Nursing Investigation Results -

Pennsylvania Department of Health
CATHEDRAL VILLAGE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
CATHEDRAL VILLAGE
Inspection Results For:

There are  68 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.
CATHEDRAL VILLAGE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to a complaint, completed on May 17, 2019, it was determined that Cathedral Village, was not in compliance with the 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 related to the health portion of the survey process.




 Plan of Correction:


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).
Observations:

Based on review of facility policy, clinical records and facility documentation and interviews with staff and resident representatives, it was determined that the facility failed to immediately notify the physician and/or resident representative of a change in a resident's medical condition in a timely manner for two of 42 residents reviewed (Resident R321 and R74).

Findings include:

Review of facility policy, "Change in Medical Condition," dated February 18, 2019, revealed that the facility "shall provide notice of changes in medical condition related to ... UTI (urinary tract infection), ... incidents, and other care issues in a timely manner meeting the requirements of accrediting agencies and federal and state regulations."

Review of the clinical record for Resident R321 revealed that the resident was admitted to the facility on May 8, 2019, with diagnoses including, but not limited to, dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and lumbar laminectomy (procedure to the lower back that relieves pressure in the spinal canal).

Review of facility documentation related to Resident R321's fall completed by a nurse aide on May 13, 2019, revealed that "I was making my round and I heard help so I went to the room and found her by the bathroom door stating she was going to the bathroom." The nurse aide indicated in her documentation that the fall occurred on May 13, 2019, at 4:30 p.m.

Review of facility documentation related to Resident R321's fall completed by a registered nurse on May 13, 2019, at 7:40 p.m., revealed that "This nurse was alerted that resident was on floor ... Resident noted to have an abrasion 0.1 cm (centimeter) x 14 cm on her right lower back."

Continued review of facility documentation related to Resident R321's fall revealed that the resident's physician was notified on May 13, 2019, at 6:29 p.m. and gave instructions to monitor the resident for any changes.

Further review of the clinical record revealed that Resident R321's representative was notified on May 13, 2019, at 7:45 p.m. and that the representative expressed concerns about the resident injuring her back.

Continued clinical record review revealed an interdisciplinary note, dated May 17, 2019, at 10:06 a.m., which indicated that Resident R321 was subsequently admitted to the hospital and that "Resident has a diagnosis of dementia and has been noted with confusion. Unable to educate resident on call bell usage due to confusion and dementia."

Interview on May 15, 2019, at 10:45 a.m., with Resident R321's representative revealed that the resident fell on May 13, 2019, at 4:30 p.m.. Resident R321's representative further indicated that the physician was not notified of the fall until 6:30 p.m. and the resident's family was not notified of the fall until 7:42 p.m., approximately three hours after it occurred.
Resident R321's representative stated that if the family had been notified at the time of the fall, the family would have come to the facility sooner to request that the resident go to the emergency room.

Interview with the Director of Nursing on May 16, 2019, at 1:20 p.m., revealed that he was unable to explain why the facility took two hours to notify the physician and three hours to notify the family after Resident 321's fall.


Interview with Resident R74 on May 14, 2019 at 10:00 a.m., revealed that the resident was not feeling well. The resident reported that she was having hallucinations (an experience involving the apparent perception of something not present). Interview with the registered nurse at 10:30 a.m., on May 14, 2019 revealed that the nurse remembered that the psychiatrist evaluated this resident on May 7, 2019. The registered nurse also reported that the psychiatrist had recommended that laboratory studies be completed related to a possible urinary tract infection for Resident R74 in light of the fact that the resident was reporting having hallucinations.

Clinical record review confirmed that this resident was evaluated by the psychiatrist on May 7, 2019. The psychiatrist noted that it would be prudent to have a urine culture and sensitivity completed for Resident R74 to rule out a urinary tract infection. On May 8, 2019 the physician ordered a urine culture and sensitivity test (a urine culture is a method to grow and identify bacteria in the urine). The test will identify the microorganism that causes the infection and find a suitable antibiotic to kill the microorganism. The physician also ordered a hematology study (complete blood count) for Resident R74. The complete blood count indicated that on May 9, 2019 Resident R74 had an elevated white blood cell count (indicator of an infection).

Review of the urine culture and sensitivity final report dated May 11, 2019, indicated that 100,000+ gram-positive cocci (bacteria) in chains were present in the urine. There was no documentation to indicate that the physician was notified of Resdient R74's change in condition and abnormal laboratory results on May 11, 2019.

Interview with the director of nursing on May 15, 2019 at 1:00 p.m., confirmed that the facility failed to immediately notify the resident's physician on May 11, 2019 when there was a need to commence a new form of treatment for Resident R74.

The facility failed to ensure that the physican and family/representatives were notified of changes in resident's medical condition in a timely manner for two residents.

28 Pa Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 9/10/18, 4/23/18, 4/12/18, 8/22/17, 1/3/17

28 Pa Code 211.10(d) Resident care policies
Previously cited 4/23/18, 4/12/18, 1/3/17






 Plan of Correction - To be completed: 07/01/2019

1. Resident R321 no longer resides in the community and was discharged. Resident R74 received treatment and the urinary tract infection has resolved.
2. An audit of current residents with a change in condition in the last 7 days will be reviewed for timely physician notification and timely family notification.
3. Licensed Nursing staff will be re-educated regarding physician notification and family notification when there is a change in medical condition.
4. An audit of 5 residents will be completed to ensure timely physician and timely family notification for changes in medical condition will be completed weekly for 4 weeks then monthly for 2 months. Audit results will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.

483.10(j)(1)-(4) REQUIREMENT Grievances: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(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 facility policies, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to post their grievance policy in prominent locations throughout the facility for three of three nursing units and failed to investigate concerns voiced by a resident representative for one out of 42 residents reviewed (Resident R11).

Findings include:

Review of facility policy, "Grievance, Complaints and Suggestions," dated September 14, 2017, revealed that "Communities have a mechanism in place to assist the resident, and/or their resident representative, in voicing conflicts about care decisions, grievances, or complaints ... This policy will be posted in prominent locations throughout the facility." Continued review revealed that "Each community must designate a Grievance Officer ... The name and contact information of the Grievance Officer must be posted on each neighborhood and at the main entrance of the health center ... The Grievance Officer as identified will maintain complaint logs. All grievances/complaints or suggestions shall be maintained on the Grievance Log. The resident and/or their resident representative, will be kept informed of the process taking place to resolve the grievance, complaint or suggestion ... residents/resident representative have a right to a written grievance decision"

An interview on May 15, 2019 at 11:15 a.m., during the group meeting that was held with nine alert and oriented residents revealed that Resident R11's representative (niece) filed a grievance related to a missing personal item for Resident R11. The grievance was filed approximately one to two weeks prior to the group meeting on May 15, 2019. Resident R11 reported during the group meeting that the facility never responded to the resident or the resident's niece about the results of the investigation into the resident's missing item (perfume).

Review of the facility's concern logs for the past five months revealed that Resident R11's concern was not listed on the log.

Interview with the director of nursing on May 16, 2019, at 10:00 a.m. revealed that the facility must have lost the grievance form for Resident R11.

A tour of the facility completed between 10:00 a.m. and 10:30 a.m. on May 17, 2019, revealed that the facility grievance policy was not posted on any of the nursing units and that there were no grievance forms readily available on any of the nursing units.

Interviews on May 17, 2019, at 10:00 a.m., with Employee E3, registered nurse and Employee E4, unit clerk, from the first floor nursing unit, confirmed that neither the grievance policy nor grievance forms were posted or readily available on the unit.

Interviews on May 17, 2019, at 10:20 a.m., with Employee E6, licensed practical nurse, and Employee E5, nurse aide, from the second floor nursing unit, confirmed that neither the grievance policy nor grievance forms were posted or readily available on the unit.

Interview on May 17, 2019, at 10:30 a.m., with Employee E7, registered nurse, from the third floor nursing unit, confirmed that neither the grievance policy nor grievance forms were posted or readily available on the unit.

Interview on May 17, 2019, at 11:05 a.m. with Employee E8, Regional Nurse, confirmed that neither the grievance policy nor grievance forms were posted or readily available by the health center entrance and stated that they should be.

The facility failed to post their grievance policy in prominent locations throughout the facility and failed to investigate a concern voiced by one resident's representative.

28 Pa. Code 201.29(a)(b)(d) Resident rights.

28 Pa. Code: 201.18(b)(1) Management.
Previously cited 4/12/18 and 1/3/17

28 Pa. Code: 201.14(a) Responsibility of licensee.
Previously cited 4/12/18 and 1/3/17










 Plan of Correction - To be completed: 07/01/2019

1. Resident R11's perfume has been found and returned to the resident. Grievance policy has been posted in prominent locations throughout the community and includes the Grievance Officer Contact and grievance forms.
2. Grievances in the past 15 days have been reviewed to ensure that the results of the grievance investigations were communicated to the resident/family member. Postings and forms are as stated above.
3. Re- education will be given to the Grievance Officer and the Social Service staff regarding the need to provide grievance results to the residents or their representative. The Nursing supervisors and Nursing Administration were re-educated on the locations of the postings and the availability of the grievance forms. Residents will be re-educated at resident council.
4. An audit of Grievance Log will be completed weekly for 4 weeks and then monthly for 2 months to ensure that results of investigations have been communicated to the resident or their representative. An audit will be completed to verify that the postings are in place and that the forms are readily available weekly x 4 weeks and then monthly X2. Audits results will be forwarded to the Quality Assurance Process Improvement Committee.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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.
§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:

Based on review of clinical records, facility policies and procedures, facility documentation and interviews with staff, it was determined that the facility failed to protect residents from verbal/emotional abuse for two of 42 residents reviewed (Resident R74 and R107).

Findings include:

Review of facility policy, "Abuse, Neglect or Exploitation", dated July 2, 2009 revealed that each resident is provided with a safe environment where they are not subject to mental, physical, verbal and sexual abuse.

Review of information submitted by the facility dated April 26, 2019, revealed that Resident R107's nursing assistant, Employee E10, was verbally abusive to the resident when the resident was incontinent of feces and soiled his sheets. Continued review of the information submitted by the facility revealed that Employees E11 and E12, Physical therapists, witnessed the verbal abuse while providing the resident with incontinence care.

Review of the witness statement from Employee E11 indicated that the resident had a bowel movement in bed and while providing incontinence care the resident was concerned and very upset that he would get in trouble. The witness statement further indicated that the resident's nursing assistant (NA), Employee E10, came into the room and in a short tone told the resident not to do it again, that if he did, she was not going to change the sheets.

Review of the witness statement from Employee E12 also indicated that while providing incontinence care to Resident R107 he kept saying they are going to be mad at him for soiling his bed. The witness statement also included that Employee E10, NA, told the resident, "We are not doing that again today. I am not changing your sheets again today."

Review of the information submitted by the facility, dated February 3, 2019, revealed that Resident R74's nursing assistant was verbally abusive toward her. Resident R74 reported that her nursing assistant yelled at her and called her "fat".

Review of Resident R74's clinical record indicated that the resident had a mild cognitive impairment with a BIMS (Brief Mini-Mental State exam) score of 11 out of 15. The comprehensive Minimum Data Set (MDS-an assessment of resident care needs) dated February 6, 2019, indicated that the resident had mildly impaired cognition (cognition- mental process of being awake, alert and aware, with sound judgement and capable of making independent decisions).

Review of Resident R74's witness statement revealed that on February 5, 2019, Employee E14, nursing assistant, had been yelling and talking down to her for a long time. The resident reported that the nursing assistant told the resident that she was entitled to speak to the resident however she wanted. Resident R74 reported that the nursing assistant treated her like she was inferior and yelled at her, telling her to get out of bed, "you'll listen to me, I am the new manager here." She raises her voice and yells at the resident "I am getting you out of bed whether you like it or not." Resident R74 reported feeling humiliated by this treatment in front of the other residents. Resident R74 reported that the accused nursing assistant ignores her request to be put into bed. The nursing assistant leaves Resident R74 in her wheelchair for up to five hours. Further review of Resident R74's witness statement noted that the resident was visibly upset, while reporting these allegations. Resident R74 was provided comfort and emotional support by Employee E21, social services worker.

Review of a witness statement obtained from Employee E20, licensed practical nurse, reported that she had witnessed Employee E14, nursing assistant, telling Resident R74 that "You are too fat for me to be able to change your diaper, so we have to have a second person to help. That costs this facility extra money". The licensed practical nurse further reported witnessing Employee E14 tell Resident R74 that "you'll listen to me, I am the new manager and I will talk to you how I want too", You'll get out of bed whether you like it or not" and "You're fat you don't need to eat all the sweets".

Further review of information submitted by the facility revealed a witness statement dated February 5, 2019 from Employee E20, licensed practical nurse. The LPN indicated that Resident R74 had told her about Employee E14, nursing assistant, on different occasions. The LPN said that she was aware of the abuse allegations one month prior to the February 5, 2019 interview. The LPN's witness statement further indicated that the abuse was reported to the nursing unit manager; however, nothing came of it. Additionally,the LPN reported that she witnessed Resident R74 crying because of the treatment she was being subjected to by the nursing assistant. The licensed practical nurse reported that Resident R74 told her that the accused nursing assistant yells at her, tells her that she is fat and that she does not need to eat all the sweets and desserts. The LPN also reported that Resident R74 said that when she asks to receive bowel or bladder incontinence care, she was told she has to wait.

Continued review of the information submitted by the facility regarding the alleged abuse and neglect of Resident R74 confirmed that Employee E14 verbally/emotionally abused Resident R74 on February 3, 2019.

Interview with the administrator on May 16, 2019, at 10:30 a.m. confirmed that the facility failed to substantiate Resident R74's allegation of verbal/emotional abuse despite the fact that Employee E14, nursing assistant, admitted to teasing the resident about her weight and that Employee E20, licensed practical nurse, had stated that she was present and witnessed the abuse of Resident R74 on February 3, 2019.

The facility failed to protect two residents from verbal and mental abuse.

42 CFR 483.12(a)(1) Freedom from Abuse, Neglect and Exploitation.
Previously cited 4/23/18.

28 Pa. Code: 201.18(a)(b)(1)(2)(3)(d)(1) Management.
Previously cited 4/12/18 and 1/3/17

28 Pa. Code: 201.29(a)(b)(c) Resident rights.

28 Pa. Code: 211.12(d)(1)(5) Nursing services.
Previously cited 4/12/18, 8/22/17 and 1/3/17

28 Pa. Code: 211.12(c) Nursing services.
Previously cited 4/12/18 and 1/3/17









 Plan of Correction - To be completed: 07/01/2019

1. Resident R107 and Resident R74 did not sustain lasting harm from the events occurring on 2/5/19 and 4/26/19.
2. An audit of incidents/grievances in the last 14 days concerning possibilities for abuse or neglect has been completed with no other residents being affected.
3. Staff will be re-educated regarding identifying and reporting allegations of abuse or neglect. Management team will be re-educated on investigation and interview protocols for incidents and/or grievances from employees and residents by the corporate clinical representative. Incidents and grievances will be reviewed at the morning clinical meeting to monitor for appropriate processes.
4. The nursing home administrator/designee will audit grievances and incidents that may involve abuse or neglect weeklyX4 weeks and then monthly X2 months to ensure appropriate investigation and follow through has been completed. Audit results will be forwarded to the Quality Assurance Process Improvement Committee.

483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on review of clinical records, review of facility policies and interviews with staff, it was determined that the facility failed to report an allegation of neglect for one of forty-three residents reviewed (Resident R74).

Findings include:

Review of facility policy, "Abuse, Neglect or Exploitation", dated July 2, 2009, revealed that each resident is provided with a safe environment where they are not subject to mental, physical, verbal and sexual abuse.

Interview with Employee E1, nursing home administrator, on May 16, 2019 at 1:00 p.m. confirmed that the facility failed to report an allegation of neglect reported by Resident R74 on February 5, 2019.

review of facility documentation related to Resident R74's report of verbal/emotional abuse on February 3, 2019, the resident stated that the nursing assistant, Employee E14 ignores her request to be transferred from the wheelchair into the bed, after the resident had been sitting in the wheelchair, constantly/continuously for up to five hours.

The comprehensive assessment MDS (an assessment of care needs) dated February 6, 2019 indicated that Resident R74 had BIMS ( mini-mental state exam) score of 11 of 15. Facility documentation dated February 3, 2019 indicated that Resident R74 had mild confusion. The comprehensive assessment dated February 6, 2019 indicated that Resident R74 required extensive assist of two staff persons for transfers (how a resident moves between surfaces including to and from bed, chair).

The facility failed to report an allegation of neglect for one resident as required.

28 Pa. Code: 201.18(b)(1)(3) Management.
Previously cited 4/12/18 and 1/3/17

28 Pa. Code: 201.29(a)(b)(c) Resident rights






 Plan of Correction - To be completed: 07/01/2019

1. Resident R74 did not sustain lasting harm from the reported incident of February 3, 2019.
2. A review of resident grievances for the last 14 days has been completed. Any other resident concerns will be reported as needed.
3. Nursing Home Administrator and the nursing management team will be re-educated regarding the reporting requirements and process for allegations of abuse or neglect by the corporate clinical representative.
4. Audit of grievances for concerns relating to abuse or neglect will be completed by the nursing home administrator/designee weekly for X4 weeks and then monthly X2 months to ensure appropriate reporting of incidents occurred. Audit results will be forwarded to the Quality Assurance Process Improvement Committee.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on review of clinical records, review of facility policies and facility documentation and interviews with staff, it was determined that the facility failed to complete a thorough investigation into allegations of abuse and/or neglect for three of 42 resident records reviewed (Residents R93, R107 and R109).

Findings include:

Review of the information submitted by the facility on April 14, 2019 revealed that when Resident R93 asked to go to the bathroom the resident was told by Employee E17, Nursing Assistant (NA), to "go in her brief ". Further review of the investigation revealed a witness statement from Employee E16, Registered Nurse (RN) which stated that Resident R93 had complained that she was treated poorly overnight, she was told to go in her brief and that the staff would clean her up later. Employee E16, further indicated that the resident was continent of bowl and bladder and was in tears when the day shift staff arrived. The resident also believed the staff were laughing at her after being forced to be incontinent.

Continued review of the facility's investigation revealed undated resident interviews conducted by Employee E19, Social worker. Review of the resident responses to the question do they had any issues with the 11-7 staff during that past weekend revealed the following:

One resident that was interviewed stated that one day he rang his bell to go to the bathroom, a women answered the bell and said she would be back but she never returned.

One other resident stated, '11-7 shift takes a little longer to get here. A few weeks ago it took so long for someone to answer my bell, over 45 minutes and I had an accident. Their famous words are, "I'll be right back." The resident also stated that sometimes when they are busy "they would give me a bed pan instead of taking me to the toilet."

Another resident was asked if his call bell was answered when he rings it, he replied, 'Sometimes, sometimes not.'

Interview with the Nursing Home Administrator on May 17, 2019 at 11:20 a.m. revealed that the above allegations related to the care and services received from the interviewed residents were never further investigated to rule out abuse and/or neglect.

Review of the information submitted by the facility dated April 26, 2019 revealed that Resident R107's Nursing Assistant (NA), Employee E10, was verbally abusive to the resident when an incontinence episode caused him to soil his sheets. Review of Resident R107's witness statement revealed that,"Sometimes when they (nursing staff) come in, they roll me around like a paper doll and it hurts really bad. Sometimes I think they do stuff on purpose. If they don't get here in time, I scratch and itch and it (feces) gets all over the place."

Review of the facility's investigation report into Resident R107's allegations dated May 1, 2019, included additional information from Employee E10, "She (NA) stated that she conveyed that there were several call outs that day and she did not have time to give him additional time to change his bed more than once that day."

Interview with the Nursing Home Administrator on May 16, 2019 at approximately 10:00 a.m. related to the new allegations from Resident R107's statements that " the staff purposefully hurts him when being rolled in bed", "staff not answering the call bells in a timely manner" or the allegation from the NA stating that "there were many call outs that day and did not have time to give him additional care." The NHA stated he did not look into the above concerns because he "thought it was a general statement without any time line" and felt it hadn't warranted an investigation.

A review of Resident R109's clinical record revealed that the resident was admitted to the facility on March 20, 2019, with diagnoses, including but not limited to, gastroesophageal reflux disease (digestive disease in which the stomach acids or bile irritates the esophageal lining), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow). A review of physician orders dated March 20, 2019 revealed an order for a mechanical soft diet with honey thick liquids.

A review of nurse's notes dated March 25, 2019, revealed that Resident R109 had choked in the dinning room during the breakfast meal. Nurse's notes further indicated that at the time the resident could not talk and was blue. The Heimlich maneuver (a first aid procedure of abdominal thrusts to treat upper airway obstructions or choking)was used. Then a physician walked in and took over the Heimlich. The resident coughed up some food. The resident was taken to his room and the Heimlich was continued and more food was expelled. The resident could speak and breath. The physician ordered the resident to be sent to the hospital due to the difficulty clearing his throat and due to the aggressive nature of the Heimlich, to rule out fractured ribs.

The resident returned to the facility the same day with no new orders. A review of nurse's notes dated March 27, 2019 revealed that speech therapy evaluated the resident and recommended no bread and continue current diet of mechanical soft, honey thick liquids.

Further review of the resident's clinical record revealed no evidence that an investigation had been initiated to determine what food items the resident was eating and/or had he received the correct diet.

Interview with the Director of Nursing on May 15, 2019 at 4:00 p.m. confirmed that the facility had not conducted an investigation to determine what the resident was eating and had he received the correct diet on the day that he choked.

The facility failed to thoroughly investigate allegations of potential resident abuse and/or neglect.

42 CFR 483.12(c)(2)(3)(4) Investigate/Prevent/Correct Alleged Violation
Previously cited 4/23/18 and 4/12/18

28 Pa. Code: 211.12 (d)(1)(5) Nursing services.
Previously cited 4/12/18, 8/22/17 and 1/3/17

28 Pa. Code: Responsibility of licensee.
previously cited 4/12/18 and 1/3/17

28 Pa. Code: 201.18(b)(1)(3) Management.
Previously cited 4/12/18 and 1/3/17












 Plan of Correction - To be completed: 07/01/2019

1. Residents R93, 107 and 109 did not sustain lasting harm from the reported incidents. R109 was receiving the correct diet at the time of the choking incident.
2. Incidents and grievances for the last 14 days have been audited for any potential abuse, neglect or other reportable incidents. No other incidents were noted.
3. Nursing Home Administrator and Nursing management team will be re-educated on proper investigation policies and protocols by the corporate nursing representative. Incidents and grievances will be reviewed at the morning clinical meeting to determine necessity for further investigations.
4. Nursing Home Administrator/designee will audit 5 grievances/ incidents to ensure investigations were completed and reported as necessary weekly X4 weeks and then monthly X2 months. Audit results will be forwarded to the Quality Assurance Process Improvement Committee.

483.20(f)(1)-(4) REQUIREMENT Encoding/Transmitting Resident Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(f) Automated data processing requirement-
§483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:
(i) Admission assessment.
(ii) Annual assessment updates.
(iii) Significant change in status assessments.
(iv) Quarterly review assessments.
(v) A subset of items upon a resident's transfer, reentry, discharge, and death.
(vi) Background (face-sheet) information, if there is no admission assessment.

§483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.

§483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:
(i)Admission assessment.
(ii) Annual assessment.
(iii) Significant change in status assessment.
(iv) Significant correction of prior full assessment.
(v) Significant correction of prior quarterly assessment.
(vi) Quarterly review.
(vii) A subset of items upon a resident's transfer, reentry, discharge, and death.
(viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment.

§483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.
Observations:

Based on clinical record review, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that resident assessments were encoded and transmitted in a timely manner for two of 42 residents reviewed (Residents R2 and R3).

Findings include:

Clinical record review for Resident R2 revealed a quarterly MDS assessment (Minimum Data Set-mandatory periodic resident assessment tool) dated March 18, 2019, that had not yet been encoded or transmitted at that time.

Clinical record review for Resident R3 revealed a quarterly MDS assessment dated March 22, 2019, that had not yet been encoded or transmitted at that time.

Interview with Employee E9, Registered Nurse Assessment Coordinator (RNAC), on May 16, 2019, at 12:50 p.m., confirmed that the above assessments were not submitted within the required timeframes.

The facility failed to ensure that resident assessments were encoded and transmitted in a timely manner.

28 Pa Code 211.5(f) Clinical records
Previously cited 9/10/18, 4/23/18, 4/12/18

28 Pa. Code: Responsibility of licensee.
previously cited 4/12/18 and 1/3/17

28 Pa. Code: 201.18(b)(1)(3) Management.
Previously cited 4/12/18 and 1/3/17








 Plan of Correction - To be completed: 07/01/2019

1. Resident R2 and Resident R3 continue to reside in the community. E9 was re-educated and Quarterly assessments were transmitted.
2. An audit of current resident's most recent MDS assessment was completed by the Corporate MDS Coordinator to ensure assessments were codes and transmitted in a timey manner.
3. The RNAC's, Director of Therapy , Nursing Home Administrator and Business Office will be re-educated by the Corporate MDS Coordinator on the Triple check process to ensure MDS assessments are encoded and transmitted in a timely manner.
4. An audit of 5 resident MDS Assessments will be reviewed weekly X 4 weeks and then monthly X 2 to verify that each assessment is encoded and transmitted in a timely manner. Audit results will be forwarded to the Quality Assurance Process Improvement Committee.

483.21(a)(1)-(3) REQUIREMENT Baseline 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 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:

Based on review of facility policies and clinical records and interviews with staff, it was determined that the facility failed to develop a baseline care plan related to dementia care for one of 42 residents reviewed (Resident R321).

Findings include:

Review of facility policy, "Falls Management Program," dated February 28, 2019, revealed that "All new residents will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan interventions will be developed to prevent falls and will consider the particular elements of the assessment that put the resident at risk."

Review of the clinical record revealed that Resident R321 was admitted to the facility on May 8, 2019, with diagnoses, including but not limited to, dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and lumbar laminectomy (procedure to the lower back that relieves pressure in the spinal canal).

Review of Resident R321's care plan dated May 8, 2019, indicated that the resident was identifed as at risk for falls and to "consult with therapy regarding current functional status" and to "answer call bells quickly." There was no indication on the care plan that Resident R321 had dementia.

Continued review of Resident R321's care plan, dated May 10, 2019, revealed there was no indication on the care plan that Resident R321 had dementia and/or what level of assistance the resident required with meals. Additionally, there was no indication of her prescribed diet. Further review of Resident R321's care plan dated May 8, 2019, indicated that the resident's discharge goals for eating, oral hygiene, toileting hygiene and walking were incomplete/not specified on the care plan and did not indicate what the resident's level of functioning was related to these skills or how her dementia impacts her ability to perform these skills.

Interview with the Director of Nursing on May 17, 2019, at 4:15 p.m., confirmed that Resident R321's baseline care plan was incomplete and did not provide any information on how the resident's dementia impacted her related to falls, mobility, toileting and eating.

The facility failed to develop a baseline care plan for one resident with dementia.

42 CFR 483.21(a) Baseline Care Plans
Previously cited 4/23/18

28 Pa Code 211.11(d) Resident care plan
Previously cited 9/10/18, 4/23/18, 1/3/17

28 Pa. Code: 211.12 (d)(1)(5) Nursing services.
Previously cited 4/12/18, 8/22/17 and 1/3/17








 Plan of Correction - To be completed: 07/01/2019

1. Resident R321 is no longer at the community and discharged.
2. An audit of residents who were admitted in the last 14 days will be completed to ensure baseline care plans accurately reflect resident care needs.
3. The Licensed nursing staff will be re-educated to accurately complete the baseline care plan to reflect resident care needs.
4. A random audit of 5 newly admitted residents will be completed to ensure baseline care plans were completed to reflect resident care needs weekly X4 weeks and then monthly X2 months. Audit results will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on observation, review of clinical records and interviews with family and staff, it was determined that the facility did not ensure that one of 42 residents reviewed was assisted with mouth care (Resident R82).

Findings include:

Review of Resident R82's clinical record revealed that the resident was admitted to the facility on October 11, 2018, with a diagnosis of Parkinson's disease (a disorder of the central nervous system that affects movement, and often includes tremors). Further review of the clinical record indicated that the resident was severly impaired in decision making skills.

Interview with Resident R82's family member on May 14, 2019, at 11:00 a.m. revealed that the facility staff are not consistently assisting the resident with mouth care. The resident's family members stated that they have to remind the nursing assistants to brush his teeth.

A review of the residents clinical record revealed a dental consult dated March 19, 2019, the dentist documented that the resident had moderate plaque (sticky film that coats the teeth and contains bacteria. Dental plaque can damage a tooth and lead to tooth decay or tooth loss) calculus/tartar (form of hardened dental plaque). Dentist also recorded refer to hygiene.

A review of nursing assistant's documentation of daily oral care called for brushing Resident R82's teeth two times a day. A review of the daily oral care form for the month of March 2019 revealed ten times in March that brushing the resident's teeth was not documented.

A review of the daily oral care for the month of April 2019, revealed seven times in April that brushing the resident's teeth was not documented.

A review of the daily oral care for May 1 to May 16, 2019 revealed ten times in May that brushing the resident's teeth was not documented.

Interview with the Director of Nursing on May 16, 2019 at 2:30 p.m. confirmed that the brushing of Resident R82's teeth was not documented and that the dental consult indicated the presence of moderate plaque.

The facility failed to assist a dependant resident with Parkinson's disease with oral care on a consistent basis.

28 PA Code:211.12 (d)(1)(5) Nursing services.
Previously cited 4/12/18, 8/22/17 and 1/3/17







 Plan of Correction - To be completed: 07/01/2019

1. Resident R82's oral care is being completed an appointment for dental hygienist is scheduled.
2. An audit of current residents who require assistance will be completed to determine the need for referral to dental hygienist.
3. The nursing assistants will be re-educated on oral hygiene to be completed twice a day.
4. A random audit of 5 resident's who require assistance with oral care will be reviewed weekly X 4 weeks and then monthly X 2 to ensure oral hygiene is adequate. Audit results will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.

483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to follow physician orders regarding laboratory tests and blood glucose readings for two of 42 resident records reviewed (Resident R3 and R12).

Findings include:

A review of Resident R3's clinical record revealed that the resident was admitted to the facility on December 10, 2013 with a diagnosis of paroxysmal tachycardia (episodes of an irregular heart beat that increases the heart rate).
The clinical record further indicated that the resident is severly impaired in decision making skills.

A review of physcian orders dated December 13, 2018, revealed an order for digoxin (used to treat heart failure and heart rhythm problems) 125 micrograms, one tablet by mouth once daily, hold if pulse below 60. Used for
paroxysmal tachycardia.

Further review of Resident R3's clinical record revealed a physician order dated May 7, 2019 for a digoxin level (a blood test to ensure the patient is taking the right amount of medication) and a basic metabolic panel (a blood test measuring eight important levels in the blood).

Continued review of the Residents R3's clinical record revealed no evidence that the digoxin level and basic metabolic panel facility had been completed as ordered.

Interview with Employee E16, nurse, on May 16, 2019 at 10:35 a.m. confirmed that the laboratory blood work was not done.

Review of Resident R12's clinical record revealed that the resident was admitted to the facility on March 23, 2018, with a diagnosis of diabetes (a group of diseases that result in too much sugar in the blood) and a sacral pressure ulcer. The clinical record further indicated that the resident was moderately impaired in decision making skills.

A review of physician orders dated July 27, 2018, revealed an order to test resident R12's blood glucose levels (the amount of sugar in your blood) before meals and at bedtime (four times daily), call physician if less than 60 milligrams per deciliter or greater than 350 milligrams per deciliter.

A review of the results for blood glucose checks for Resident R12, dated March 2019 revealed eleven times the blood glucose was over 350, and the physician was not notified. A review of April 2019, blood glucose monitoring revealed ten times the blood glucose was over 350 and the physician was not notified. A review of blood glucose monitoring for the month of May 1 until May 15, 2019, revealed that the resident's blood glucose monitoring results was over 350, five times and the physician was not notified.

Interview with Employee E18, nurse, on May 17, 2019 at 11:00 a.m. confirmed that the physician had not been notified of Resident R12's elevated blood sugar levels as ordered.

The facility failed to ensure that physician orders were followed.

42 CFR 483.25 Quality of care.
Previously cited 9/10/18, 4/23/18 and 4/12/18

28 Pa. Code: 211.12(d)(1)(5) Nursing services.
Previously cited 4/12/18, 8/22/17 and 1/3/17

28 Pa. Code: 210.18(b)(1) Management.
Previously cited 4/12/18 and 1/3/17

28 Pa. Code: 211.10 (c) Resident care policies.
Previously cited 4/12/18









 Plan of Correction - To be completed: 07/01/2019

1. Resident R3 and Resident R12 both continue to reside in the community. Resident R3 had her labs drawn and Resident R12 had his blood sugar variances addressed. Both residents did not experience any ill effects.
2. An audit of current resident's medical records in the last 7 days that are ordered labs and are receiving blood glucose monitoring with parameters is being reviewed to ensure labs are scheduled and completed per physician order and that per physician order physicians are notified of any blood glucose variances outside parameters.
3. Licensed nursing staff will be re-educated on physician notification for blood glucose results that are outside physician ordered parameters. Licensed nursing staff will be re-educated to ensure all labs are scheduled and completed per physician order.
4. A random audit of 5 residents receiving blood glucose monitoring with parameters will be reviewed weekly X4 weeks and monthly X2 months to ensure and variances are reported to the physician as appropriate per physician order. A random audit of 5 residents receiving labs will be reviewed weekly X4 weeks and monthly X2 months to ensure labs are scheduled and completed per physician order. All audit results will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.

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 clinical record review and staff and resident interviews, it was determined that the facility failed to assist the resident in gaining access to vision services for one of forty-three residents reviewed (Resident R74).

Findings include:

Review of the clinical record for Resident R74 revealed that the resident had been evaluated by a vision specialist on November 6, 2018. The evaluation indicated that the resident was to return to the ophthalmologist (a specialist in the branch of medicine concerned with the study and treatment of disorders and diseases of the eye) within six months or if the resident was experiencing any new distortion or blurring of the eyes. Further review of the clinical record revealed no documentation that the facility had obtained an order from the physician, made an appointment or arranged for transportation services for Resident R74 to return to the consulting eye specialist.

Interview with Resident R74 on May 14 at 9:30 a.m., revealed that the resident was having worsening vision. The resident reported a decrease in vision and not being able to see out of one eye.

Interview with Employee E7, registered nurse,on May 14, 2019, at 10:45 a.m. confirmed that no arrangements had been made for Resident R74 to be seen by the Ophthalmologist as recommended.

The facility failed to ensure that one resident received the proper assistance and/or treatment to maintain his vision.

28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.
Previously cited 4/12/18, 8/22/17 and 1/3/17

28 Pa. Code: 201.18(b)(1) Management.
Previously cited 4/12/18 and 1/3/17

28 Pa. Code: 211.10(c) Resident care policies.
Previously cited 4/12/18







 Plan of Correction - To be completed: 07/01/2019

1. Resident R74 has been scheduled for an Ophthalmology Consult.
2. An audit of current residents has been completed to ensure that vision consult appointments have been scheduled as needed.
3. Nursing staff and Unit Clerks will be re-educated to schedule vision appointments and vision follow-up appointments as appropriate.
4. A random audit of 5 residents with vision consultant appointments will be reviewed weekly X4 weeks and monthly X2 months to ensure appointments and follow appointments are scheduled as needed. All audit results will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.

483.55(a)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in SNFs:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.55 Dental services.
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

§483.55(a) Skilled Nursing Facilities
A facility-

§483.55(a)(1) Must provide or obtain from an outside resource, in accordance with with §483.70(g) of this part, routine and emergency dental services to meet the needs of each resident;

§483.55(a)(2) May charge a Medicare resident an additional amount for routine and emergency dental services;

§483.55(a)(3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility;

§483.55(a)(4) Must if necessary or if requested, assist the resident;
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services location; and

§483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay.
Observations:

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that one of 42 residents reviewed was seen by the dentist in a timely manner. (Resident R12).

Findings include:

Review of Resident R12's clinical record revealed that the resident was admitted to the facility on March 23, 2018, with a diagnoses of diabetes (failure of body to produce enough Insulin to enable sugar to pass from the bloodstream into the cell for energy) and a sacral pressure ulcer (breakdown of skin caused by unrelieved pressure).
The clinical record further indicated that the resident was moderately impaired in decision making skills.

Interview with the Resident R12 on May 17, 2019 at 10:00 a.m. revealed that he has not seen the dentist and would like to see the dentist.

Further review of Resident R12's clinical record revealed no documented evidence that the resident was seen by the dentist.

Interview with Employee E16, nurse, on May 16, 2019, at 11: a.m., confirmed that Resident R12 had not been seen by a dentist.

The facility failed to ensure that one resident was seen by the dentist in a timely manner.

42 CFR 483.55(a)(1)-(5) Routine/Emergency Dental Srvcs in SNFs
Previously cited 4/12/18

28 PA. Code: 211.12 (d)(1)(5) Nursing services.
Previously cited 4/12/18, 8/22/17 and 1/3/17.











 Plan of Correction - To be completed: 07/01/2019

1. Resident R12 is scheduled for a dental exam.
2. An audit of current resident's records has been reviewed to determine when the last dental exam occurred and to ensure residents were scheduled for appropriate dental follow–up.
3. Dental Mobile representative, Social service and Unit clerks were educated and will communicate quarterly to ensure residents are scheduled for dental appointments and appropriate follow up.
4. A random audit of 10 residents will be completed weekly X 4 weeks and then monthly X2 months to ensure that routine dental appointments and follow-up appointments have been scheduled. Audit results will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that documentation was complete and accurate for two of 43 residents reviewed. (Resident R82 and R76).

Findings include:

A review of Resident R82's clinical record revealed that the resident was admitted to the facility on October 11, 2018, with a diagnosis of Parkinson's disease (a disorder of the central nervous system that affects movement, and often includes tremors). The resident was severely impaired in decision making.

Further review of Resident R82's clinical record revealed a dental consult dated March 19, 2019, the dentist documented that the resident had moderate plaque (a sticky film that coats the teeth and contains bacteria, if dental plaque is not removed when it is soft, it can harden and become difficult to remove. Dental plaque can damage a tooth and lead to tooth decay or tooth loss) calculus/tartar (is a form of hardened dental plaque). Dentist also recorded refer to hygiene.

A review of nursing assistant's documentation of daily oral care called for brushing Resident R82's teeth twice a day. A review of the daily oral care form for the month of March 2019 revealed ten times in March that brushing the resident's teeth was not documented.

A review of the daily oral care for the month of April 2019, revealed seven times in April that brushing the resident's teeth was not documented.

A review of the daily oral care for the month of May up to May 16, 2019 revealed ten times in May that brushing the resident's teeth was not documented.

Interview with the Director of Nursing on May 16, 2019 at 2:30 p.m. confirmed that the brushing of the Resident R82's teeth was not consistently documented.

Review of the clinical record for resident R76 revealed the dietitian's progress note dated April 12, 2019 which indicated that Resident R76 had a height of 66 inches. Ideal body weight range was 118 to 148 pounds, according to Nutrition Care of the Older Adult, Academy of Nutrition and Dietetics, 2016, for Resident R76. Continued review of the clinical record revealed that Resident R76's physician had ordered ensure supplementation three times a day in March, April and May, 2019.

Further review of resident R76's clinical record revealed no documentation related to the consumption of this nutritional supplement for Resident R76. The lack of recording Resident R76's nutritional supplement intake for March, April and May, 2019 was confirmed with the registered dietitian Employee E23 at 1:10 p.m., on May 16, 2019.

The facility failed to ensure complete and accurate documentation was recorded.

42 CFR 483.20(f)(5), 483.70 (i)(1)(-5) Resident Records- Identifiable Information
Previously cited 4/23/18.

28 PA Code:211.12 (d)(1)(5) Nursing services.
previously cited 4/12/18, 8/22/17 and 1/3/17

28 Pa. Code: Clinical records
Previously cited 4/12/18













 Plan of Correction - To be completed: 07/01/2019

1. Resident R82's and R74 had no ill effects from inaccurate documentation.
2. An audit of current resident's oral care and supplement consumption will be reviewed for the last 14 days and any variances were addressed.3.
3. The Nursing staff will be re-educated to document oral care accurately in electronic medical record. Licensed nursing staff will be re-educated to document supplement consumption accurately in the medication administration record.
4. A random audit of 5 resident's oral care documentation will be reviewed weekly X 4 weeks and then monthly X 2 to ensure documentation is completed accurately. A random audit of 5 residents will be completed to ensure supplement consumption is completed accurately weekly X4 weeks and then monthly X2 months. Audit results will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.

§ 211.7(b)(1)-(4) LICENSURE Phys. Assist. & Cert. Nurse Practitioners.:State only Deficiency.
(b) If the facility utilizes the services of physician assistants or certified registered nurse practitioners, the following apply:

(1) There shall be written policies indicating the manner in which the physician assistants and
certified registered nurse practitioners shall be used and the responsibilities of the supervising
physician.

(2) There shall be a list posted at each nursing station of the names of the supervising physician
and the persons, and titles,whom they supervise.

(3) A copy of the supervising physician's registration from the State Board of Medicine or State
Board of Osteopathic Medicine and the physician assistant's or certified registered nurse practitioner's
certificate shall be available in the facility.

(4) A notice plainly visible to residents shall be posted in prominent places in the institution
explaining the meaning of the terms "physician assistant" and "certified registered nurse practitioner".
Observations:

Based on observations, interviews with residents and staff, it was determined that the facility failed to post at each nursing station a list of the names of the supervising physician, and the nurse practitioners or physician assistants whom they supervise, for three of three nursing units reviewed.

Findings include:

Interview on May 14, 2019 at 11:30 a.m.,with Resident R103's representative revealed that a physician had not been in to see the resident. Continued interview revealed that Resident R103's representative did not know the role of a nurse practitioner or physician assistant and was unsure if the resident had been seen by one.

A tour of the facility completed between 10:00 a.m. and 10:30 a.m. on May 17, 2019, revealed that a list of the names of the supervising physician, and the nurse practitioners or physician assistants whom they supervise, could not be found on any of the nursing units.

Interview on May 17, 2019, at 11:05 a.m. with Employee E8, Regional Nurse, confirmed that the names of the supervising physician, and the nurse practitioners or physician assistants whom they supervise, was not posted as required.

Interview on May 17, 2019, at 11:26 a.m. the Nursing Home Administrator also confirmed that the names of the supervising physician, and the nurse practitioners or physician assistants whom they supervise, was not posted on any of the nursing units.

The facility failed to post at each nursing station a list of the names of the supervising physician, and the nurse practitioners or physician assistants whom they supervise.




 Plan of Correction - To be completed: 07/01/2019

1. No residents were affected by this citation
2. Posting were place at each nursing station listing of the names of the supervising physician, nurse practitioners or physician assistants whom they supervise.
3. The Nursing home administrator will be re-educated for the need to have all postings at each nursing station.
4. An audit of each nursing station will be completed weekly X4 weeks and then monthly X2 months to ensure the names of the supervising physician, nurse practitioners or physician assistants whom they supervise are in place.


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