels of the apple and grape juice cases, which are served to the residents requesting "apple juice" and "grape juice" were not 100% fruit juice and both contained high fructose corn syrup. The product identified as "orange juice," which is served on the resident menu as "orange juice" contained both orange and pear juice.

Interview with the food and nutrition services department director on March 1, 2019, at approximately 12:00 PM confirmed that the facility did not provide 100% apple juice or grape juice and would provide the apple and grape fruit beverages to any residents who requested apple juice or grape juice. The food and nutrition services director confirmed that the menu did not differentiate that the beverage identified as orange juice on the menu was actually an orange/pear juice blend and was not 100% orange juice.

Review of the December 12, 2018, Food Committee Minutes revealed that residents' who received the 2 gram sodium diet (sodium is restricted to 2000 mg or less per day) had concerns over repeated food items, too many scrambled eggs and too much canned fruit. Review of the January 10, 2019, Food Committee minutes revealed that residents on therapeutic diets had concerns of repeated items and missing items on the menu.

Review of the Week 1 Wednesday supper menu revealed that residents on a Regular diet receive a hamburger with bun, Tater tots, lettuce, tomato, and onion. Residents on a mechanical soft (ground texture) diet or pureed diet (all items are blenderized) do not receive anything to replace the lettuce, tomato, and onion, which are not allowed in whole form on the mechanically altered diet.

Review of the Week 2 Regular Diet for Wednesday supper revealed that baked beans were served as part of the meal. Residents on a 2 gram Sodium diet received a slice of bread as the substitution.

Interview with the registered dietitian and the food and nutrition services director on March 1, 2019, at approximately 12:00 PM revealed that the facility dietitian does not plan the menus. The facility failed to provide documented evidence that residents' food concerns had been resolved.





28 Pa. Code 211.6 (a)(b)(c)(d) Dietary services

28 Pa. Code 201.29 (j) Resident rights
Previously cited 3/5/18









 Plan of Correction - To be completed: 04/09/2019

0800
-The facility cannot retroactivity correct the concerns addressed by the surveyors.
- Juice products will be changed to 100% fruit juice products.
-The orange juice product will be changed to a 100% orange juice product.
-Menus including restricted menus are be reviewed and revised to assure diet accuracy and address the resident concerns.
-The Nutrition Services Director will randomly audit the juice products received and the revised diets weekly for 4 weeks and then monthly for 2 months to verify compliance. Any concerns will be forwarded to the Regional Director of Culinary & Nutrition Services for immediate follow-up.
-Audits will be forwarded to the monthly QAPI meeting for review and any concerns will be addressed by the Nutrition Services Director or designee immediately.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on a review of clinical records and staff interview, it was determined that the facility failed to provide medical justification for the administration of an anti-anxiety medications and/or attempt non-pharmacologic interventions prior to the medication administration to demonstrate necessity of administration for two residents (Resident 41 and 1) of five residents sampled.

Findings include:

Review of Resident 41's clinical record indicated that the resident was admitted to the facility on December 17, 2017, and had diagnosis that included dementia, depression and anxiety. The resident had physicians orders dated January 30, 2019 for Lorazepam (an antianxiety medication) 0.5 milligrams (mg) by mouth every 8 hours as needed for for anxiety, which was modified on February 15, 2019, to Lorazepam 0.5 mg by mouth every 6 hours as needed for for anxiety.

Review of the resident's Medication Administration Record (MAR) for February 2019 revealed that this psychoactive drug was administered to the resident on February 2, 2019, at 8:51 a.m., February 3, 2019, at 7:55 p.m., February 4, 2019, at 7:54 a.m. February 5, 2019 at 7:26 p.m. and February 15, 2019, at 9:37 a.m.

Review of nurse's notes and February 2019 MAR for Behavior Monitoring for the above dates revealed no indication of that the resident had displayed behaviors/symptoms of anxiety that required treatment with the drug or that staff had attempted non-pharmacologic interventions, which proved ineffective, prior to the medication administration of the antianxiety medication on the above dates and times.

Interview with the Director of Nursing on March 1, 2019 at 9:30 a.m. confirmed that there was no documented evidence that the resident displayed symptoms/behaviors requiring treatment with the drug and that staff had implemented non-pharmacologic interventions prior to the medication administration to demonstrate that drug administration was necessary to alleviate the resident's anxiety.

Review of Resident 1's clinical record revealed that the resident was admitted to the facility on July 12, 2018, with diagnoses to include anxiety. The resident had a current physician order for Ativan 0.5 mg to be administered by mouth every six hours, as needed, for agitation.

Review of the resident's January 2019 and February 2019 MARs revealed that staff administered Ativan .5 mg to the resident 17 times during January 2019 and seven times during February 2019. The resident was also given Ativan on March 1, 2019.

Review of progress notes from January 1, 2019, through March 1, 2019, failed to reveal documented evidence that the resident had displayed behaviors requiring treatment with the prn (as needed) an anti-anxiety medication. Further review of the progress notes failed to indicate that the facility had attempted the use of non-pharmacological interventions prior to the administration of Ativan on those occassions during January 2019, February 2019 and March 1, 2019.

During an interview with the Director of Nursing on March 1, 2019, at 10:35, she acknowledged that the facility failed to attempt non-pharmacological interventions prior to the administration of a prn anti-anxiety medication and failed to document signs and symptoms displayed by the resident requiring treatment with the psychoactive drug.


28 Pa. Code 211.9(k) Pharmacy services
Previously cited 3/5/18

28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services
Previously cited 3/5/18, 11/20/18

28 Pa. Code 211.5(f)(g)(h) Clinical records









 Plan of Correction - To be completed: 04/09/2019

0758
-The facility cannot retroactivity correct the concerns addressed by the surveyors.
-Resident 41 and 1 were evaluated for the need of the anti-anxiety medication. Behavior monitoring and interventions are added to the TAR. The medication is ordered for 14 days and to be re-evaluated for continue use.
-Audit will be completed with resident on anti-anxiety medication for behavior monitoring, interventions before medications are given and review the order for the 14 days order with any PRNs and further need for the medication.
-In-service/Education will be completed on March 26th, for all nursing staff to review anti-anxiety procedure for orders, behaviors and intervention prior to the use of the medication.
-Residents with new or order changes for anti-anxiety medications will be reviewed at the scheduled morning IDT meeting to verify orders are correct.
-The Director or designee will conduct random weekly audits for 3 months on anti-anxiety orders and interventions prior to administration of medication.
-All audits will be reviewed at the Monthly QAPI Meeting and all concerns will be addressed by the Director of Nursing or designee immediately.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that pharmacy consultant's recommendations was acted upon timely for three of 20 residents sampled (Resident 49, 52, and 88) and failed to identify irregularities related to multiple pain medications prescribed for one resident out of 20 sampled (Resident 88)

Findings include:

A review of the clinical record revealed that Resident 49 had diagnoses to include dementia, anxiety and schizophrenia.

Review of the pharmacy consultant's monthly reviews indicated that the pharmacist reviewed Resident 49's medications and clinical record on March 22, 2018. Recommendations were made at that time indicating that a gradual dose reduction (GDR) was indicated at this time for the resident's Ativan (an antianxiety medication) 0.5 milligram (mg) by mouth, twice daily, for anxiety, and Trazodone ( is used to treat major depressive disorder as well as decrease anxiety and insomnia related to depression) 25 mg at bedtime for insomnia. The physician disagreed with the GDR, but no clincal rationale for the disagreement was documented.

Pharmacy drug regimen reviews of Resident 49's medications and clinical record dated November 28, 2018, revealed that the pharmacist recommended a GDR for the resident's Risperdal (an antipsychotic medication) 0.5 mg twice daily, Ativan 0.5 mg by mouth, twice daily, for anxiety, and Trazodone 25 mg at bedtime for insomnia. There was no indication that the physician responded to these pharmacy recommendations.

The pharmacist reviewed Resident 49's medications and clinical record on February 23, 2019, with recommendations made at that time noting that a GDR was indicated for the resident's Ativan 0.5 mg by mouth, twice daily, for anxiety, and Trazodone 25 mg at bedtime for insomnia. There was no indication, at the time of the survey ending March 1, 2019, that the physician responded to these pharmacy recommendations.

A review of the clinical record revealed that Resident 52 had diagnoses to include dementia, anxiety and insomnia.

The pharmacist reviewed Resident 52's medications and clinical record on July 31, 2018, and October 25, 2018, with resulting recommendations that a GDR was indicated for the resident's Ativan 0.5 mg by mouth once daily. There was no documented evidence at the time of the survey ending March 1, 2019, that the physician had acted upon these recommendations.

During interview with the Director of Nursing on March 1, 2019, at 9:30 a.m. she confirmed that there was no documented evidence that the physician had documented individualized clinical rationale for disagreeing with the pharmacist's GDR recommendation of March 22, 2018, and that there was no documented evidence that the physician had acted upon the pharmacy recommendations made for Resident 49 on November 28, 2018, and February 23, 2019, and for Resident 52 on July 31, 2018 and October 25, 2018.


A review of the clinical record revealed that Resident 88 had diagnoses to include pain, anxiety and depression. February 2019 physicians orders included Tylenol ( a non narcotic pain medication) 650 mg by mouth every 6 hours as needed for pain, initially ordered June 10, 2018, Lidocaine gel 4 % (a non narcotic topical pain reliever) apply to lower back every 24 hours as needed for pain, initially ordered June 21, 2018, Tylenol Arthritis pain tablet ( a non narcotic pain reliever) extended release 650 mg, give one tablet by mouth every 8 hours as needed for pain, initially ordered September 16, 2018 and Ibuprofen (a non-steroidal anti-inflammatory; non narcotic pain medication) 600 mg by mouth every 6 hours as needed for pain, first ordered October 19, 2018.

A review of the pharmacist's monthly drug regimen reviews completed from October 2018 through February 2019, revealed that the pharmacist failed to identify drug irregularities in the resident's drug regimen related to the multiple medications prescribed for pain, on an as needed basis, without physician prescribed specific clinical indicators and parameters for administration. .

Interview with the Director of Nursing on March 1, 2019 at 9:30 a.m. confirmed that the consultant pharmacist did not identify the residents' multiple pain medications and absence of defined parameters for use.


28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.
Previously cited 3/5/18, 11/20/18.

28 Pa. Code 211.9(k) Pharmacy services.
Previously cited 3/5/18.

28 Pa. Code 211.5(g)(h) Clinical records
Previously cited 3/5/18.

28 Pa. Code 211.2(a) Physician services









 Plan of Correction - To be completed: 04/09/2019

0756
-The facility cannot retroactivity correct the concerns addressed by the surveyors.
-Residents 49's recommendations have been reviewed again with recommendation for the physician with GDRs. Resident 52 recommendations have been reviewed and recommendations will be reviewed with the Physician again for possible reduction. Resident 88's pain medications were reviewed with updated orders were obtained. Consultant Pharmacist also reviewed the resident's orders with recommendation to the physician with clarification of orders.
- An audit will be completed on residents who GDR were not completed and update those residents who are needed.
-A new form has been implemented to better monitor, as a back up to the pharmacy reports to be sure that GDRs are being completed.
-In-servicing/education will be completed on March 26th, by the Director of Nursing or designee on monitoring resident's behaviors and reasons for GDRs.
-The Director or designee will conduct random weekly audits for 3 months on the GDR completions and pain medication orders including parameters.
-All audits will be reviewed at the Monthly QAPI Meeting. All concerns will be addressed by the Director of Nursing or designee immediately.

483.25(k) REQUIREMENT Pain Management:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on clinical record and select facility policy review and staff interview, it was determined that the facility failed to obtain parameters for the use of pain medications prescribed on a needed basis and failed to administer pain medication as prescribed by the physician for three residents (Resident 76, 1 and 88 ) out of 20 residents sampled.

Findings include:

A review of the facility's policy entitled "Pain-Clinical Protocol" last reviewed by the facility Janaury 2019, indicated that staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern and severity. Staff will use a consistent approach and a standardized pain assessment instrument.

A review of Resident 76's February 2019 MAR (Medication Administration Record) revealed a physician order for Acetaminophen 650 mg (non-narcotic pain medication) by mouth every 6 hours, as needed, for pain (no level of pain noted with physician order).

The resident received the Acetaminophen 650 mg, 22 times during the month for pain levels ranging from two to eight on a scale of 10 (with 10 being the most severe pain).

The resident also had a physician order for Ultram (narcotic pain medication) 50 mg, give 1 tablet every eight hours, as needed, for severe pain (7-10). The resident received the medication 27 times during February 2019 and on four occassions the medication was given for pain levels of 3, 5 and 6 on a scale of 10.

A review of Resident 1's clinical record revealed January 2019 MAR revealed a physician order for Acetaminophen 650 mg by mouth every 6 hours, as needed, for pain (no level of pain noted with physician order). The resident was medicated with Acetaminophen 650 mg twice in January 2019. A review of February 2019 MAR revealed the resident was medicated with Acetaminophen twice in February 2019 without prescribed parameters for administration.

A review of Resident 88's October 2018, MAR (Medication Administration Record) revealed a physician order for Ibuprofen 600 mg (a non-steroidal anti-inflammatory pain medication) by mouth every 6 hours as needed for pain. The resident received the Ibuprofen 600 mg, 7 times during the month of October 2018 for pain levels ranging from two to six on a scale of 10 (with 10 being the most severe pain).

During an interview with the Director of Nursing on February 28, 2019, at 1:45 PM, the DON acknowledged that the physician orders failed to provide pain level parameters for pain medication administration and that staff were inconsistent in the administration of these pain medications as related to the severity of pain expressed by the resident. The DON further confirmed that nursing staff adminsitered the non-narcotic pain reliever, Acetaminophen for pain without assessing and identifying the resident's pain rating.



28 Pa. Code 211.2(a) Physician Services

28 Pa. Code 211.5(f)(g) Clinical records
Previously cited 3/5/18

28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing Services
Previously cited 11/20/18, 3/5/18











 Plan of Correction - To be completed: 04/09/2019

0697
-A complete review of medications for pain was completed for Residents 76, 1 and 88, with clarification of the orders as per policy, such as; location, intensity, frequency, patterns and severity.
-The facility will conduct a full facility audit on all residents that their pain medications are ordered correctly with the correct parameters.
-In-Service/Education will be provided to Licensed Nursing Staff on March 26th about orders, interventions and the parameters of medications by the Director of Nursing or designee.
-New or order changes for pain medication will be reviewed at the scheduled morning IDT meeting to verify orders are correct.
-Random monthly audits will be completed for 3 months by the Consultant Pharmacist, with concerns addressed to the Director of Nursing or designee to address immediately.
-All audits will be reviewed at the Monthly QAPI Meeting with any concerns addressed by the Director of Nursing or designee.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to thoroughly assess and evaluate bladder function and implement individualized approaches to restore normal bladder function to the extent possible for two residents with urinary incontinence (Resident 39 and 41) out of 4 sampled residents.

Findings include:

Review of Resident 39's clinical record indicated that the resident was admitted to the facility on January 31, 2018 and had diagnosis that included hypertension, and diabetes. Quarterly Minimum Data Set Assessment (MDS -a federally mandated standardized assessment completed at specific intervals to define resident care needs) dated September 22, 2018, and December 21, 2018, both indicated that the resident was cognitively intact, dependent on staff for activities of daily living (ADLs- the basic tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring and repositioning) and was continent of urine. An annual MDS dated February 2, 2019, indicated that the resident was cognitively intact, dependent on staff for activities of daily living and was now occasionally incontinent of urine.

Review of Resident 39's "3 Day Bladder and Bowel Diary" dated February 2, 2019, revealed a a pattern of incontinence at 6:00 p.m. The resident was also noted to be incontinent at 2:00 p.m. 5:00 p.m. 7:00 p.m. and 10:00 p.m. over the 3 day period.

However, a review of Resident 39's "Comprehensive Bladder and Bowel Evaluation" dated February 2, 2019, indicated that the resident was noted to be continent of bladder. The facility did not develop or implement an individualized plan in an attempt to restore normal bladder function to the extent possible for Resident 39 based on the results of the resident's 3 day diary, which revealed episodes of incontinency.

Review of Resident 41's clinical record indicated that the resident was admitted to the facility on December 17, 2017, and had diagnoses that included dementia, hypertension, and diabetes. Quarterly MDS Assessment dated August 29, 2018, indicated that the resident was cognitively intact, dependent on staff for activities of daily living and was occasionally incontinent of urine. A significant change MDS dated December 25, 2018, indicated that the resident was cognitively intact, dependent on staff for activities of daily living and was always incontinent of urine.

Review of Resident 41's "Comprehensive Bladder and Bowel Evaluation" dated March 21, 2018, June 21, 2018, and September 21, 2018, indicated that the resident was incontinent of bladder and should be placed on a bladder retraining program.

A review of Resident 41's "Comprehensive Bladder and Bowel Evaluation" dated December 18, 2018, indicated the resident was incontinent of bladder and that the resident should be placed on a scheduled toileting/habit training program.

However, there was no documented evidence that the facility had developed and implemented an individualized bladder program for this resident since the evaluation dated March 21, 2018, "Comprehensive Bladder and Bowel Evaluation" which indicated that the resident was a candidate for a program.

The facility failed to implement individualized approaches to decrease incontinency to the extent possible for Resident 41.

Interview with the Administrator on February 28, 2019, at approximately 9:30 a.m. verified that the facility did implement individualized bladder programs for the above residents.



28 Pa. Code 211.10(a)(d) Resident care policies.
Previously cited 3/5/18.

28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services
Previously cited 3/5/18, 11/20/18.





 Plan of Correction - To be completed: 04/09/2019

0690
-Resident 39 and 41 has had repeated 3 Day Bladder Diary, to assist in determining a pattern to create a specific program for those residents.
-Both residents diaries were reviewed and specific program for Residents 39 and 41 developed.
- Other residents in the facility will be assessed for change in incontinence and will be assessed with the 3 Day Bladder Diary to determine a specific program for and will be placed on the program and monitored to verify that the program is effective.
-In-Service/education will be provided to the nursing staff on the programs and monitoring that the program is appropriate for the resident on March 26th by the Director of Nursing or designee.
-A comprehensive bowel and bladder evaluation will be completed. From the information a individualized bowel and bladder program with be developed and evaluated weekly until program is completely established.
-The Director of Nursing or designee will be conducted random audits weekly for 4 weeks and then monthly for 2 months to verify compliance with the Bowel and Bladder program.
-All audits will be reviewed at the monthly QAPI meeting and any concerns will be addressed by the DON or designee immediately.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:

Based on observations, review of clinical records and select facility policy and staff interview, it was determined that the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement nursing practices for accurate administration and documentation of narcotic medications for three residents (Resident 64, 88 and CR1) and provide appropriate care and services for one resident receiving enteral feedings (Resident 36) out of 20 sampled.

Findings include:

According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice.

According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.11 Functions of the RN (Registered Nurse) requires the following: The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. 21.14 administration of drugs (a) a licensed registered nurse may administer a drug for a patient in the dosage and manner prescribed.

A review of the facility policy for administration of enteral feeding:enteral pump reviewed December 18, 2018, revealed that prior to the administration of flushes and enteral feeding, verify correct placement of the G-tube by placing a stethoscope on the residents abdomen, inject 10-15 ccs of air via the 60 cc syringe, listen for a "whooshing" sound, then slowly draw back gastric contents, evaluate color and amount of residual: gastric secretions. Reinstill the aspired fluid into the stomach.

A review of the clinical record review revealed that Resident 20 was admitted to the facility on December 11, 2014, with diagnosis to include dementia, seizures and gastrostomy status and had a PEG tube (Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate (for example, because of dysphagia) for enteral feeding (enteral nutrition generally refers to any method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements).

A review of the resident's current monthly recapped physician's orders dated February 27, 2019, revealed an order for Jevity 1.2 (enteral feeding formula) at 60 ccs per hour from 6 PM to 2 PM.

Observation during medication pass on February 27, 2019, at approximately 11:15 AM revealed Resident 36 was lying on her bed. Employee 2 (LPN) turned off the tube feeding pump, disconnected the resident's tube feeding from the G-tube. Employee 2 (LPN) drew up 60 ccs of water from a plastic cup into a piston syringe, opened the plug to the g-tube, placed the syringe into the g-tube and pushed the water flush. He then drew up the 30 ccs of the medication Lactulose (a medication used in an individual with high ammonia levels in their blood) into the piston syringe, placed it into the g-tube, pushed it into the piston syringe. Employee 2 (LPN) then drew another 60 ccs into the piston syringe, placed it into the g-tube and pushed the water into the tube. He then reattached the tube feed catheter into the g-tube. Employee 2 (LPN) then left Resident 36's room without turning the tube feeding pump back on.

The medication pass observation continued. At approximately 11:35 AM, Resident 36's tube feed pump started to alarm. Employee 2 (LPN) stated that he forgot to restart Resident 36's tube feeding pump after administering her medications. Employee 2 also failed to check placement of the resident's g-tube prior to flushing and administering medications via the g-tube.

A review of the facility policy for administering oral medications, revised by the facility on January 1, 2019, revealed that the purpose of this procedure is to provide guidelines for the safe administration of oral medications. The policy continues to state, for narcotics, check the narcotic record for the previous drug count and compare with the supply on hand. Report any discrepancies to the nurse supervisor. Administration of medication must include, at a minimum, name and strength of the med, dosage, method of administration, reason why a medication was withheld, not administered or refused, signature and title of the person administrating the medication and the response to the medication.

A review of the clinical record revealed that Resident 64, a cognitively intact resident, was admitted to the facility on October 26, 2018, with diagnoses to include low back pain. Physician orders dated October 27, 2018, included Oxycodone/APAP (a narcotic/non narcotic, combination pain medication) 5-325 mg, take 2 tablets every 4 hours as needed for severe pain.

A review of the individual resident controlled substance record for Resident 64 for Oxycodone/APAP 5-325 mg indicated that on October 27, 2018, no time indicated, Employee 3 (RN) signed out two tablets of Oxycodone/APAP 5-325 mg and marked the drug as given to the resident on the form.

However, a review of the resident's corresponding October 2018 medication administration record revealed no evidence that Oxycodone/APAP 5-325 mg was given to the resident on the above dates.

A review of a facility investigation and a Pennsylvania Department of Health, PB-22 report for investigation of alleged abuse, neglect or misappropriation of property dated October 27, 2018 at 11:55 AM, revealed that Residents' CR1 and Resident 64 alleged that they were not given their narcotic pain medication on October 26, 2018, and October 27, 2018.

A review of the clinical record revealed that Resident 88 was cognitively intact resident with diagnoses to include chronic pain. The resident had a physician order dated October 26, 2018, for Oxycodone ( a narcotic pain medication) 5 mg tablets, take 1 tablet, by mouth every 4 hours as needed for moderate pain and 2 tablets by mouth every 4 hours as needed for severe pain.

A review of the resident's controlled substance record for Oxycodone 5 mg tablets indicated that Employee 3 (RN) signed out Oxycodone 5 mg, 2 tablets on October 26, 2018 at 1 AM and again at 8:24 PM and October 27, 2018 at 3:40 AM.

A review of the resident's corresponding October 2018 medication administration record (MAR) revealed that Employee 3 (RN) administered Oxycodone 5 mg, 2 tabs on October 26, 2018, at 1 AM and again at 8:24 PM and on October 27, 2018, at 3:40 AM.

A witness statement included in the facility investigation for misappropriation dated October 27, 2018 (no time indicated) revealed that Resident 88 stated that she did not request the above three doses of the narcotic pain medication Oxycodone Employee 3 had documented as being administered to the resident on those dates.

A review of the clinical record revealed that Resident CR1 was cognitively intact resident and admitted to the facility on October 14, 2018, with diagnoses to include a post fractured ankle and rehabilitative services.

A physician order dated October 22, 2018, was noted for Oxycodone 5 mg tablet, one tablet every 4 hours as needed for severe pain.

A review of the individual resident controlled substance record for Resident CR1's supply of Oxycodone 5 mg revealed that on October 26, 2018, at 9:23 PM and on October 27, 2018, at 3:25 AM, Employee 3(RN) signed the the record indicating that Oxycodone 5 mg was given to Resident CR1.

A corresponding medication administration record dated October 2018 revealed that Employee 3 (RN) administered Oxycodone 5 mg to Resident CR1 on October 26, 2018, at 9:23 PM and on October 27, 2018, at 3:24 AM.

A witness statement included in the facility investigation for misappropriation of resident property dated October 27, 2018 (no time indicated) revealed tht Resident CR1 stated that she did not request the above two doses of the Oxycodone, which Employee 3 documented as being administered to the resident.

During an interview on February 27, 2019, at 2:30 PM the Director of Nursing
confirmed that the facility was unable to verify that the medications had been administered to these residents on the above dates and times as documented by Employee 3.


28 Pa. Code 201.20(a) Staff Development

28 Pa. Code 211.9(a)(1)(k) Pharmacy Services
Previously cited 3/5/18

28 Pa Code 211.10(a)(d) Resident care policies
Previously cited 3/5/18


Pa Code 211.12(a)(c)(d)(5)(1) Nursing services
Previously cited 3/5/18/16

















 Plan of Correction - To be completed: 04/09/2019

0658
-The facility cannot retroactivity correct the concerns addressed by the surveyors.
-Employee 2 was educated on the properly checking the placement of PEG Tubes and about checking the pump before leaving the resident to be sure it is running as per the facility's policy and procedures.
-Resident 64, CR1 and 88 medications were replaced at the cost of the facility, that was reported missing. This incident was reported to the Dept. of Health, Aging Office, Office of the Attorney General and the Nursing License Board. This is a continuing investigation/court case. Residents were also assessed for any noted increased pain and this was found to be no increase in pain for any of the residents during that incident time. Education was provided to staff and investigation at the time was conducted and no other medications were signed off by the Employee3.
-Narcotic sheets will be signed off between shifts, which includes counting that all medications are accounted for. Any discrepancies are reported immediately and full investigation is completed.
–The Director of Nursing or designee will in-service and review this incident again and also will review the policy/procedure of PEG tube placement with nursing competency for all licensed nurses.
- Random medication observation will be conduct with the Licensed Nursing with PEG Tubes and review of Narc sheets weekly for 4 weeks and the monthly for 2 months to verify compliance.
-All audits will be reviewed at the Monthly QAPI Meeting and any concerns will be addressed by the Director of Nursing or designee immediately.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
§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.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet the individualized needs of six out of six residents who smoke (Resident 76, 62, 85, 86, 19 and 28) and one resident receiving dialysis services (Resident 21) out of 20 sampled residents.

Findings include:

A review of the clinical records revealed six residents who smoked at the facility, Residents 76, 62, 85, 86, 19 and 28. Further review of the clinical records and current plans of care for these residents revealed that the facility failed to develop and implement individualized smoking care plans for Residents 76, 62, 85, 86, 19 and 28.

An interview with the Director of Nursing on March 1, 2019, at 11:12 AM, failed to provide documented evidence that individualized care plans were developed and implemented for Residents s 76, 62, 85, 86, 19 and 28, who smoke at the facility, including each residents functional capabilities for smoking and safety measures required based on each residents' smoking assessment.

A review of the clinical record revealed that Resident 21 was receiving dialysis services. Further review of the clinical record and current plan of care for Resident 21 revealed that the facility failed to develop individualized care plan for the resident related to dialysis and coordination of schedules and resident-centered care.

An interview with the Director of Nursing on March 1, 2019 at 11:30 AM, failed to provide documented evidence that an individualized care plan was developed and implemented for Resident 21, who receives dialysis services.


28 Pa. Code 211.11(d) Resident care plan
Previously cited 3/5/18

28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services
Previously cited 11/20/18, 3/5/18














 Plan of Correction - To be completed: 04/09/2019

0656
-The facility cannot retroactivity correct the concerns addressed by the surveyors for residents 76, 62, 85, 86, 19, and 28.
-Comprehensive care plans have been developed to meet the individual needs of the six residents who have been identified and that smoke.
-Audits have been completed for residents that smoke to verify that they have a comprehensive individualized care plan to address their smoking needs.
- The Regional Director of Clinical Reimbursement or designee will re-educate the RNAC team and Activities Director on properly care planning the individualized needs of residents that smoke.
- The Regional Director of Clinical Reimbursement or designee will randomly audit the care plan of residents that smoke weekly for 4 weeks and then monthly for 2 months to verify compliance.
-Audits will be forwarded to the monthly QAPI meetings for review and any concerns will be immediately addressed by the RNAC or designee.


483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:

Based on a review of clinical records and staff interview it was determined that the facility failed to provide evidence of written information of the facility's bed hold policy provided upon transfer to the hospital for seven of 20 residents reviewed (Residents 41, 49, 97, 8, 76, 47, and 93).

Findings include:

A review of the clinical record revealed that Resident 41 was transferred and admitted to the hospital on December 11, 2018.

A review of the clinical record revealed that Resident 49 was transferred and admitted to the hospital on April 11, 2018. He was also transferred and admitted to the hospital on April 15, 2018. He was also transferred and admitted to the hospital on May 1, 2018.

A review of the clinical record revealed that Resident 97 was transferred and admitted to the hospital on October 26, 2018. He was also transferred and admitted to the hospital on November 13, 2018.

A review of the clinical record revealed that Resident 8 was transferred and admitted to the hospital on December 14, 2018. Resident 8 was again transferred and admitted to the hospital on February 6, 2019.

A review of the clinical record revealed that Resident 76 was transferred to the hospital on January 25, 2019. Resident 76 was transferred and admitted to the hospital on February 1, 2019.

A review of the clinical record revealed that Resident 93 was transferred to the hospital on December 7, 2018, and returned to the facility on December 20, 2018.

A review of the clinical record revealed that Resident 47 was transferred to the hospital on December 11, 2018, and returned to the facility on December 15, 2018.

Clinical record review and interview with the Administrator on February 28, 2019, at approximately 10:30 a.m. confirmed that the facility did not provide the resident or resident's representative with a written notice which specifies the duration of the bed hold at the time of transfer of the above residents.




28 Pa Code 201.18 (e)(1) Management
Previously cited 11/20/18, 3/5/18

28 Pa Code 201.29 (b)(d)(f) Resident rights
Previously cited 11/20/18, 3/5/18



















 Plan of Correction - To be completed: 04/09/2019

0625
-The facility cannot retroactivity correct the concerns addressed by the surveyors for residents 41, 49, 97, 8, 76, 47 and 93.
-The Business Office Manager will be re-educated on the requirement before transfer and discharge of a resident by the Nursing Home or Designee to verify understanding.
-Notices of bed holds will be review at the scheduled morning Inter-disciplinary meetings to verify notification has been given.
-The Nursing Home Administrator will conduct random audits weekly for 4 weeks and then monthly for 2 months to verify compliance of notification.
-Audits will be forwarded to the monthly QAPI meetings for review and any concerns will be immediately addressed by the Nursing Home Administrator.


483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a written notice of transfer to the hospital was provided to the resident and the residents' responsible representatives for seven of 20 residents reviewed (Residents 41, 49, 97, 8, 76, 47, and 93).

Findings include:

A review of the clinical record revealed that Resident 41 was transferred and admitted to the hospital on December 11, 2018, and returned on December 18, 2018.

A review of the clinical record revealed that Resident 49 was transferred and admitted to the hospital on April 11, 2018, and returned on April 14, 2018. He was also transferred and admitted to the hospital on April 15, 2018, and returned on April 20, 2018, and transferred and admitted to the hospital on May 1, 2018, and returned on May 2, 2018.

A review of the clinical record revealed that Resident 97 was transferred and admitted to the hospital on October 26, 2018, and returned on October 29, 2018. He was also transferred and admitted to the hospital on November 13, 2018, and returned on November 16, 2018.

A review of the clinical record revealed that Resident 8 was transferred and admitted to the hospital on December 14, 2018 and returned on December 15, 2018. Resident 8 was again transferred and admitted to the hospital on February 6, 2019 and returned on February 7, 2019.

A review of the clinical record revealed that Resident 76 was transferred to the hospital on January 25, 2019, and returned to the facility on the same day. Resident 76 was transferred and admitted to the hospital on February 1, 2019 and returned to the facility on February 2, 2019.

A review of the clinical record revealed that Resident 93 was transferred to the hospital on December 7, 2018, and returned to the facility on December 20, 2018.

A review of the clinical record revealed that Resident 47 was transferred to the hospital on December 11, 2018, and returned to the facility on December 15, 2018.

There was no evidence that written notice was provided to the above residents and their responsible parties regarding the transfer that included the required contents: reason for the transfer, contact and address information for the Office of the State Long-Term Care Ombudsman, and if applicable, information for the agency responsible for the protection and advocacy of individuals with developmental disabilities and mental disorder or related disabilities.

Interview with the Administrator on February 28, 2019, at approximately 10:30 a.m. verified that the facility did not send written notices to the resident and their residents' representatives of the facility initiated transfers of the above residents, but does send a monthly report to the State Ombudsman of facility initiated transfers.

28 Pa. Code 201.14(a) Responsibility of Licensee.
Previously cited 11/20/18.

28 Pa. Code 201.29 (f)(g)(h) Resident rights.
Previously cited 3/5/18, 11/20/18.

28 Pa Code 201.18 (e)(1) Management
Previously cited 3/5/18, 11/20/18.






























 Plan of Correction - To be completed: 04/09/2019

0623
-The facility cannot retroactivity correct the concerns addressed by the surveyors for residents 41, 49, 97, 8, 76, 47 and 93.
-The Licensed Nursing Staff and Business Office Manager will be re-educated on the requirement before transfer and discharge of a resident by the Nursing Home or Designee to verify understanding.
-Transfers and discharges will be review at the scheduled morning Inter-disciplinary meetings to verify notification has been given.
-The Nursing Home Administrator will conduct random audits weekly for 4 weeks and then monthly for 2 months to verify compliance of notification.
-Audits will be forwarded to the monthly QAPI meetings for review and any concerns will be immediately addressed by the Nursing Home Administrator.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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.
§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to afford residents the right to formulate advance directives (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) as evidenced by three residents out of 20 residents sampled (Residents 21, 93, and 349).

Findings include:

A review of the clinical records revealed that Resident 93 was admitted to the facility on April 25, 2013.

A review of the clinical records revealed that Resident 21 was admitted to the facility on August 20, 2018.

A review of the clinical records revealed that Resident 349 was admitted to the facility on February 11, 2019.

A review of the above residents' clinical records failed to indicate whether the residents had an advance directive. The residents' clinical records did not include documented evidence of discussions of the resident's right to formulate an Advance Directive or how to go about formulating an Advanced Directive if the residents wished to do so.

An interview with the nursing home administrator on February 28, 2019, at approximately 11:00 AM failed to provide evidence that each resident was provided information on the right to formulate an advance directive or how to formulate an advanced directive if they wished to do so.


28 Pa. Code 211.5 (f) Clinical records
Previously cited 3/5/18

28 Pa. Code 201.29(a)(l)(2) Resident rights
Previously cited 3/5/18















 Plan of Correction - To be completed: 04/09/2019

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely because it is by the provisions of federal and state law. The plan of correction represents the facility's credible allegation of compliance as of April 09, 2019.


0578
-Residents 21, 93 and 349 have been afforded the right to formulate an advanced directive.
-An audit of current residents will be completed to verify that they have been afforded the right to formulate an advance directive.
-Upon admission residents will be afforded the right to formulate an advanced directive
-The Admissions Director will randomly audit all new admissions for 4 weeks and then monthly for 2 monthly to verify that they have been afforded the right to formulate an advanced directive.
-Audits will be forwarded to the facility's monthly QAPI meeting for review and any concerns will addressed to the Administrator for immediate follow-up.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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.
§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on clinical record review, and staff interview, it was determined that the facility failed to provide restorative nursing services for one of four sampled residents (Resident 45).

Findings include:

A review of Resident 45's clinical record revealed that the resident was admitted to the facility on March 15, 2012 with diagnoses that included depression and cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture).

Further review of Resident 45's clinical record revealed that on May 11, 2018, Resident 45 was discharged from physical therapy. Discharge orders indicated that Resident 45 was to receive Restorative Nursing Services. The restorative program established included range of motion, in all ankle, knee, and hip planes to decrease the risk of contractures. At the time of the survey ending March 1, 2019, there was no documented evidence that Resident 45 had received restorative nursing services as planned upon discharge from physical therapy.

Interview with the Director of Nursing on March 1, 2019 at 10:30 a.m. confirmed that there was no documented evidence that a restorative nursing program was implemented by the facility as recommended upon Resident 45's discharge from skilled physical therapy.




28 Pa. Code: 211.5(f) Clinical records
Previously cited 3/5/18.

28 Pa Code 211.12 (a)(c)(d)(5) Nursing services
Previously cited 3/5/18, 11/20/18.




 Plan of Correction - To be completed: 04/09/2019

0688
-Resident 45 has being re-evaluated by Therapy and will be placed on a restorative program that includes ROM for bilateral ankles, knees and hips.
-Therapy will look back three months to check that no other residents were missed for any programs.
-Education will be completed on the new process/procedure will be provided to therapy staff by Therapy Manager or designee.
-A check list will be created when a resident is being discharged off skilled therapy to verify a restorative program is completed.
-Random audits of therapy discharges and start of restorative nursing programs will be competed weekly for 4 weeks and then monthly for 2 months to verify compliance.
-All audits will be reviewed at the Monthly QAPI Meeting for 3 months. All concerns will be addressed by the therapy manager or designee immediately.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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.
§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on review of clinical records and facility incident reports and staff interview, it was determined that the facility failed to implement effective supervision and planned interventions to ensure that the resident environment remains as free from accident hazards as possible for one of one residents reviewed (Resident 46) for this care area.

Findings include:

Review of the clinical record revealed that Resident 46 had diagnoses, which included obsessive compulsive disorder, impulse control and judgement disorder, PICA (a craving or appetite for nonfood substances), was physician ordered NPO (nothing by mouth) due to dysphagia (difficulty swallowing) and was at high risk for aspiration (the taking of foreign matter into the lung with respiration).

A quarterly Minimum Data Set assessment (standardized completed at specific intervals to identify specific resident care needs) dated January 4, 2019, indicated the resident was severely cognitively impaired and required staff assistance for transfers and ambulation.

Review of the resident's current care plan revealed that the resident had a behavior problem related to mood disorder and poor impulse control. The goal was to have fewer episodes of behaviors. Interventions included a motion sensor alarm on the resident's dresser when in bed, check placement and function every shift.

A nurses note dated February 7, 2019, indicated that Resident 46 was in the hallway holding a styrofoam cup. A nurses note dated February 8, 2019, noted no adverse reaction from the resident drinking water yesterday.
Review of a facility incident report dated February 7, 2019, at 3:30 PM indicated the resident was found in the hallway with styrofoam water cup, unsure if the resident drank any of the water.

Further review of the investigation failed to determine how the resident obtained the styrofoam cup. The investigation did conclude that the care planned motion detector was not turned to the correct position and failed to sound to alert staff of the resident's activities.

Interview with the director of nursing on March 1, 2019, at approximately 10:00 AM failed to provided documented evidence that the facility implement effective interventions and supervision to ensure an environment free of accident hazards for the resident who was to have nothing by mouth and had a diagnosis of PICA.

28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services
Previously cited 3/5/18, 11/20/18









 Plan of Correction - To be completed: 04/09/2019

0689
-Resident 46 was returned to his room by staff and the cup with the water was removed from the resident. Assessment was completed and there was no evidence that the resident had drank any of the water. Resident was monitored for any adverse reactions, none was noted.
-Resident 46 has been known to occasionally turn off his bed alarm allowing him to get up unassisted. A motion alarm has also been added to his door, but the day of the incident there was an emergency needing help down the hall and the C.N.A rushed out of the room and had not turned the alarm on properly.
-Resident 46 bed alarm to be placed out of residents reach to deter him from shutting it off.
-Education will be provided to staff by the Director of Nursing or designee on the safe placement and monitoring the alarms are functioning properly on March 26, 2019.
- Random alarm checks will be conducted by the Assistant Director of Nursing or designee weekly for 4 weeks and then monthly for 2 months to monitor that alarms are functioning.
-All audits will be reviewed at the monthly QAPI meeting for 3 months and any concerns will be addressed by the DON or designee immediately.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills: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.
§483.25(g)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:

Based on observations, review of clinical record and staff interviews it was determined that the facility failed to provide appropriate care and services one resident with enteral feedings out of 20 sampled residents (Resident 36).

Findings include:

A review of a facility policy for administration of enteral feeding : enteral pump reviewed December 18, 2018, revealed that prior to the administration of flushes and enteral feeding, verify correct placement of the G-tube by placing a stethoscope on the residents abdomen, inject 10-15 ccs of air via the 60 cc syringe, listen for a "whooshing" sound, then slowly draw back gastric contents, evaluate color and amount of residual: gastric secretions. Reinstill the aspired fluid into the stomach.

A review of the clinical record review revealed that Resident 20 was admitted to the facility on December 11, 2014, with diagnoses to include dementia, seizures and gastrostomy status ( issues with her digestive tract) and had a PEG tube (Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube [PEG tube] is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate [for example, because of dysphagia] for enteral feeding [enteral nutrition generally refers to any method of feeding that uses the gastrointestinal [GI] tract to deliver part or all of a person's caloric requirements].

A review of the resident's current monthly recapped physician's orders dated February 27, 2019, revealed an order for Jevity 1.2 (enteral feeding formula) at 60 ccs per hour from 6 PM to 2 PM.

Observation during medication administration pass on February 27, 2019, at approximately 11:15 AM revealed that Resident 36 was lying on her bed. Employee 2 (LPN) turned off the tube feeding pump and disconnected the resident's tube feeding from the G-tube. Employee 2 (LPN) drew up 60 ccs of water from a plastic cup into a piston syringe, opened the plug to the g-tube, placed the syringe into the gtube and pushed the water flush in. He then drew up the 30 ccs of the medication Lactulose (a medication used in an individual with high ammonia levels in their blood) into the piston syringe, placed it into the g-tube, pushed it into the piston syringe. Employee 2 (LPN) then drew another 60 ccs into the piston syringe, placed it into the g-tube and pushed the water into the tube. He reattached the tube feed catheter into the g-tube. Employee 2 (LPN) then left Resident 36's room without turning the tube feeding pump back on.

The medication pass observation continued. At approximately 11:35 AM, Resident 36's tube feed pump started to alarm. Employee 2 (LPN) stated that he forgot to restart Resident 36's tube feeding pump after administering her medications.

Employee 2 (LPN) also failed to check the placement of the g-tube prior to the administration of flushes and medications.

During an interview conducted on February 27, 2019, at approximately 1 PM the Director of Nursing confirmed that a licensed nurse should have checked placement prior to administering fluids into the g-tube.

Refer F658


28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services.
Previously cited: 11/20/18, 3/5/18




















 Plan of Correction - To be completed: 04/09/2019

0693
-The facility cannot retroactivity correct the concerns addressed by the surveyors regarding Employee 2.
-Employee 2 has had education annually on placement check of the PEG Tube and PEG Tube procedure, and has been re-educated and competency was completed with him.
-The alarm on the pump did sound as it is designed to do incase pump was not turned back on or was not functioning properly. The nurse had stated he was nervous and forgot to restart the pump, but as soon as it sounded he did restart the pump.
-The Director of Nursing or designee will re-educate Licensed Nursing staff on checking of PEG Tube placement and procedures.
-Competencies are to be completed on Licensed Nursing that they are able to check placement correctly and that they are following procedures and orders.
-Random audits will be completed with resident with a PEG Tube medication delivery to be sure that placement and correct procedure is followed.
-All audits will be reviewed at the Monthly QAPI Meeting, with any concerns address by the Director of Nursing or designee immediately.

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 clinical records and staff interview, it was determined that the facility failed to offer routine annual dental services for two Medicaid payor sources out of six residents sampled (Resident 39, and 41) for dental services.

Findings include:

Review of Resident 39's clinical record indicated that the resident was admitted to the facility on January 31, 2018, and that the resident's payor source was Medicaid. There was no documented evidence that the resident had been offered dental services in the past year.

Review of Resident 41's clinical record indicated that the resident was admitted to the facility on December 17, 2017, and that the resident's payor source was Medicaid. There was no documented evidence that the resident was offered dental services in the past year.

Interview with the Director of Nursing on February 28, 2019, at 1:00 p.m. confirmed that the facility had not offered Residents 39 and 41 routine dental services in the past year.




28 Pa. Code 211.12(c)(d)(3)(5) Nursing services
Previously cited 3/5/18, 11/20/18.

28 Pa. Code 211.15(a) Dental services







 Plan of Correction - To be completed: 04/09/2019

0791
-The facility cannot retroactivity correct the concerns addressed by the surveyors.
-Resident 39 and 41 was offered dental care and Resident 39 refused an annual checkup and education was provided regarding the risk verse the benefit. Resident 41 was offered dental care and appointment is scheduled.
-A complete audit was performed for all residents and all resident who wanted to be seen by dental services were scheduled. Any resident that refused was educated on risk vs. the benefits.
-Education was completed with scheduling staff by the Director of Nursing or designee.
-Information on all residents was placed in binder by date when they will be due for their next annual dental appointment to assist with tracking.
-Random weekly audits will be completed by the Assistant Director of Nursing or designee weekly for 4 weeks and then monthly for 2 months to verify compliance.
-Audits will be forwarded to the monthly QAPI meeting for review and any concerns will be addressed by Director of Nursing or designee immediately

§ 209.3(a) LICENSURE Smoking.:State only Deficiency.
(a) Policies regarding smoking shall be adopted. The policies shall include provisions for the protection of the rights of the nonsmoking residents. The smoking policies shall be posted in a conspicuous place and in a legible format so that they may be easily read by residents, visitors and staff.
Observations:

Based on observation and staff interviews, it was determined that the facility staff failed to post the smoking policy in a conspicuous place and in a legible format that could be easily read by residents, visitors and staff.

Findings include:

During an observation on February 26, 2019, at 1:00 PM, the facility's smoking policy, including provisions for the protection of the rights of non-smoking residents, was not posted in the facility and was not accessible to residents, staff and visitors.

During an interview with the Nursing Home Administrator on February 27, 2019, at 1:30 PM, the NHA confirmed that the facility failed to post the smoking policy.









 Plan of Correction - To be completed: 04/09/2019

1530
-The facility cannot retroactivity correct the concerns addressed by the surveyors
-Signs have been posted in the main lobby of the facility and also on Unit B with the smoking area identified and specific times for smoking.
-Audits for sign placement will be added onto the Weekly Manager on Duty's round sheet.
-The posting will be addressed at the next scheduled Resident Council Meeting.
-Audits will be forwarded to the monthly QAPI meeting for review and if any signs are noted to be missing these will be replaced immediately.


§ 211.8(c) LICENSURE Use of restraints.:State only Deficiency.
(c) Physical restraints shall be removed at least 10 minutes out of every 2 hours during the normal waking hours to allow the resident an opportunity to move and exercise. Except during usual sleeping hours, the resident's position shall be changed at least every 2 hours. During sleeping hours, the position shall be changed as indicated by the resident's needs.
Observations:

Based on a review of clinical records and select facility policy it was determined that the facility failed to release a physical restraint every two hours for one of one resident reviewed for restraints (Resident 1).

Findings include:

Review of the facility's policy entitled "Use of Restraints" last reviewed by the facility January 2019, indicated that restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. restrained residents must be repositioned at least every two hours on all shifts.

Review of Resident 1's clinical record revealed a physicians order, dated January 15, 2019, for resident to utilize reclining Broda chair with ROHO cushion (pressure reducing cushion) with pelvic strap that needs to be released every 2 hours for 10 minutes . Offer toileting/care, food/fluids, and repositioning and then reapply. Also release for meals when supervised.

Further review of the clinical record failed to provide evidence the staff released the physical restraint, per physician orders, from January 15, 2019, through February 18, 2019.

During an interview with the Director of Nursing on February 28, 2019, at 10:35 AM, it was confirmed that the facility failed to release the physical restraint every two hours for 10 minutes.


















 Plan of Correction - To be completed: 04/09/2019

1805
-Resident 1 was being released at least every 2 hours for 10 minutes, but this was not being recorded until it was noted during a mock survey. Record of the release and care was starting to be recorded January 19th.
-In-service will be completed for all nursing staff on the completion of the paperwork and review of the policy by the Director of Nursing or designee on March 26th.
-Residents with new or order changes for restraints will be reviewed at the scheduled morning IDT meeting to verify orders are correct and placed on 2 hour release paperwork.
-All residents with restraints are being monitored and recorded that they are being released as per -policy. Any new restraints will be placed on the "every 2 hours restraint release paperwork" and will be audited weekly for 4 weeks and the monthly for 2 months to verify that the releases are being completed.
-Audits will be forwarded to the monthly QAPI meeting for review and concerns will be addressed by the Director of Nursing or designee immediately.



Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port