Nursing Investigation Results -

Pennsylvania Department of Health
CANTERBURY PLACE
Patient Care Inspection Results

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CANTERBURY PLACE
Inspection Results For:

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CANTERBURY PLACE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance survey completed on March 1, 2019, it was determined that Canterbury Place was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


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

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:
Based on clinical record review, observation and resident and staff interviews, it was determined that the facility failed to prevent involuntary seclusion for four of 23 residents on a secure unit (Residents R61, R68, R70 and R139).

Findings include:

A review of the facility policy "Abuse" updated 1/1/19, revealed that the facility prohibits all forms of abuse. Each resident has the right to privacy and confidentiality and freedom from all type of abuse, including verbal, sexual, physical, mental abuse, corporal punishment and involuntary seclusion. The policy defines involuntary seclusion as separation of a resident from other residents, from his or her room against the residents will or the will of the legal representative.

A review of the facility Admission Agreement indicated that the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. Further review of the facility Admission Agreement revealed it did not include documentation that residents are made aware upon admission to the facility that they are being placed in a secured unit.

During observations of the First floor Nursing Unit from 2/25/19 to 3/1/19, the doors for residents to leave the unit were secured with key pads and required access codes to unlock them.

A review of the Admission face sheet for Resident R61 indicated they were admitted to the facility on 11/2/18, with diagnoses that inlcuded artificial heart valve, liver transplant and epilepsy (abnormal activity in the brain causing fatigue and seizures).

A review of Resident's R61 physicians orders dated 1/28/19, indicated the resident was ordered out of bed to chair, ambulatory-needs assistance and did not include orders for a secured nursing unit (restricts independently leaving a unit).

A review of Resident's R61 comprehensive Minimum Data Set (MDS - periodic review of care needs) dated 11/9/18, indicated that the resident had a Brief Interview for Mental Status score of 13 (assessment of a residents cognitive skills, scores over 13 indicate resident is cognitively intact). Section B of the MDS of indicated the resident was able to makes himself understood and understands others during conversations.

A review of quarterly MDS, dated 2/9/19, indicated that the resident had a BIMS of 14. Section B of the MDS of indicated the resident was able to makes himself understood and understands others during conversations.

During an interview on 2/27/19, at 9:00 a.m. with Resident R61 who resides on the first floor indicated he has to go down to the ground floor to meet transportation that takes him to an outside appointment three days a week. Resident R61 stated that staff has to put in the access codes for him to get past the secured door. Resident R61 stated he is able to reach the access pad, can self propel his wheelchair, and once he is past the secured door they go to the first floor on their own. Resident R61 indicated that his brother told him he wasn't allowed to give him the access code. Resident R61 stated "I'd like to be able to go through the doors without having to wait on staff. Really don't know why I can't have the code to get out."

During an interview on 2/27/19, at 2:30 p.m. Unit Manager Employee E5 confirmed that Resident R61's clinical record did not include documentation requiring a secured unit.

A review of Resident's R68 quarterly MDS dated 2/19/19, indicated they were admitted to the facility on 8/31/10, their BIMS was 15 (highest score possible) current diagnosis included right sided weakness, seizures and head injury.

During an interview with Resident R68 on 2/25/19, at 10:00 a.m. and on 2/27/19, 9:51 a.m. the resident who resides on the first floor indicated they must wait by the secure door for staff to enter the codes when they want to go too activities. Resident R68 was observed to self propel their wheelchair about their room during the interview.

A review of Resident's R139 clinical record indicated they were admitted to the facility on 2/25/19, a review of their hospital discharge summary indicated they had current diagnosis of multiple sclerosis, diabetes and high blood pressure. A review of their physician orders dated 2/25/19, indicated the resident is aware of their medical condition and treatment plan, and did not include orders for a secured unit.

During an interview with Resident R139 on 2/27/19, at 9:56 a.m. the resident who resides on the first floor indicated they must wait by the locked door when their son is with them and they require staff to leave them out.

A review Residents R70 admission face sheet indicated they were admitted to the facility on 2/6/19, with current diagnosis that included anxiety, anemia, and ankle fracture.

A review of Residents R70 admitting physician orders dated 2/6/19, did not include orders for a secured unit.

During an interview in the main hall near the locked door on the first floor unit on 3/1/19, at 11:51 a.m. Resident R70 indicated they go to chapel which is not located on the secured unit and they cannot leave the unit without staff entering the code for them.

During an interview on 3/1/19, at 8:47 a.m. with the Nursing Home Administrator and Director of Nursing confirmed that all units are secured with a key pad and they do not give access key codes to residents, the residents are not made aware of this at admission, and the first floor unit is a secured unit.

28 Pa. Code: 201.18(b)(1) Management.
Previously cited 1/23/18.

28 Pa. Code: 201.18(b)(2) Management.

28 Pa. Code: 201.29(a)(c)(d)(j)(m) Resident rights.













 Plan of Correction - To be completed: 04/22/2019

Residents R61, R68, R70 and R139 will be interviewed and screened to ensure their cognitive and safety awareness allow them to be independent off the unit. This screening will involve a BIMS, wandering/ cognitive assessment, and a conversation with the family/responsible party. This information will be shared with the resident such that their safety needs and their dignity are maintained. A physician's order will be obtained for those residents leaving the unit independently.

The facility's admission agreement has been amended to state that the facility utilizes key pad access doors on its units and that staff are available to let appropriate residents off the unit as needed. If a current resident is deemed to be able to leave the unit independently then a physician's order will be obtained, and key pad code provided to the resident. Any resident or resident/responsible party that does not sign the agreement and the resident is deemed unsafe to be off the unit independently will be aided in securing alternative placement. Random monitoring of the doors on all units will take place to ascertain if resident safety and dignity are maintained. Four monitors will be completed weekly for four weeks and then two monitors per week for two months. Any deficient practice will be immediately corrected, and a report will be submitted to the Quality Assurance Performance Improvement Committee and the need for further monitoring will be determined by the committee.

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 facility staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education for nurse aides as required for five of five nurse aides reviewed Employees E6, E11, E12, E13 and E14.

Finding include:

Review of Nurse Aide (NA) Employee's E6, E11, E12, E13 and E14 education records with hire dates from 8/24/15, to 6/12/17, revealed there was no documentation of the number of hours of annual inservice education for each NA.

During an interview on 3/1/19, at 1:30 p.m. Staff Development Registered Nurse Employee E3 confirmed that the facility did not document the number of hours of annual inservice education for NA Employee E6, E11, E12, E13, and E14, as required.

28 Pa. Code: 201.14(a) Responsibility of Licensee.
Previously cited 1/23/18.

28 Pa. Code: 201.20(c) Staff Development.
Previously cited 1/23/18.







 Plan of Correction - To be completed: 04/22/2019

The five employees listed (E6, E11, E12, E13, and E14) have received additional in-service training such that their cumulative records meet the 12-hour requirement for certified nursing assistants. This has been documented.

The curriculum for in-service training of certified nursing assistants has been reviewed and amended such that the facility now accurately accounts for the time spent annual in-service trainings. on UPMC U-Learns (identified credit hours according to industry standards) Additionally, this education is now supplemented with external training modules approved for certified nursing assistants that have identified credit hours according to industry standards. Also, the topics have been set up to recur on an annual basis so in a 12-month period, a certified nursing assistant will receive at least 12 hours of the required Inservice education.

All new employees over the next three months will be reviewed by the Staff Development Coordinator or designee to ensure that they are correctly documenting the number of hours of annual in-service education. A monthly report will be forwarded to the QAPI Committee with the need for further monitoring being determined by the committee. Any deficient practice will be immediately corrected.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

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

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

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

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

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:
Based on facility policy, observations and staff interviews, it was determined that the facility failed to provide services in a manner that enhanced resident dignity during dining for five of 14 residents (Resident R4, R21, R35, R36, and R64).

Findings include:

Review of the facility "Meal Service in Dining Room" policy last reviewed on 1/1/19, indicated that the residents are provided meal service to encourage social interaction and meal enjoyment.

During an observation of the breakfast meal on 2/25/19, the following was observed:

Nurse Aide (NA) Employee E7 fed Resident R64, then Resident R4, without providing any observable verbal interaction.
NA Employee E6 fed Resident R35 and NA Employee E8 fed Resident R36, then Resident R21 with minimal verbal interactions.

During an interview on 3/1/19, at 2:31 p.m. Unit Manager Employee E1 confirmed that the facility failed to provide a dignified dining experience, providing for social interaction and meal enjoyment for five residents, during the breakfast meal on 2/25/19.

28 Pa. Code: 201.29(j) Resident rights.

28 Pa. Code: 211.10(a)(b)(c)(d) Resident care policies.
Previously cited 1/23/18

28 Pa. Code: 211.12(d)(1)(2)(3)(4) Nursing services.
Previously cited 1/23/18











 Plan of Correction - To be completed: 04/22/2019

All Aides will again be educated on methods of interacting with residents with Alzheimer's disease, the need to do so and that the level and type of interaction is based on the resident's cognitive abilities with the specific needs of residents R64,R4, R35,R36 and R21 being addressed.

The facility will monitor the interaction of the aides and residents through meal time monitors as well as random monitoring during care and recreational pursuits. Seven observations will occur weekly for two weeks and then four observations weekly times two months. Any deficient practice will be immediately corrected. The need for additional monitoring will be determined by the committee.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:
Based on facility policy and clinical record review and staff interviews, it was determined that the facility failed to make certain that each resident's drug regimen was free from unnecessary drugs used without adequate indications for use for two of eight residents. (Resident R21 and R58)

Findings include:

The facility "Psychotropic Drug Management" policy reviewed 1/1/19, indicates the facility will use psychotropic medications only when needed to treat a specific condition that is diagnosed and documented.

A review of Resident's R21 significant change Minimum Data Set (MDS - periodic review of care needs) dated 12/10/18, indicated the resident was admitted on 11/29/15, current diagnosis included dementia, high blood pressure and high cholesterol.

A review of the clinical record revealed that Resident R21 was prescribed Seroquel (an anti-psychotic) 50 milligrams (mg) at bedtime, for a diagnosis of dementia without behaviors.

A review of Resident's R58 quarterly MDS dated 2/1/19, indicated they were admitted on 12/18/18, current diagnosis included high blood pressure, asthma, and Alzheimers (loss of memory and mental functions)

A review of the clinical record revealed that Resident R58 was prescribed Seroquel 50 MG at bedtime, for a diagnosis of dementia without behaviors.

During an interview 3/1/19, at 2:31 p.m. Unit Manager Employee E1 confirmed dementia without behaviors is not a recognized diagnosis for anti-psychotic use.

28 Pa. Code: 201.14(a) Responsibility of licensee.
Previously cited 1/23/18.

28 Pa. Code: 211.2(a)(c) Physician services.

28 Pa. Code: 211.9(a)(1)(d)(k) Pharmacy services.
Previously cited 1/23/18.

28 Pa. Code: 211.12(c) Nursing services.

28 Pa. Code: 211.12(d)(5) Nursing services.
Previously cited 1/23/18.






 Plan of Correction - To be completed: 04/22/2019

The residents' (R-58 and R21) diagnosis has been corrected to include dementia with behavior disturbances to be in concert with the MDS recorded diagnosis. The residents will be reviewed at the next psychoactive meeting to ensure accuracy of both diagnosis and treatment modality.

All psychotics will be reviewed to ensure that a diagnosis accompanies each medication. A letter will be sent to the physicians reminding them to place a diagnosis with each medication. Nursing staff will be educated again on the importance of having an appropriate diagnosis for each anti- psychotic medication. Pharmacy will generate a report of anti-psychotic medications with the associated diagnosis. This report will be reviewed weekly for four weeks and then once every other week for two months by the DON or designee. Any deficient practice will be immediately corrected. A report will be submitted to the Quality Assurance Performance Improvement Committee and the need for further monitoring will be determined by the committee.

483.25(a)(1)(2) REQUIREMENT Treatment/Devices to Maintain Hearing/Vision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(a) Vision and hearing
To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-

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

483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.
Observations:
Based on review of facility policies and clinical records and resident and staff interviews, it was determined that the facility failed to make certain that residents receive proper treatment and assistive devices to maintain visual ability for one of one residents (Resident R75).

Findings include:

Facility policy "Visually Impaired Residents" dated 1/1/19, indicated the facility will promote optimal vision function.

During an interview on 2/26/19, at 3:31 p.m. Resident R75 stated that she needed glasses, and does not have any.

A review of the quarterly Minimum Data Set (MDS - periodic assessment of care needs) dated 2/6/19, indicated Resident R75 was admitted to the facility on 7/4/13, and had diagnosis that included dementia, high blood pressure and asthma.

A review of the clinical record indicated a vision assessment was completed on 8/6/18, with a referral ordered for an optometrist.

The optometrist visit was completed on 8/21/18, and a prescription for glasses was received.

During an interview on 2/27/19, at 1:30 p.m. Unit Clerk Employee E4 indicated that the prescription was faxed at the time of the optometrist visit no further action was taken by the facility until a later vision screening on 2/5/19, revealed that Resident R75 had not yet received her glasses.

During an interview 3/1/19, at 2:31 p.m. Unit Manager Employee E1 confirmed that the facility failed to make certain that residents receive proper treatment and assistive devices to maintain visual ability in a timely manner.

28 Pa. Code: 211.10(a)(c)(d) Resident care policies.

28 Pa. Code: 211.12(d)(3)(5) Nursing services.




 Plan of Correction - To be completed: 04/22/2019

Resident 75 has received the proper treatment and devices (eye glasses) to maintain her visual acuity.
In the future, to ensure more timely service, a monitor has been created that tracks each step in the process to receive eye glasses. This will allow the Director of Social Services or designee to know where in the process the residents' glasses are from examination, through ordering to arrival at the facility and this, more quickly recognize the need for follow up. If follow up is needed this also will be recorded.
The Director of Social Services will monitor weekly the eye glass monitor for four weeks and then every other week for two months. Any deficient practice will be immediacy corrected and a report will eb sent to the Quality Assurance Performance Improvement Committee who will determine the need for additional monitoring.


483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:
Based on review of facility policy and clinical record review, observations and staff interviews, it was determined that the facility failed to follow accepted standards of practice during medication administration for one of five residents (Resident R79).

Findings include:

A review of facility policy "Medication Administration General Guidelines" updated 1/1/19, indicated accepted standard of practice will be followed.

A review of Resident's R79 quarterly Minimum Data Set dated 2/7/19, indicated the resident was admitted to the facility on 3/9/18, current diagnosis included high blood pressure, heart failure (heart cannot pump enough blood to meet bodies needs), and diabetes.

A review of Resident's R79 physician order dated 2/20/19, indicated the resident is ordered irbesartan (treats high blood pressure ) 75 milligrams by mouth once a day, hold for systolic (first number) blood pressure under 100.

During an observations of Resident's R79 medication administration on 2/27/19, at 8:44 a.m., Licensed Practical Nurse Employee (LPN) E10, administered Resident R79's, irbesartan, and did not assess the residents blood pressure prior to administration.

During an interview on 2/27/19, at 2:12 p.m. with Registered Nurse Unit Manager Employee E5, and LPN Employee E10, confirmed that the facility failed to assess Resident's R79 blood pressure prior to administering irbesartan as ordered by the physician.

28 Pa. Code: 211.12(d)(1)(2) Nursing Services.
Previously cited 1/23/18.


 Plan of Correction - To be completed: 04/22/2019

Resident 79 has been assessed and he remains on the blood pressure medication

Facility will generate a report with the assistance of pharmacy, of those blood pressure medications that have parameters. All nurses will be re-educated on the importance of knowing about medication parameters when administering blood pressure medications, when transcribing new orders and/or when verifying orders.
Additionally, a letter will be sent to physicians requesting parameters for their residents on blood pressure medications when clinically indicated. Three charts per week for four weeks will be checked to ensure that if a blood pressure medication was ordered with parameters that they are being followed per physician order. Then 2 charts will be checked per week for two months. Any deficient practice will be immediately corrected. A report will be submitted to the Quality Assurance Performance Improvement Committee. The need for additional monitoring will be determined by the committee.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on a review of facility policy, clinical record review and family and staff interviews, the facility failed to provide Activity of Daily Living (ADL) assistance of a shower and/or bed bath for four of nine residents (Resident R5, R39, R58 and R85).

Findings include:

A review of the facility "Showers and Bath Tubs" policy dated 1/1/19, indicated a shower or tub bath, is provided to residents who are able to participate.

A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 11/17/18, Section G Functional Status, Question G0120 indicated that Resident R5 is unable to self-perform bathing and requires a support of two or more people.

A review of the facility's shower schedule indicated that Resident R5, was to receive a shower on Wednesdays and a bed bath on Saturdays, during the day shift.

A review of Resident R5's clinical record indicated that from 12/1/18 through 2/28/19, the resident did not receive a shower for 11 of 13 opportunities and did not receive bed bath for eight of 12 opportunities, with no refusals noted. The clinical record did not indicate a reason for the 23 missed opportunities.

A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 1/22/19, Section G Functional Status, Question G0120 indicated that Resident R39 is unable to self-perform bathing and requires a support of one person.

During an interview on 2/26/19, at 1:44 p.m. the Resident Family member RF39 stated that she does not feel like her mother is showered enough.

A review of the facility's shower schedule indicated that Resident 39, was to receive a shower on Thursdays and Sundays, during the day shift.

A review of Resident R39's clinical record indicated that from 11/28/18 through 2/28/19, the resident did not receive a shower for 21 of 27 opportunities, with no refusals noted. The clinical record did not indicate a reason for the missed opportunities.

A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 2/1/19, Section G Functional Status, Question G0120 indicated that Resident R58 is unable to self-perform bathing and requires a support of two or more people.

A review of the facility's shower schedule indicated that Resident R58, was to receive a shower on Thursdays and Sundays, during the evening shift.

A review of Resident R58's clinical record indicated that from 12/18/18 through 2/28/19, the resident did not receive a shower for 19 of 21 opportunities. The clinical record did not indicate a reason for the 19 missed opportunities.

A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 2/14/19, Section G Functional Status, Question G0120 indicated that Resident R85 is unable to self-perform bathing and requires a support of one person.

A review of the facility's shower schedule indicated that Resident 85, was to receive a shower on Tuesdays and Fridays, during the evening shift.

A review of Resident R85's clinical record indicated that from 12/1/18 through 2/25/19, the resident did not receive a shower for 18 of 24 opportunities. The clinical record did not indicate a reason for the 18 missed opportunities.

During an interview on 3/1/19, at 2:31 p.m. Unit Manager Employee E1 confirmed the clinical record did not include documentation that ADL assistance for a showers and bed baths was provided for four of nine residents.


28 Pa. Code: 211.11(d)(e) Resident care plan.

28 Pa. Code: 211.12(3)(5) Nursing services.
Previously cited 1/23/18.
















 Plan of Correction - To be completed: 04/22/2019

All residents cited (R5, R39, R58, R85) were checked and they were clean.

All certified nursing assistants will be again educated on the importance of documenting the care they provide; specifically, ADL assistance for showers.

The Director of Nursing or designee will randomly check the ADL shower documentation to ensure that it is complete and accurate. This will be completed three times per week for the first month and then twice per week for the next two months. Any deficient practice will be immediately corrected. A report will be submitted to the Quality Assurance Performance Improvement Committee. The need for additional monitoring will be determined by the committee.

483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:
Based on a review of facility policy, clinical record review and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for three of 12 residents (Resident R39, R75, and R85).

Findings include:

A review of the facility "Resident Assessment: RAI Process (MDS & CAAs)" policy dated 1/1/19, indicated that the RAI process includes accurate completion of quarterly and annual assessments.

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set assessments (mandated assessments of a resident's abilities and care needs), dated October 2018, indicated that Section C: Cognitive Patterns, Question C0100 "Should Brief Interview for Mental Status Be Conducted?" should be coded as "0" if the resident is rarely/never understood, if the resident is at least sometimes understood it should be coded "1" and the BIMS assessment should be completed.

A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 1/22/19, Section B: Hearing, Speech, and Vision, Question G0700 and G0800 indicated that Resident R39 is sometimes understood, and sometimes understands.

Review of Section C: Cognitive Patterns, revealed that Resident R39 is coded as "rarely/never understood" and the BIMS assessment was not completed.

A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 2/6/19, Section B: Hearing, Speech, and Vision, Question G0700 and G0800 indicated that Resident R75 is understood and understands.

Review of Section C: Cognitive Patterns, revealed that Resident R75 is coded as "rarely/never understood" and the BIMS assessment was not completed. .

A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 2/14/19, Section B: Hearing, Speech, and Vision, Question G0700 and G0800 indicated that Resident R85 is sometimes understood, and sometimes understands.

Review of Section C: Cognitive Patterns, revealed that Resident R85 is coded as "rarely/never understood" and the BIMS assessment was not completed.

During an interview on 2/28/19, at 12:09 p.m. Social Worker Employee E2 confirmed that the facility did not complete the Brief Interview for Mental Status when the resident is at least sometimes understood, as required in the RAI Manual, for three of 12 residents.


28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing Services.
Previously cited 1/23/18.















 Plan of Correction - To be completed: 04/22/2019

The assessments for residents R39, R75 and R85 have been submitted and amended as appropriate.
All Social Workers will receive additional education that the Brief Interview for Mental Status (BIMS) must be completed for all residents who are at least sometimes understood.

The Director of Social Service or designee will check the MDS of five residents weekly for four weeks to ensure that the BIMS is completed appropriately for those residents who are at least sometimes. Then two charts will be checked weekly for two months. All data will be forwarded to the QAPI committee for review. Any deficient practice will be immediately corrected. The need for additional monitoring will be determined by the committee

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 is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.15(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 review of clinical records and staff interviews, it was determined that the facility failed to provide the resident and/or residents representative a notice of bed hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) during emergency transfers for three of three residents as required. (Residents R60, R66 and R79).

Findings include:

A review of Resident's R60 quarterly Minimum Data Set (MDS - periodic review of care needs) dated 2/9/19, indicated they were admitted to the facility on 11/20/18, current diagnosis included high blood pressure, heart failure (heart does not pump blood as well as it should), and anemia.

A review of Resident's R60 clinical record indicated they were discharged to the hospital on 1/20/19. The clinical record did not include documentation that the resident and/or residents representative was provided the notice of bed hold policy.

A review of Resident's R66 quarterly MDS dated 2/12/19, indicated the resident was admitted to the facility on 12/5/17, current diagnosis included diabetes, high blood pressure and high cholesterol.

A review of Resident's R66 clinical record indicated they were discharged to the hospital on 2/3/19. The clinical record did not include documentation that the resident and/or residents representative was provided the notice of bed hold policy.

A review of Resident's R79 quarterly MDS dated 2/1/19, indicated they were admitted to the facility on 3/9/18, current diagnosis included high blood pressure, heart failure, and peripheral vascular disease (poor blood flow to arms and legs).

A review of Resident's R79 clinical record indicated they were discharged to the hospital on 12/15/18. The clinical record did not include documentation that the resident and/or residents representative was provided the notice of bed hold policy.

During an interview on 2/28/19, at 10:27 a.m. the Director of Nursing and Social Worker Employee E2, confirmed the clinical record did not include documentation that the resident and/or residents representative was provided the notice of bed hold policy.

28 Pa. Code: 201.18(e)(1) Management.
Previously cited 1/23/18

28 Pa. Code: 201.29(f) Resident rights.


 Plan of Correction - To be completed: 04/22/2019

As residents R60, R66, R79 have already been sent to the hospital the written notice of the facility's bed hold policy cannot be provided.

In the future, written notice will be provided to the resident and/or resident's responsible party of the facility's bed hold policy. The facility's bed hold policy will be placed in binders. This policy will be provided by the staff transferring the resident. Staff will indicate that the bed hold policy was provided. If the resident's clinical condition permits they will be provided the policy. If not, then it will be forwarded to the responsible party. The Director of Nursing or designee will check the book for completeness (policy in the binder or bed hold policy initialed) three times per week for four weeks and then twice per week for two months. All professional Nurses will be trained in this new practice. All data will be forwarded to the QAPI committee for review. Any deficient practice will be immediately corrected. The need for additional monitoring will be determined by the committee

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.15(c)(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 review of clinical records and staff interviews, it was determined that the facility failed to provide written notice to the resident and/or resident's representative of the transfers and reason for transfers to acute care facilities for three of three residents (Residents R60, R66 and R79).

Findings include:

A review of Resident's R60 quarterly Minimum Data Set (MDS - periodic review of care needs) dated 2/9/19, indicated they were admitted to the facility on 11/20/18, current diagnosis included high blood pressure, heart failure (heart does not pump blood as well as it should), and anemia.

A review of Resident's R60 clinical record indicated they were discharged to the hospital on 1/20/19. The clinical record did not include documentation that written notice including reason for transfer was sent to the resident and/or resident's representative.

A review of Resident's R66 quarterly MDS dated 2/12/19, indicated the resident was admitted to the facility on 12/5/17, current diagnosis included diabetes, high blood pressure and high cholesterol.

A review of Resident's R66 clinical record indicated they were discharged to the hospital on 2/3/19. The clinical record did not include documentation that written notice including reason for transfer was sent to the resident and/or resident's representative.

A review of Resident's R79 quarterly MDS dated 2/1/19, indicated they were admitted to the facility on 3/9/18, current diagnosis included high blood pressure, heart failure, and peripheral vascular disease (poor blood flow to arms and legs).

A review of Resident's R79 clinical record indicated they were discharged to the hospital on 12/15/18. The clinical record did not include documentation that written notice including reason for transfer was sent to the resident and/or resident's representative.

During an interview on 2/28/19, at 10:27 a.m. with the Director of Nursing and Social Worker Employee E2, confirmed that the clinical record did not include documentation that written notice including reason for transfer was provided to the residents and/or resident's representatives as required.


28 Pa. Code: 201.29(a) Resident Rights.




 Plan of Correction - To be completed: 04/22/2019

As residents R60, R66, R79 have already been sent to the hospital the written notice why they were sent cannot be provided.

In the future, written notice will be provided to the resident and/or resident's responsible party of the reason for transfer. Blank forms will be placed in the binders with the care plans (see F622). These forms will be completed by the staff transferring the resident to the hospital. Staff will utilize the transfer checklist form and indicate that the form was provided to the resident/family by their initials. If the resident's clinical condition permits they will be informed at the time of transfer. If not, then this written notice will be forwarded to the responsible party. The Director of Nursing or designee will check the book for completeness (notice of discharge form in the book or notice of transfer initialed) three times per week for four weeks and then twice per week for two months. All professional Nurses will be trained in this new practice. All data will be forwarded to the QAPI committee for review. Any deficient practice will be immediately corrected. The need for additional monitoring will be determined by the committee

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

483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i) Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with 483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.
Observations:
Based on review of clinical records and staff interviews, it was determined that the facility failed to provide copies of the comprehensive care plan to the receiving provider when discharging residents for three of three residents discharged to the hospital (Residents R60, R66 and R79).

Findings include:

A review of Resident's R60 quarterly Minimum Data Set (MDS - periodic review of care needs) dated 2/9/19, indicated they were admitted to the facility on 11/20/18, current diagnosis included high blood pressure, heart failure (heart does not pump blood as well as it should), and anemia.

A review of Resident's R60 clinical record indicated they were discharged to the hospital on 1/20/19. The clinical record did not include documentation that a copy of the comprehensive care plan was sent to the receiving provider.

A review of Resident's R66 quarterly MDS dated 2/12/19, indicated the resident was admitted to the facility on 12/5/17, current diagnosis included diabetes, high blood pressure and high cholesterol.

A review of Resident's R66 clinical record indicated they were discharged to the hospital on 2/3/19. The clinical record did not include documentation that a copy of the comprehensive care plan was sent to the receiving provider.

A review of Resident's R79 quarterly MDS dated 2/1/19, indicated they were admitted to the facility on 3/9/18, current diagnosis included high blood pressure, heart failure, and peripheral vascular disease (poor blood flow to arms and legs).

A review of Resident's R79 clinical record indicated they were discharged to the hospital on 12/15/18. The clinical record did not include documentation that a copy of the comprehensive care plan was sent to the receiving provider.

During an interview on 2/28/19, at 10:27 a.m. the Director of Nursing and Social Worker Employee E2, confirmed that the comprehensive care plan was not sent to the receiving provider as required.

28 PA Code: 201.25 Discharge Policy.

28 PA Code: 211.5 (f) Clinical Records.


 Plan of Correction - To be completed: 04/22/2019

As residents R60, R66, R79 have already been sent to the hospital so their care plan cannot accompany them.

In the future, the comprehensive care plans will be sent with the resident to the receiving provider. This will be accomplished by the creation of binders that include the resident's care plan. If a resident is transferred to another provider, the nurse will remove the care plan and check the care plan box on the transfer checklist form and initial. These books will be maintained by the unit clerks.
The Director of Nursing or designee will check the book for completeness (the book contains the care plan or transfer checklist form is completed) three times per week for four weeks and then twice per week for two months. All professional Nurses will be trained in this new practice. All data will be forwarded to the QAPI committee for review. Any deficient practice will be immediately corrected. The need for additional monitoring will be determined by the committee

483.10(j)(1)-(4) REQUIREMENT Grievances:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

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

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

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

Findings include:

A review of facility policy "Grievance Policy" last reviewed 1/1/19, revealed that the contact information for the facility designated Grievance Official Name, Business address, Email address, and Business phone are blank.

During the resident group meeting on 2/26/19, at approximately 2:00 p.m. Residents R600, R601, R602, R603, R604, R605 and R606 expressed that they were unaware of whom the facility's grievance officer is.

During an interview 2/28/19, at 2:00 p.m. Director of Nursing confirmed that the facility policy did not identify a designated grievance officer, as required.

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

28 Pa. Code: 201.29(a) Resident rights


 Plan of Correction - To be completed: 04/22/2019

The grievance officer's name and contact information (business address, email address and phone number) have been provided to the seven residents cited (R600, R601, R602, R603, R604, R605, R606). At the next three resident council meetings the grievance officer will be identified and the means of contacting the grievance officer reviewed. This includes business mailing address, email address and phone number. Additionally, the facility will post this information for other interested parties in areas throughout the building.

The Administrator or designee will check monthly for three months to ensure that the survey books are up to date and remain in place in all locations. The QAPI Committee will review the Resident Council Meeting minutes for three months to ensure compliance as well as monthly checking for three months the posting of the grievance officer notification. Any deficient practice will be immediately corrected. The need for additional monitoring will be determined by the committee. (see also F574)

483.10(g)(4)(i)-(vi) REQUIREMENT Required Notices and Contact Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including:
(i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes -
(A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section;
(B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act.
(C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and
(D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.
(ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.)
(iii) Information regarding Medicare and Medicaid eligibility and coverage;
(iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program;
(v) Contact information for the Medicaid Fraud Control Unit; and
(vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.
Observations:
Based on facility document review, group interview, observations and staff interview, it was determined that the facility did not ensure that the grievance officer's name and contact information was prominently posted and communicated to the residents as required, for seven of seven residents (Residents R600, R601, R602, R603, R604, R605 and R606).

Findings include:

A review of facility policy "Grievance Policy" updated 1/1/19, indicated that the facility grievance policy will be overseen by a designated grievance officer.

During the resident council interview conducted on 2/26/19, at approximately 2:00 p.m. Residents R600, R601, R602, R603, R604, R605 and R606 expressed that they were unaware of whom the facility's grievance officer was.

Observations conducted on 2/27/19, on the Ground, First and Third floor nursing units at approximately 2:15 p.m., revealed the required postings of the grievance officer's name and contact information (business mailing and email addresses, business phone number) was not posted.

During an interview on 2/28/19, at 2:00 p.m. the Director of Nursing confirmed that the facility does not have a designated grievance officer and does not have postings as required..

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



 Plan of Correction - To be completed: 04/22/2019

The grievance officer's name and contact information (business address, email address and phone number) have been provided to the seven residents cited (R600, R601, R602, R603, R604, R605, R606). At the next three resident council meetings the grievance officer will be identified and the means of contacting the grievance officer reviewed. This includes business mailing address, email address and phone number. Additionally, the facility will post this information for other interested parties in areas throughout the building. Additionally, the April 2019 family/responsible party letter will contain this same information.

At the next three resident council meetings the grievance officer will be identified and the means of contacting the grievance officer reviewed. This includes business mailing address, email address and phone number. Additionally, the facility will post this information for other interested parties in areas throughout the building. Additionally, the April 2019 family/responsible party letter will contain this same information.

The QAPI Committee will review the Resident Council Meeting minutes for three months to ensure compliance as well as monthly checking for three months the posting of the grievance officer notification. Any deficient practice will be immediately corrected. The need for additional monitoring will be determined by the committee.
483.10(g)(10)(11) REQUIREMENT Right to Survey Results/Advocate Agency Info:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.10(g)(10) The resident has the right to-
(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and
(ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.

483.10(g)(11) The facility must--
(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility.
(ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and
(iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.
(iv) The facility shall not make available identifying information about complainants or residents.
Observations:
Based on review of facility policy, resident council interview, observation, and staff interviews, it was determined that the facility failed to have reports of survey results, and to post notice of their availability in a prominent location for three of three nursing units (Ground, 1st and 3rd floor nursing units).

Findings Include:

The Facility "Admissions Notice Packet" last reviewed 1/1/19, states the residents have the right to examine the results of the most recent surveys of the nursing facility. The facility will make the results available in a place accessible to residents and must post a notice of their availability.

During observations from 2/25/19 to 3/1/19, in the main lobby, and the Ground, 1st and 3rd floor nursing units revealed the facility failed to post notice of survey results availability.

During a resident council group interview on 2/26/19, at 2:00 p.m. residents Residents R600, R601, R602, R603, R604, R605 and R606 agreed that they were unaware of the location of the survey results.

During an observation on 3/01/19, at 12:50 p.m. the survey results binder located in the main lobby did not contain results of complaint surveys completed on 3/21/18, and 8/29/18.

During interviews on 3/01/19, at 12:55 p.m. the Nursing Home Administrator and Director of Nursing confirmed the above observations, and that the facility failed to post notice of survey results and to have reports of results of complaints in the survey binder.


28 Pa Code: 201.13 (g) Issuance of License.


 Plan of Correction - To be completed: 04/22/2019

The survey book is up to date containing all surveys both annual, abbreviated and complaint visits for three years.
The book has been moved to a location closer to the front desk counter area. Additionally, books have been created and placed on each unit at wheelchair height. The Administrator or designee will check monthly for three months to ensure that the survey book is up to date and remains in place by at all locations. Administrative staff will be re-educated on the importance of keeping the books up to date. This will be completed for three months and the data forwarded to the QAOI committee for review. The need for additional monitoring will be determined by the committee

483.35(g)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.35(g) Nurse Staffing Information.
483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.

483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.
Observations:
Based on observations and staff interview it was determined that the facility failed to prominently display and maintain facility daily nurse staffing hours as required for five of five days.

Findings Include;

During observations from 2/25/19, to 3/1/19, the daily posted facility nurse staffing hours were maintained in a hallway used for emergency exits on the ground floor. No residents or family members were observed to use this area during the survey.

During entrance conference on 2/25/19, at 7:30 a.m. with the Nursing Home Administrator three weeks of posted nurse staffing hours for the weeks of 11/4/17, 12/30/17, and 2/24/18 were requested.

During an interview on 3/1/19, at 12:30 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility did not have the posted staffing hours for the weeks requested or for the past 18 months that are required to be maintained, and failed to post daily nurse staffing hours in a prominent location.

28 Pa. Code: 201.14(a) Responsibility of Licensee.
Previously cited 1/23/18.




 Plan of Correction - To be completed: 04/22/2019

The staffing sheet has been moved to a more prominent position in the main lobby and the facility is keeping these sheets for a period of 18 months. The presence of the sheets in the lobby will be checked at least three times weekly for four weeks and then two times weekly for a period of two months by the Director of Nursing or designee. Any deficient practice will be immediately corrected. Data will be submitted to the QAPI committee and the need for additional monitoring be determined by the committee.
201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:
Based on review of facility infection control policies and procedures, quality assurance surveillance, and staff interview, it was determined that the facility failed to comply with the following requirement of MCARE Act 403(a)(1)(ix) for the one of four quarters for 2018 (January 2018 through March 2018).

Findings include:

MCARE Act, Section 403(a)(1), 40 P.S. 1303.403(a)(1) - Infection Control Plan, states:
(a) Development and compliance - Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of patients and health care workers and shall include:
(1) A multidisciplinary committee including representatives from each of the following, if applicable to the specific health care facility:
(i) Medical staff that could include the chief medical officer or the nursing home medical director.
(ii) Administration representatives that could include the chief executive officer, the chief financial officer or the nursing home administrator.
(iii) Laboratory personnel.
(iv) Nursing staff that could include a director of nursing or a nursing supervisor.
(v) Pharmacy staff that could include the chief of pharmacy.
(vi) Physical plant personnel.
(vii) A patient safety officer.
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility or ambulatory surgical facility.

A review of the facility infection control surveillance (tracking of all infections within the facility in an effort to identify trends or to prevent further infections from developing) and Quality Assurance Committee meeting minutes for January 2018 through December 2018, revealed no evidence that the facility had laboratory personnel as part of the interdisciplinary Quality Control Committee for the one of four quarters for 2018 (January 2018 through March 2018).

During an interview on 2/27/19, at 3:00 p.m. the Staff Development/Infection Control Nurse Employee E3 confirmed that the quarterly review of Infection Control data completed at the Quality Assurance Committee meetings failed to include a laboratory personnel for one of four quarters.




 Plan of Correction - To be completed: 04/22/2019

The laboratory personnel that will be attending the facility's Quality Assurance Performance Improvement Committee meetings has received additional education of the need for and the importance of his attendance on an at least quarterly basis. The dates for meetings in 2019 have been provided. If the individual cannot attend, then a substitute will be permitted provided the substitute can speak on behalf of the laboratory operation.

If the individual fails to attend, then his direct supervisor will be informed. The individual's quarterly attendance will be monitored by the QAPI committee.

211.7(c) LICENSURE Phys. Assist. & Cert. Nurse Practitioners.:State only Deficiency.
(c) Physician assistants' and certified registered nurse practitioners' documentation on the resident's record shall be countersigned by the supervising physician within 7 days with an original signature and date by the licensed physician. This includes progress notes, physical examination reports, treatments, medications and any other notation made by the physician assistant or certified registered nurse practitioner.
Observations:
Based on review of facility policy and closed clinical record and staff interview it was determined that the facility failed to ensure that documentation by the certified nurse practitioner was countersigned by the appropriate supervising physician for one of three discharged residents (Resident CR89)

Findings include:

A review of facility policy "Certified Registered Nurse Practitioner Protocol" indicated the certified registered nurse practioner works under the supervision of a licensed physician.

Review of Resident CR89's discharge summary indicated it was completed by a Certified Registered Nurse Practitioner Employee E15 on 2/18/19, and it did not include a countersignature by the supervising physician.

During an interview on 2/28/19, at 2:28 p.m. the Director of Nursing confirmed that Residents CR89 physician discharge summary did not include a countersignature by the physician within 7 days as required.


 Plan of Correction - To be completed: 04/22/2019

The facility will ensure that all discharge summaries are countered when appropriate in accordance with both state and federal guidelines. The Medial records personnel or designee will monitor four discharges per week for the first four weeks and then two discharges per week for the next two months to ensure compliance. PA Act 48 states that physicians can delegate to CRNPs responsibilities including the signing of discharge plans. Any deficient practice will be immediately corrected. A report will be submitted to the Quality Assurance Performance Improvement Committee and the need for further monitoring will be determined by the committee.
211.10(a) LICENSURE Resident care policies.:State only Deficiency.
(a) Resident care policies shall be available to admitting physicians, sponsoring agencies, residents and the public, shall reflect an awareness of, and provision for, meeting the total medical and psychosocial needs of residents. The needs include admission, transfer, and discharge planning.
Observations:
Based on review of facility policy and staff interview, it was determined that the facility lacked a policy to ensure comprehensive care plans are provided to the receiving provider when discharging residents.

Findings include:

A review of the facility policy "Transfer of Resident to another facility" updated 1/1/19, revealed it failed to include that the comprehensive care plan (measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs) would be sent to a receiving provider when the resident is discharged from the facility.

During an interview on 2/28/19, at 10:27 a.m. with the Director of Nursing and Social Worker Employee E2 confirmed that the facility had no policy or procedure for providing the receiving provider a copy of the comprehensive care plan.




 Plan of Correction - To be completed: 04/22/2019

The facility now has a policy to ensure that the comprehensive care plans are provided to the receiving provider when discharging residents.
The QAPI committee will review this policy at the next meeting and all professional nurses will receive additional education to ensure their understanding and compliance. ( see 622)



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