Nursing Investigation Results -

Pennsylvania Department of Health
TOWNE MANOR EAST
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
TOWNE MANOR EAST
Inspection Results For:

There are  124 surveys for this facility. Please select a date to view the survey results.

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TOWNE MANOR EAST - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure Survey, Civil Rights Compliance Survey, and an abbreviated survey in response to two complaints, completed on March 7, 2019, it was determined that Towne Manor East, was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.





 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) 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 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 observations of the food and nutrition department, interviews with staff, reviews of the pest control operator's reports and the Montgomery County office of public health report, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Findings include:

Observations of the Food and Nutrition Department at 10:00 a.m., on March 5, 2019, were made in the presence of the food service director, Employee E6. It was evident that the flooring inside the kitchen was in need of repair. The most notable area was the flooring in the dish machine area. The grouting was missing, leaving deep spaces/grooves; where food debris had accumulated and excess water was pooling. The baseboard was missing along one wall area of the dish room. The ceramic tiled floor was not flush with the wall. Recessed cement was noted on the floor. Mice droppings were scattered along the wall in this cement indentation against the dividing wall. The flooring area near the ice machine and juice dispensing station was also in need of grouting repair.

The flooring inside the dry food storage area contained dried food spillage. The director of dietary identified the food debris as chocolate syrup. Observations of the syrup revealed that it had harden to the linoleum flooring and was not readily disturbed with a broom.

The kitchen area interior flooring was not easily cleanable. The food debris, water and cracks and crevices were providing areas where household pests harbor and breed.

The interior of the Food and Nutrition County office of public health report dated August 17, 2018 indicated that the kitchen was out of compliance for an unclean physical environment, related to the flooring in the Food and Nutrition Department.

A work-order submitted by the director of dietary service requesting the facility's maintenance department to repair the kitchen flooring was dated July 10, 2018.

The metal door, located on the ground floor near the Food and Nutrition Department was was in need of repair. This door opens directly to the outside of the building. This access was the designated doorway to the outdoor trash/garbage dumpsters and served as a receiving area for the facility. This door was not sealed properly, allowing easy access to the facility for pests and rodents . The threshold of the metal door, upon closing was not flush with the metal door plate. There was a two inch gap at the bottom of the door after closing.

A review of the pest control operators reports for the months of December, 2018 and January, February and March, 2019 revealed that the facility's kitchen had been treated for common household pests (mice). According to the Servsafe Manager, National Restaurant Association, 2012, pest management was critical in pest control. The rules to keeping the operation pest free were to deny pests access to the operation, deny pests food, water and shelter and work with a licensed pest control operator.

The facility failed to maintain cleaning, housekeeping and maintenance of the building in satisfactory condition. good repair in the Food and Nutrition Department.

28 PA. Code: 211.6(d) Dietary service

28 PA. Code: 205.13(b) Floors

28 PA. Code: 207.2(a) Administrator's responsibility
Previously cited 11/2/17, 5/1/17, 10/3/16



 Plan of Correction - To be completed: 04/18/2019

Please accept this 2567 with our completed Plan Of Correction for Towne Manor East as our letter of assertion of substantial compliance. Preparation and submission of this plan of correction does not constitute an admission or agreement with the alleged deficiencies. This plan is provided as required by the CMS regulations.
1.Flooring near the dish machine has been scheduled for repair. The kitchen has been thoroughly cleaned including inside dry food storage area. Maintenance Director reviewed all previous work orders back to July 2018 to ensure noted areas of concern have been addressed. Repair for the metal door completed on 3/4/2019.
2. Food Service Director will educate dietary staff to maintain clean housekeeping and maintenance of food and nutrition department in accordance with professional standards for food and safety in kitchen area.
3. NHA/ Designee will conduct a sanitation and infection control food storage audit weekly x 4 then monthly x 3.
4. Results of this audit will be prepared and presented at monthly QA & A x 3 to ensure compliance and for further IDT review and recommendations.
483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on a group meeting with resident's, observations, interviews with facility staff, review of facility documentation and review of facility policy and procedure, it was determined, that the facility failed to maintain a homelike environment related to water temperature for showers and air temperature in the central shower rooms, for two of two resident shower rooms (first and second floor central bathrooms).

Findings include:

Review of facility policy and procedure, titled, "Physical Environment", dated June, 2012, indicated that it is the facility policy and procedure, "To provide each resident with a home-life environment".

During the group meeting on March 6, 2019, at 1:30 p.m. with six alert and oriented residents, (Resident's: R1, R13, R23, R59, R88 and R97), which were identified by the facility, revealed that the water temperature in the showers, on both the first and second floor nursing units, was cold and the air temperature was also cold in the central shower rooms on both nursing units.

Observation of the first floor central bathroom on March 7, 2019, at 8:45 a.m. in the presence of the Nursing Home Adminstrator and Employee E4, Maintance Director, revealed the water temperature in shower #2, was 99.4 degrees farenheit and the air temperature was 70 degrees farenheit.

An observation of the 2nd floor central shower room again in the presence of the Nursing Home Administrator and Maintance Director, at 9:10 a.m. again on March 7, 2019, revealed the shower water temperature was 74 degrees farenheit. During this observation the Nursing Home Adminstrator indicated the missing valve is set at 113 degrees farenheit and shared that the mixing valve was recently replaced. Also the Maintance Director indicated that water and air temperatures are taken every day and recorded.

An interview with Employee E5, Nurses Aide, during the observation of the 2nd floor central shower room, in the presence of the Nursing Home Adminstrator and Maintance Director, was not able to indicate what the appropriate water temperature should be for shower water temperature.

Observation of the mixing valve with the Maintance Director and Nursing Home Adminstrator, at 9:30 a.m. revealed that the mixing valve temperature gage was fluctuating between, 120 - 130 degrees farenheit, during the five minute observation of the mixing valve. Both the Nursing Home Adminstrator and Maintance Director could not indicate why the temperature gage was fluctuating between, 120 - 130 degrees.

Review of facility documentation, revealed, the mixing valve was recently replaced, which was confirmed by the Nursing Home Adminstrator and Maintance Director.

Also review of facility documentation titled, "Weekly TELS Temperature Audits", revealed that the facility is recording a water temperature and air temperature from a resident room, on a daily basis.

Continued review of the "Weekly TELS Temperature Audits", from current, (March 7, 2019), back to December 3, 2018, revealed that no shower water and/or air temperatures were taken and/or recorded. At the time of the review of the facility documentation, the Nursing Home Adminstrator and Maintance Director, confirmed that they have not been monitoring the water temperature for showers and/or the air temperature in central bathrooms.

The facility did not ensure resident's were provided with a homelike environment related to appropriate water temperatures for showers and also air temperature in central bathing rooms.

28 Pa. Code: 207.2(a) Housekeeping and Maintance

28 Pa. Code: 201.29(j) Resident rights
Previously cited 5/1/17.

28 Pa. Code: 205.37(e) Equipment for bathrooms





 Plan of Correction - To be completed: 04/18/2019

Please accept this 2567 with our completed Plan Of Correction for Towne Manor East as our letter of assertion of substantial compliance. Preparation and submission of this plan of correction does not constitute an admission or agreement with the alleged deficiencies. This plan is provided as required by the CMS regulations.
1. Residents R1, R13, R23, R59, R88, R97 to be interviewed to determine if the water and air temperatures in the shower rooms feel cold on both nursing units. The mixing valve was replaced on 3/22/2019. Water and air temperatures were taken on 3/22/19 and were within acceptable range. Employee E5 was educated that appropriate shower water temperature range not to exceed 110 degrees.
2. Activities Director will conduct resident council meetings to identify if facility is maintaining a homelike environment related to water and air temperatures in the central shower rooms. IDT will make daily room rounds and conduct resident interviews as appropriate to identify if facility is maintaining a homelike environment related to water and air temperatures in the central shower rooms.Random staff will be interviewed weekly to determine if they can indicate appropriate water temperature for shower. Staff to take water and air temperatures prior to showering residents twice weekly. Maintenance director/ Designee will monitor water and air temperatures for central shower rooms daily and monitor mixing valve to ensure they are within acceptable range.Staff Development Coordinator/ Designee will educate nursing staff on facility TELS policy including room air temps to remain between 71-81 degrees and shower water temps not to exceed 110 degrees or the comfort of the resident. Maintenance Director/ Designee will be educated on facility TELS policy including obtaining and recording shower water and air temps daily.
3. Activities Director/ Designee will audit monthly x 3 to identify if facility is maintaining a homelike environment related to water and air temperatures in the central shower rooms based on response from resident council. IDT will audit weekly x 4 monthly x 3 by conducting resident interviews during room rounds to identify if facility is maintaining a homelike environment relater to water and air temperatures in the central shower rooms. Unit Manager/Designee will audit by random staff interviews to determine if they are able to indicate appropriate water temperatures for showers weekly x 4 then monthly x 3. Maintenance Director/ Designee will audit mixing valve, water and air temperatures in central shower rooms daily to ensure within acceptable range.
4. Results of these audits will be prepared and presented at monthly QA & A x 3 to ensure compliance and for further IDT review and recommendations.
483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime: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.
483.60(f) Frequency of Meals
483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.
Observations:

Based on observation and interviews with staff and residents and review of facility policy, it was determined that the facility failed to provide a nourishing snack for residents at bedtime.

Findings include:

Observation on March 4, 2019 at 7:15 p.m. of Employee E14, a nursing assistant, revealed Employee E14 pushing a cart with several sandwiches with resident labels and a bag of cookies without a label. When asked, Employee E14 explained that the bag of cookies was the bulk snack for the night. When asked how the cookies are distributed, Employee E14 looked at the cart and stated that she could get some cups and put cookies inside. Employee E14 was not wearing gloves. Employee E14 stated that "residents don't even want the snack usually."

Group meeting on March 6, 2019 at 1:30 p.m. with six alert and oriented resident revealed that they do not receive an evening snack. All reported that people with diabetes get a sandwich before bed. All were in agreement. All residents stated that "nobody else gets snacks."

Interview with Employee E13, a registered dietician, stated, "Residents may have a snack if they request it. We provide bulk snacks on the carts and we rotate the snacks. When asked if the residents have a beverage with the snacks, Employee E13 stated, "Well, they have water in their rooms." Bulk snack list was provided: Monday-vanilla wafer; Tuesday-potato chips; Wednesday-animal crackers; Thursday-pretzels, Friday-graham cracker; Saturday-vanilla wafer; and Sunday-animal crackers. When asked about how bulk snacks are distributed, Employee E13 stated, "When residents ask for a snack, we will provide it." There were no small cups, bowls or napkins on the snack cart.

Review of facility policy, "Snacks" revealed...Bedtime (a.k.a.HS) snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non-traditional times....6. Nursing services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all residents."

Residents are not required to ask for a bedtime snack. All residents must be offered suitable, nourishing snacks. The bulk items provided are very dry and would necessitate a beverage to be provided with snack. Residents stated they were not being offered a snack at bedtime.

The facility failed to offer all residents a nourishing snack.

28 PA. Code: 211.12(c)(d)(1)(5) Nursing services
Previously cited 11/2/17, 5/1/17, 10/3/16




 Plan of Correction - To be completed: 04/18/2019

Please accept this 2567 with our completed Plan Of Correction for Towne Manor East as our letter of assertion of substantial compliance. Preparation and submission of this plan of correction does not constitute an admission or agreement with the alleged deficiencies. This plan is provided as required by the CMS regulations.
1. Residents R1, R13, R23, R59, R88, R97 are offered nourishing snacks every evening. E13 education completed on facility Nourishment/ Snack Policy.
2. residents notified by Unit Manager/ designee that they will be offered nourishing snack every evening. Staff development will educate nursing staff on facility Nourishments/ Snacks Policy.
3. Evening shift Supervisor will keep log of evening snacks and audit three times weekly x 4 then monthly x 3 the number of residents offered a nourishing evening snack. IDT will interview residents during room rounds to ensure nourishing HS snacks are being offered weekly then monthly x 3.
4. Results of this audit will be prepared and presented at monthly QA & A x 3 to ensure compliance and for further IDT review and recommendations.
483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on observations, interviews with residents and staff members, it was determined that the facility failed to accommodate resident needs related to overbed light cords, not being long enough to operate independently for 7 of 54 residents on the second floor nursing unit (Resident's: R19, R21, R42, R45, R57, R63 and R97).

Findings include:

During the initial tour of the facility on March 4, 2018, at 6:50 p.m. an individual resident interview with Resident R21, revealed that the pull cords for the overbed lights, were to short for him to reach when he was laying in bed, he further indicated that he can only reach the cord when he is standing up out of bed.

At the time of the interview an observation of the the two pull cords for the overbed lights, revealed that both of the pull chains were only three inches in length. At the time of the observation, Resident R21, was laying in his bed.

During a further observation of Resident R21 and during an interview with Employee E3, Licensed Nurse/Risk Manager, on March 4, 2019, at 7:30 p.m. Resident R21, demonstrated to Employee E3, how when he is laying in bed he is not able to reach the pull chains for the overbed lights

Employee E3, confirmed that the pull chains were each only three inches long and Resident R21, could not independently use the pull chains to turn on and off the overbed light as he wished.

Further observations of the 2nd floor nursing unit, on all days of the survey, (March 4, 5, 6 and 7, 2019), at various times, revealed the following residents were also with pull chains for overbed lights, that were only three inches long and were not able to reach them when they were laying in bed, Resident's R19, R21, R42, R45 R57 R63 and R97.

An interview with the Nursing Home Administrator on March 7, 2019, at 11:30 a.m. confirmed the residents indicated, that there pull chains for overbed lights were not long enough to accommodate individual resident needs.

The facility failed to accommodate resident needs in being independent with using pull chains to turn on and off overbed lights.

Reasonable Accommodations of Needs/Preferences
CFR(s): 483.10(e)(3)

28 Pa. Code: 201.29(j) Resident rights
Previosly cited 5/1/17.

28 Pa. Code: 201.14(a) Responsibility of licensee
Previosly cited 5/1/17.

28 Pa. Code: 201.14(b) Responsibility of licensee

28 Pa. Code: 201.18(b)(1) Management
Previosly cited 5/1/17.

28 Pa. Code: 201.18(b)(3) Management
Previously cited 5/1/17.

28 Pa. Code: 211.12(d)(1)(5) Nursing services
Previously cited 5/1/17.







 Plan of Correction - To be completed: 04/18/2019

Please accept this 2567 with our completed Plan Of Correction for Towne Manor East as our letter of assertion of substantial compliance. Preparation and submission of this plan of correction does not constitute an admission or agreement with the alleged deficiencies. This plan is provided as required by the CMS regulations.
1. Residents R19,R21,R42, R45, R57, R63 and R97 were interviewed and observed to have overbed lights long enough to operate independently. Room Rounds were made by Maintenance Director to identify overbed light cords not long enough to operate independently and corrected upon identification.
2. IDT will make rounds daily to identify overbed light cords not long enough to operate independently and correct upon identification. Staff Development Coordinator/ Designee will educate staff on facility Physical Environment Policy.
3. IDT will audit weekly x 4 then monthly x 3 during room round observations to ensure resident overbed light cords are long enough to operate independently.
4. Results of this audit will be prepared and presented at monthly QA & A x 3 to ensure compliance and for further IDT review and recommendations.
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 observations, clinical record review, interviews with resident representatives and interviews with staff, it was determined that the facility failed to assess a new skin condition for one resident (Resident R57), failed to document in a Minimum Data Set (MDS) that one resident received oxygen therapy (Resident R108), failed to complete an accurate smoking assessment for one resident (Resident R21), and failed to accurately document in a MDS the discharge status for one resident (Resident R106) for four of 33 records reviewed.

Findings include:

Interview on March 4, 2019, at 8:05 p.m., with Resident R57's representative, revealed that on March 2, 2019, she identified a new skin injury on the resident's right shin. Observation at the time of the interview with Resident R57's representative revealed that the resident had reddened area with a scratch on his right shin. The representative stated that she was waiting to hear back from the facility as to how the resident got this new skin injury.

Clinical record review for Resident R57 revealed a weekly skin check, dated March 5, 2019, at 6:33 a.m., that indicated "No new areas of skin impairment." Continued record review revealed that there was no documentation available in the record related to a right shin skin injury for Resident R57.

Observation on March 5, 2019, at 2:35 p.m. with Employee E3, Risk Manager, revealed that Resident R57 had a reddened area with an indentation on his right shin. Employee E3 stated that she was unaware of this new skin injury and stated that it appeared as an indent from a zipper on the resident's pants. Interview with Employee E10, unit manager, at the time of the observation, also confirmed that she was unaware of the new skin injury to the resident's right shin.

Interview on March 6, 2019, at 2:20 p.m., with the Director of Nursing (DON), revealed that a change of condition report should have been completed related to the new skin injury on Resident R57's shin.

Clinical record review for Resident R108 revealed an admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated February 5, 2019, which indicated that the resident was admitted to the facility on January 30, 2019, was severely cognitively impaired and had diagnoses including stroke, aphasia (loss of ability to understand or express speech, caused by brain damage), paralysis, seizures, a tracheostomy and a feeding tube.

Continued record review revealed a physician's order, dated January 30, 2019, specifying that Resident R108 has a #8 Shiley (size and brand of tracheostomy tube) and is on two liters of oxygen continuously. Review of progress notes from January 30, 2019, (resident's admission to the facility) through February 5, 2019, (the day the assessment was completed), revealed that the resident received oxygen therapy daily via his tracheostomy.

Further review of Resident R108's admission MDS, dated February 5, 2019, revealed that under Section O, "Special Treatment's, Procedures, and Programs," that the resident did not receive oxygen therapy during the 14-day look back period of the assessment.

Interview on March 6, 2019, at 2:20 p.m., with the Director of Nursing (DON), confirmed that Resident R108's oxygen therapy was not included in the MDS assessment.

Clinical record review for Resident R106 revealed that this resident was admitted to the facility On September 6, 2018. The clinical record indicated that Resident R106 was discharged to an assisted living community on November 16, 2018. The comprehensive assessment MDS (an assessment of care needs for this resident) was inaccurately documented. The discharge status for this resident was noted as an acute care hospital. The inaccurate assessment was verified with the Clinical Reimbursement Director, Employee E11 at 10:00 p.m., on March 7, 2019.

During the initial entrance conference with the Nursing Home Adminsitrator and Director of Nursing, on March 4, 2019, at 8:40 p.m. identified Resident R21, as a resident that smokes.

Clinical record review for Resident R21, revealed a "Smoking" careplan, dated, February 4, 2019, which indicated Resident R21, is a current smoker. An interview with Employee E10, Licensed Nurse, on March 5, 2019, at 9:40 a.m. also confirmed that Resident R21, is a smoker.

Further review of Resident R21's clinical record, on March 5, 2019, at 9:50 a.m. revealed the last smoking assessment completed, for Resident R21, was done on December 4, 2017. At the time of the review of Resident R21's clinical record, an interview with Employee E10, confirmed, several smoking assessments, for Resident R21, were missed and no current information was available for review related to Resident R21's ability to safely smoke.

The facility failed to complete accurate assessments for four residents.

28 Pa Code 211.5(f) Clinical records
Previously cited 5/1/17, 10/3/16

28 Pa Code 211.5(g) Clinical records

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 11/2/17, 5/1/17, 10/3/16







 Plan of Correction - To be completed: 04/18/2019

Please accept this 2567 with our completed Plan Of Correction for Towne Manor East as our letter of assertion of substantial compliance. Preparation and submission of this plan of correction does not constitute an admission or agreement with the alleged deficiencies. This plan is provided as required by the CMS regulations.
1. R57 skin was assessed on 3/5/19 with MD and RR notification. R108 MDS was modified on 3/6/2019. R21 smoking assessment was completed on 3/21/2019. R106 was discharged from facility unable to modify discharge MDS.
2. Unit Manager/ Designee will perform house wide skin sweeps on current residents and verify changes reported to RR and MD for follow up. For any newly identified areas, resident's electronic record will be reviewed for initiation of a change resident condition in addition to completion of the event report. CRD will review the electronic health record of all resident admissions in the last 30 days for accurate reflection of oxygen administration in admission MDS and submit modifications as appropriate. CRD will also review the electronic health record of all residents scheduled for discharge to ensure the MDS accurately reflects discharge status. Unit Manager / Designee will review the EHR of residents that smoke to ensure smoking assessment updated and accurate. Staff development/ Designee will educate nursing staff on Notification of Resident/Change in Condition Policy, Event Management Policy and Smoking/Tobacco Use Policy. CRD will be educated on the Interdisciplinary Plan of Care from Interim to Meeting.
3. Unit Manager/ designee will complete 10 skin sweeps weekly x 4 then monthly x 3 to verify the assessment of new skin conditions. CRD will audit electronic health records of residents scheduled for weekly care conference to ensure MDS accurately reflects use of oxygen administration and will audit EHR weekly of residents scheduled for discharge to ensure MDS accurately reflects discharge status weekly x 4 then monthly x 3. Unit Manager/ designee will audit electronic health record of residents that smoke monthly x 3 to ensure assessment updated and accurate.
4. Results of this audit will be prepared and presented at monthly QA & A x 3 to ensure compliance and for further IDT review and recommendations.
483.25(a)(1)(2) REQUIREMENT Treatment/Devices to Maintain Hearing/Vision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(a) Vision and hearing
To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-

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

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

Based on resident interview, observations, interview with facility staff and review of facility policy and procedure, it was determined the facility failed to ensure one of 33 residents had prescription glasses readily available for daily use as prescribed (Resident R21).

Findings include:

Review of the facility policy and procedure, titled, "Vision/Hearing Services", dated, June, 2013, indicated, "The facility will assist residents/patients in obtaining routine and prompt vision/hearing care".

During a resident interview with Resident R21, during the initial tour of the facility on March 4, 2019, at 6:50 p.m. indicated he did not have his glasses that the doctor prescribed him so he could see better. At the time of the initial observation and interview with Resident R21, he was not wearing any glasses and no glasses were noticed on any counter surface within his room.

An interview with Employee E10, Licensed Nurse, on March 5, 2019, at 10:30 a.m. confirmed Resident R21, has prescription strength glasses, that he should be wearing on a daily basis.

Further observations of all days of the survey, (March 4, 5, 6 and 7, 2019), at various times revealed that Resident R21, was not wearing prescribed glasses and observation of his room area, also revealed no glasses.

An interview with Employee E10, on March 7, 2019, at 2:30 p.m. revealed documentation with a picture of Resident R21's prescribed glasses. Employee E10, further indicated she could not recall the last time she observed Resident R21, wearing his prescribed glasses.

The facility failed to ensure a resident had prescribed glasses readily available for daily use.

28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services
Previously cited 5/1/17.

28 Pa. Code: 201.29(j) Residents rights
Previously cited 5/1/17.

28 Pa. Code: 201.14(a)(b) Responsibility of licensee
Previously cited 5/1/17.



 Plan of Correction - To be completed: 04/18/2019

Please accept this 2567 with our completed Plan Of Correction for Towne Manor East as our letter of assertion of substantial compliance. Preparation and submission of this plan of correction does not constitute an admission or agreement with the alleged deficiencies. This plan is provided as required by the CMS regulations.
1. New glasses were ordered for Resident R21 glasses. Clinical administration will review optometrist consults from last year to determine residents prescribed glasses.
2. Unit manager/ designee will audit current residents to determine if prescribed glasses are readily available for daily use and will consult optometrist if glasses not available. Staff Development Coordinator/ designee will educate all nursing staff on facility Vision/Hearing Services Policy.
3. DON/ Designee will review optometrist consults during clinical meeting monthly x 3 to ensure follow up services are provided as recommended. Unit Manager/ Designee will perform weekly audit x 4 then monthly x 3 by interviewing and observing residents who are prescribed glasses to ensure glasses are readily available for daily use.
4. Result of this audit will be prepared and presented at monthly QA &A x 3 to ensure compliance and for further IDT review and recommendations.
483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Based on observation, interview with staff and review of facility policy and procedures, it was determined that the facility failed to ensure an environment free of accident hazards.

Findings include:

Review of facilty policy, "Medication Administration", dated, December, 2012, indicated, "Medications are to be administered at the time they are poured". "The person who prepares the dose for administration is the person who administers the dose".

During the initial tour of facility on March 4, 2019 at approximately 7:00 p.m., revealed one medication cup with four medications as well as a liquid substance in a medication cup at the bedside table of Resident R48. Resident R48 was in bed as were his two roommates. The medications at the bedside were identified as: Atorvastatin Calcium tablet 20mg; Ferrous Gluconate 240 mg; Melatonin 3 gm; and Zyprexa tablet 5mg. The liquid was identified as Prostat, a liquid protein supplement. The resident did not have an order for Prostat. Rather resident had an order for Healthshake 4 oz. every day and evening for supplement.

Interview on March 4, 2019 at approximately 7:02 p.m. with Employee E12, a licensed nurse, revealed that Employee E12 "Placed the medication on the bedside table when another nurse called out for assistance and I responded".

Interview on March 4, 2019 at approximately 7:05 p.m. with Employee E8, a licensed nurse and Unit Manager, confirmed that Employee E12 should not have left the medications at the bedside of Resident R48.

The facility failed to ensure that the resident environment remains free of accident hazards.

28 Pa. Code 211.5(f) Clinical records
Previously cited 5/1/17, 10/3/16

28 Pa Code 211.12(d)(1)(5) Nursing services
Previously cited 11/2/17, 5/1/17, 10/3/16



 Plan of Correction - To be completed: 04/18/2019

Please accept this 2567 with our completed Plan Of Correction for Towne Manor East as our letter of assertion of substantial compliance. Preparation and submission of this plan of correction does not constitute an admission or agreement with the alleged deficiencies. This plan is provided as required by the CMS regulations.
1.Resident R48 and his roommates have been assessed and not showing any change in condition due to meds left at bedside. Employee E12 was educated on facility Medication Administration Policy on 3/21/2019 and had Medication Observation Pass on 3/23/2019.
2. Unit Manager/ Designee and IDT will perform daily rounds to ensure resident environment is free of accident hazards by ensuring medications are not left at resident bedside unattended. Staff Development Coordinator/ Designee will educate all licensed nursing staff on facility Medication Administration Policy and on Physician Order Policy.
3. Unit Manager/ designee will audit resident rooms weekly x 4 then monthly x 3 to ensure resident environment is free of accident hazards by ensuring medications are not left at resident's bedside unattended. Staff development/ Designee will preform random weekly Med Pass Observations on licensed nurses to ensure compliance with Physician orders during medication adminsitration weekly x 4 then monthly x 3.
4. Results of this audit will be prepared and presented at monthly QA & A x 3 to ensure compliance and for further IDT review and recommendations.
483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to provide proper tracheostomy care and services for one out of 33 residents reviewed (Resident R108).

Findings include:

Review of facility policy "Tracheostomy (a surgically created hole in your trachea that allows for breathing) Tube Change," dated effective November 2013, revealed that "only respiratory therapists or nurses who have completed the appropriate competency reviews are authorized to perform this procedure. Back-up tracheostomy tubes of actual size and the next smaller must be readily available at all times." Continued policy review revealed "insert new tracheostomy tube with an obturator (acts as a guide to help place the tube into the airway, is only used when inserting a tracheostomy tube and must be removed as soon as the tube has been placed) until phalange (neck plate) of trach tube rests against resident's neck. Immediately remove obturator."

Clinical record review for Resident R108 revealed an admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated February 5, 2019 which indicated that the resident was admitted to the facility on January 30, 2019, was severely cognitively impaired and had diagnoses including stroke, aphasia (loss of ability to understand or express speech, caused by brain damage), paralysis, seizures, a tracheostomy and a feeding tube.

Review of Resident R108's care plan, dated initiated January 31, 2019, revealed that the resident has a #8 Shiley (size and brand) tracheostomy tube related to impaired breathing. An intervention, dated initiated February 19, 2019, indicated "Emergency back up trach #6. Keep in room."

Observation of Resident R108's room and tracheostomy supplies on March 5, 2019, at 9:25 a.m., revealed that there were no spare tracheostomy tubes in the room available for the resident. Interview with Employees E7 and E8, Registered Nurses, at the time of the observation, confirmed that there were no spare tracheostomy tubes in the room for Resident R108. During the interview Employee E8 stated that in an emergency if the resident's tracheostomy tube came out that he would insert the obturator into the stoma (surgical opening that the tracheostomy tube fits into) to maintain the patency of the stoma.

Continued record review for Resident R108 revealed a progress note, dated February 11, 2019 at 10:55 a.m., that the resident's tracheostomy tube had dislodged from the stoma and was found lying on the resident's chest. Review of facility documentation prepared by Employee E7, revealed that after the tube had dislodged, the employee placed the obturator in the trach stoma, then transferred the resident via 911 to the emergency room.

Interview on March 6, 2019, at 9:10 a.m. with Employee E9, staff educator, confirmed that an obturator is used to assist in placing a new tracheostomy tube into the stoma and then promptly removed once the tube is in place. Employee E9 also confirmed that an obturator would block the airway if left in and that it should not be placed directly in a stoma. Continued interview with Employee E9 confirmed that there was no documentation available for review at the time of the survey to indicate if nursing staff had been trained on how to insert a tracheostomy tube and what to do in an emergency if a tracheostomy tube falls out.

Interview on March 6, 2019, at 2:20 p.m., with the Director of Nursing (DON), confirmed that an obturator should not be placed directly in a stoma and was unable to explain why the nurse had done that on February 11, 2019, when Resident R108's tracheostomy tube came out.

The facility failed to provide proper tracheostomy care and services.

28 Pa Code 201.20(a) Staff development

28 Pa Code 211.12(d)(1)(5) Nursing services
Previously cited 11/2/17, 5/1/17, 10/3/16





 Plan of Correction - To be completed: 04/18/2019

Please accept this 2567 with our completed Plan Of Correction for Towne Manor East as our letter of assertion of substantial compliance. Preparation and submission of this plan of correction does not constitute an admission or agreement with the alleged deficiencies. This plan is provided as required by the CMS regulations.
1. Resident R108 assessed without any changes noted. #8 Shiley trach replaced at resident bedside. Employee E8 and E7 educated on appropriate procedure for trach replacement.
2. Unit Manager/ designee will review resident electronic health record during daily clinical meeting to ensure proper tracheotomy care and services are provided for residents with tracheotomy tubes when trach is replaced. Will also round daily to ensure back up trach remains at bedside.
3. Staff Development Coordinator/ designee will perform random trach competencies on licensed nurses weekly x 4 then monthly x 3 to ensure proper tracheotomy care and services are provided for residents during trach replacement. Unit Manager/ designee will round weekly x 4 then monthly x 3 in rooms of residents with trachs to ensure back up trach remains at bedside at all times.
4. Results of these audits will be prepared and presented at monthly QA & A x 3 to ensure compliance and for further IDT review and recommendations.
483.40 REQUIREMENT Behavioral Health Services: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 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations:

Based on clinical record review and interviews with staff, it was determined that the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and care plan for one of thirty-three residents reviewed (Resident R83).

Findings include:

The comprehensive assessment MDS, (an assessment of care needs), dated February 6, 2019, indicated that this resident was cognitively intact and that the resident was using antidepressant medications over the past seven days.

Resident R83 was admitted to the facility on March 6, 2018. The resident was admitted with a diagnosis of major depressive disorder (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and/or routine) and generalized anxiety disorder (chronic condition characterized by an excessive and persistent sense of apprehension with symptoms of sweating, palpitations and feelings of stress). Clinical record documentation indicated that the physician had ordered Resident R83 antidepressant medications (Celexa and trazodone). Care planning measures, according to the physician revealed that the physician planned that Resident R83 be evaluated and treated by the psychiatric and behavioral services group of specialists on December 17, 2018. There was no documentation to indicate that the resident received the behavioral health care and services as ordered by the physician. The lack of assessment and evaluation by the psychiatric and behavioral health specialist for Resident R83 was confirmed by the Director of Nursing, Employee E2 at 10:00 a.m., on March 6, 2019.

The nursing progress dated January 22, 2019 indicated that this resident had an outburst of aggressive behavior toward a nursing staff member. According to the nursing documention the resident complained that the nurse was not giving the resident his pain medication timely. The resident became belligerent and knocked all the supplies from the top of the medication cart onto the floor. The nurse contacted the local police related to the resident's physical aggression toward staff.

The nursing progress note dated February 20, 2019 indicated that the nurse entered the resident's room to administer the resident's morning medications and take blood pressure. The nurse observed the resident to be groggy. The resident became combative using foul language. The physician was notified and gave an order for this resident to be transferred to the hospital on an emergency basis. The facility staff found a bottle of alcohol at the resident's bedside.

The facility failed to ensure a resident received Behavioral health services to meet the resident's whole emotional and mental well-being to prevent and treat mental and substance use disorders.

28 PA. Code: 211.11(a)(b) Resident care plan

28 PA. Code: 211.12(c)(d)(1)(5) Nursing services
Previously cited 11/2/17, 5/1/17, 10/3/16

28 Pa Code 211.12(d)(1)(5) Nursing services
Previously cited 11/2/17, 5/1/17, 10/3/16




 Plan of Correction - To be completed: 04/18/2019

Please accept this 2567 with our completed Plan Of Correction for Towne Manor East as our letter of assertion of substantial compliance. Preparation and submission of this plan of correction does not constitute an admission or agreement with the alleged deficiencies. This plan is provided as required by the CMS regulations.
1. Resident R83 had psych consult completed on 3/13/2019.
2. Unit Manager/ designee will review electronic health record of current residents receiving antidepressants and antianxiolytics to ensure residents are receiving behavioral health care and services as ordered by physician.
3. Staff Development/ Designee will educate licensed nursing staff on facility Behavior Management Overview Policy. Unit Mnaager/ Designee will perform audits weekly x 4 then monthly x 3 by reviewing the resident's electronic health record to ensure all residents receiving antidepressants and antianxiolytics are receiving behavioral health acre and services as ordered by physician.
4. Results of this audit will be prepared and presented at monthly QA & A x 3 to ensure compliance and for further review and recommendations.
483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

483.55(b) Nursing Facilities.
The facility-

483.55(b)(1) Must provide or obtain from an outside resource, in accordance with 483.70(g) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

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

483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.
Observations:

Based on observations of care and services, clinical record review, interview with residents and staff and review of facility policy and procedure, it was determined that the facility failed to provide or obtain dental services to meet the needs of two of thirty-three residents (Residents R7 and R21).

Findings include:

Review of facility policy and procedure, titled, "Dental Services", dated, October, 2017, indicated, "The facility will assist residents in obtaining routine care". Continued review of the policy and procedure indicated, "Facility will identify dental needs of the residents through interview, assessment and observation". Lastly review of the policy and procedure, indicated, "Any resident identified needing dental services will be referred to the dental provider within 3 days of the identification".

The comprehensive assessment MDS (an assessment of care needs) for Resident R7 dated November 29, 2018 revealed that this resident was cognitively intact and the resident's nutritional approaches to care were providing the resident with a mechanically altered diet.

A nursing admission assessment for Resident R7 dated January 27, 2016, indicated that this resident had no natural teeth.

On March 5, 2019 at 2:00 p.m., Resident R7 was interviewed. The resident reported that she was edentulous. The resident also reported that she was waiting for dentures. Clinical record review revealed that the resident had a dental assessment and evaluation on May 22, 2018. The dentist documented that Resident R7 wanted full upper and lower dentures. There was no documented follow through related to this resident's dental care needs. The lack of following Resident R7's dental care plan was confirmed during an interview with the Director of Nursing at 1:30 p.m., on March 6, 2019.

During a resident interview with Resident R21, during the initial tour of the facility on March 4, 2019, at 6:50 p.m. indicated he did not have any teeth, and further explained to the surveyor that, he has talked to the staff about wanting dentures.

Review of facility documentation related to dental services, indicated the last full complete exam Resident R21, had was on May 10, 2017. Review of recent dental documentation indicated that Resident R21, was to have a dental appointment on June 4, 2018, but his responsible party refused the treatment.

An interview with Employee E10, Licensed Nurse, on March 5, 2019, at 10:30 a.m. indicated Resident R21, would be appropriate for dentures and would be able to make his own independent decision on being fitted for dentures.

An interview with Employee E14, Social Worker, on March 7, 2019, at 11:45 a.m. verified that Resident R21, did express to her an interest in the recent past of wanting dentures.

During the same interview, Employee E14, Social Worker, confirmed that it is her responsibility to ensure residents receive dental services needed and/or as wanted. Employee E14, further indicated, that Resident R21, has not received prompt dental services related to being fitted for dentures.

The facility failed to ensure prompt dental services were provided.

28 Pa. Code: 211.15(a)(b) Dental services

 Plan of Correction - To be completed: 04/18/2019

Please accept this 2567 with our completed Plan Of Correction for Towne Manor East as our letter of assertion of substantial compliance. Preparation and submission of this plan of correction does not constitute an admission or agreement with the alleged deficiencies. This plan is provided as required by the CMS regulations.
1. R7 and R21 were seen on 3/12/2019 by dentist and facility will assist in denture replacement.
2. Dental consults for the last year will be reviewed by clinical administration and services provided as recommended. Remaining residents have been scheduled. Staff development/ designee will educate licensed nursing staff and social services on facility dental policy.
3. DON/ Designee will review dental consults during clinical meeting for recommendations. Unit Manager/ designee will audit dental recommendations monthly x 3 to ensure follow up services are provided as recommended.
4. Result of this audit will be prepared and presented at monthly QA & A to ensure compliance and for further IDT review and recommendations.
483.70(o)(1)-(4) REQUIREMENT Hospice Services: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.
483.70(o) Hospice services.
483.70(o)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in 418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.

483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at 483.24.
Observations:

Based on a review of clinical records, interviews with residents and interviews with staff, it was determined that the facility failed to ensure that adequate communication was maintained between a hospice provider (end of life care to support resident and family) and the facility, for two out of 33 records reviewed (Residents R77 and R42).

Findings include:

During an interview on March 5, 2019, at 10:10 a.m., Resident R77 stated she wanted to know if her hospice aide was coming in that day.

Review of Resident R77's care plan, dated initiated February 11, 2019, revealed that the resident was diagnosed with a terminal condition and receives services from a hospice nurse and a hospice nurse aide. Interventions on the care plan include: collaborate with hospice team to ensure the resident's needs are met, hospice to provide supplemental services per plan of care (with instructions to see hospice documentation for more detail), and hospice aide (with instructions to refer to hospice schedule).

Review of Resident R77's hospice binder on March 7, 2019, at 9:15 a.m., with Employee E10, unit manager, revealed that the following documents were not readily available in the record in the facility: a current hospice care plan, a current hospice aide care plan and a schedule for hospice personnel involved in the care of Resident R77.

Clinical record review for Resident R42, revealed a physician order written, on January 30, 2019, for R42, to receive care and services by Season's Hospice.

A review of Resident R42's Season's Hospice binder, revealed a current hospice care plan, a current hospice aide care plan and a schedule for hospice personnel involved in the care of Resident R42, was not readily available.

Employee E10, Licensed Nurse, confirmed, on March 7, 2019, at 10:30 a.m. that the documentation was not readily available at the facility as required for Resident's R77 and R42.

The facility failed to ensure that adequate communication was maintained between a contracted hospice provider and the facility.

28 Pa Code 211.5(f) Clinical records
Previously cited 5/1/17, 10/3/16






 Plan of Correction - To be completed: 04/18/2019

Please accept this 2567 with our completed Plan Of Correction for Towne Manor East as our letter of assertion of substantial compliance. Preparation and submission of this plan of correction does not constitute an admission or agreement with the alleged deficiencies. This plan is provided as required by the CMS regulations.
1. Resident R77 and resident R42 have been notified of hospice aide schedule. The hospice provider's care plans, their hospice aide care plans and their hospice aide schedules have been added to the hospice binder and is readily accessible.
2. Unit Manager/ designee will review current hospice binders to ensure hospice provider's care plans, their hospice aide care plans and their hospice aides schedule have been added to the Hospice binder and it is readily accessible.Staff development/ Designee will educate nursing staff on facility Hospice Policy.
3. Unit Manager/ Designee will audit clinical records of residents receiving hospice services to ensure hospice provider's care plans, their hospice aide plans and hospice aide schedules have been added to the Hospice binder and they are readily accessible.
4. Results of thsi audit will be prepared and presented at monthly QA & A x 3 to ensure compliance and for further IDT review and recommendations.


483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program: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.
483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.
Observations:

Based on observations of the Food and Nutrition Department, interviews with staff and reviews of the consulting pest control operator's reports, it was determined that the facility failed to maintain an effective pest control program, so that the facility was free of pests and rodents.

Findings include:

Observations of the Food and Nutrition department at 10:00 a.m., on March 5, 2019 revealed mice droppings inside the kitchen 's dish room. Further observations of the Food and Nutrition Department revealed glue traps and mice traps placed in areas throughout the kitchen.

A review of the pest control operator's report for December 31, 2018 revealed that the facility was being treated for mice. The pest control operator mentioned that the flooring in the kitchen had loose and missing tiles, with areas of standing water. The pest control operator suggested that the facility address these problems.

The pest control operator's report dated January 14, 2019 indicated that the facility's kitchen was treated for mice. The suggestion made by the pest control operator was for the floor to be repaired in the kitchen.

The pest control operator's report for February 25, 2019 revealed that the facility's kitchen was treated for mice. The pest control operator indicated that standing water was evident in the dish room and that floor tiles were missing and loose in this area and should be repaired.

The pest control operator's report dated March 4, 2019 indicated that the kitchen was again treated for mice. The pest control operator advised that the flooring in the kitchen had loose and missing tiles and standing water that needed repair for effective cleaning and household pest and rodent prevention and maintenance.

Interview with the Nursing Home Administrator at 1:00 p.m., on March 6, 2019 confirmed the pest control operators monthly measures to eradicate and contain household pests and rodents were ineffective.

28 Pa. Code: 207.2(a) Administrator's responsibility
Previously cited 11/2/17, 5/1/17, 10/3/16

28 Pa. Code: 201.18(a)(b)(1) Management
Previously cited 11/2/17, 5/1/17, 10/3/16




 Plan of Correction - To be completed: 04/18/2019

Please accept this 2567 with our completed Plan Of Correction for Towne Manor East as our letter of assertion of substantial compliance. Preparation and submission of this plan of correction does not constitute an admission or agreement with the alleged deficiencies. This plan is provided as required by the CMS regulations.
1.Kitchen dish room including floor thoroughly cleaned and pest control company scheduled to visit bi-weekly.
2. Food Service Director will educate dietary staff to maintain clean Food and Nutrition Department in accordance with professional standards for food and safety in kitchen area.
3. NHA/ Designee to exit with Pest Control company biweekly x 6 monthly to compare pest control logs with pest treatment summary to ensure pest and rodent prevention is effective. Dietary/Housekeeping Health Care Services group will ensure entire kitchen will be deep cleaned biweekly. NHA will audit kitchen weekly to ensure cleaning and housekeeping maintained in keeping with professional standards for food and safety in the kitchen area.
4. Results of this audit will be prepared and presented to QA & A x 3 months to ensure compliance and for further IDT review and recommendations.

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