Nursing Investigation Results -

Pennsylvania Department of Health
ELIZABETH MANOR HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ELIZABETH MANOR HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  75 surveys for this facility. Please select a date to view the survey results.

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ELIZABETH MANOR HEALTHCARE AND REHABILITATION CENTER - 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 and a complaint investigation completed on January 14, 2019, it was determined that Elizabeth Manor Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the health portion of the survey process.





 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected 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 observation, clinical record review and facility documentation, it was determined that the facility failed to ensure that proper staff assistance was provided to Resident #63 resulting in Resident #63 falling from bed and sustaining a fracture of the femur (bone in upper part of leg). The facility failed to use the required equipment to prevent accidents for two of ten residents reviewed (Resident #50 and Resident #63).

Findings include:

Review of Resident #63's diagnosis list revealed diagnoses that included atrial fibrillation (irregular and rapid heartbeat); heart failure (progressive disease that results from damaged muscles of the heart that affect their blood pumping action); neuromuscular dysfunction of bladder (lacks bladder control); morbid obesity (abnormal or excessive body fat accumulation in excess of 100 pounds); mild cognitive impairment and acquired absence of right above knee.

Review of Resident #63's Significant Change Minimum Data Set (MDS - periodic assessment of resident needs) dated June 28, 2018, revealed that the resident required the extensive assistance of two staff members for bed mobility, transfers and toilet use. Further review of Resident #63's MDS revealed Resident #63's balance was assessed as not steady and only able to stabilize with staff assistance.

Review of Resident #63's Activities of Daily Living (ADL) care plan revised on June 30, 2018, identified Resident #63's as having a deficit with activities of daily living related to physical limitations. The interventions included total assist of two for bed mobility. Further review of Resident #63's care plan included the intervention that the resident was to be transferred with the use of a mechanical lift and two person assist.

Review of Resident #63's interdisciplinary notes dated June 27, 2018 at 3:50 a.m. revealed "called to assess resident after a witnessed fall. Found resident on the floor on back alert and oriented. Neuro(checks) wnl [within normal limits]. ROM [range of motion] performed able to move all extremities with no pain, some discomfort reported on the left leg as normal per patient. No visible injury noted. CNA [nursing assistant] was giving care to patient and patient slid out of bed while [resident] was on [resident's] left side.... PT [patient] assist by four staff members with hoyer lift [mechanical lift] to bed."

Further review of Resident #63's interdisciplinary notes dated June 27, 2018 at 1:53 p.m. noted "Tylenol 325 mg [milligrams] instructed to give 650 mg every six hours as needed for pain... resident needed for back and knee pain due to fall."

Further review of Resident #63's interdisciplinary notes dated June 27, 2018 at 4:30 p.m. revealed "received x-ray report of back and left knee. Notified MD [physician], N.O. [new order]." Resident #63's physcian ordered the resident to be sent to the local hospital for evaluation.

Review of X-Ray report dated June 27, 2018 revealed "ongoing concern for acute fracture."

Review of Resident #63's nursing notes dated June 27, 2018 at 10:12 p.m. noted that the physician indicated not to have the resident transported to the emergency room.

Review of Resident #63's nursing notes dated June 28, 2018 at 11:00 a.m. revealed Resident #63 was transported to the orthopedic practice.

Review of the Resident #63's orthopedic consult dated June 28, 2019 confirmed the diagnosis of a fracture of the distal (situated away from the center of the body or from the point of attachment) femur (the bone of the thigh).

Review of Resident #63's June 28, 2018 nursing progress note at 1:25 p.m. revealed "Resident is being monitored for pain due to fracturing [resident's] femur during a fall that was witnessed by staff. Resident has had pain off and on, it was alleviated by Tylenol order."

Review of the nurse aide, Employee E11, statement obtained by the facility on June 27, 2018, revealed that the nurse aide indicated, "Approximately 4 am, I changed my resident. She was lying on her side; as I instructed the resident to come back to lying on her back I noticed she was rolling opposite direction from me. I was unable to assist her back to the bed upon falling. She did not hit her head, I assisted her to a safe position and yelled for help."

Further review of the nurse aide statement revealed that when questioned about the Kardex care instructions (card that provides written instructions of the daily care of a resident), "Resident is a two person assist for transfer, which is what I looked at on the Kardex." When asked for interpretation of above statement, Employee E11 responded "Resident is a Hoyer lift and two persons assist."

An interview with the Nursing Home Administrator and the Director of Nursing on January 11, 2018 at approximately 1:15 p.m. confirmed that the nurse aide did not follow the personal care recommendations of needing two person assistance for Resident #63.

The facility failed to ensure that Resident #63 was provided personal hygiene with the assistance of two staff while in bed which resulted in the resident falling from the bed and sustaining a fractured femur.

Review of Resident #50's diagnosis list revealed diagnoses including right below knee amputation, left above knee amputation and muscle weakness.

Review of Resident #50's quarterly MDS dated December 20, 2018, revealed Resident #50 required the extensive assistance of two persons for transfer between surfaces including to or from bed, chair, wheelchair and standing position and is totally dependent on two staff persons for bathing.

Review of Resident #50's plan of care revealed that Resident #50 required extensive assist of two staff for transfers with a sit-to-stand lift.

Review of the facility investigation into the fall incident sustained by Resident #50 revealed a written statement by nursing staff, Employee E12 indicating the "resident said he felt off balance, legs started to give out, lowered resident to floor during 2 assist transfer." Review of a second written statement by nursing staff, Employee E13 who was present during the fall incident revealed that "resident said he was off balance, legs gave out... lowered him to floor during two ast. transfer."

Further review of this documentation revealed that Resident #50's knees buckled and Resident #50 was lowered to the floor without injury.

Interview with the Director of Nursing on January 14, 2019, at approximately 1:30 p.m. confirmed that the nursing assistants were required to use the sit-to-stand lift at all times when transferring Resident #50.

Free of Accident Hazards/Supervision/Devices
CFR(s): 483.25(d)(1)(2) - Previously cited 01/17/17

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 01/17/17

28 Pa. Code 201.18(b)(1)(3) Management
Previously cited 03/30/18, 01/17/17

28 Pa. Code 201.18(e)(1) Management
Previously cited 01/17/17

28 Pa. 211.11(a) Resident care plan
Previously cited 01/17/17

28 Pa. Code 211.12(c) Nursing services
Previously cited 01/17/17

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 03/30/18, 01/17/17























 Plan of Correction - To be completed: 02/27/2019

1. Resident R63 continues to require assist of two for bed mobility. Resident R50 continues to require a sit to stand lift for transfers.
2. Current residents will continue to receive proper assistance for bed mobility and transfers.
3. Facility staff will receive directed in-serving by LW Consulting related to fall, accidents and ensuring that all staff are aware of what their roles are in implementing care plan safety interventions, what their roles are related to resident level of mobility, transfer and environmental safety and what their roles are in ensuring proper supervision of residents.
4. Audits will be conducted by the Director of Nursing or designee to verify staff are utilizing proper bed mobility and transfer statuses. Results of these audits will be reviewed at the facility QAPI meeting.

483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:


Based on a review of facility policy, resident group interview, and staff interview, it was determined that the facility failed to ensure residents were notified of the procedure for filing grievances anonymously on two of two nursing units (Second Floor Nursing Unit and Third Floor Nursing Unit).

Findings include:

Review of the facility policy undated and titled, "Grievance Policy," revealed that the policy is for residents who may have concerns and the facility will seek to resolve them. Further review of the policy revealed that concerns should be made to the Director of Nursing, Administrator, Nursing Supervisor, or Department Head. The policy further revealed that a "concern box" was located in the building.

During a resident group interview on January 11, 2019, at approximately 1:30 p.m. with ten alert and oriented residents from the Second and Third floors revealed that these residents were unclear on the procedure of filing a grievance anonymously. This group interview further revealed that the residents could not identify the grievance officer and were not aware of a "concern box" in the building.

An observation on the Third Floor Nursing Unit on January 14, 2019, at approximately 10:00 a.m. failed to reveal the process of filing a grievance anonymously, failed to reveal that Grievance/Concern Forms were visible on the unit, and failed to reveal a "concern box."

An observation on the Second Floor Nursing Unit on January 14, 2019, at approximately 12:15 p.m. failed to reveal that the process of filing a grievance anonymously was displayed and also failed to reveal the presence of a "concern box" on the unit. Observation of the outside of the dining room area on the Second Floor Nursing Unit revealed forms located on a shelf with a sign stating,"submit comments to receptionist."

An interview on January 14, 2019, at approximately 1:15 p.m. with the Director of Nursing confirmed that the residents and/or families were unable to file an anonymous grievance and further confirmed that grievance/concern forms were not accessible to residents or families.

The facility failed to ensure residents were notified of the procedure for filing grievances anonymously.

28 Pa. Code 201.18(b)(3) Management
Previously cited 03/30/18, 01/17/17

28 Pa. Code 201.29(i) Resident rights






















 Plan of Correction - To be completed: 02/27/2019

1. Concern boxes will be made available for anonymous grievances. Grievance procedure, indicating grievance official will be posted by the grievance forms.
2. Current residents and families will be provided with the written grievance procedure, which includes how to file an anonymous grievance, the name and contact information of the grievance officer and the location of the concern boxes. Grievance procedure will be reviewed at the resident council meeting.
3. Staff will be educated on the grievance procedure by the Nursing Home Administrator or designee.
4. Resident, Staff, and Family interviews will be conducted by Social Services or designee to verify knowledge of the grievance procedure. Results of these audits will be reviewed at the facility QAPI meeting.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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(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 and review of facility policy, it was determined that the facility failed to store food in accordance with professional standards as observed during the initial tour of the main kitchen.

Findings include:

Review of facility policy titled, "Food Storage," with a revision date of December 14, 2017, revealed an instruction bullet indicating "all opened and partially used foods shall be dated, labeled and sealed before being returned to the storage area."

Review of facility policy titled, "Recommended Storage Practice," with a revision date of December 14, 2017, revealed under Subsection "Frozen" two bullet instructions of "cover all food containers" and "Wrap all food well to prevent freezer burn, label with name of contents and date of entry to freezer."

Observation of the first section of the freezer during the initial tour of the main kitchen on January 9, 2019, at approximately 12:45 p.m. in the presence of the Dietary Director, Employee E4, revealed a plastic bag of chicken pieces; plastic bag of chicken thighs/drumsticks; and an open box/bag of "Char" broiled beef patties with no label and no date when they were opened.

Observation of the second section of the freezer revealed an open plastic bag of Monterey/Jack Cheese without an open date and a Best Buy date of December 13, 2018.

Further observation of the cooling refrigerator revealed a tray with containers of salad with four plastic lids only partially covering the container and contents of salad. A second tray of containers filled with applesauce revealed four plastic lids partially covering the contents of the containers.

Additional observation during the initial kitchen tour revealed two packages of sandwich bread open without an identified open date.

Interview with dietary staff, Employee E10, during the observation, confirmed that the items should have been labeled, dated, and that the containers should have been tightly closed.

The facility failed to ensure that food was properly dated and in closed containers.

Food Procurement, Store/Prepare/Serve-Sanitary
CFR(s): 483.60(i)(1)(2) - Previously cited 01/17/17

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 01/17/17

28 Pa. Code 201.18(b)(1)(3) Management
Previously cited 03/30/18, 01/17/17






 Plan of Correction - To be completed: 02/27/2019

1. No individual residents were identified.
2. The chicken thighs/drumsticks, char broiled beef patties, Monterey Jack cheese, salad, applesauce and bread were discarded during the survey.
3. The Registered Dietitian/designee will educate the food and nutrition services department on the proper dating, labeling and storage of food.
4. The Food and Nutrition Service Manager/designee will conduct dating, labeling and food storage audits to ensure that proper dating, labeling and storage of food is being followed. Results of these audits will be reviewed at the facility's QAPI meeting.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:


Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to follow physician's orders for anticoagulant medication resulting in a significant medication error for one of six residents reviewed (Resident #63).

Findings include:

Review of facility policy titled, "Anticoagulant Therapy Guideline," revealed "schedule and complete laboratory procedure as per physician order."

Review of Resident #63's clinical record revealed diagnoses including, atrial fibrillation (irregular and rapid heartbeat) and heart failure (progressive disease that results from damaged muscles of the heart that affect their blood pumping action).

Review of Resident #63's September 2018 physician orders revealed an order for Coumadin (Warfarin - an anticoagulant medication used to treat or prevent blood clots in the veins, arteries, lungs or heart) 2 milligrams (mg) to be adminitered at bedtime.

Further review of Resident #63's clinical record revealed that a one-time order for PT/INR (laboratory study used to determine the clotting tendency of the blood) screening was performed on September 24, 2018, to be completed on September 21, 2018.

Review of Resident #63's clinical record revealed laboratory results dated September 21, 2018, for PT/INR clinical values with physician notation "Coumadin 2 mg, Hold. Recheck on Monday September 24, 2018."

Further review of Resident #63's clinical record failed to reveal laboratory PT/INR results for September 24, 2018.

Review of Resident's #63 clinical record failed to reveal physician notification of missed PT/INR laboratory screening for September 24, 2018.

Review of Resident #63's physician orders for October, November, December 2018, and January 2019, failed to reveal an order for Coumadin.

Review of Resident #63's October 2018, November 2018, December 2018 and January 1-19, 2019 Medication Administration Records revealed that the resident was not adminsitered the anticoagulant medication Coumadin.

Review of Resident #63's physician's progress notes for October 6, 2018, November 4, 2018, November 15, 2018, December 10, 2018, and December 13, 2018, indicated "nursing states the patient is doing well without any complications or setbacks" Further review of the above stated physician progress notes indicated that the resident denied any leg swelling and denied any chest palpitations. "The patient appeared well nourished and normally developed." The section title "Assessment/Plan" noted "Atrial Fibrillation - continue Coumadin and monitor PT/INR."

Interview on January 11, 2019, at approximately 11:43 a.m. with the Director of Nursing revealed that Resident #63 should still be receiving Coumadin and the PT/INR laboratory screening was not completed as directed on September 24, 2018, by the physician.

Interview on January 11, 2019, at approximately 12:15 p.m. with the Medical Director revealed that the physician was not notified of the significant medication error of not receiving Coumadin nor missing the PT/INR laboratory screening until January 11, 2019. The physician indicated that Resident #63 should have been receiving Coumadin medication and that it was restarted effective January 11, 2019.

The facilty failed to monitor Resident #63's PT/INR levels and the administration of the anticoagulant medication Coumadin which resulted in a significant medication error.

Residents Are Free of Significant Med Errors
CFR(s): 483.45(f)(2) - Previously cited 01/17/17

28 Pa. Code 211.5(f) Clinical records
Previously cited 03/30/18, 01/17/17

28 Pa. Code 211.5(h) Clinical records

28 Pa. Code 211.9(a)(1) Pharmacy services
Previously cited 01/17/17

28 Pa Code 211.10(c) Resident care policies
Previously cited 01/17/17

28 Pa. Code 211.12(c) Nursing services
Previously cited 01/17/17

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 03/30/18, 01/17/17

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 01/17/17







 Plan of Correction - To be completed: 02/27/2019

1. Resident 63's MD was notified of the missed PT/INR lab and missed Coumadin doses, resident was re-started on Coumadin therapy.
2. Current residents who receive Coumadin will be monitored per the anti-coagulation protocol to verify PT/INR lab results and proper Coumadin dosing.
3. Licensed staff will be in-serviced by the Director of Nursing or designee on the anti-coagulation policy.
4. Audits will be conducted by the Director of Nursing or designee to verify that resident's PT/INRs and Coumadin dosing are adequately monitored. Results of these audits will be reviewed at the facility QAPI meeting.

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, it was determined that the facility failed to ensure that advance directive information was obtained from a resident's representative for one of four residents reviewed (Resident #7).

Findings include:

Review of Resident #7's diagnosis list revealed diagnoses including dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and depression (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and/or daily routine).

Review of Resident #7's Quarterly Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated October 12, 2018, revealed Resident #7 was severely cognitively impaired.

Review of Resident #7's clinical record revealed a Physician's Order for Life Sustaining Treatment (POLST) indicating that Resident #7 had a code status of Do Not Resuscitate (DNR).

Further review of Resident #7's POLST revealed that the POLST was unsigned by Resident #7 or Resident #7's representative.

Review of Resident #7's clinical record revealed a physician's order dated August 21, 2017, indicating a DNR code status.

Interview with the Director of Nursing on January 14, 2019, at approximately 10:00 a.m. revealed that Resident #7 had no appointed Power of Attorney and that no Advance Directive had been formulated.

This interview further revealed that the facility was unaware of Resident #7's wishes and unaware of why Resident #7 had a DNR code status.

The facility failed to ensure that Resident #7's advance directive information was obtained from the resident's representative to determine the appropriate code status.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 01/17/17

28 Pa. Code 201.18(b)(3) Management
Previously cited 03/30/18, 01/17/17

28 Pa. Code 201.29(j) Resident rights
Previously cited 03/30/18, 01/17/17









 Plan of Correction - To be completed: 02/27/2019

1. Resident R7's POLST will be revised to reflect resident's RP's signature. Resident's RP does wish for resident to remain a DNR.
2. Current residents advance directives will be reviewed to ensure proper completion of POLST forms.
3. POLSTs will be completed upon admission with new residents. Social Services and licensed staff will be in-serviced by the Nursing Home Administrator or Designee on the advanced directives policy.
4. Audits will be conducted by the Director of nursing or designee to verify POLST are completed per policy. Results of these audits will be reviewed at the facility QAPI meeting.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(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 81F; 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 ensure clean shower rooms and resident care equipment on one of two floors observed (Second Floor).

Findings Include:

Review of facility policy titled "Quality of Life-Homelike Environment" with revision date of May 2017, revealed Number 2 "facility staff and management shall maximize, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a). Clean, sanitary and orderly environment."

Observation on January 9, 2019, at approximately 1:35 pm of the 2nd floor central bath, nearest the dining room; a pile of towels, hospital gowns, and wash clothes lying on the shower room floor.

Further observation of 2nd floor central bath noted four medium sized deposits of brownish colored residue on shower stall floor.

Observation on January 9, 2019, at approximately 1:46 pm of the 2nd floor central bath, nearest the nursing station; revealed a bathing stretcher with two dried hair clumps. Further observation of the bathing stretcher revealed under the blue comfort mat, four large clumps of a grayish, black, green substance.

Interview on January 9, 2019, at approximately 2:02 pm with licensed nursing staff, Employee E3, confirmed the observations of the central shower rooms that were not a clean or sanitary and did not create a homelike environment for the residents.

The facilty failed to ensure sanitary equipment and shower rooms on the Second Floor.

28 Pa. Code 201.18(b)(3) Management
Previously cited 03/30/18, 01/17/17

28 Pa. Code 207.2(a) Administrators responsibility
Previously cited on 01/17/17











 Plan of Correction - To be completed: 02/27/2019

1. Items from second floor central bath were removed and central bath was cleaned. The second floor bathing stretcher was cleaned and sanitized.
2. Central bath areas will be cleaned and any items will be removed. Bathing stretchers will be cleaned and sanitized.
3. Housekeeping and nursing staff will be in-serviced by Director of Nursing or designee on the quality of life homelike environment policy.
4. Audits will be conducted by the Director of nursing or designee of the central baths and bathing stretchers to verify cleanliness. Results of these audits will be reviewed at the facility QAPI meeting.

483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements: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.
483.15(c) Transfer and discharge-
483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i) Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with 483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.
Observations:


Based on clinical record review, it was determined that the facility failed to send all appropriate clinical documentation for residents transferred to acute care facilities for two of sixteen residents reviewed (Resident #35 and Resident #48).

Findings include:

Review of Resident #48's progress nursing note dated December 4, 2018, revealed that Resident #48's physician ordered Resident #48 to be sent to the emergency room (ER) for evaluation of a laceration sustained after a fall.

Review of Resident #48's clinical record failed to reveal evidence that the resident's nursing care plan was sent to the acute care facility.

Review of Resident #35's nursing documentation dated November 23, 2018, revealed that the resident was transferred to the hospital for possible heart failure.

Further review of Resident #35's clinical record failed to reveal evidence that the resident's nursing care plan was sent to the acute care facility.

An interview with the Director of Nursing on January 14, 2019, at approximately 1:30 p.m. revealed that the facility did not send the nursing care plan with the residents when the residents are transferred to an acute care facility.

The facility failed to ensure that nursing care plans for Resident #35 and Resident #48 were send to the acute care hospital at the time of transfer.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 01/17/17

28 Pa. Code 201.18(b)(1)(3) Management
Previously cited 03/30/18, 01/17/17

28 Pa. Code 201.29(f) Resident rights





















 Plan of Correction - To be completed: 02/27/2019

1. Resident R35 & R48 have returned from the acute care setting and continue to reside in the facility.
2. Current residents who transfer to an acute care facility will be provided a written care plan.
3. Licensed staff will be educated by the Director of Nursing or designee on providing a written care plan at the time of transfer to an acute care facility.
4. Audits will be conducted by Director of Nursing or designee to verify care plans are sent on acute care transfers. Results of these audits will be reviewed at the facility QAPI meeting.

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



Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS - periodic assessment of resident needs) accurately reflected the status for one of one residents reviewed (Resident #36).

Findings include:

Review of Resident #36's Admission MDS dated December 10, 2018, revealed that the resident was receiving Dialysis treatment (treatment that filters and purifies the blood using a machine) while a resident at the facilty.

Interview with the Director of Nursing on January 9, 2019 at approximately 4:15 p.m. confirmed that Resident #36's MDS was inaccurate and further confirmed that the resident was not receiving Dialysis treatment while at the facility.

The facility failed to ensure that Resident #36's MDS assessment was accurate.

28 Pa. Code 211.12(c) Nursing services
Previously cited 01/17/17

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 01/17/17

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 03/30/18, 01/17/17











 Plan of Correction - To be completed: 02/27/2019

1. Resident R36's MDS dated 12/10/2018 Section O0100J1&2 were modified to accurately reflect the resident's current status.
2. An audit of Comprehensive Assessments for the month of December was completed to ensure no other resident's Section O0110J1&2 were coded inaccurately.
3. Education of Section O0100J1&2 coding was provided to the RNAC by the regional clinical reimbursement consultant.
4. Audits of Comprehensive Assessments of Section O0100J 1&2 will be completed and results of audits reviewed at the facility QAPI meeting.

483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of 483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
Observations:

Based on closed record review and staff interview, it was determined the facility failed to provide a discharge summary that included a recapitulation of a residents stay at the time of discharge for one of two closed records reviewed (Resident #68).

Findings include:

Review of Resident #68's closed record revealed that Resident #68 was discharged from the facility on October 29, 2018.

Further review of Resident #68's closed record failed to reveal a discharge summary signed by the resident's physician.

An interview with the Director of Nursing on January 14, 2019 at approximately 1:30 p.m. confirmed that Resident #68's physician failed to provide a discharge summary.

The facility failed to ensure that Resident #68's discharge summary was completed by Resident #68's physician.



28 Pa. Code 211.5(f) Clinical records
Previously cited 03/30/18, 01/17/17












 Plan of Correction - To be completed: 02/27/2019

1. Resident R68 has been discharged from the facility.
2. Current residents who discharge from the facility will have a discharge summary completed by the Physician.
3. Licensed staff and Physicians will be in-serviced by the Director of Nursing or designee on the Discharge Summary and Plan Policy.
4. Audits will be conducted by the Director of Nursing to verify that discharge summaries are completed upon discharge. Results of these audits will be reviewed at the facility QAPI meeting.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:


Based upon review of manufacturer guidelines and observation, it was determined the facility failed to ensure that medications were properly labeled upon opening in two of three medication carts observed and one of two medication room refrigerators observed (Second Floor A Hall Medication Cart and Second Floor B Hall Medication Cart and Second Floor Medication Room Refrigerator).

Findings include:

Review of manufacturer's guidelines for Basaglar Insulin (medication used to treat high blood sugar levels) revealed open and in use Basaglar Insulin should be discarded 28 days after opening. Further review of manufacturer's guidelines for Basaglar Insulin revealed that unopened and unrefrigerated Basaglar Insulin should be discarded 28 days after removal from refrigeration.

Review of manufacturer's guidelines for Levemir Insulin revealed that Levemir Insulin should be discarded 42 days after opening.

Review of manufacturer's guidelines for Combigan Ophthalmic drops revealed that open bottles should be discarded four weeks after opening.

Review of manufacturer's guidelines for Dorzolamide Ophthalmic drops revealed that open bottles should be discarded 28 days after opening.

Review of manufacturer's guidelines for Ketotifen Ophthalmic drops revealed that open bottles should be discarded 28 days after opening.

Review of manufacturer's guidelines for Tubersol Tuberculin Purified Protein Derivative revealed that vials of this medication should be discarded 30 days after opening.

Observation of the Second Floor B Hall Medication Cart on January 9, 2019, at 3:20 p.m. revealed one open and undated Basaglar Insulin KwikPen and one unopened and unrefrigerated Basaglar Insulin KwikPen; one open and undated bottle of Combigan ophthalmic drops; one open bottle of Dorzolamide Ophthalmic drops with an open date of September 11, 2018, and one open and undated bottle of Ketotifen Ophthalmic drops; one open and undated vial of Levemir Insulin.

Observation of the Second Floor A Hall Medication Cart on January 9, 2019, at 3:40 p.m. revealed one open and undated Basaglar Insulin KwikPen; one unopened, undated and unrefrigerated Basaglar Insulin KwikPen; one open and undated vial of Humalog Insulin.

Observation of the Second Floor Medication Room Refrigerator revealed one open and undated vial of Tubersol PPD.

The above information was conveyed to the Director of Nursing on January 14, 2019, at approximately 1:30 p.m.

The facility failed to ensure that medications were properly labeled upon opening.

28 Pa. Code 211.9(h) Pharmacy services

28 Pa. Code 211.9(i) Pharmacy services
Previously cited 01/17/17

28 Pa. Code 211.12(c) Nursing services
Previously cited 01/17/17

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 03/30/18, 01/17/17






 Plan of Correction - To be completed: 02/27/2019

1. Identified Basaglar Insulin, Combigan, Dorzolamide, Levemir and Tubersol were discarded per manufacturer's guidelines.
2. Medication carts and refrigerators will be checked to verify medications are dated and stored correctly.
3. Licensed staff will be in-serviced by the Director of Nursing or designee on proper medication storage and labeling.
4. Audits will be conducted by the Director of Nursing or designee to verify medications are dated and labeled correctly. Results of these audits will be reviewed at the facilities QAPI meeting.

483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides: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.
483.95(g) Required in-service training for nurse aides.
In-service training must-

483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

483.95(g)(2) Include dementia management training and resident abuse prevention training.

483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at 483.70(e) and may address the special needs of residents as determined by the facility staff.

483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
Observations:


Based on review of facility policy, review of personnel records, and interviews with staff, it was determined that the facility failed to ensure newly hired employees received resident abuse prevention training as outlined in their policy for four of five personnel records reviewed (Employee #5, Employee #6, Employee #7 and Employee #8).

Findings include:

Review of facility policy, "Abuse Prohibition," revised July 2017, revealed that the facility would implement an abuse prohibition program during its orientation and through ongoing training programs, provide all employees with information regarding abuse, including prevention, intervention, and detection and related reporting requirements.

Review of licensed dietary staff, Employee #5's, personnel record revealed that Employee #5 was hired on September 4, 2018. Further review of Employee #5's personnel record failed to reveal completed abuse training.

Review of non licensed staff, Employee #6's, personnel record revealed that Employee #6 was hired on October 1, 2018. Further review of Employee #6's personnel record failed to reveal completed abuse training.

Review of Licensed Nurse, Employee #7's, personnel record revealed that Employee #7 was hired on December 17, 2018. Further review of Employee E #7's personnel record failed to reveal completed abuse training.

Review of non licensed staff, Employee #8's, personnel record revealed that Employee #8 was hired on December 7, 2018. Further review of Employee #8's personnel record failed to reveal completed abuse training.

Interview with the Nursing Home Administrator and the Director of Nursing on January 14, 2018, at 11:30 a.m. confirmed that no abuse training was conducted for Employee #5, Employee #6, Employee #7 and Employee #8.

The facility failed to ensure that Employee #5, Employee #6, Employee #7 and Employee #8 received the required resident abuse prevention training.

28 Pa. Code 201.14(a) Responsibility of Licensee
Previously cited 01/17/17

28 Pa. Code 201.18(b)(3) Management
Previously cited 03/30/18, 01/17/17

28 Pa. Code 211.10(d) Resident care policies
Previously cited 01/17/17

28 Pa. Code 201.20(c)(d) Staff development



























 Plan of Correction - To be completed: 02/27/2019

1. Employee E5, E6, E7 & E8 have completed abuse training.
2. Upon hire new employees will complete mandatory abuse training.
3. HR has been in-serviced by the Nursing Home Administrator on the requirement of abuse training upon hire for new employees.
4. Audits will be completed by the Nursing Home Administrator to verify new employees have completed the required abuse training. Results of these audits will be reviewed at the facility's QAPI meeting.

211.5(d) LICENSURE Clinical records.:State only Deficiency.
(d) Records of discharged residents shall be completed within 30 days of discharge. Clinical information pertaining to a resident's stay shall be centralized in the resident's record.
Observations:


Based on a closed record review, it was determined that the facility failed to complete a discharge summary for one of three closed records reviewed. (Resident #68).

Findings include:

Review of Resident #68's closed record revealed that the resident was discharged from the facility on October 29, 2018.

Further review of Resident #68's closed record failed to reveal evidence that a discharge summary was completed.

Interview with the Director of Nursing on January 14, 2019 at approximately 2:00 p.m. confirmed that a discharge summary was not completed for Resident #68.













 Plan of Correction - To be completed: 02/27/2019

1. Resident R68 was discharged from the facility and continues to reside outside the facility.
2. Current residents will have a discharge summary completed upon discharge from the facility.
3. Licensed staff will be in-serviced by the Director of Nursing or designee on Discharge Summary and Plan Policy.
4. Audits will be completed by the Director of Nursing or designee to verify discharge summaries are completed upon discharge. Results of these audits will be reviewed at the facility's QAPI meeting.

211.9(i) LICENSURE Pharmacy services.:State only Deficiency.
(i) At least quarterly, outdated, deteriorated or recalled medications shall be identified and returned to
the dispensing pharmacy for disposal in accordance with acceptable professional practices. Written documentation shall be made regarding the disposition of these medications.
Observations:

Based on closed record review and staff interview, it was determined that the facility failed to reveal evidence of disposition of medications for two of three discharged residents (Resident #67 and Resident #68).

Findings include:

Review of Resident #67's closed record revealed that the resident was admitted to the facility on November 28, 2018.

Further review of Resident #67's closed record failed to reveal evidence of the disposition of medications at the time of discharge on December 24, 2018.

Review of Resident #68's closed record revealed that the resident was admitted to the facility on October 8, 2018.

Further review of Resident #68's closed record failed to reveal documentation of the disposition of medications at the time of discharge on October 29, 2018.

An interview with the Director of Nursing on January 14, 2019 at approximately 2:00 p.m. confirmed that the disposition of medications were not completed for Resident #67 and Resident #68 at the time of discharge.





 Plan of Correction - To be completed: 02/27/2019

1. Resident R67 & R68 remain discharged from the facility.
2. Current residents who discharge will have a disposition of medication completed upon discharge.
3. Licensed staff will be in-serviced by the Director of Nursing or designee on Discharge medication policy.
4. Audits will be completed by the Director of Nursing or designee to verify a disposition of medication is complete. Results of these audits will be reviewed at the facility's QAPI meeting.


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