Pennsylvania Department of Health
PAVILION AT BRMC, THE
Patient Care Inspection Results

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PAVILION AT BRMC, THE
Inspection Results For:

There are  70 surveys for this facility. Please select a date to view the survey results.

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PAVILION AT BRMC, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on January 5, 2024, it was determined that The Pavilion at BRMC was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.10(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, facility grievances, and resident and staff interviews, it was determined that the facility failed to provide acknowledgement of a complaint/grievance and actively work toward resolution of that complaint/grievance for two of 19 residents reviewed (Residents R9 and R11).

Findings include:

Review of the facility policy entitled, "Pavilion Complaint/Grievance Policy," dated 12/28/23, revealed that the Pavilion grievance official will oversee the Pavilion grievance process, receive and track grievances through their conclusion, will lead any necessary investigation by the facility, will maintain confidentiality of all information associated with grievances, will be responsible in issuing written grievance decision to the resident/resident representative and will coordinate with state and federal agencies as necessary in light of specific allegations. The grievance official of the Pavilion will also take immediate action to prevent potential violation of any resident right while the alleged violation is being investigated.

During an interview on 1/03/24, at 10:00 a.m. Resident R9 indicated he/she discussed concerns with administrative staff about being left on the toilet for long periods of time. Resident R9 further indicated administrative staff implied the concern would be addressed, however, no resolve of the grievance had occurred.

During an interview on 1/03/24, at 1:00 p.m. Resident R11 indicated he/she discussed several concerns with administrative staff such as a brace for his/her right knee, a dental appointment, cell phone usage by staff during care, and urine collection device not being emptied. Resident R11 indicated further that no resolve of the grievances had occurred.

On 1/04/24 at 8:40 a.m., the Nursing Home Administrator (NHA) provided two complaints/grievances from residents/resident representatives for review and there was no evidence that the concerns were investigated, tracked through to a conclusion, and that a written grievance decision was provided to the resident/resident representative.

During an interview on 1/05/24, at 10:15 a.m. the Director of Nursing confirmed that the facility lacked evidence that the complaints/grievances for Residents R9 and R11 as noted above, were investigated, tracked through to a conclusion, and that a written grievance decision was provided to Resident R9 and Resident R11.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1) Management

28 Pa. Code 201.18(b)(3)(e)(1)(3) Management





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

The Administrator spoke to residents R9 and R11 post survey and neither wanted to fill out a grievance form at that time. Since conversation with administrator resident R11 has filed a grievance with other concerns. Resident R11's concerns were addressed and plans were put in place. R11 was satisfied with the results and signed the grievance form. Staff was educated on the importance of checking on residents while in the bathroom, call bells and cell phone usage. there were only 2 found grievances from 2023 and both were handled prior to survey. The Pavilion's Grievance process has been updated. The Social Service Director will be the new grievance officer going forward and will be responsible for handling any grievances appropriately and in a timely manner that are submitted and giving to the Administrator. The grievance form has been updated to reflect the changes, a new grievance log and binder will be kept. Residents will be notified of the change at the next resident council meeting scheduled for 1/24/2024. All staff education will be provided to ensure the new process is followed properly. Administrator/designee will conduct audits on the grievance log and grievance binder 2x/week for 2 weeks, weekly for 2 weeks and periodically thereafter until compliance is met. Findings will be discussed in QAPI.
483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:


Based on observations, review of facility policy and clinical records, and staff and resident interviews, it was determined that the facility failed to maintain resident dignity by placing a wander guard bracelet (a device with a small box on a plastic bracelet placed on an at risk wandering person to alert the staff if that person attempts to exit the facility without staff supervision) on one of two residents reviewed for wander guard usage (Resident R24).

Findings include:

Review of a facility policy entitled "General Safety Practices at The Pavilion" dated 12/28/2023, revealed "All residents at risk for elopement will be placed on the second floor and a wander guard bracelet will be initiated."

Review of Resident R24's clinical record revealed an admission date of 4/15/16, with diagnoses that included hypertension (high blood pressure), heart failure (a condition where the heart cannot supply the body with enough blood), presence of artificial knee joint, and edema (swelling to an area of body due to holding excessive fluid).

Review of residents that reside on the second floor locked unit revealed that only eight of 25 residents had wander guards in place.

Further review of Resident R24's clinical record revealed, no evidence of an evaluation for elopement risk. Review of MDS Section C - Cognitive Patterns C0500 with assessment dates of 2/24/23, 5/11/23, 8/8/23 and 11/5/23, revealed a BIMS (Brief Interview of Mental Status- cognitive interview to check mental status of a person with a score of zero being severely impaired and 15 being alert and oriented) of 15 on all four dates.

Review of MDS Section E Behavior E0900 with assessment dates of 2/24/23, 5/11/23, 8/8/23 and 11/5/23 revealed a Wandering - Presence and Frequency (assessment codes as 0-behavior not exhibited through three indicating that the behavior of this type occurred daily) assessment coded as zero-behavior not exhibited, on all four dates for Resident R24.

Observations on 1/2/2024, at 4:06 p.m. revealed a wander guard bracelet on Resident R24's left ankle.

Interview with Resident R24 on 1/2/2024, at 4:06 p.m. revealed he/she had the wander guard bracelet placed several years ago due to him/her leaving the facility and going to the store. He/she stated that he/she did not know that they were not allowed to leave the facility, he/she used to sit outside the facility without supervision. When he/she returned to the facility staff placed a wander guard bracelet on Resident R24 and placed Resident R24 on the second floor locked unit. Resident R24 also stated that he/she told the facility he/she would not leave the facility again without staff knowledge. Resident R24 also revealed that he/she had cut the wander guard bracelet off several times and staff would replace it but never asked him/her why he/she kept cutting it off. He/she revealed that he/she is embarrassed by the wander guard bracelet. Resident R24 stated that when he/she goes out to appointments, he/she finds the wander guard bracelet embarrassing and stated, "it's my house arrest."

During an interview on 1/4/2024, at 3:19 p.m. the DON (Director of Nursing) revealed that facility had no evidence of elopement assessments being completed. He/she also revealed that Resident R24 had cut off his/her wander guard bracelet on several occasions and that facility staff had replaced the wander guard bracelet.

Observation on 1/5/2024, at 9:05 a.m. revealed the wander guard bracelet remained on Resident R24's left ankle. During an interview at that time, Resident R24 stated "yes I still have the little box, it's embarrassing, my house arrest."

Interview with Employee E1 on 1/5/2024, at 8:40 a.m. revealed that he/she has worked at the facility for one year in a full time position on the second floor locked unit. He/she revealed that Resident R24 has had no elopement episodes while he/she was working.

Interview with Employee E2 on 1/5/2024, at 8:50 a.m. revealed that he/she has worked at the facility for three years in a full-time position on the second floor locked unit. He/she revealed that Resident R24 has had no elopement episodes while he/she was working. Interview also revealed that Resident R24 has verbally communicated to him/her when he/she was going out into the garden which is part of the second floor locked unit.

Interview with DON on 1/4/2024, at 3:19 p.m. he/she confirmed that Resident R24 should have been reassessed for the use of the wander guard bracelet. He/she also confirmed that the use of a wander guard is not appropriate for a resident that is alert and oriented with a BIMS of 15.

28 Pa. Code 201.29(a) Resident rights

28 Pa. Code 211.12(d)(1)(5) Nursing Services







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

An Elopement Risk Assessment will be completed by 1/19/2024 on any resident currently with a wander guard and will be given to all new admissions starting 1/16/2024 to determine elopement risk. The Elopement Risk Assessment will be given quarterly thereafter to any resident meeting criteria for a wander guard or any resident with any significant change in condition that would require the assessment being completed. Nursing staff education will be completed by 1/19/2024 on the Elopement Risk Assessment. Resident R24 was assessed on 1/16/2024 and met the criteria for Elopement Risk. A score of 10 or greater indicates that the resident is considered an elopement risk. R24 scored a 20. Resident R24's wander guard remained on because of previous history of elopement, being fully ambulatory and during the assessment, R24 expressed that he/she cannot wait until the wander guard is taken off so he/she can walk to his/her family's house just down the road whenever he/she wanted. R24 was educated that he/she can leave the facility anytime he/she wants as long as he/she has a representative that signs him/her out and in. Alternative bands for the wander guard are being looked into such as different colors, designs to give a more "fashionable" appearance, also different placement on the body for the wander guard such as on the wrist is being looked into. The Director of Nursing/designee will do Elopement Risk Assessment audits on all new admissions starting 1/19/2024 2x/week for 2 weeks, weekly for 2 weeks and quarterly thereafter until compliance is met. Findings will be discussed in QAPI.
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 review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure a physician's order was completed correctly to indicate the code status as Full Code (CPR/Attempt Resuscitation) or Do Not Resuscitate (DNR/Do Not Attempt Resuscitation-Allow Natural Death) for one of 19 residents reviewed (Resident R39).

Findings include:

Review of a facility policy "Advance Directives-Health Care Proxy, MOLST/POLST, Living Will" dated 12/28/23, revealed "All adult individuals in New York State and in Pennsylvania have the right to self-determination in Health Care and the right to express their preferences regarding health care treatment, including decisions to continue or refuse routine or major medical treatment, as well as life-sustaining treatment without which the individual is expected to die. Advance directives such as health care proxies (HCP), living wills and consents to Do Not Resuscitate (DNR) orders allow an adult to express his/her healthcare treatment preferences and wishes, in order to be prepared for those situations in which that individual may be unable to communicate for him/herself. Instructions - It is a BRMC-OGH goal to encourage Health Care Proxy completion among competent patients, and to place those documents in the permanent medical record in ambulatory, acute, and long-term care settings. For patients who are already incapacitated with no proxy, it is a goal to identify surrogate decision makers as early as possible and actively engage them in the care of those patients."

Review of Resident 39's clinical record revealed an admission date of 11/16/23, with diagnoses that included weakness, urinary tract infection, failure to thrive, and Parkinson's disease (a disorder of the central nervous system that affects movement, often tremors).

Resident R39's clinical record indicated Full Code on the Code Status Form dated 11/16/23, signed by Resident R39's power of attorney (POA). A physician order dated 1/3/24, indicated Resident R39 to be a DNR.

Review of Resident R39's clinical record on 1/04/24, at 2:00 p.m. lacked evidence of a POLST.

During an interview on 1/04/24, at 3:20 p.m. the Registered Nurse Assessment Coordinator (RNAC) provided Resident R39's POLST which indicated a Full Code status. The RNAC confirmed the POLST was not maintained, but should be on Resident R39's clinical record for direction of Resident R39's plan of care.

During an interview on 1/04/24, at 3:25 p.m. the RNAC confirmed Resident R39's code status was documented in error as a DNR as a physician order and should be a Full Code as indicated by the POA and POLST.

28 Pa. Code 201.18 (b)(1)(e)(1) Management

28 Pa. Code 201.29(a) Resident rights

28 Pa. Code 211.10(c) Resident care policies






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

A facility wide code status audit was completed on all current residents on 1/15/2024 to ensure that the POLST/MOLST matched the code status in the doctor's order for all residents. A care conference was set up with any resident and family/representative that was identified with a code status discrepancy to determine the appropriate code status. Resident R39's power of attorney was contacted to confirm full code status was accurate. POA confirmed full code status and the doctors order was corrected from DNR to Full Code to reflect the POLST. A POLST we be completed upon admission of all new residents starting 1/16/2024 and will be checked by DON to ensure that doctors orders match POLST. Staff education will be completed by 1/24/2024 on the Advance Directives-Health Care Proxy, MOLST/POLST, Living Will. POLST/order review will be incorporated into monthly QAPI by Medical Records to ensure that compliance is met. DON/designee will conduct an audit on all new admissions starting 1/16/24 2x/week for 2 weeks, weekly for 2 weeks and will be incorporated into the monthly QAPI meeting. POLST/order review will be incorporated into the weekly interdisciplinary care plan review meetings.
483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan regarding the use of side rails for one of 17 residents reviewed (Resident R32).

Findings include:

Review of a facility policy entitled "Resident Care Plan" dated 12/28/23, indicated that the facility will develop a comprehensive care plan of care to reflect the needs of the resident, be individualized and resident driven, and utilize nursing assessments, evaluations, etc.

Resident R32's clinical record revealed an admission date of 10/19/16, with diagnoses that included dementia, generalized muscle weakness, heart disease, arthritis, and limitations of activities due to disability.

Current physician's orders for January 2024, indicated that Resident R32 was to have siderails up on both sides of his/her bed to promote independence with bed mobility and transfers. The clinical record lacked evidence of a care plan to address his/her side rail use.

Review of Resident R32's clinical record documentation the daily use of side rails on both sides of his/her bed for November 2023, December 2023, and January 2024.

Multiple observations on 1/02/24, and 1/03/24, revealed Resident R32 in bed positioned on his/her side and both half rails were in the up position.

During an interview on 1/03/24, at 10:50 a.m. Registered Nurse Employee E3 confirmed that Resident R32 always has his/her side rails up on both sides of the bed.

During an interview on 1/04/24, at 11:00 a.m. the Registered Nurse Assessment Coordinator confirmed there was no evidence that a care plan was developed for Resident R32's use of side rails on both sides of the bed.

28 Pa. Code 211.10(c) Resident care policies

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




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

Resident R32 does not meet the requirements for siderails. R32's care plan was updated to reflect the findings and the doctors order was discontinued. Residents care plans will be reviewed at resident's quarterly care plan meeting or if there is a significant change in residents health. A facility wide care plan audit for all existing residents will be completed by 1/24/2024 to determine if a proper care plan was developed for the use of bed side rails. Care plans will be properly updated with findings of the audit. The Resident Care Plan policy will be reviewed with the Interdisciplinary Team to ensure the policy is being followed correctly. Administrator/designee will conduct a care plan audit on all new admissions and any current resident with a new order for side rails starting 1/19/2024 2x/week for 2 weeks, weekly for 2 weeks and quarterly thereafter. Findings will be discussed in QAPI.
483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:


Based on observations, review of facility policy and clinical records, and staff interview, it was determined that the facility failed to administer supplemental oxygen as ordered and promote cleanliness regarding respiratory care equipment according to physician orders for one of 19 residents reviewed (Resident R17).

Findings include:

Review of a facility policy entitled "Care of Oxygen Tubing/Nebulizer Tubing and Filters" dated 12/28/23, indicated that oxygen concentrator filters will be cleaned monthly.

Review of a facility policy entitled "Medication Administration" dated, 12/28/23, revealed that medications shall be administered in accordance with the orders of the prescribing Healthcare Practitioner, and oxygen administration must have a physician order, the order must be written on the Medication Administration Record (MAR) and the nurse is to monitor oxygen flow rate every shift.

Resident R17's clinical record revealed an admission date of 1/25/14, with diagnoses that included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), heart disease, heart failure, muscle wasting, amputation of left fingers and left foot, high blood pressure, unsteady on feet, and difficulty walking.

The most recent physician's order dated 12/25/23, indicated to administer oxygen at two liters per minute (LPM) through a nasal cannula (a device that gives you additional oxygen [supplemental oxygen or oxygen therapy] through your nose), as needed for shortness of breath/wheezing. The December 2023 MAR indicated that Resident R17 was receiving his/her oxygen at two LPM on two-to-three shifts daily.

Observations on 1/02/24, at approximately 4:00 p.m. and on 1/03/24, at 8:50 a.m. revealed that Resident R17 was in bed and his/her oxygen concentrator filter was blowing a significant amount gray fluffy substance into the air, and the oxygen flow rate was set at one and a half LPM.

During an interview on 1/02/24, at approximately 4:00 p.m. Resident R17 confirmed that he/she was supposed to receive oxygen at two LPM.

During an interview on 1/03/24, at 8:55 a.m. the Nursing Home Administrator and Director of Nursing confirmed that upon opening the oxygen concentrator filter casing, the filter was covered with copious amounts of a gray fluffy substance, and had not been cleaned recently, and that the oxygen flow rate was set for one and a half LPM, and that Resident R17 was ordered two LPM.

28 Pa. Code 211.10(c) Resident care policies

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









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

Resident R17's Oxygen flow setting was adjusted back to 2 L and the concentrator filter cleaned immediately upon surveyor's findings. A facility wide audit will be completed by 1/19/2024 on oxygen concentrator filters for cleanliness and the O2 flow rates are as ordered by the physician. Staff education on the policy "care of oxygen tubing/nebulizer tubing and filters" will be completed by 1/19/2024. An oxygen concentrator filter cleaning log will be kept at the nurse's station on each floor to be completed monthly on each concentrator in use by maintenance. Nursing education on the policy "medication administration" will be completed by 1/19/2024. A log will be kept at the nurse's station on each floor to be completed every shift by the floor nursing to ensure the correct oxygen flow rate is being used to match the doctor's order. DON/designee will conduct audits on the concentrator filter log monthly periodically and will conduct an audit on the oxygen flow rate log daily for 2 weeks, 2x/wk for 2 weeks, weekly for 2 weeks and monthly thereafter until compliance is met. DON/designee will do random checks on 50 percent of concentrator filters monthly on each floor to ensure that they are being cleaned and will do random checks on 50 percent concentrators weekly for 4 weeks to ensure that flow settings are being checked. Findings will be discussed in QAPI.
483.25(n)(1)-(4) REQUIREMENT Bedrails: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(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

§483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

§483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

§483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

§483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.
Observations:

Based on observations, review of clinical records and facility policy, and staff interviews it was determined that the facility failed thoroughly review and assess the use of bed rails prior to their use and review the risk versus benefits of using bed rails with the resident's representative and obtain informed consent for the installation and use of bed rails prior to the installation for two of 19 residents reviewed (Residents R32 and R67).

Findings include:

Review of a facility policy entitled "Side Rails and Use of Side Rails" dated 12/28/23, indicated that half side rails may be utilized to assist a resident with bed mobility and transfers or to assist the resident with bed controls but only after an individual Side Rail assessment is completed on admission, quarterly, annually, and as needed.

Resident R32's clinical record revealed an admission date of 10/19/16, with diagnoses that included dementia, generalize muscle weakness, heart disease, arthritis, and limitations of activities due to disability.

Review of current physician's orders for January 2024, revealed Resident R32 was to have siderails up on both sides of his/her bed to promote independence with bed mobility and transfers. Review of Resident R32's clinical record documentation revealed daily use of side rails on both sides of his/her bed for November 2023, December 2023 and January 2024

Further review of Resident R32's clinical record revealed no evidence of that an individual Side Rail assessment was completed upon admission, quarterly, annually, or as needed, and lacked the required informed consent from the resident/representative for the use of side rails prior to installation.

Multiple observations on 1/02/24, and 1/03/24, revealed Resident R32 in bed positioned on his/her side and both half side rails were in the up position.

Review of Resident R67's clinical record revealed an admission date of 9/14/23, with diagnoses that included Down Syndrome (genetic condition that causes mild to serious physical and developmental problems), long-term kidney disease, malnutrition, and embolism and thrombosis (clots get stuck in an artery and block blood flow, the blockage starves tissues of blood and oxygen).

Review of current physician's orders for January 2024, revealed Resident R67 was to have siderails up on both sides of his/her bed to promote independence with bed mobility and transfers. The clinical record revealed a care plan addressing self-care deficit and included an intervention to use half rails during the provision of care and included access to bed controls. Review of Resident R32's clinical record documentation revealed daily use of side rails on both sides of his/her bed for December 2023, and January 2024.

Further review of Resident R67's clinical record revealed an incomplete individual Side Rail assessment dated 9/14/23 (upon admission) and lacked the required quarterly Side Rail assessment and informed consent from the resident/representative for the use of side rails prior to their installation.

During an interview on 1/04/24, at 1:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed there was lack of evidence that the required periodic side rail assessments were completed, and that informed consents were not obtained from the resident/representative for the use of side rails prior to installation.

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 201.18(b)(1) Management





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

A facility wide side rail assessment will be completed on all current residents by 1/24/2024 and any new admissions starting 1/24/2024 to assess if a resident can utilize side rails to assist in mobility and transfers or to assist the resident with the bed controls which are built into the side rail. If a resident assessment finds that the resident cannot utilize the side rails for mobility and transfers or cannot utilize the bed controls, then the side rails will be kept down at all times. If the assessment indicates that the side rails can be utilized for mobility or transfers, or the controls can be utilized then the side rails will remain up. Updates will be made to the side rail policy to reflect the changes. An entrapment risk assessment will be completed on any resident identified to being able to utilize side rails by 1/26/2024 and the benefits and risks will be reviewed with the resident or resident representative and an informed consent will be obtained. Red tape will be placed on side rails that are to remain down at all times, green tape will be placed on the side rails that can be kept up. Staff education to be completed by 1/19/2024 on the utilization of side rails in accordance with the updated policy and the meaning of the red and green tape. Residents R32 and R67 were assessed and did not meet the requirements for siderails. Side rails were put down and red tape was wrapped around the top of the rail. side rails will be looked at during resident's care plan meeting or with a significant change in condition to determine appropriateness. DON/designee will conduct a side rail assessment audit weekly for 2 weeks, every other week for a month and monthly to ensure resident's whose side rails are up have proper assessments completed and consent form signed. audits will be based on new admissions only after initial audit is complete. Findings will be discussed in QAPI.
483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:


Based on observations, review of clinical records and facility policy and staff interview, it was determined that the facility failed to prevent the potential for cross contamination during a dressing change for one of 19 residents (Resident R32).

Findings include:

Review of a facility policy entitled "Standard Precautions" dated 12/28/23, revealed that staff are expected to change their gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms, and remove gloves promptly after use, before touching non-contaminated items and environmental surfaces.

Observation of wound care on 1/03/24, at 3:12 p.m. revealed that Registered Nurse (RN) Employee E3 performed hand hygiene and donned (put on) clean gloves; removed the soiled dressing containing a moderate amount of exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation); picked up the multi-use bottle of wound cleanser; applied wound cleanser solution to two, four inch by four inch cotton gauzes; cleansed the wound of a moderate amount of exudate; opened the sealed package of wound dressing (Promogran- cellulose, collagen and silver dressing); used scissors to cut the Promogran to the size of the wound bed; opened the sealed package of Allevyn (dressing indicated for exudate absorption in wound care); applied the Allevyn to the wound; obtained a wound label and used a pen to write the date on the label.

During an interview at that time RN Employee E3 confirmed that he/she didn't know if staff was supposed to change gloves and cleanse hands during dressing changes when going from dirty to clean areas.

During an interview on 1/04/24, at 1:50 p.m. the Director of Nursing confirmed that staff are to change gloves and perform hand hygiene after removing soiled dressings, and after wound cleansing if exudate present.

28 Pa. Code 211.10(c)(d) Resident Care Policies

28 Pa. Code 211.12 (d)(1)(5) Nursing Services





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

Resident R32 has been monitored weekly during wound rounds and has not had any negative outcomes from the dressing changes and will continue to be monitored weekly during rounds. A step by step procedure guide on the proper steps to take for a wound dressing was created and inserted in each floor's treatment book. The nursing staff will be educated on the new procedure guide and where to find it. Staff re-education on the standard precautions policy will be completed by 1/24/2024. Employee E3 will be re-trained in wound care procedure. Nursing re-education on proper wound care procedure will be completed by 1/24/2024 and demonstrated during annual competencies. DON/designee will do wound dressing audits on 2 residents per floor weekly x's 4 weeks and monthly x's 3 months to ensure compliance is met. DON/designee will audit new hire competencies monthly to ensure compliance is being met. Findings will be discussed in QAPI.
§ 211.5(f)(i)-(xi) LICENSURE Medical records.:State only Deficiency.
(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a resident ' s medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death.

Observations:


Based on a review of closed clinical records and staff interview, it was determined that the facility failed to ensure that a discharge summary, with the physician's final diagnosis, was completed for one of three discharged residents reviewed (Closed Record Resident CR71).

Findings include:

A review of Resident CR71's closed clinical record revealed that the resident was admitted to the facility on 10/02/23, with diagnoses that included heart failure, kidney disease, Type 2 Diabetes (condition that effects how the body uses glucose [sugar]), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), morbid obesity, and irregular heartbeat.

Departmental progress notes dated 10/18/23, indicated that Resident CR71 was transported to the acute hospital for fluid retention and anasarca (a condition characterized by severe generalized edema of the body).

A review of the Resident CR71's closed clinical record revealed that there was no physician's discharge summary with the resident's final diagnosis.

During an interview on 1/05/24, at 11:15 a.m. the Director of Nursing confirmed the facility could not provide documentation of a physician discharge summary completed for Resident CR71.



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

A discharge summary was completed on Resident CR71. An audit on closed charts starting on 1/1/2024 will be completed by Medical Records by 1/24/2024 to ensure discharge summary with the resident's final diagnosis and prognosis or cause of death is being completed. Staff education with staff responsible for closed charts will be completed by 1/24/2024 on resident's medical record. Administrator/designee will conduct audits on closed charts weekly for 2 weeks, every other week for 4 weeks and periodically thereafter starting 1/25/2024. Findings will be discussed in QAPI.
§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on review of nursing time schedules and staff interviews, it was determined that the facility failed to provide a minimum one nurse aide (NA) per 20 residents during the overnight shift on five of 14 days (9/08/23, 9/09/23, 9/11/23, 9/12/23, and 9/13/23).

Findings include:

Review of facility census data revealed that on 9/08/23, and 9/09/23, the facility census was 80, which required four NAs during the overnight shift. Review of the nursing time schedules revealed that 3.28 NAs provided care on the overnight shift on 9/08/23, and 3.75 NAs provided care on the overnight shift on 9/09/23, therefore not meeting the NA ratio for the overnight shift on those dates.

Review of facility census data revealed that on 9/11/23, the facility census was 81, which required 4.05 NAs during the overnight shift. Review of the nursing time schedules revealed that 3.84 NAs provided care on the overnight shift on 9/11/23, therefore not meeting the NA ratio for the overnight shift on that date.

Review of facility census data indicated that on 9/12/23, the facility census was 83, which required 4.15 NAs during the overnight shift. Review of the nursing time schedules revealed that 3.78 NAs provided care on the overnight shift on 9/12/23, therefore not meeting the NA ratio for the overnight shift on that date.

Review of facility census data indicated that on 9/13/23, the facility census was 82, which required 4.10 NAs during the overnight shift. Review of the nursing time schedules revealed that 3.31 NAs provided care on the overnight shift on 9/13/23, therefore not meeting the NA ratio for the overnight shift on that date.

During an interview on 1/05/24, at 11:00 a.m. the Nursing Home Administrator confirmed that the facility did not meet the NA ratio during the overnight shift for the above identified dates.




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

A staff ratio instruction guide on how to calculate accurate staffing ratios in case of staff call offs was created and will be kept at each nurses station along with a staff phone number list. Nurse supervisor Education on the ratio instruction guide will be completed by 1/19/2024. Education will be provided to the scheduler on staff ratios and will be completed by 1/19/2024. Daily staffing meetings with scheduler to discuss ratios will begin on 1/19/2024. We will continue to do staff recruitment and retention programs, we will closely monitor admissions in conjunction with our staffing numbers, we have pick-up bonuses in place, and we will continue to keep CNA staffing agency contracts open and use if necessary. Administrator/designee will audit staffing numbers daily x's 2 weeks, 2xs/week for 2 weeks, weekly x's 2 weeks and periodically thereafter. Findings will be discussed in QAPI.


§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on review of nursing time schedules and staff interviews, it was determined that the facility failed to provide a minimum of one Licensed Practical Nurse (LPN) per 25 residents during the day shift on 10 of 14 days (9/09/23, 9/10/23, 9/12/23, 9/13/23, and 12/29/23-1/03/24).

Findings include:

Review of facility census data revealed that on 9/09/23, and 9/10/23, the facility census was 80, which required 3.2 LPNs during the day shift. Review of the nursing time schedules revealed that three LPNs provided care on the day shift on 9/09/23, and 2.9 LPNs provided care on the day shift on 9/10/23, therefore not meeting the LPN ratio for the day shift on those dates.

Review of facility census data revealed that on 9/12/23, the facility census was 81, which required 3.24 LPNs during the day shift. Review of the nursing time schedules revealed that 3.06 LPNs provided care on the day shift on 9/12/23, therefore not meeting the LPN ratio for the day shift on that date.

Review of facility census data revealed that on 9/13/23, the facility census was 83, which required 3.32 LPNs during the day shift. Review of the nursing time schedules revealed 3.06 LPNs provided care on the day shift on 9/13/23, therefore not meeting the LPN ratio for the day shift on that date.

Review of facility census data revealed that on 12/29/23, and 12/30/23, the facility census was 77, which required 3.08 LPNs during the day shift. Review of the nursing time schedules revealed two LPNs provided care on the day shift on 12/29/23, and 3.03 LPNs provided care on the day shift on 12/30/23, therefore not meeting the LPN ratio for the day shift on those dates.

Review of facility census data revealed that on 12/31/23, to 1/03/24, the facility census was 76, which required 3.04 LPNs during the day shift. Review of the nursing time schedules revealed three LPNs provided care on the day shift on 12/31/23, to 1/03/24, therefore not meeting the LPN ratio for the day shift on those dates.

During an interview on 1/05/24, at 11:00 a.m. the Nursing Home Administrator confirmed that the facility did not meet the LPN ratio for the day shift on the above identified dates.



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

Nurse supervisor Education on the ratio instruction guide will be completed by 1/19/2024. Education will be provided to the scheduler on staff ratios and will be completed by 1/19/2024. Daily staffing meetings with scheduler to discuss ratios will begin on 1/19/2024. We will continue to do staff recruitment and retention programs, we will closely monitor admissions in conjunction with our staffing numbers, we have pick-up bonuses in place, and we will continue to keep LPN/RN staffing agency contracts open and use if necessary. Administrator/designee will audit staffing numbers daily x's 2 weeks, 2xs/week for 2 weeks, weekly x's 2 weeks and periodically thereafter. Findings will be discussed in QAPI.

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