Nursing Investigation Results -

Pennsylvania Department of Health
ROSE CITY NURSING AND REHAB AT LANCASTER
Patient Care Inspection Results

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

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ROSE CITY NURSING AND REHAB AT LANCASTER
Inspection Results For:

There are  179 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.
ROSE CITY NURSING AND REHAB AT LANCASTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare and Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey, completed on April 16, 2019, it was determined that Rose City Nursing and Rehab at Lancaster was not in compliance with the following requirements of 42 CFR 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.


 Plan of Correction:


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

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


Based on clinical record review, it was determined that the facility failed to send all appropriate clinical documentation for residents transferred to acute care facilities for ten of ten residents reviewed (Residents #44, #47, #62, #81, #99, #100, #108, #111, #118, and #121).

Findings include:

Review of Resident #44's progress note dated December 23, 2018 revealed that the resident was sent to the hospital on December 22, 2018 and admitted with a diagnosis of pleural effusion (build-up of excess fluid between the layers of the pleura outside the lungs). Further clinical record review failed to reveal evidence that all appropriate documentation was sent to the acute care facility.

Review of Resident #47's progress note dated February 22, 2019 revealed that the resident was sent to the hospital on February 22, 2019 related to aggressive and threatening behaviors. Further record review failed to reveal evidence that all appropriate documentation was sent to the acute care facility.

Review of Resident #62's progress note dated February 2, 2019, revealed that the resident was admitted to the hospital with a diagnosis of sepsis. Further review of the record revealed no evidence that all appropriate documentation was sent to the acute care facility.

Review of Resident #81's progress note dated December 16, 2018 revealed that the resident was sent to the hospital on December 16, 2018 and admitted with a diagnosis of human metapneumovirus (a respiratory virus that causes an upper respiratory infection). Further record review failed to reveal evidence that all appropriate documentation was sent to the acute care facility.

Review of Resident #99's clinical record revealed an interdisciplinary note dated October 24, 2018 indicating that resident was sent to the hospital for evaluation of a possible right hip fracture.

Further review of Resident #99's clinical record failed to reveal documentation, including care plans, accompanying resident to emergency room.

Review of Resident #100's progress note dated February 20, 2019, revealed that the physician ordered the resident be sent to the emergency room for evaluation and treatment of an acute left femur fracture. Further review of the record revealed no evidence that all appropriate documentation was sent to the acute care facility.

Review of Resident #108's clinical record revealed resident was admitted to the hospital in December 2018 with an admitting diagnosis of bowel obstruction. Further record review failed to reveal evidence that all appropriate documentation was sent to the acute care facility.

Review of Resident #111's progress note dated December 29, 2018 revealed that the resident was sent to the emergency room for homicidal threats against staff members. Further review of the record failed to reveal evidence that all appropriate documentation was sent to the acute care facility.

Review of Resident #118's progress note dated March 21, 2019 revealed that the resident was sent to the hospital on March 21, 2019 to be evaluated for a change in mental status. Further record review failed to reveal evidence that all appropriate documentation was sent to the acute care facility.

Review of Resident #121's clinical record revealed an interdisciplinary note dated February 1, 2019 indicating the resident was admitted to the hospital for Sepsis. Further review of Resident #121's clinical record failed to reveal documentation required to accompany resident including care plans for transfer to the hospital on February 1, 2019.

Interview on April 16, 2019 at approximately 12:49 p.m. with Director of Nursing confirmed that the facility did not provide required paperwork including care plans during transfer or discharge of residents.

483.15(c)(2)(iii)(E) Transfer and discharge documentation
Previously cited 2/28/19

28 PA Code 201.18(b)(1)(2) Management














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


1. Residents 44, 47, 62, 81, 99, 100, 108, 111, 118, and 121 will have appropriate clinical documentation sent when/if transferring to an acute care facility.
2. Current residents transferring to an acute care facility will have appropriate clinical documentation sent to the acute care facility.
3. Facility will develop a checklist for clinical items to be sent along with resident when transferring to an acute care facility. Licensed nursing staff will be educated on utilization of checklist and sending appropriate clinical documentation when transferring a resident to an acute care facility.
4. DON/Designee will audit transfers to acute care facilities weekly to ensure appropriate clinical documentation is being sent. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

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

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

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

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

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

Based on review of the facility's staff education records and interview with staff, it was determined that the facility failed to conduct at least 12 hours per year of in-service education for four of five nurse aides reviewed (Employees E5, E6, E7, and E8).

Findings include:

Review of the facility's nurse aide education records for the past 12 months revealed that there was no documented evidence that Employees E5, E6, E7, and E8 completed 12 hours of annual in-service training.

Interview with the Nursing Home Director on April 16, 2019, at 9:45 a.m. confirmed that the above employees had not completed 12 hours of annual in-service training.

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




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

1. Employee 5, 6, 7 8 will receive 12 hours of in-service training
2. Review of nurse aide records will be completed. For those who have not received 12 hours of in-service training, they will be added to a schedule to receive training.
3. Facility will implement a schedule of in-services to ensure that nursing aides are receiving 12 hours of in-service annually.
4. NHA/Designee will audit monthly based on schedule to ensure that nursing aides are receiving 12 hours of in-service annually. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

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

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



Based on review of manufacturers' guidelines, review of facility policy and procedure and observation, it was determined that the facility failed to properly label medications and failed to dispose of expired medications in two of two medication carts observed (Third Floor Medication Cart and Fourth Floor Medication Cart).

Findings include:

Review of facility policy and procedure titled "Storage of Medications" revealed "drug containers that have missing, incomplete, improper or incorrect labels shall be returned to the pharmacy for proper labeling before storing; the facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed."

Review of manufacturer's guidelines for Novolog Mix 70/30 Insulin (medication used to treat high blood sugar levels) FlexPen revealed that opened FlexPens must be discarded 14 days after opening.

Review of manufacturer's guidelines for Novolog Insulin Flex Pen revealed that opened FlexPens must be discarded 28 days after opening.

Review of manufacturer's guidelines for Basaglar KwikPen Insulin revealed that unopened and opened Basaglar must be discarded after 28 days.

Review of manufacturer's guidelines for Humalog Insulin KwikPen revealed that opened Humalog must be discarded 28 days after opening.

Review of manufacturer's guidelines for Lantus Insulin SoloStar Pen revealed open and in use pens must be discarded 28 days after opening.

Review of manufacturer's guidelines for Humalog 75/25 Insulin vials revealed that opened vials must be discarded 28 days after opening.

Review of manufacturer's guidelines for Levemir Insulin FlexTouch Pens revealed that unrefrigerated and unopened FlexTouch Pens must be discarded 42 days after opening or after they are first kept out of the refrigerator.

Observation on April 14, 2019 at 8:42 a.m. of the Fourth Floor Medication Cart revealed two open and undated Novolog Mix 70/30 Insulin Flex Pens; one open Novolog Flex Pen with an open date of March 12, 2019 which was required to have been discarded April 8, 2019 and one open and undated Novolog FlexPen.

Observation on April 14, 2019 at 9:16 a.m. of the Third Floor Medication Cart revealed one open and undated Novolog 70/30 FlexPen; one open and undated Humalog KwikPen; one unopened and undated Basaglar KwikPen; one open Novolog FlexPen with an expiration date of April 5, 2019; one unopened and undated Novolog FlexPen; one opened Novolog FlexPen with an expiration date of February 13, 2019; one unopened and undated Novolog FlexPen; one open and undated Humalog KwikPen with a handwritten name on the pen and a pharmacy label with a different resident name on the pen; one Lantus SoloStar Pen with an expiration date of April 11, 2019; one open and undated vial of Humalog 75/25 Insulin and one unopened, unrefrigerated and undated Levemir FlexTouch Pen.

The above information was conveyed to the Nursing Home Administrator and the Director of Nursing on April 16, 2019 at approximately 1:00 p.m.



28 Pa. Code 211.9(a)(1) Pharmacy services
Previously cited 4/24/18

28 Pa. Code 211.9(j) Pharmacy services

28 Pa. Code 211.10(c) Resident care policies
Previously cited 2/28/19, 5/14/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 2/28/19, 9/20/18, 5/14/18











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


1. Insulin is being properly dated and expired insulin is being discarded.
2. Review of medication carts will be completed to ensure that insulin is being properly dated and expired insulin has been discarded.
3. Licensed nursing staff will be educated to ensure that insulin is being properly dated when opened and expired insulin are discarded.
4. Nursing Supervisor/Designee will audit medications carts weekly to ensure that insulin are being properly labeled and expired insulin are being discarded. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.45(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

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

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

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


Based upon clinical record review, it was determined that the facility failed to ensure medication regimen reviews were acted upon by a physician and failed to ensure that residents' physician provided clinical rationales for declining pharmacy recommendations for six of six residents reviewed (Resident #1, Resident #39, Resident #54, Resident #67, Resident #76 and Resident #117).

Findings include:

Review of resident #1's clinical record revealed the resident medication regimen was reviewed on August 28, 2018, September 26, 2018, November 28, 2018, and January 27, 2019. The facility was unable to provide a copy of the recommendations made by the pharmacist or any evidence that the facility had responded to those recommendations.

Review of Resident #39's clinical record revealed a pharmacist recommendation dated January 2, 2019. Further review of Resident #39's clinical record failed to reveal that the pharmacist recommendation was addressed by Resident #39's physician.

Review of Resident #39's Pharmacy Review Report dated January 27, 2019 revealed that a recommendation was made to the facility regarding Resident #39's medications. Further review of Resident #39's clinical record failed to reveal the clinical pharmacy report submitted by the pharmacy or the physician's response to the clinical pharmacy recommendation.

Review of Resident #54's clinical record revealed a Pharmacy Review dated January 27, 2019 that indicated the consultant pharmacist provided a recommendation to the facility regarding Resident #54's medications.

Further review of Resident #54's clinical record failed to reveal that Resident #54's physician addressed the consultant pharmacist's recommendations.

Review of Resident #67's Pharmacy review dated January 25, 2019, revealed that the consultant pharmacist made a recommendation regarding the resident's medication regime. Further review of the clinical record revealed that the content of the recommendation was not available and no evidence that the recommendation was addressed.

Review of Resident #76's clinical record revealed a pharmacist recommendation dated July 2, 2018. Further review of the pharmacist recommendation revealed that Resident #76's physician did not accept the recommendation but failed to provide clinical rationale for declining the recommendation.

Further review of Resident #76's clinical record revealed a Consultant Pharmacist's Monthly Report dated August 30, 2018 with two recommendations regarding medication. The facility failed to provide documentation that Resident #76's physician addressed the Consultant Pharmacist's recommendations.

Further review of Resident #76's clinical record revealed that on November 30, 2018 and December 27, 2018 the consultant pharmacist provided recommendations to the facility regarding Resident #76's medication. Further review of the clinical record failed to reveal copies of the consultant pharmacist's reports or physician review of these recommendations.

Further review of Resident #76's clinical record revealed a Consultant Pharmacist's Monthly Report dated January 27, 2019. Further review of Resident #76's clinical record failed to reveal that Resident #76's physician reviewed the consultant pharmacist's recommendation dated January 27, 2019.

Review of Resident #117's clinical record revealed the resident was admitted to the facility on March 26, 2019.

Further review of Resident #117's clinical record revealed the residents record was reviewed by the pharmacist on March 28, 2019 and made six recommendations for the physician and 24 nursing recommendations for the resident ' s medication regimen. Review of the entire clinical record revealed the facility failed to act on any of the recommendations made by the pharmacist.

Interview with the Nursing Home Administrator and Director of Nursing on April 16, 2019 at approximately 1:00 p.m. confirmed that the above recommendations from the consultant pharmacist were not available, and further confirmed that residents' physician failed to address the consultant pharmacist recommendations.

483.45(c)(4) Drug Regimen Review
Previously cited 5/14/18

28 Pa. Code 211.5(f) Clinical records
Previously cited 2/28/19, 5/14/18

28 Pa. Code 211.12(c) Nursing services
Previously cited 5/14/18

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 2/28/19, 5/14/18


28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 5/14/18, 9/20/18, 11/29/18, 2/28/19






















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

1. Resident 1, 39, 54, 67, 76 will have their medical regimen reviews acted upon by physician and/or given clinical rationale for declining pharmacy recommendations. #117 has been discharged from the facility.

2. Review of current residents with medication regimen reviews in the last 30 days will be reviewed to ensure they were acted upon by a physician and/or given clinical rational for declining pharmacy recommendations.
3. DON will review medication regimen reviews upon receipt to ensure they are acted upon by physician and/or given clinical rationale for declining pharmacy recommendations.
4. NHA/Designee to audit medication regimen reviews monthly to ensure they were acted upon by physician and/or given clinical rationale for declining pharmacy recommendations. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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.
483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of 483.95(g).
Observations:

Based on review of the facility's staff education records and interview with staff, it was determined that the facility failed to complete performance reviews at least once every 12 months for 5 of 5 nurse aids (Employees E4, E5, E6, E7, and E8).

Findings include:

Review of the facility's nurse aide education records for the past 12 months revealed that there was no documented evidence that Employees E4 - E8 received performance reviews at least once every 12 months.

Interview with the Nursing Home Director on April 16, 2019, at 9:45 a.m. confirmed that performance evaluations had not been completed for the above employees at least once every 12 months.

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






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

1. Employee's #4,5,6,7,8 will have performance evaluations completed.
2. A review of current nurse aides will be completed and those identified without a performance review within the last 12 months will be added to the schedule for completion.
3. DON will implement schedule for nursing aides to ensure they will receive performance evaluations at least once every 12 months.
4. Director of Human Resources/designee to audit completed performance evaluations to ensure the schedule is being followed. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Based on clinical record review, facility documentation review, and staff interview, it was determined the facility failed to ensure proper supervision and interventions to prevent accidents for one of 24 residents reviewed. (Resident #41)

Findings include:

Review of Resident #41 most recent fall risk assessment dated February 9, 2019 revealed resident scored an 11.0 indicating high risk.

Review of Resident #41's annual MDS (Minimum Data Set-periodic assessment of resident needs) dated February 14, 2019 revealed in Section C Cognitive Patterns a BIMS (Brief Interview of Mental Status)score of 10 out of 15 indicating moderately impaired cognitive functioning.

Review of Resident #41's current care plan revealed a focus to address risk for falls. The care plan for falls included an intervention of "keep environment well lit and free of clutter. Keep environment free of cords." The intervention was initiated on May 14, 2017 and subsequently revised on February 9, 2019.

Interview conducted with Resdient# 41 pm April 16, 2019 at approxiamtely 10:31 a.m. revealed that the resident confirmed that he had a fall. Resident # 41 stated "I had a broken nose. I tripped going to the bathroom but I don't know on what."

Review of Resident #41's clinical record revealed an interdisciplinary progress note dated February 9, 2019 (12:18 p.m.) "When this writer and supervisor entered room resident was on right side between bed and bedside chair. Resident head was at the foot of the bed and legs were straight out towards the head of the bed. Fall mat was in place and resident was lying partially on the fall mat and partially on the floor. Resident was wearing non-skid socks. Resident did not ring call-bell and did not use walker. Skin tear noted on right outer wrist measuring 6 cm W 9(width) x 0.2 cm in L (length). A hematoma was noted on forehead near a mole measuring 4 cm (centimeter) x 4 cm. A small abrasion noted on tip of nose measuring 1 cm in length x 0.8 cm in W and her nose was grossly swollen. The mole on face was also noted to be bleeding. Resident c/o (complained of) tenderness on forehead and nose." "Resident stated, 'I was trying to transfer to my chair to eat breakfast and I think I tripped on my O2 tubing.' When asked why did not ring call-bell for assist resident stated, "I thought I could do it myself."

Review of Resident #41's clinical record revealed an interdisciplinary progress note dated February 9, 2019 (11:00 p.m.) "Resident's after visit summary from hospital noted that the resident had a 'tiny minimally displaced fracture involving the anterior tip of the midline nasal bone and adjacent soft tissue swelling.' Resident had a fall causing her to strike her head and face. Also, X-ray of right wrist noted that the bones have normal alignment, no fracture identified. Diffuse osteopenia". CT (computer-processed combinations of many X-ray measurements taken from different angles to produce cross-sectional images of specific areas) of cervical spine negative for acute injury and CT of head negative for acute injury."

Review of the fall investigation document provided by facility, revealed Predisposing Environmental factors of electrical cords, crowding, and medical equipment.

Observation on April 14, 2019 at approximately 1:24 p.m. revealed oxygen tubing on floor and power strip cord next to bedside table in resident's room.

Interview on April 16, 2019 at approximately 10:46 a.m. with Licensed Employee 10, confirmed the resident tripped over an environmental hazard oxygen tubing) causing an injury.



483.25(d)(1) Accidents
Previously cited 11/18/18, 5/14/18

28 Pa Code 201.14(a) Responsibility of Licensee
Previously cited 11/18/18, 5/14/18

28 Pa Code 201.18(b)(1)(3) Management
Previously cited 11/18/18

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

28 Pa. Code 211.12 (d)(3) Nursing services
Previously cited 2/28/19, 5/14/18

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















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

1. Resident #41 was given shorter oxygen tubing to reduce environmental hazard.
2. The facility will complete review of current resident rooms who have oxygen to ensure tubing is not causing an environmental hazard.
3. Nursing staff will review resident's with oxygen to ensure the tubing length is appropriate for resident needs and is not causing an environmental hazard.
4. Environmental Services Director/Designee will conduct observation of resident rooms with oxygen weekly to ensure that tubing is not causing an environmental hazard. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25 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 review of facility policy, observation, clinical record review, it was determined that the facility failed to administered medication timely in accordance with physcian's orders for one of two residents observed. (Resident #119)

Findings include:

Review of facility policy and procedure titled "Administering Medications" revealed "medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders)."

Review of Resident #119's diagnosis list revealed diagnoses including congestive heart failure (CHF - excessive body/lung fluid caused by a weakened heart muscle), major depressive disorder (MDD - major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and/or daily routine), anemia (reduction in red blood cells), enlarged prostate, hypertension (high blood pressure), and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).

Review of Resident #119's physician's orders revealed orders for Amiodarone (medication used to treat irregular heart beat) 200 milligrams (mg) to be administered daily at 8:00 a.m.; Depakote (medication used as a mood stabilizer) 125 mg to be administered daily at 8:00 a.m.; Iron tablet (used to treat anemia) 325 mg to be administered daily at 8:00 a.m.; Flomax (medication used to treat enlarged prostate) 0.4 mg to be administered daily at 8:00 a.m.; Lasix (water pill) 20 mg to be administered daily at 8:00 a.m.; Losartan Potassium (medication used to treat high blood pressure) 25 mg to be administered daily at 8:00 a.m.; Multiple Vitamin (supplement) to be administered daily at 8:00 a.m. and Vitamin D-3 (supplement) to be administered daily at 8:00 a.m.

Observation of medication administration on April 14, 2019 revealed the above medications were administered to Resident #119 at 9:12 a.m. not in accordance with physician's orders.

The above information was conveyed to the Nursing Home Administrator and Director of Nursing on April 16, 2019 at approximately 1:00 p.m.

483.25 Quality of Care
Previously cited 2/28/19

28 Pa. Code 211.5(f) Clinical records
Previously cited 2/28/19, 5/14/18

28 Pa. Code 211.10(c) Resident care policies
Previously cited 2/28/19, 5/14/18

28 Pa. Code 211.12(c)(d)(1)(5) Nursing services
Previously cited 5/14/18












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

1. Resident #119 is receiving medications timely in accordance with physician orders.
2. DON to review medication administration times to ensure medications are administered in timely manner in accordance with physician orders for current residents.
3. licensed nursing staff will administrator medications in accordance to physician orders.
4. DON/Designee will conduct an audit of medication administration weekly to ensure that facility is administering medications timely in accordance with physician orders. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.15(d) Notice of bed-hold policy and return-

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

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

Based on clinical record review it was determined that the facility failed to provide a bed-hold notice to the resident or responsible party upon transfer to the hospital for ten of ten residents reviewed (Residents #44, #47, #62, #81,
#99, #100, #108, #111, #118, and #121).

Findings include:

Review of Resident #44's progress note dated December 23, 2018 revealed that the resident was sent to the hospital on December 22, 2018 and admitted with a diagnosis of pleural effusion (build-up of excess fluid between the layers of the pleura outside the lungs). Further record review failed to reveal evidence that the bed-hold notice was provided to the resident or responsible person upon transfer to the hospital.

Review of Resident #47's progress note dated February 22, 2019 revealed that the resident was sent to the hospital on February 22, 2019 related to aggressive and threatening behaviors. Further record review failed to reveal evidence that the bed-hold notice was provided to the resident or responsible person upon transfer to the hospital.

Review of Resident #62's progress note dated February 2, 2019, revealed that the resident was admitted to the hospital with a diagnosis of sepsis. Further review of the record revealed no evidence that the bed-hold notice was provided to the resident or responsible person upon transfer to the hospital.

Review of Resident #81's progress note dated December 23, 2018 revealed that the resident was sent to the hospital on December 22, 2018 and admitted with a diagnosis of pleural effusion (build-up of excess fluid between the layers of the pleura outside the lungs). Further record review failed to reveal evidence that the bed-hold notice was provided to the resident or responsible person upon transfer to the hospital.

Review of Resident #99's clinical record revealed an interdisciplinary note dated October 24, 2018 indicating that resident was sent to the hospital for evaluation of a possible right hip fracture.

Further review of Resident #99's clinical record failed to reveal notification regarding the facility's bed hold policy to the resident or representative.

Review of Resident #100's progress note dated February 20, 2019, revealed that the physician ordered the resident be sent to the emergency room for evaluation and treatment of an acute left femur (hip) fracture. Further review of the record revealed no evidence that the bed-hold notice was provided to the resident or responsible person upon transfer to the hospital.

Review of Resident #108's clinical record revealed resident was admitted to the hospital in December 2018 with an admitting diagnosis of bowel obstruction. Further record review failed to reveal evidence that the bed-hold notice was provided to the resident or responsible person upon transfer to the hospital.

Review of Resident #111's progress note dated December 29, 2018 revealed that the resident was sent to the emergency room for homicidal threats against staff members. Further review of the record failed to reveal evidence that the bed-hold notice was provided to the resident or responsible person upon transfer to the hospital.

Review of Resident #118's progress note dated March 21, 2019 revealed that the resident was sent to the hospital on March 21, 2019 to be evaluated for a change in mental status. Further record review failed to reveal evidence that the bed-hold notice was provided to the resident or responsible person upon transfer to the hospital.

Review of Resident #121's clinical record revealed an interdisciplinary note dated February 1, 2019 indicating the resident was admitted to the hospital with a diagnosis of Sepsis.

Further review of Resident #121's clinical record failed to reveal documented evidence of notification to the resident or their representative regarding the nursing facility's bed hold policy.

Interview on April 16, 2019 at approximately 2:30 p.m. with Nursing Home Administrator that the facility did not notify the resident or their representative regarding the facility's bed hold policy at the time of the transfers.

28 Pa Code. 211.5(f) Clinical records
Previously cited 2/28/19, 5/14/18

28 Pa Code. 211.12(d)(1)(3)(5) Nursing services
Previously cited 5/14/18





















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

1. Resident 44, 47,62,81, 99, 100, 108, 111, 118, 121, will have bed hold notice completed upon transfer to the hospital.
2. Current residents will have bed hold notices completed upon transfer to the hospital.
3. Licensed nursing home staff will be educated on providing bed hold notice to residents or responsible parties upon transfer to the hospital. Licensed nursing staff will provide the bed hold notice to resident or responsible party upon transfer to the hospital. The Business of Manager will validate that bed hold notice was provided and if it was not, she will ensure that one will be provided.
4. DON/Designee will audit bed hold notifications weekly to ensure resident or responsible party was notified upon transfer to the hospital.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

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

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

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

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

Based on clinical record review, it was determined that the facility failed to notify the State Ombudsman's office of residents transferred to acute care facilities for ten of ten residents reviewed (Residents #44, #47, #62, #81, #99, #100, #108, #111, #118, and #121).

Findings include:

Review of Resident #44's progress note dated December 23, 2018 revealed that the resident was sent to the hospital on December 22, 2018 and admitted with a diagnosis of pleural effusion (build-up of excess fluid between the layers of the pleura outside the lungs). Further record review failed to reveal evidence that the State Ombudsman's office was notified of the transfer to the hospital.

Review of Resident #47's progress note dated February 22, 2019 revealed that the resident was sent to the hospital on February 22, 2019 related to aggressive and threatening behaviors. Further record review failed to reveal evidence that the State Ombudsman's office was notified of the transfer to the hospital.

Review of Resident #62's progress note dated February 2, 2019, revealed that the resident was admitted to the hospital with a diagnosis of sepsis. Further review of the record revealed no evidence that the State Ombudsman's office was notified of the transfer to the hospital.

Review of Resident #81's progress note dated December 16, 2018 revealed that the resident was sent to the hospital on December 16, 2018 and admitted with a diagnosis of human metapneumovirus (a respiratory virus that causes an upper respiratory infection). Further record review failed to reveal evidence that the State Ombudsman's office was notified of the transfer to the hospital.

Review of Resident #99's clinical record revealed an interdisciplinary note dated October 24, 2018 indicating that resident was sent to the hospital for evaluation of a possible right hip fracture.

Further review of Resident #99's clinical record failed to reveal notification of ombudsman occurred regarding resident's transfer to the hospital.

Review of Resident #100's progress note dated February 20, 2019, revealed that the physician ordered the resident be sent to the emergency room for evaluation and treatment of an acute left femur fracture. Further review of the record revealed no evidence that the State Ombudsman's office was notified of the transfer to the hospital.

Review of Resident #108's clinical record revealed resident was admitted to the hospital in December 2018 with an admitting diagnosis of bowel obstruction. Further record review failed to reveal evidence that the State Ombudsman's office was notified of the transfer to the hospital.

Review of Resident #111's progress note dated December 29, 2018 revealed that the resident was sent to the emergency room for homicidal threats against staff members. Further review of the record failed to reveal evidence the State Ombudsman's office was notified of the transfer to the hospital.

Review of Resident #118's progress note dated March 21, 2019 revealed that the resident was sent to the hospital on March 21, 2019 to be evaluated for a change in mental status. Further record review failed to reveal evidence that the State Ombudsman's office was notified of the transfer to the hospital.

Review of Resident #121's clinical record revealed an interdisciplinary note dated February 1, 2019 indicating the resident was admitted to the hospital with a diagnosis of Sepsis.

Further review of Resident #121's clinical record failed to reveal notification to Ombudsman office regarding the resident's transfer to the hospital.

Interview on April 16, 2019 at approximately 2:30 p.m. with Nursing Home Administrator that the facility did not notify to Ombudsman office regarding transfers or discharges that occurred within the facility.

28 Pa Code 201.18(b)(1)(2) Management







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

1. State Ombudsman's Office has been notified of transfer to acute care facilities for Resident's #44, 47,62, 81, 99, 100, 108, 111, 118, and 121.
2. A review transfers to acute care facilities for residents during the last 30 days will be completed to ensure State Ombudsman's Office has been notified.
3. Education to Social Service Director regarding discharge and transfer notice requirement will be completed.
4. NHA/Designee will audit discharges/transfers to an acute care facilities to ensure State Ombudsman's Office is notified as required. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

483.10(c)(2)(3) REQUIREMENT Right to Participate in Planning 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.
483.10(c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:
(i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.
(ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
(iii) The right to be informed, in advance, of changes to the plan of care.
(iv) The right to receive the services and/or items included in the plan of care.
(v) The right to see the care plan, including the right to sign after significant changes to the plan of care.

483.10(c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-
(i) Facilitate the inclusion of the resident and/or resident representative.
(ii) Include an assessment of the resident's strengths and needs.
(iii) Incorporate the resident's personal and cultural preferences in developing goals of care.
Observations:

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure that one of 24 residents reviewed participated in the development and impementation of their plan of care. (Resident #63)

Findings include:

Review of Resident #63's admission Minimum Data Set (MDS- periodic assessment of resident care needs) assessment completed on January 23, 2019, revealed a BIMS (Brief Interview for Mental Status) of a score of 15 which indicated that the resident was cognitely intact.

Interview conducted with Resident #63 on April 13, 2019, at 1:55 p.m. revealed that Resident #63 was not aware of a care plan meeting and had not participated.

Interview conducted the Nursing Home Administrator on April 16, 2019, confirmed that there was no evidence that Resident #63 was invited to participate in his plan of care.

28 Pa Code 211.11(e) Resident care plan







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

1. Resident #63 was invited to and participated in care plan meeting.
2. Current residents will be invited to participate in care plan meeting based on
their next assessment date.
3. Education will be provided to the Social Services Director on resident's right to participate in planning care.
4. NHA/Designee will conduct an audit of scheduled care plan meetings weekly to ensure that each resident has been invited to participate in their care plan meeting. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response: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(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

483.10(f)(6) The resident has a right to participate in family groups.

483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:


Based on review of facility policy, review of resident council meeting minutes, interviews with residents and staff, it was determined that the facility failed to promptly act on a grievance voiced by the resident council.

Findings include:

Review of facility policy "Grievance Policy" reviewed January 14, 2019, revealed that the facility has a system in place to ensure the residents right to prompt efforts to resolve grievances that they may have. The reasonable timeframe the resident can expect a completed review of the grievance is within 5 to 7 business days.

Review of resident council minutes of February 21, 2019, revealed that residents have concerns that nursing aides were standing at the desk talking about their social life and not answering phones and call bells.

Review of resident council minutes of March 28, 2019, revealed that the same concern was voiced by the residents during the resident council meeting. Review of grievance/concern form of March 28, 2019, indicated that this concern would be discussed at the next nursing staff meeting.

Interview with seven alert and oriented residents during a group meeting on April 14, 2019, revealed that the grievance had not been addressed.

Interview with the Nursing Home Administrator on April 16, 2019, at 9:45 a.m. revealed that the grievance from February had not been addressed and the March grievance would be addressed at the next nursing staff meeting (more than 5 to 7 business days from the date of the grievance).

483.10(f)(5)(iv) Resident/family Group and Response
Previously cited 5/14/18

28 Pa. Code 201.14(a) Responsibility of Licensee
Previously cited 11/14/18, 5/14/18

28 Pa. Code 201.18(b)(3) Management
Previously cited 5/14/18











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

1. Resident Council nursing grievance was addressed on April 25, 2019.
2. NHA to meet with Resident Council to identify if there are any other outstanding grievances.
3. Activities Director to bring resident council grievances to morning stand up to review with department heads.
4. NHA/Designee will conduct an audit of resident council grievances to ensure that each grievance was handled in timely manner. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

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 clinical record review, it was determined that the facility failed to timely notify the physician of a change in condition for one of 24 residents reviewed. (Resident #44 )

Findings include:

Review of Resident #44's progress notes revealed a nursing entry on December 22, 2018 at 1:30 p.m. stating [Resident continues to complain of RLQ (right lower quadrant of the abdomen) pain. Complained of feeling SOB (short of breath). Difficulty exhaling. MDI (Metered Dose Inhaler) administered as per orders. O2 (oxygen) sat 86% (level of oxygenation in the blood normal is 92-100%) on RA (Room Air- no supplemental oxygenation). Taken to room and administered oxygen@ 2LPM (Liters Per Minute- amount of oxygen administered) Follow up sat 96%. Stated "feeling a little better".]

Further review of Resident #44's rogress notes revealed the next entry was on December 22, 2018 at 6:30 p.m. stating "Resident called his RP (responsible party) then called 911 (Emergency Medical Services) to take him to the Hosp. (hospital) D/T (due to) pain of right ABD (abdomen) and SOB (shorthness of breath)." Another entry on December 23, 2018 at 4:20 p.m. stated "admitted to hospital with pleural effusion (an abnormal collection of fluid in the pleural space resulting from excess fluid production)."

Further review of Resident #44s' progress notes revealed a progress note on December 31, 2019 at 3:50 p.m. stating the resident was re-admitted to the facility after being admitted to the hospital after a CT scan (computerized tomography- combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside your body) revealed a right pleural effusion that required a chest tube (a hollow, flexible tube placed into the chest. It acts as a drain) and 2500 milliliters was drained from the resident's chest.

Review of the entire clinical record revealed there was no documented evidence the resident physician was notified of the change in the resident status when his oxygen saturation levels dropped requiring supplemental oxygenation. The resident initiated the transfer to the hospital on his own which required admission for 7 days.


28 Pa. Code 211.10(c) Resident care policies
Previously cited 2/28/19, 5/14/18

28 Pa. Code 211.12(c)(d)(1)(5) Nursing services
Previously cited 5/14/18



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


1. When Resident #44 has a change in condition, timely notification will be made to physician.
2. Review of current residents will be completed to ensure that physician notification has been made for changes in condition identified in the last 14 days.
3. Licensed nursing staff will be educated to notify physician immediately upon identification of change in condition. DON/Designee will review changes in condition at the facility's daily clinical meeting to ensure timely responsible party notification.
4. DON/Designee will audit physician notification of changes in condition weekly to ensure timely notification. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice: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)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:


Based on review of facility documentation and staff interview, it was determined that the facility failed to provide the
required Notice of Medicare Provider Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) to the resident or resident's representative for one of three records reviewed (Resident 120).

Findings include:

The form "Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123," (a notice that informs the recipient when care receive from skilled nursing facility is ending and how you can contact a Quality Improvement Organization (QIO) to appeal) instructs that a Medicare provider must be delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed.

Review of facility documentation revealed that Resident 120 was discontinued from Medicare Part A on January 15, 2019, with benefit days remaining. There was no documentated evidence that the resident or resident's representative was provided the required NOMNC or SNF-ABN form (provides information to the beneficiary so that she/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility).

Interview with the Nursing Home Administrator on April 15, 2019, at 2:40 p.m. confirmed that the NOMNC and SNF-ABN notice was not provided to Resident 120 or their representative.

483.10(g)(18)(i) Medicaid/Medicare Coverage/liability notice
Previously cited 5/14/18

28 Pa. Code 201.18(b)(2) Management
Previously cited 5/14/18

28 Pa 201.18 (b)(3) Management
Previously cited 5/14/18

28 Pa. Code 201.18(e)(1) Management
Previously cited 5/14/18


























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


1. Resident #120 was discharged from the facility on 2/9/19.
2. Facility identified that required notice of Medicare Provider Non-Coverage and Skilled Nursing Beneficiary Notices were not being provided on 2/22/19. There were no other residents affected.
3. Education was provided to Social Services Director on completion of beneficiary notices in timely manner.
4 Business office manager/designee will continue to conduct audit of all cut letters weekly to validate that beneficiary notices were given in timely manner and notify NHA of any beneficiary notices that were not given in a timely manner. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

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 clinical record review, facility documentation, facility policy, and staff interview, it was determined that the facility failed to complete a comprehensive investigation of an injury of unknown origin for one of one resident reviewed (Resident #99)

Findings include:

Review of facility policy titled Abuse Investigation and Reporting with revision date of July 2017 revealed under the subheading "Role of Investigator" the following was stated: Review the completed documentation forms. Review the resident's medical record to determine events leading up to the incident. Interview the person(s) reporting the incident. Interview any witnesses to the incident. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident.

Review of Resident #99's clinical record revealed diagnoses including but not limited to following: Osteoporosis (decreased bone density and softening of the bone); Alzheimer's disease (Irreversible progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability); Dysarthria (difficult to pronouncing words); Muscle weakness; Abnormalities of gait and mobility; Unsteadiness on feet.


Review of Resident #99's clinical record revealed an interdisciplinary note dated October 18, 2018 at 12:38p.m., "Resident assessed post fall, reports resident did hit head, no injury noted, no swelling, neurochecks initiated. Resident holding head and lower back, able to move all extremities without increase in pain but reports lower back pain. Attending physician and CRNP (Certified Nurse Practicioner) notified and new order given for x-ray bilateral hips and pelvis, liberty x-ray notified."

Continued review of Resident #99's interdisciplinary notes revealed a note dated October 19, 2018 at 1:45 p.m. "X-ray report reviewed by attending physician this morning, findings are suggestive of a vascular necrosis in left femoral head, old right inferior pubic ramus fx (fracture), age indeterminate minimally displaced right greater trochanteric fracture. Call placed to orthopedist and they have no recorders of left hip studies, right hip with previous fx 2013 and 2015. Appointment with orthopedist scheduled for this Monday, attending physician updated."

Further review of Resident #99's interdisciplinary notes revealed a note dated October 24, 2018 at 12:49p.m., which indicated "Resident out for MRI (Magnetic Resonance Imaging) today, after return writer received call MRI + for right hip fracture, they request resident be sent to hospital for eval(uation) and have called report to ER (Emergency Room). Attending physician updated and ok to send to hospital."

Continued review of Resident #99's interdisciplinary notes revealed a note dated October 26, 2018 (15:10) "Resident readmitted today from hospital, dx of right hip fx (fracture). No surgical intervention per POA (Power of attorney) and is to follow with orthopedist on November 2, 2018. WBAT (Weight baring as tolerated) and resident noted to be standing at times and found ambulating in room soon after readmit, reminded to request assist with ambulation. Skin assessment completed and no open areas noted, skin intact and with faint bruising to right hip, faded light blue. Admission orders verified with attending physician and faxed to pharmacy."

Review of facility investigation documentation revealed it was initiated on October 18, 2019 then revised on February 12, 2019 regarding Resident #99's injury of unknown origin, including incident description of "Resident had a verbal altercation with another resident and followed into back lounge and was found on the floor. Unknown if resident fell or was pushed."

Continued review of facility investigation documentation revealed under subsection "Witness" the following note of "no witnesses found."

Further review of facility investigation documentation revealed under "Notes" subsection dated October 26, 2018 "IDT (interdisciplinary team) review of resident fall in which resident fell from wheelchair upon trying to stand during an episode of escalated agitation involving a verbal altercation with a male peer. Resident lost balance and fell to the floor. Event was described by a resident witness detailing that the residents were shouting at each other and the fall occurred when the resident stood up."

Continued review of facility investigation documentation failed to reveal any witness statements from staff or residents.

Interview on April 16, 2019 at approximately 12:49 p.m. with Nursing Home Administrator confirmed that the facility did not fully investigate the hip fracture injury sustained by Resident #99 on October 18, 2018

28 Pa Code 201.14(a) Responsibility of Licensee
Previously cited 5/14/18, 11/29/18

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

28 Pa Code 201.29(a)(d) Resident Rights











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

1. Resident #99 will have comprehensive investigation completed when/if any injury of unknown origin is identified.
2. Review of current residents will be completed to identify injuries of unknown origin in the last 30 days to ensure a comprehensive investigation was completed.
3. Comprehensive Investigations will be completed on injuries with unknown origin. DON/Designee to review injuries of unknown at facility clinical meeting to ensure comprehensive investigation is completed.
4. NHA/Designee will audit injuries of unknown origin weekly to ensure that comprehensive investigation is completed. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to revised plan of care in a timely manner for one of 24 residents reviewed,. (Resident #81)

Findings include:


Review of Resident #81's progress notes revealed the resident had falls on March 12th, 21st had two falls, 23rd, and 25th 2019 and on April 1st, and 2nd 2019.

Review of the facility incident reports for each of these falls and the clinical record revealed there were no new interventions to prevent falls developed and implemented to prevent further falls.

Interview with the Director of Nursing on April 15, at 1:30 p.m. confirmed there were no new falls interventions developed after each of these falls in March and April 2019.


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

28 Pa. Code 211.12 (d)(3) Nursing services
Previously cited 2/28/19, 5/14/18

28 Pa. Code 211.12 (d)(5) Nursing services
Previously cited 2/28/19, 9/20/18, 5/14/18


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

1. Resident #81's fall plan of care was revised.
2. Review of current residents with falls in the last 30 days will be completed to ensure that revisions to fall plan of care were completed.
3. Unit Manager/Designee will review falls during clinical meeting to ensure plans of care are updated in timely manner.
4. DON/Designee will audit plans of care for residents that had falls weekly to ensure fall plans of care were updated in a timely manner. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

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

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

Based on review of facility policy, clinical record review, and staff interview, it was determined the facility failed to provided care and services to restore bladder continence for one of two residents reviewed (Resident #117).

Findings include:

Review of facility policy, titled Urinary Incontinence- Clinical Protocol, last revised April 2018, revealed for incontinent individuals, the nursing staff will identify, and document circumstances related to the incontinence. As appropriate, based on assessments of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual ' s continence status.

Review of Resident #117's demographic sheet revealed the resident was admitted to the facility on March 26, 2019 with a diagnosis of Overactive Bladder.

Review of Resident #117's Admission Minimum Data Set (periodic assessment of resident needs), dated April 9, 2019 revealed the resident was cognitively intact, and frequently incontinent of bladder.

Review of Resident #117's physician's orders revealed an order for Detrol (medication for bladder spasms) 1 milligram, twice a day.

Review of Resident #117's care plan revealed there was no care plan developed for urinary incontinence.

Review of Resident #117's clinical record revealed there was no assessments completed to determine the resident severity or type of urinary incontinence.

Interview with the Nursing Home Administrator on April 16, 2019 at 12:30 p.m. confirmed there was no care plan, assessment or program developed for Resident #117 's urinary incontinence.

483.25(e)(1) Incontinence
Previously cited 5/14/18


28 Pa. Code 211.5 (f) Clinical record
Previously cited 2/28/19, 5/14/18

28 Pa. Code 211.10 (d) Resident care policies
Previously cited 5/14/18

28 Pa. Code 211.12 (c) Nursing services
Previously cited 5/14/18

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

28 Pa. Code 211.12 (d)(3) Nursing services
Previously cited 2/28/19, 5/14/18

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





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


1. Resident #117 was discharged from facility.
2. Review of current residents with dx of overactive bladder will be completed to ensure care plans have been developed for urinary incontinence.
3. licensed nursing staff will be educated to ensure that care plans for urinary incontinence are developed for residents with overactive bladder.
4. Medical Records Director/Designee will audit residents with dx of overactive bladder weekly to ensure that urinary incontinence care plans are implemented. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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.
483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address a resident's dementia for two of 24 residents reviewed (Residents #67 and #100).

Findings include:

Review of Resident #67's admission Minimum Data Set assessment (MDS- periodic assessment of resident needs) dated March 8, 2019, included a diagnosis of dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functionng ability). Review of the Care Area Assessment (CAA) Summary revealed that cognitive loss/dementia would be addressed in the care plan.

Review of Resident #67's interdisciplinary plan of care revealed no care plan to address the resident's cognitive loss and dementia.

Interview with the Nursing Home Administrator on April 16, 2019, at 9:45 a.m confirmed that no dementia care plan had been developed for Resident #67.

Review of Resident #100's significant change MDS assessment dated March 5, 2019, included a diagnosis of dementia. Review of the Care Area Assessment (CAA) Summary revealed that cognitive loss/dementia would be addressed in the care plan. Review of Resident #100's interdisciplinary plan of care revealed no care plan to address the resident's cognitive loss and dementia.

Interview with the Nursing Home Administrator on April 16, 2019, at 12:45 p.m. confirmed that no dementia care plan had been developed for Resident #100.


28 Pa Code 211.11(d) Resident care plan
Previously cited 5/14/18

28 Pa Code 211.12 (d)(1)(3)(5) Nursing service
Previously cited 5/14/18






















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

1. Dementia Care plan for resident# 67 and #100 was completed.
2. Review of current residents with Dementia Diagnosis will be completed to ensure they have care plan to address diagnosis.
3. Education will be provided to Social Services Director on completion of Dementia care plans for residents with dx of dementia.
4. NHA/Designee will conduct an audit of residents with dx of Dementia weekly to ensure that each resident has a care plan addressing Dementia dx. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

483.40(d) REQUIREMENT Provision of Medically Related Social Service: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.
483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to provide medically-related social services for psycho-social wellbeing of one of four residents reviewed (Resident #32).

Findings include:

Observation on April 14, 2019 at approximately 1:45 p.m. revealed Resident #32 arguing with roommate. Subsequently both residents began shoving wheelchair located between them into each other legs. Resident #32 was overheard to inform staff "Resident doesn't put hand on her, not my wife. Take care of it or I'll send him out of here in a bag."

Review of Resident #32's clinical record revealed the diagnoses including but not limited to the following: Schizophrenia (mental disease characterized by loss of reality contact, delusions, hallucinations and/or feelings of persecution); Depression (loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and or daily routine); and Dementia with Behavioral Disturbance (Irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).

Review of Resident #32's clinical record revealed a physician's order dated October 12, 2018 for the resident to be evaluated by the psychiatrist. Review of Resident #32's physician progress notes revealed a clinical note dated October 15, 2018 "Resident was in A. Hospital for quite some time after resident was found to be suicidal and homicidal." "In the facility where resident was, resident found to be aggressive towards others and was wondering into other resident rooms."

Review of Resident #32's current care plan revealed a social services intervention of "Validate resident's perceptions, do not challenge reality orientation. Offer support. If resident appears worried or concerned r/t (related to) delusional thought process provide validation and offer to help resident," under the goal for Problematic Manner in which Resident Acts.

Review of Resident #32's interdisciplinary dated January 11, 2019 indicating "Resident extremely agitated, trying to physically attack other residents. Resident getting on elevator refusing to get off."

Further review of Resident #32's clinical record revealed an interdisciplinary progress note dated January 14, 2019 at 8:25 a.m. indicating "Resident verbally threatening roommate and threatening to beat him up if he doesn't give resident his shoes." A second interdisciplinary progress note of same date at 2:58 p.m. revealed "Roommate came into resident room and resident told him to get out of here and they both started to raise hands as if to fight each other."

Continued review of Resident #32's interdisciplinary progress notes revealed a note dated January 17, 2019 indicating "Resident has recently become more verbally aggressive towards new roommate."

Continued review of Resident #32's interdisciplinary progress notes revealed note dated January 23, 2019 indicating, "Wandering into other residents' room and taking their clothes out of their closets."

Further review of Resident #32's January 2019 interdisciplinary progress notes revealed a note dated January 28, 2019, "Intimidating roommate, threatening to fight him and saying he stole resident's phone and has resident's dog hiding behind bed and won't let resident have dog."

Additional review of Resident #32's interdisciplinary progress notes revealed a note dated February 1, 2019 indicating "Resident observed pushing another male resident in the hallway for no apparent reason."

Further review of Resident #32's February 2019 interdisciplinary progress notes revealed note dated February 12, 2019 indicating "Observed by staff member pushing roommate."

Continued review of Resident #32's February 2019 interdisciplinary progress notes revealed note date February 26, 2019 indicating, "resident disrobed and was walking the hallway. Staff tried to redirect him and he would not comply with re-direction."

Further review of resident's interdisciplinary progress notes revealed a note dated February 27, 2019 indicating "Trying to get into bed with his roommate."

Continued review of February 2019's interdisciplinary progress notes revealed a note dated February 28, 2019 indicating "Resident agitated and was trying to transport residents and trying to get residents out of their chairs."

On March 1, 2019 it was noted "Wandering hallways and into other residents' rooms. Trying to have other residents leave with him. Going up to residents and trying to 'pick a fight' with them." On March 9, 2019 it was stated "Verbal altercation with another male resident. Also had arms and fists raised and threatened to fight him."

Further review of Resident #32's interdisciplinary progress notes revealed a progress note dated March 25, 2019 indicating, "Resident was exit seeking." "Truing to open the stairwell door. Ran at stairwell door after a staff member exited and tried to hold door open."

Continued review of interdisciplinary progress notes of Resident #32 revealed a note dated March 27, 2019 indicating, "Resident went into the room and was arguing with bed B in the room and Bed A bot up to defend roommate and it escalated to the hallway with both residents lying on the floor wrapped around each other hitting each other." "Resident has scratch under bottom lip, scratch on left side of neck, scratch on left ear lobe, abrasion on left cheek 5cm long."

Further review of Resident #32's clinical record failed to reveal social services contact or interventions during times of behavioral outbursts.

Review of the resident's clinical record revealed that there was no document evidence that social services intervened to assist Resident #32 with negative behaviors including aggressive and behavioral actions towards staff.

Interview on April 16, 2019 at approximately 10:10 a.m. confirmed with Nursing Home Administrator and Social Services Director revealed that social services interactions were limited to medication management referral in October 2018 and MDS (Minimum Data Set -periodic assessment of resident needs) assessments.


28 Pa Code 211.5(f) Clinical record
Previously cited 2/28/19, 5/14/18

28 Pa Code 211.16(a) Social services









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

1. Resident #32 is now receiving medically related social services to address psychosocial well-being.
2. Review of current residents with behavioral outbursts will be reviewed to ensure there is documented social service contact or inventions.
3. Education will be provided to Social Services Director on providing medically related social services for resident's psychosocial well-being.
4. NHA/Designee will conduct an audit of residents with behavioral outbursts weekly to ensure that there was provision of social service contact or interventions to ensure psychosocial well-being. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

483.45(d)(1) In excessive dose (including duplicate drug therapy); or

483.45(d)(2) For excessive duration; or

483.45(d)(3) Without adequate monitoring; or

483.45(d)(4) Without adequate indications for its use; or

483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
Observations:

Based on policy and procedure review, clinical record review, and staff interview, it was determined the facility failed to ensure residents were not receiving unnecessary medications for two of 8 residents reviewed. (Resident #1 and #117)

Findings include:

Review of facility policy, titled Antipsychotic Medication Use, revised December 2016, revealed the physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. The need to continue PRN (as needed) orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order.

Review of Resident 1's physician's order revealed an order for the anti anxiety medication Ativan 0.5 milligrams as needed every 12 hours for anxiety dated March 26, 2019.

Review of Resident 1's Medication Administration record revealed the resident received the medication on April 12, 2018. There was no stop date of 14 days after it being ordered and review of the clinical record revealed there was no clinical ration for the continuation of the order.

Interview with the Nursing Home Administer on April 16, 2019 at 12:30 p.m. confirmed the order should have included a stop date of 14 days.

Review of Resident #117's physician orders revealed the resident was admitted to the facility on March 26, 2019 with a diagnosis of Insomnia (inability to get to sleep or stay asleep through the night) and orders for Melatonin (supplement) 3 milligrams (mg) at bed time for insomnia, Rozerem (sedative) 8mg at bedtime for insomnia, and Trazadone (sedative) 150 milligrams at bedtime for insomnia.

Review of the resident's entire clinical record revealed there was no clinical justification by the physician as to why the resident was ordered three medications for insomnia.

Interview with the Nursing Home Administrator on April 16, 2019 at 12:30 confirmed the resident's medications for insomnia were not evaluated by the physician for a risk vs. benefit analysis for the concurrent medications for insomnia.



28 Pa. Code 211.5(f) Clinical records
Previously cited 2/28/19, 5/14/18

28 Pa. Code 211.12 (d)(1)(5) Nursing services
Previously cited 2/28/19, 9/20/18, 5/14/18

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 2/28/19, 5/14/18








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


1. Resident #117 has a been discharged from the facility. Resident #1 PRN order was discontinued.
2. Facility will have Pharmacist consultant to complete review of current residents to ensure they are not receiving unnecessary medications.
3. DON/Designee to review residents with new medications during daily clinical meeting to ensure they have clinical rationale for continuation of the medication order.
4. NHA/designee to audit weekly residents with new medications to ensure they have clinical rational for continuation of medication order. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff: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.
483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e)

This includes:
483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who-
(i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is:
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.
Observations:


Based on staff interview, it was determined that the facility failed to employ a full-time qualified dietary services supervisor in the absence of a full-time qualified dietitian.

Findings include:

Interview with the Registered Dietitian on April 16, 2019 at approximately 1:30 p.m. revealed that she was at the facility one day a week and works remotely two days a week.

Interview with the Nursing Home Administrator (NHA) on April 16, 2019, at 2:35 p.m. revealed that the facility has not had a food service director since February 2019. The NHA confirmed that the facility does not currently employ a full-time qualified dietary services supervisor in the absence of a full-time qualified dietitian.

28 Pa Code 201.18(e)(1)(6) Management

28 Pa. Code 211.6(c) Dietary services















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


1. The facility has hired a CDM with expected start date of 5/28/19.
2. CDM from sister facility, Fairlane Gardens, will assist with oversight until new CDM starts on 5/28/19.
3. The Human resource director will review the Dietary Manager qualifications at least annually and upon hire to ensure the requirement is met. Facility will actively recruit qualified candidates any time there is a position vacancy.
4. The NHA/designee will audit the dietary manager qualifications upon hiring and at least annually to ensure requirement is met. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(i) Food safety requirements.
The facility must -

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

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


Based on observation and review of facility policy, it was determined that the facility failed to maintain, store, and prepare food in a sanitary manner in the kitchen.

Findings include:

Review of facility policy titled "Food Storage" dated June 2014 revealed under Guidelines number 1 of "Food storage areas shall be clean at all times." Under guideline number 5, "All food shall be dated at time of the receipt and be inventoried using the FIFO method (first in first out).

Observation conducted of the main kitchen on April 13, 2019 at approximately 9:19 a.m. revealed the following:
the walk-in freezer had multiple food particles and dirt debris on the floor, under the mat, and next to shelving units.

Observation of walk in refrigerator on April 13, 2013 approximately 9:45 a.m revealed a box of celery stalks that were shriveled, wilted, and brown. A brownish, green substance was observed on one of the celery stalks.

Continued observation of walk in refrigerator on April 13, 2019 at approximately 9:46 a.m. revealed a half bag of brown, wilted, spoiled lettuce.

Observation of the dry storage room revealed an open plastic bin with numerous large chip pieces and cookie crumbs.

Interview on April 13, 2019 at approximately 9:31 a.m. confirmed with Employee E11 that the food items should have been discarded and freezer floor needs to be cleaned.

483.60(i)(2) Food safety requirements
Previously cited 5/14/18

28 Pa. Code: 201.18(b)(3) Management
Previously cited 5/14/18

28 Pa. Code 211.6(d) Dietary services





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

1. The walk-in freezer was cleaned of debris. Celery and lettuce were discarded. Dry storage bin was cleaned.
2. Review of items in the walk-in refrigerator was completed and there were no further items that needed to be discarded. Review of dry storage bin was also completed and there were no further items that needed to be discarded. Bins were cleaned as needed.
3. Dietary staff will be educated on keeping walk-in refrigerator, freezer, and dry storage areas free from food debris as well as discarding food items that are wilted such as celery and lettuce. Dietary staff will complete daily observation of walk-in refrigerator, freezer, and dry storage to ensure they are free of food debris and food items that are wilted such as celery and lettuce have been disposed of as needed.
4. Assistant Dietary Manager/designee will conduct an observation weekly to ensure that walk-in refrigerator, freezer, and dry storage to ensure they are free of food debris and food items that are wilted such as celery and lettuce have been disposed of as needed. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.


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 observation, clinical record review and review of facility policy and procedure, it was determined that the facility failed to ensure appropriate infection control procedures were implemented during tracheostomy care for one of one resident reviewed (Resident #108).

Findings include:

Review of facility policy and procedure titled "Tracheostomy Care" revealed "Aseptic technique [a method requiring the use of various barriers to prevent the transfer of microorganisms from health care personnel and the environment to the patient] must be used during cleaning and sterilization of reusable tracheostomy tubes; during all dressing changes until the tracheostomy wound has healed and during tracheostomy tube changes, either reusable or disposable; sterile gloves must be used during aseptic procedures."

Further review of this facility policy and procedure revealed "Preparation and Assessment - check physician order; explain procedure to resident; wash hands; put exam gloves on both hands; remove supplemental oxygen mask from tracheostomy." "Remove old dressings. Pull soiled glove over dressing and discard into appropriate receptacle. Wash hands."

Further review of this policy and procedure revealed "Put on sterile gloves; secure the outer neck plate with non-dominate gloved hand; unlock the inner cannula with gloved dominate hand; remove the inner cannula; remove and discard gloves into appropriate receptacle; wash hands and put on fresh gloves; replace the cannula and lock in place."

Further review of this policy and procedure for site care revealed "apply clean gloves; clean stoma with two peroxide-soaked gauze pads; rinse the stoma with saline-soaked gauze pads; wipe with dry gauze; remove neck ties and replace with clean ones; apply a fenestrated gauze pad around insertion site; remove gloves and discard into appropriate receptacle; wash hands."

Observation of Resident #108's tracheostomy care on April 16, 2019 at 10:34 a.m. revealed Licensed Employee E3 put on a pair of sterile gloves without washing hands; lifted the supplemental oxygen mask away from resident's tracheostomy; opened a saline bottle; removed the supplemental oxygen tubing; removed the inner cannula from the tracheostomy tube; cleaned the tracheostomy tube on the outside; inserted a swab into the tracheostomy tube to clean it; cleaned resident's neck around the stoma sight and under the strap; cleaned the supplemental oxygen mask; opened the package with the new inner cannula; inserted the new inner cannula; applied a new neck strap and replaced the supplemental oxygen mask. All the above tasks were completed while wearing one pair of sterile gloves.

The above information was conveyed to the Nursing Home Administrator and Director of Nursing on April 16, 2019 at approximately 1:15 p.m.

The facility failed to ensure appropriate infection control interventions were utilized during tracheostomy care.

28 Pa. Code 211.10(d) Resident care policies
Previously cited 5/14/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 2/28/19, 9/20/18, 5/14/18










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


1. Resident #108 is receiving tracheostomy care with proper infection control procedures
2. Review of current residents was completed and there are no other residents with tracheostomy.
3. Education will be provided to Licensed nursing staff on proper infection control procedures.
4. DON/Designee will observe tracheostomy care weekly to ensure that proper infection control procedure is being followed. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

201.29(k) LICENSURE Resident rights.:State only Deficiency.
(k) The resident shall be permitted to retain and use personal clothing and possessions as space permits unless to do so would infringe upon rights of other residents and unless medically contraindicated, as documented by his physician in the clinical record. Reasonable provisions shall be made for the proper handling of personal clothing and possessions that are retained in the facility. The resident shall have access and use of these belongings.
Observations:

Based on a review of closed clinical records and interview with the staff, it was determined that the facility failed to ensure documentation regarding the disposition of resident property upon discharge for two of three resident records reviewed (Resident #120 and #121).

Findings include:

Review of Resident #120's clinical record indicated that the resident was admitted on to the facility on February 16, 2015 and expired in the facility on February 9, 2019. There was no documented evidence in the resident's clinical record to indicate the disposition of the resident's personal belongings at the time of discharged.

Review of Resident #121's clinical record indicated that the resident was admitted on to the facility on January 31, 2019 and discharged to the hospital for sepsis on February 1, 2019. There was no documented evidence in the resident's clinical record to indicate the disposition of the resident's personal belongings at the time of discharged.

Interview on April 16, 2019 at approximately 2:05 p.m. with the Nursing Home Administrator confirmed that disposition of personal belongings was not completed for these residents.






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

1. Residents #20 & 120 were discharged from the facility
2. Review of residents discharged from facility in last 30 days will be completed to ensure documentation of disposition of resident property has been completed.
3. Licensed nursing staff will be educated on proper documentation of disposition of resident property upon discharge.
4. NHA/designee will audit discharges weekly to ensure that documentation of disposition of resident property has been completed. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

211.5(f) LICENSURE Clinical records.:State only Deficiency.
(f) At a minimum, the resident's clinical record shall include physicians' orders, observation and progress notes, nurses' notes, medical and nursing history and physical examination reports; identification information, admission data, documented evidence of assessment of a resident's needs,
establishment of an appropriate treatment plan and plans of care and services provided; hospital diagnosis authentication--discharge summary, report from attending physician or transfer form--diagnostic and therapeutic orders, reports of treatments, clinical findings, medication records and discharge summary including final diagnosis and prognosis or cause of death. The information contained in the record shall be sufficient to justify the diagnosis and treatment, identify the resident and
show accurately documented information.
Observations:

Based on review of clinical records, it was determined that the facility failed to ensure that each resident's clinical record contained a dated discharge summary including final diagnosis, prognosis, or summary of care for three of three residents reviewed (Residents #119, #120, and #121).

Findings include:

Review of the clinical record of Resident #119 revealed that the resident was discharged from the facility onJanuary 17, 2019. There was no documented evidence that a discharge summary was completed by the physician.

Review of the clinical record of Resident #120 revealed that the resident expired in the facility on February 9, 2019. There was no documented evidence that a discharge summary was completed by physician.

Review of the clinical record of Resident #121 revealed that the resident was discharged from the facility on February 1, 2019. There was no documented evidence that a discharge summary was completed by the physician.

Interview with the Nursing Home Administrator on April 16, 2019, at 2:05 p.m. confirmed that discharge summaries were not completed for these residents.






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


1. Residents #119, 120, and 121 were discharged from facility without documentation of discharge summary in clinical record. Attending physician during this time frame is no longer providing services to the facility.
2. Facility will review residents discharged from facility in the last 30 days to ensure that clinical records contains dated discharge summary, including final diagnosis, prognosis or summary of care.
3. Nursing staff will be educated on documentation of discharge summary in clinical record to include final diagnosis, prognosis, and summary of care. Medical Records will review discharged resident charts to ensure that clinical records contains dated discharge summary, including final diagnosis, prognosis, or summary of care. Medical Records will bring to clinical meeting any resident charts that does not contain this information.
4. DON/Designee will audit discharges weekly to ensure that clinical record contains dated discharge summary including final diagnosis, prognosis, or summary of care. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.


211.9(j) LICENSURE Pharmacy services.:State only Deficiency.
(j) Disposition of discontinued and unused medications and medications of discharged or deceased residents shall be handled by facility policy which shall be developed in cooperation with the consultant pharmacist. The method of disposition and quantity of the drugs shall be documented on the respective resident's chart. The disposition procedures shall be done at least quarterly under Commonwealth and Federal statutes.
Observations:

Based on review of closed clinical records and interview with staff, it was determined that the facility failed to document the quantity of medications following discharge for one of three residents reviewed (Residents #119).

Findings include:

Review of Resident #119's closed clinical record revealed that the resident was discharged on January 17, 2019. Review of the progress note of January 17, 2019, revealed that the resident was released with his remaining cycle of medications. There was no documented evidence in the resident's closed clinical record to indicate the quantity of medications sent with the resident.

Interview with the Nursing Home Administrator on April 16, 2019, at 2:05 p.m. confirmed that there was no account of the quantity of drugs sent with the resident upon discharge.





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


1. Resident #119 was discharged from facility.
2. Upon resident discharge, staff will ensure documentation in clinical record contains quantity of medications sent with resident.
3. Medical records will review discharged resident charts to ensure there is documentation in clinical record containing quantity of medications sent with the resident. Medical Records will bring to clinical meeting any charts that do not contain quantity of medications sent with resident.
4.DON/Designee will audit discharges weekly to ensure that clinical record contains documentation of quantity of medications sent with resident. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.


Back to County Map


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



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

Visit the PA Power Port