Nursing Investigation Results -

Pennsylvania Department of Health
BUFFALO VALLEY LUTHERAN VILLAGE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BUFFALO VALLEY LUTHERAN VILLAGE
Inspection Results For:

There are  62 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.
BUFFALO VALLEY LUTHERAN VILLAGE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey completed on April 19, 2019, it was determined that Buffalo Valley Lutheran Village 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.


 Plan of Correction:


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 observations, review of select facility policies and procedures, and resident and staff interviews, it was determined that the facility failed to make information available regarding the facility's grievance/complaint process and the residents' rights to file a grievance in prominent locations on all five nursing units (Blue Jay Way, Pheasant Ridge, Country Lane, Chestnut Trail, and Bison Boulevard; Residents 22, 30, 48, 83, and 150).

Findings include:

During a group interview conducted on April 17, 2019, at 10:30 AM with five alert and oriented residents (Residents 22, 30, 48, 83 and 150) revealed that the residents were not aware of a formal process to voice a grievance in writing, verbally, or anonymously. All five residents in attendance stated that there were no postings in the facility, comprised of five nursing units, regarding the facility's grievance process or how to file a grievance anonymously.

Observations of all five nursing units and the front lobby on April 16, 2019, at 9:46 AM and again on April 17, 2019, at 12:45 PM, revealed no evidence of postings of the procedural information, including how to file anonymously - with the contact information of the grievance official with whom a grievance can be filed; to include a business address (mailing and email) and a business phone number; the right to obtain a written decision regarding his or her grievance; and a reasonable expected time frame for completing the review of the grievance.

The policy entitled "Senior Living Grievance Process" last revised by the facility on November 13, 2018, indicated that grievance forms can be obtained by contacting the executive director or a department head. It further indicates that the forms are available at the nurse's station. Observations of the nursing stations on April 17, 2019, at 12:45 PM revealed that the grievance forms are behind the closed and locked doors of the nursing stations, and only available to a resident if they ask for the form. There was nothing contained in the policy about how a resident would file a grievance anonymously.

Interview with the Administrator and Director of Nursing on April 18, 2019, at 2:00 PM confirmed that the residents do not currently have the means to anonymously access grievance forms and that there are no postings throughout the facility regarding the facility's grievance process.

483.10(j) Grievances
Previously cited 10/3/18

28 Pa. Code 201.18(e)(1) Management
Previously cited 10/3/18 and 5/4/18

28 Pa. Code 201.29(a)(b)(i) Resident rights
Previously cited 10/3/18


 Plan of Correction - To be completed: 06/04/2019

All nursing units and the front lobby will have information on the grievance policy including how to file anonymously readily available. Information will also include contact information for the grievance official.

All nursing units and the front lobby will have the necessary forms for filing a grievance as well as the method by which to submit the information anonymously to a grievance official.

Staff will be educated on the process for residents/families to file a grievance including anonymously. During resident council the residents will be re-educated on the process for filing grievances, the location of grievance forms to complete as well as the grievance officer contact information. The education will include the policy entitled, "Senior Living Grievance Process."


Weekly audits times four and monthly times three will be completed by the Nursing Home Administrator or designee to ensure proper notification of grievance procedures are accessible on all nursing units and the front lobby. The results of the audits will be reviewed at the monthly QAPI meeting.
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 review of select facility policies, clinical record review, and staff and resident interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications for two of six residents reviewed (Residents 24 and 70).

Findings include:

The facility policy entitled, "Pain Clinical Protocol," last reviewed without changes on November 13, 2018, revealed that the physician and staff will identify individuals who have pain or who are at risk for having pain. The nursing staff will assess each individual for pain upon admission, quarterly, and whenever there is a significant change in condition, and when there is an onset of new pain or worsening of existing pain. The staff and physician will identify the nature and severity of pain. Staff will assess pain using a consistent approach and a standardized pain assessment. The staff will evaluate and report how much and how often the individual asks for as needed pain medications. The staff will reassess the individual's pain and related consequences at regular intervals. The staff will discuss significant changes in levels of comfort with the attending physician who will consider adjusting interventions accordingly.

Review of Physiopedia's and Wikipedia's definition of the numeric pain rating scale from zero to 10 indicates that no pain is identified as zero, mild pain is identified as one to three, moderate pain is identified as four to six, and severe pain is identified as seven to 10.

Clinical record review for Resident 70 revealed physician's orders for Tylenol (medication used for mild pain) 650 mg (milligrams) by mouth (PO) every four hours PRN (as needed) for pain 1-3, not to exceed 3,000 mg in 24 hours

Review of Resident 70's April 2019 MAR (medication administration record, a form to document medication administration) revealed that staff administered Tylenol to him on the following dates and times. There was no documentation indicating Resident 70's pain level at the time of the Tylenol administration.

April 4, 2019, at 8:57 AM
April 4, 2019, at 3:22 PM
April 4, 2019, at 9:58 PM
April 6, 2019, at 1:21 PM
April 8, 2019, at 7:42 AM
April 10, 2019, at 8:01 AM
April 11, 2019, at 8:10 AM
April 12, 2019, at 1:04 PM
April 13, 2019, at 1:10 PM
April 14, 2019, at 9:17 AM
April 16, 2019, at 8:07 AM
April 16, 2019, at 4:01 PM
April 18, 2019, at 7:35 AM

Interview with Employee 1, Assistant Director of Nursing, on April 19, 2019, at 10:01 AM confirmed that staff failed to document a pain scale with administration of the tylenol as noted

Interview with Resident 24 on April 16, 2019, at 1:37 PM revealed that she has pain in her left arm, shoulder to wrist, related to a fracture. Interview with Resident 24 on April 17, 2019, at 10:58 AM revealed that her pain is interfering with her eating, mainly her appetite.

Observation while interviewing Resident 24 on April 17, 2019, at 10:58 AM revealed frequent facial grimacing with movement of her left arm.

Clinical record review revealed that Resident 24 had a physician's order for oxycodone (a narcotic medication used to treat moderate to severe pain) 5 mg one time daily. She also had an order for oxycodone 5 mg as needed every six hours for moderate pain (a pain level of 4-6 on a 1-10 scale), and oxycodone 10 mg every six hours as needed for severe pain (pain level of 7-10 on a 1-10 scale).

Review of Resident 24's 2019 MAR's indicated that she took the as needed oxycodone 5 mg or 10 mg, for moderate to severe pain, 25 times in February, 15 times in March, and 27 times in April.

Further clinical record review revealed no evidence that the facility notified Resident 24's physician regarding her uncontrolled pain with excessive PRN pain medication use.

Interview with Employee 1 on April 18, 2019, at 2:30 PM confirmed the above noted findings that the facility failed to provide Resident 24 with the highest practicable level of pain management.

28 Pa. Code 211.10(a)(c)(d) Resident care policies
Previously cited 5/4/18

28 Pa. Code 211.12(c) Nursing services
Previously cited 5/4/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 10/3/18 and 5/4/18

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 10/3/18


 Plan of Correction - To be completed: 06/04/2019

Resident 70 PRN order from Tylenol has been updated to indicate the pain level for administering Tylenol.


Resident 24 physician was updated regarding her indicated pain in her left arm and use of PRN medication.


An audit of current residents in the facility will be completed to ensure residents have appropriate pain control. The audit will also include review of residents PRN mediation use and physicians will be updated as needed.


Nursing staff will be re-educated on the policy entitled, "Pain-Clinical Protocol." The education will include the use of PRN medications and updated physicians as needed.


Weekly audits time four and monthly times three will be completed to ensure residents with pain have appropriate pain control. The audits will include reviewing the use of PRN pain medication and ensuring physicians are updated as needed. The audits will be reviewed at the monthly QAPI meeting.

483.20(b)(2)(ii) REQUIREMENT Comprehensive Assessment After Signifcant Chg: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(b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to complete a significant change Minimum Data Set assessment for one of two residents reviewed (Resident 24).

Findings include:

Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual (reference used to complete an MDS) revealed that the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition.

Clinical record review for Resident 24 revealed a comprehensive MDS (Minimum Data Set assessment, an assessment completed by the facility to determine resident care needs) dated February 7, 2019, that indicated Resident 24 was independent with transfers, toilet use, and walking in her room and in the hallways. Current nurse aide documentation on the facility ADL (activities of daily living) by day report, indicated that as of April 18, 2019, Resident 24 required limited to extensive assistance with transfers and toilet use, and she was not able to ambulate.

Review of the RAI revealed that the staff should complete a significant change MDS when a resident has a decline or improvement that will not normally resolve itself without interventions by staff, impacts more than one area of the resident's health status, and requires interdisciplinary review and or revision of the care plan.

Interview with Employee 1, Assistant Director of Nursing, on April 19, 2019, at 10:02 AM revealed that the facility did not complete a significant change MDS assessment and could not provide documentation to support why the significant change assessment was not completed on Resident 24.

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 10/3/18 and 5/4/18


 Plan of Correction - To be completed: 06/04/2019

The facility is unable to submit a significant change MDS for Resident 24 due to the timeframe.


Current facility residents will be reviewed weekly at the IDCP team meeting and as needed to identify resident's requiring a significant change MDS.


The RNAC's and IDCP team will be re-educated on the significant change MDS criteria/process.


Weekly audits times four and monthly times three will be completed by the Director of Nursing or designee to identify resident's meeting the criteria for a significant change MDS. The results of the audits will be reviewed at the monthly QAPI meeting.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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) Assisted nutrition and hydration.
(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)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on review of select facility policies and procedures, clinical record review, observation, and staff and resident interview, it was determined that the facility failed to accurately assess and monitor the implementation of a physician ordered therapeutic diet for one of one residents reviewed for hydration concerns (Resident 5).

Findings include:

The facility policy entitled, "Hydration," last reviewed without changes on November 13, 2018, revealed that residents will be provided with sufficient fluid to maintain proper hydration and health, including fluids served at mealtime and between meals, offered consistent with care plan, preferences, and choice. If a resident requires a fluid restriction, the physician or authorized health care provider will determine the total fluid amount to be provided per day. Nursing, the registered dietitian, and/or designee, will determine the percentage of fluids offered to a resident through interviewing that resident and determining their preference for fluids. The determination of total fluids allowed needs to take into consideration the fluids used for medication administration throughout the day. Nursing is responsible for recording the total fluid intake for the day. Nursing staff records (documents) in the electronic medical record or designated documentation tool.

The policy did not address the management of fluids typically maintained at bedside by the routine water pass for those residents with physician ordered fluid restrictions.

Interview with Employee 1 (assistant director of nursing) on April 18, 2019, at 1:58 PM revealed that the above policy from Clinical Nutrition Services is the facility's only policy regarding hydration management.

The facility's Fluid Restriction Guidelines indicated that a 1200 milliliter (ml) daily fluid restriction allotted 840 ml for meals and 360 ml for nursing medication administration/non-meal fluids.

Clinical record review for Resident 5 revealed a diagnoses list that included end stage renal (kidney) disease dependent on hemodialysis (loss of normal kidney function requiring artificial means of removing excess fluid and waste from the blood).

The facility provided Matrix for Providers (Centers for Medicare and Medicaid Services, CMS-802, form the facility provides to the survey team that indicates pertinent resident potential problem areas and care needs) noted Resident 5 triggered for dehydration (less fluid intake than the body needs) and hemodialysis.

Current physician orders for Resident 5 included a diet order that stipulated a 1200 ml fluid restriction since November 12, 2018.

Observation of Resident 5's room on April 16, 2019, at 12:46 PM revealed a 20-ounce Styrofoam cup on his overbed table. Interview with Resident 5 during the observation revealed that he believed the Styrofoam cup is refreshed every shift and that it is never empty. Resident 5 was unable to state how much fluid he consumes from the cup daily.

Registered dietitian documentation dated November 26, 2018, noted that Resident 5's physician ordered a 1500 ml daily fluid restriction; and that Resident 5 needed encouragement to meet that amount as he does not often feel thirsty.

A plan of care developed by the facility to address Resident 5's goal for dietary intake to meet estimated nutritional needs to promote weight stability and prevent dehydration did not address the provision of bedside supplemental fluids (Styrofoam water cup). The plan of care did not indicate what staff would be responsible, or interventions implemented, to accurately monitor the intake of fluids between meals.

Interview with Employee 3 (registered dietitian) on April 18, 2019, at 12:40 PM confirmed that the documentation dated November 26, 2018, errantly noted Resident 5's dietary orders restricted his fluid intake to 1500 ml (as his physician ordered a 1200 ml fluid restriction at that time). The interview confirmed that Employee 3 was aware that Resident 5 had a Styrofoam beverage cup at his bedside and that this was not restricted in his plan of care; however, also confirmed that one 20-ounce cup would, in and of itself, exceed the 360 ml fluid allotment for between meal fluid intake (one 20-ounce Styrofoam cup would provide 600 ml of fluid when filled). Employee 3 indicated that she believed nursing staff documented on bedside Styrofoam cups when residents are on a fluid restriction. The interview confirmed that this instruction was not included in the facility policy regarding hydration. The interview indicated that dietary staff informed the nursing department that Resident 5 is allotted 360 ml of fluid a day from their department; and it is up to the nursing department to distribute that amount as they deem appropriate.

Registered dietitian documentation (completed by Employee 4, registered dietitian) dated April 16, 2019, commented that, "Resident has been averaging 2000 ml fluid daily, Na (sodium) is slightly low, chronic. Consider D/C (discontinue) fluid restriction as resident does not typically stay within those restrictions."

Review of Resident 5's fluid intake documentation dated April 9 through 15, 2019, revealed an average fluid intake of 1782 ml per day. Fluid amounts documented for between meal intakes ranged from 335 to 960 ml (average of 630 ml per day).

Interview with Employee 4 on April 18, 2019, at 1:00 PM confirmed that her intention was to suggest a discontinuation of Resident 5's fluid restriction based on his noncompliance with the restriction. Employee 4 indicated that her determination of Resident 5's noncompliance was based on the fluid intake documentation. Employee 4 confirmed that her determination of Resident 5's average of 2000 ml per day was incorrect as she added eight days of totals and divided by 7. Employee 4 confirmed that she did not evaluate Resident 5's knowledge of his restriction as it related to the presence of a facility-provided 20-ounce cup of water at least daily on his overbed table. Employee 4 agreed that the facility-provided bedside fluids exceeded his physician ordered restriction.

28 Pa. Code 211.6(d) Dietary services

28 Pa. Code 211.10(c) Resident care policies
Previously cited 5/4/18

28 Pa. Code 211.11(d) Resident care plan
Previously cited 10/3/18

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 10/3/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 10/3/18 and 5/4/18


 Plan of Correction - To be completed: 06/04/2019

Resident 5 current physician order for fluid restriction as of 04/22/2019 is 1500 milliliters. Resident 5 bedside water cup is labeled with the fluid restriction and the amount each shift is to provide for the resident. Resident 5 care plan has been updated.


A facility audit of other resident's on fluid restrictions will be completed to ensure bedside water cups are labeled indicating the amount of the fluid restriction and the amount each shift is to provide. Residents on fluid restriction care plans have been reviewed and updated as needed.


Nursing staff will be re-educated on the policy entitled, "Hydration." The education will include labeling bedside water cups with the amount of the fluid restriction as well as the amount each nursing shift provides. Education will also include ensuring the resident plan of care is updated to include this information.


Weekly audits time four and monthly times three will be completed the Director of Nursing or designee to ensure residents on fluid restrictions bedside water cups are labeled appropriately and care plans update. The audits will be reviewed at the monthly QAPI meeting.

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 select facility policies, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to prevent accidents for one of seven residents reviewed (Resident 61).

Findings include:

The facility policy entitled, "Fall Management: During and After Care," last reviewed on November 13, 2018, revealed that all residents that experience a fall will receive an evaluation and proper after care, monitoring, and services to maintain their highest functionality.

Clinical record review for Resident 61 revealed a progress note dated August 16, 2018, at 3:15 PM that indicated Resident 61was found on the floor next to his bed sitting on his buttocks. There was no injury noted. He stated that he wanted to get out of bed.

Review of the facility's investigation into Resident 61's fall revealed that Employee 6, Nurse Aide, answered Resident 61's call bell, turned off the call bell, but did not turn his PIR (Passive infrared sensor alarm, motion detector) alarm back on before exiting the room. The facility indicated that the action they would take would be to educate the staff member.

Interview with the Director of Nursing on April 19, 2019, at 10:32 AM revealed that there was no evidence that the facility provided post fall education to Employee 6.

Clinical record review for Resident 61 revealed that he had a fall on November 3, 2018, at 11:58 AM.

Review of the facility's investigation into Resident 61's fall revealed that he was in the common area on the unit and tried to transfer himself to the sofa. A statement from Employee 5, Dietary Aide, revealed that she did not see Resident 61 fall, but that he was trying to get out of his chair and slid on to the floor. The facility's investigation indicated that they would provide education to dietary staff to verbally intervene and call for assistance when witnessing a resident attempting to self-transfer.

Interview with the Assistant Director of Nursing on April 19, 2019, at 10:08 AM revealed that the facility could not provide evidence that they provided education to dietary staff post fall.

Further clinical record review revealed that Resident 61 fell again on November 11, 2018, at 10:45 PM. He stated he was trying to get up. He was found on the floor on the left side of the bed with his head under the bed. The bed was in a low position and fall mats were in place, but his alarm was not on. Resident 61 was noted to have received a forehead abrasion measuring 1.5 cm (centimeters) x 1.5 cm and a right knee abrasion measuring 3.5 cm x 3.0 cm.

The facility's investigation into Resident 61's fall revealed Employee 6's witness statement dated November 11, 2018, indicated that she again failed to put Resident 61's alarm in place. The facility's intervention was a verbal warning education to Employee 6.

The facility failed to implement interventions to prevent Resident 61's falls.

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 10/3/18 and 5/4/18

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 10/3/18


 Plan of Correction - To be completed: 06/04/2019

Resident 61 plan of care reviewed and all fall interventions are in place.

Employee 5 will be re-educated to alert direct care staff to residents with safety concerns and documented. Employee 6 will be re-educated and documented on the ensuring resident fall preventatives are in place prior to leaving resident unattended.


Facility falls from the past 30 days will be reviewed to ensure proper staff education provided and documented.


Nursing staff will be re-educated on the policy entitled, "Fall Management: During and After Care." Dietary staff will be educated on the need to alert direct care staff of resident safety issues.


Weekly audits times four and monthly times three will completed by the Director of Nursing or designee to ensure proper staff education and documentation as needed post resident falls. The results of the audits will be reviewed at the monthly QAPI meeting.

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, review of select policies and procedures, and staff interview, it was determined that the facility failed to initiate a restorative range of motion program for two of three residents reviewed (Residents 10 and 80).

Findings include:

The policy entitled "Restorative Nursing Services" last reviewed without changes on November 13, 2018, indicates that restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services. The policy indicates that residents may be started on a restorative nursing program upon admission, during the course of their stay, or when discharged from rehabilitative care. The policy does not reference how the facility will handle a decline in a resident's range of motion or if a formal range of motion program will be implemented. Interview with the Director of Nursing on April 19, 2019, at 12:45 PM confirmed that the facility does not have any other policies or procedures regarding the restorative range of motion program.

Review of Resident 10's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated February 1, 2019, that indicated the facility assessed her as having limited range of motion to both her lower extremities. A physical therapy referral dated February 5, 2019, indicated that nursing staff wanted physical therapy to look at her because Resident 10 was exhibiting discomfort with transfers due to a contracted right leg.

Review of the undated physical therapy screen indicated that the physical therapist noted no further impairments with transfers and that Resident 10 was on a restorative range of motion program and an evaluation was not indicated at this time. Interview with Employee 2, director of rehabilitation, on April 18, 2019, at 10:53 AM confirmed that he was the therapist that screened Resident 10 after the February 5, 2019, referral by nursing. Employee 2 indicated that he did not assess her range of motion limitations, nor did he initiate a restorative range of motion program for her lower extremities after the screen. Employee 2 confirmed that Resident 10 was only on a range of motion program for her upper extremities.

Interview with the Administrator and Director of Nursing on April 18, 2019, at 2:00 PM acknowledged the above findings.

Review of Resident 80's clinical record revealed an MDS dated March 27, 2019, that indicated the facility assessed her as having limited range of motion to both of her lower extremities and both of her upper extremities. The assessment also indicated that Resident 80 was not receiving a range of motion programs to her upper or lower extremities.

Review of Resident 80's initial MDS with the assessment reference date of July 2, 2018, revealed that she was admitted to the facility with no impairments in range of motion of her upper or lower extremities.

Interview with Employee 1, Assistant Director of Nursing, on April 19, 2019, at 10:04 AM revealed that there was no evidence that Resident 80 was assessed for a restorative nursing range of motion program, that she had previously been on a restorative nursing range of motion program, or that a restorative range of motion program was contraindicated.

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 10/3/18 and 5/4/18


 Plan of Correction - To be completed: 06/04/2019

Resident 10 and 80 will have therapy screens completed for Range of Motion and implementation of appropriate Restorative Nursing Programs.

Current facility residents will be reviewed to ensure appropriate Restorative Nursing Programs are in place as needed.


Nursing staff and therapy staff will be re-educated on the policy entitled, "Restorative Nursing Services."


Weekly audits times four and monthly times three will be completed by the Director of Nursing or designee to ensure residents have appropriate Restorative Nursing programs as needed by the Director of Nursing or designee. The results of the audits will be reviewed at the monthly QAPI meeting.

483.25(a)(1)(2) REQUIREMENT Treatment/Devices to Maintain Hearing/Vision: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(a) Vision and hearing
To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-

483.25(a)(1) In making appointments, and

483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.
Observations:

Based on review of select facility policies and procedures, clinical record review, observation, and staff and resident interview, it was determined that the facility failed to ensure proper treatment and services for hearing impairment for one of two residents reviewed for vision/hearing concerns (Resident 79).

Findings include:

The facility policy entitled, "Sensory Impairments - Clinical Protocol," last reviewed without changes on November 13, 2018, revealed that the facility will help a resident with hearing impairment to obtain a hearing evaluation, hearing aid, or employ written or other means to communicate with the individual. The physician will identify and order appropriate consultations to help manage the causes, complications, and risks of sensory impairment. The staff and physician will monitor the function and symptoms of individuals with sensory impairment, and the status of any underlying causes and conditions. The physician and staff will adjust interventions based on the results of these interventions and on subsequent changes in the resident's condition, prognosis, and function.

Observation of Resident 79 on April 16, 2019, at 10:34 AM revealed that he was in his room with the television volume loud enough to hear in the hallway several rooms away.

Attempt to interview Resident 79 on April 16, 2019, at 10:34 AM revealed that he needed simple questions repeated in a louder volume before expressing understanding.

Clinical record review for Resident 79 revealed documentation by the Otolaryngologist (physician that specializes in the treatment of diseases and injuries of the ears, nose, and throat) dated September 6, 2018, that confirmed that Resident 79 exhibited sensorineural hearing loss (root cause lies in the inner ear) bilaterally. The plan of treatment included the use of a listening device. The documentation indicated that the provider would allow the resident the use of a loaned hearing device.

A physician's order dated September 6, 2018, instructed staff to give and apply a hearing device to Resident 79 in the morning and remove in the evening for a seven day trial period.

Treatment administration records dated September 2018 confirmed that staff documented the application of a hearing device for Resident 79 each morning and removal each evening from evening shift on September 6, 2018, through day shift September 12, 2018 (except September 9, 2018).

Resident 79's clinical record contained no evidence of an evaluation of the treatment following the seven day trial. Resident 79's clinical record contained no evidence of a subsequent appointment with the Otolaryngologist.

An annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated March 26, 2019, assessed Resident 79 as having moderate difficulty with hearing and that no hearing aids were used.

Interview with Employee 1 (assistant director of nursing) on April 19, 2019, at 9:58 AM confirmed that the facility had no further information regarding Resident 79's response to the hearing device trial as noted above. The facility was unable to determine the location of the hearing device (in Resident 79's possession or returned to practitioner) that Resident 79 used during the trial. The interview confirmed that Resident 79 did not have a follow-up appointment with the Otolaryngologist after September 6, 2018.

483.25(a)(1)(2) Treatment/devices to Maintain Hearing/vision
Previously cited deficiency 10/3/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 10/3/18 and 5/4/18

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 10/3/18


 Plan of Correction - To be completed: 06/04/2019

Resident 79 has an appointment on May 30, 2019 with ENT.

Current facility residents will be reviewed to ensure necessary follow up to any identified hearing impairments.


Nursing staff will be re-educated on the policy entitled, "Sensory Impairments-Clinical Protocol."


Weekly audits times four and monthly times three will be completed by the Director of Nursing or designee to ensure identified hearing impairments have follow up. The audits will be reviewed at the monthly QAPI meetings.

483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities: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.
483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

483.24(b)(2) Mobility-transfer and ambulation, including walking,

483.24(b)(3) Elimination-toileting,

483.24(b)(4) Dining-eating, including meals and snacks,

483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
Observations:

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to identify a resident's decline in ADL's (activities of daily living) for one of two residents reviewed (Resident 28).

Findings include:

The facility policy entitled, "Functional Impairment - Clinical Protocol," last reviewed without changes on November 13, 2018, revealed that periodically during a resident's stay, the physician and staff will assess the resident's physical condition and functional status. Staff will identify and evaluate the individual's co-morbidities, conditions causing functional decline, symptoms, risks, impairments, and disabilities, and investigate their causes. Staff may initiate (an) initial screening for the potential to benefit from rehabilitative services. The therapist will document whether the resident may benefit from a more detailed rehabilitation evaluation or from unskilled therapy. If a potential to benefit from rehabilitation therapies is identified, the attending physician will order relevant therapy evaluations. Staff will monitor the resident's functional progress, while in therapy and in general, while on the unit for resident improvements or declines and discuss with the resident's physician.

Clinical record review for Resident 28 revealed that the facility completed a quarterly MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) on January 10, 2019, indicating that she required one-person supervision with eating.

On February 5, 2019, the facility completed an annual MDS assessment indicating that Resident 28 required extensive assistance from one-person while eating.

Review of referral for therapy screening form (a form requesting that therapy evaluate a resident for the need of therapy services) dated February 7, 2019, revealed that nursing staff referred Resident 28 to speech therapy due to a change in eating habits, was pocketing food and/or has food residuals, and had a self-feeding decline. The speech therapist completed an evaluation on February 7, 2019 and noted that Resident 28 was "pocketing (food), had a decrease in oral food intake, and a decline in cognition." The speech therapist wrote an order for a skilled speech therapy evaluation, treat for dysphagia treatment, and cognitive communication skills. Resident 28's physician signed the order on February 21, 2019.

On March 11, 2019, facility staff sent a second referral for a therapy screening indicating that Resident 28 was pocketing food. The speech therapist completed another evaluation on March 12, 2019, which indicated that Resident 28 now had "increased oral holding in her left cheek with decreased awareness of bolus (chewed food in the mouth) requiring continuous cues from staff to continue chewing clear(ing) oral cavity of residue." On March 13, 2019, the speech therapist initiated the above noted physician order for Resident 28, 33 days after the facility initially identified Resident 28's concern with a decline in eating.

There was no documentation that the facility implemented a speech therapy program after her identified decline with eating on February 7, 2019.

Interview on April 19, 2019, at 10:42 AM with Employee 1, assistant director of nursing, and on April 19, 2019, at 11:11 AM with Employee 2, therapy director, confirmed the above findings.

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 10/3/18 and 5/4/18

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 10/3/18


 Plan of Correction - To be completed: 06/04/2019

Resident 28 was on speech therapy from March 13, 2019 to April 5, 2019.


Therapy has developed a screening log for all residents referred to therapy to ensure timely treatment. The screening log is reviewed weekly to ensure residents screened have timely evaluations and implementation of orders as needed.


Evaluating therapy staff will be re-educated on the screening log process, implementation of therapy evaluations and orders during the weekly review. Therapy staff will be re-educated on the policy entitled, "Functional Impairment-Clinical Protocol."


The screening forms will be audited weekly times four and monthly times three by the Therapy Director or designee to ensure timely therapy evaluations and orders as needed. The results of the audits will be presented at the monthly QAPI meetings.

483.10(g)(10)(11) REQUIREMENT Right to Survey Results/Advocate Agency Info:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
483.10(g)(10) The resident has the right to-
(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and
(ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.

483.10(g)(11) The facility must--
(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility.
(ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and
(iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.
(iv) The facility shall not make available identifying information about complainants or residents.
Observations:

Based on observation and resident and staff interview, it was determined that the facility failed to ensure that the most recent survey results were posted and readily accessible to all residents in the front lobby and on five of five nursing units (Blue Jay Way, Pheasant Ridge, Country Lane, Chestnut Trail, and Bison Boulevard).

Findings include:

Observation of the survey binders on all the nursing units and in the front lobby on April 16, 2019, at 9:46 AM revealed that they did not contain the results of the last complaint survey that ended on March 19, 2019. The survey results were also not in an accessible location on Blue Jay Way, Pheasant Ridge, Country Lane, and Chestnut Trail nursing units.

A group interview held on April 17, 2019, at 10:30 AM also revealed that the survey results are not accessible to a resident in a wheelchair, and that they would have to "ask for them."

Interview with the Director of Nursing on April 17, 2019, at 12:30 PM confirmed the above findings.

28 Pa. Code 201.29(i) Resident rights
Previously cited 10/3/18 and 5/4/18


 Plan of Correction - To be completed: 06/04/2019

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

The most recent survey results completed 04/19/19 has been placed in the survey binders on each nursing unit and front lobby. The survey binders have been placed at wheelchair level.

Future survey results will be placed in the binders on each nursing unit and front lobby upon receipt. Survey binders will remain at wheelchair level.

Management staff will be re-educated on the need to place most recent survey results in the binders on the units and front lobby upon receipt. Staff will be re-educated that survey binders must be at wheelchair level at all times.

Weekly audits times four and monthly times three will be completed by the Nursing Home Administrator or designee to ensure survey results remain in the binders on the units and front lobby. The audits will also ensure survey binders are at wheelchair level. The results of the audits will be reviewed at the monthly QAPI Meeting.
201.19 LICENSURE Personnel policies and procedures.:State only Deficiency.
Personnel records shall be kept current and available for each employe and contain sufficient information to support placement in the position to which assigned.
Observations:

Based on review of five newly hired employee personnel files and staff interview, it was determined that the facility failed to provide documentation of reference checks and a signed job description for one of the five sampled employees (Employee 7).

Findings include:

Review of Employee 7's (cook) personnel file revealed the facility hired her on February 13, 2019. The facility could not provide any documentation that they completed reference checks for Employee 7 or that Employee 7 acknowledged/signed what her job description was in the facility's dietary department.

Interview on April 18, 2019, at 1:25 PM with the Nursing Home Administrator and Employee 8, dietary manager, confirmed the above findings.



 Plan of Correction - To be completed: 06/04/2019

Employee 7 reference checks and job description signature were completed by the Culinary Director.


The Director of Dining will review all employees hired within the last 30 days that are still employed to ensure reference checks and a signed job description are in place.


The Culinary Director has been educated and is aware it is his responsibility to complete reference checks and signed job descriptions on dietary hires.


Weekly audits time four and monthly times three will be completed by the Culinary Director or designee to ensure new dietary hires have the appropriate reference checks and job descriptions signed prior to the first day of employment.

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 review of select facility policies and procedures, closed clinical record review, and staff interview, it was determined that the facility failed to ensure the completion of a discharge summary within 30 days of discharge for one of three discharged residents reviewed (Resident 99).

Findings include:

The facility policy entitled, "Transfers and Discharges: Physician Role," last reviewed without changes on November 13, 2018, revealed that upon or within 30 days of an individual's discharge, the physician will provide an appropriate discharge summary. The discharge summary will include: a brief summary of the resident/patient's stay at the facility, the status of significant active medical diagnoses, and patient problems at the time of discharge. If the individual has died, the final summary will review the individual's stay and identify factors contributing to death.

Closed clinical record review for Resident 99 revealed the facility admitted her on January 26, 2019, and discharged her on January 29, 2019.

Nursing documentation dated January 29, 2019, at 5:51 AM revealed that Resident 99 presented with altered mental status, the inability to follow directions, and the loss of her left handed grasp. Staff notified Resident 99's physician and obtained an order to transfer Resident 99 to the emergency room for evaluation.

Nursing documentation dated January 29, 2019, at 9:55 AM revealed that facility staff communication with the emergency room staff indicated that the emergency room admitted Resident 99 to the hospital's intensive care unit for a stroke diagnosis (brain injury resulting in loss of function).

A Notice of Resident Transfer or Discharge and Bed Hold Policy (Pennsylvania) (form the facility utilizes to communicate required information to a resident/responsible party in the event of a resident's transfer out of the facility) dated by a facility representative on January 29, 2019, revealed that Resident 99 did not return to the facility; she expired in the hospital.

Interview with Employee 9 (assistant nursing home administrator) and Employee 1 (assistant director of nursing) on April 18, 2019, at 12:30 PM confirmed that Resident 99's closed clinical record did not contain a physician's discharge summary.

Interview with Employee 9 on April 18, 2019, at 3:45 PM confirmed that the facility failed to complete Resident 99's discharge summary until after the surveyor's questioning. The Physician's Discharge Summary dated by the physician on April 18, 2019, did not include a recapitulation of Resident 99's stay in the facility. The only notation made on the document read, "Patient was transferred to Emergency Department and expired."


 Plan of Correction - To be completed: 06/04/2019

Resident 99 discharge summary cannot be corrected at this time as the discharge was more than 30 days ago.


An audit of residents discharged in the last 30 days will be completed to ensure the appropriate discharge summary has been completed by the attending physician.


A copy of the policy entitled, "Transfers and Discharges: Physician Role" will be sent to all physicians that see residents at the facility.


Weekly audits time four and monthly time three will be completed by Nursing Home Administrator or designee to ensure discharge summaries are completed within the 30 days from the date of discharge. The audits will be reviewed at the monthly QAPI meeting.


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