Pennsylvania Department of Health
MANATAWNY CENTER FOR REHABILITATION AND NURSING
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MANATAWNY CENTER FOR REHABILITATION AND NURSING
Inspection Results For:

There are 110 surveys for this facility. Please select a date to view the survey results.

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MANATAWNY CENTER FOR REHABILITATION AND NURSING - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Complaint survey, and a Civil Rights Compliance survey and one complaint investigation survey completed February 15, 2024, it was determined that Manatawny Center For Rehabilitation and Nursing, 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 of the Health portion of the survey.

Plan of Correction:

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

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

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

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

Observations:

Based on clinical record review and staff interview it was determined the facility failed to develop baseline care plans for two of 24 residents reviewed. (Resident 182 and 183)

Findings Include:

Review of Resident 182's clinical record revealed the resident was admitted to the facility on February 2, 2024.

Review of Resident 182's Nursing admission screener, dated February 2, 2024 revealed the resident should have had a basic care plan for Activities of Daily living, Allergies, Communication, Discharge planning, falls, neurological, oral/nutrition, skin, sleep pattern, and smoking cessation.

Review of Resident 182's care plan revealed the only care plan initiated in the 48 hours after admission was a nutrition care plan. All other care plans were initiated between February 5th and February 12, 2024.

Review of Resident 183's clinical record revealed the resident was admitted to the facility on February 1, 2024.

Review of Resident 183's Nursing admission screener, dated February 1, 2024 revealed the resident should have had a basic care plan for Activities of Daily living, Allergies, Communication, Discharge planning, falls, neurological, oral/nutrition, skin, sleep pattern, and smoking cessation.

Review of Resident 183's care plan revealed the only care plan initiated in the 48 hours after admission was a nutrition care plan. All other care plans were initiated between February 8th and 11th 2024.

Interview with the Director of Nursing on February 15, 2024 at 12:00 p.m. revealed Residents 182 and 183 did not have an initial care plan developed on admission.

28 Pa Code 201.18(b)(3) Management

28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 03/15/2024

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required.

1.Facility is unable to retroactively correct for Resident R182 & R183. Care plans are in place for those residents.

2.Audit of current residents completed to ensure care plans are in place.

3.DON/Designee will complete education to licensed staff on the components of this regulation to include the need for Baseline care plans in place within 48 hours of admission.

4.DON/Designee will complete audits of 5 new admissions weekly x 4 weeks, then monthly x 6 months to ensure baseline care plans are initiated within 48 hours of admission.
The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services/Designee.

5.Date of Compliance will be 3/15/2024.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on clinical record review and staff interview it was determined the facility failed to provide care and services for pressure ulcer for one of six residents reviewed. (Resident 21)

Findings Include:

Review of Resident 21's Admission Nursing Assessment, dated January 16, 2024 revealed there was a stage 1 pressure ulcer (intact reddened skin), measuring 3 centimeter (cm), 1cm wide and 1cm deep on the coccyx (small triangular bone at the base of the spinal column).

Review of Resident 21's physician orders on admission revealed there was no order for wound care to this wound.

Review of Resident 21's wound consult note, dated January 24, 2024 revealed the resident had a stage 3 pressure ulcer (extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) measuring 2cm long, 1cm wide, and 0.2cm deep. The wound specialist recommended a treatment of Triad paste and to leave open to air daily.

Review of Resident 21's physician orders revealed the triad paste as recommend by the wound specialist was not ordered for Resident 21 and they continued to have no treatment on the wound.

Review of Resident 21's wound consultant note, dated January 31, 2024, revealed the resident had a stage 3 pressure ulcer measuring 0.5cm long, 0.5cm wide, and 0.1cm deep. The wound specialist recommended a treatment of Triad paste and to leave open to air daily.

Review of Resident 21's physician orders revealed the triad paste as recommend by the wound specialist was not ordered for Resident 21 and they continued to have no treatment on the wound.

Interview with the Director of Nursing and Licensed Nursing Employee E4 on February 15, 2023 at 12:00 p.m. revealed when Resident 21 was admitted to the facility the pressure ulcer identified was incorrectly assessed as a stage one due to the measurement of depth and the facility failed to provide wound care to the wound upon admission and when recommended by the wound consultant on January 24th and January 30, 2024.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 03/15/2024

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required.

1.Resident R21's wound was reassessed, and physician was notified with treatment to sacrum initiated on 2/14/2024. There were no unfavorable outcomes related to the facilities alleged deficient practice.

2.Audit of current residents with pressure ulcers will be completed to ensure that recommended treatments are in place & that pressure ulcers are staged appropriately.

3.DON/Designee will complete education to licensed staff on the components of tis regulation, to include proper staging of pressure wounds and ensuring treatments are put in place timely.

4.DON/Designee will complete audits of 5 residents with pressure wounds weekly x 4 weeks then monthly x6 months, to ensure pressure area is staged correctly and area has a treatment ordered.
The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / Designee.

5.Date of Compliance will be 3/15/2024.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

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

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

Observations:

Based on observations, review of clinical records and facility documentation, and interviews with residents and staff, it was determined that the facility failed to provide proper continence care for one of one resident reviewed (Resident 70).

Findings include:

Review of Resident 70's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated January 19, 2024, revealed that the resident was admitted to the facility on September 24, 2021, and had diagnoses including Encounter for attention to gastrostomy (tube feed- artificial external opening into the stomach for nutritional support or gastric decompression), Scoliosis (sideways curvature of the spine or back bone), Intellectual disability (a condition that limits intelligence and disrupts abilities necessary for living independently). Continued review revealed that the resident was dependent for toileting hygiene. Further review revealed that the resident was always incontinent of bowel and bladder.

Review of Resident 70's care plan revealed the following intervention for potential for constipation: "Bowel meds as ordered" and "Following facility bowel protocol for episode of constipation" with a date initiated of April 20, 2022.

Further review of Resident 70's clinical medical record revealed an order for "Milk of Magnesia (used to treat occasional constipation) 400MG/5ML, Give 30 ml orally as needed for Constipation ON 3-11 SHIFT IF NO BOWEL MOVEMENT BY THE EVENING OF 3RD DAY."

Review of Resident 70's bowel function (task used to track bowel movement) from January 17, 2024, through February 14, 2024, revealed Resident 70 did not have a bowel movement on the following days:

January 18, 2024, January 19, 2024, January 20, 2024
January 22, 2024, January 23, 2024, January 24, 2024
February 1, 2024, February 2, 2024, February 3, 2024
February 5, 2024, February 6, 2024, February 7, 2024

Review of Resident 70's eMAR (electronic medication administration record) revealed the facility did not administer Milk of Magnesia on the evenings of January 20, 2024, January 24, 2024, February 3, 2024, or February 7, 2024.

Interview conducted with the Director of Nursing (DON) on February 15, 2024, at 1:15 p.m. confirmed Resident 70 did not receive Milk of Magnesia on the dates listed above.

28 Pa Code 201.14(a) Responsibility of licensee

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

Plan of Correction - To be completed: 03/15/2024

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required.

1.Resident R70 was reassessed, and no concerns were noted related to the facilities alleged deficient practice.

2.An audit of current residents was conducted by the DON/Designee to ensure that bowel protocols were present and being followed as ordered.

3.DON/Designee will educate licensed staff on the components of this regulation with an emphasis on ensuring that bowel protocols are present and being implemented if required.

4.DON/Designee will audit bowel movements of 5 residents weekly x 4 weeks, and monthly for 6 months to ensure bowel protocol was initiated per orders.
The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / Designee.

5.Date of Compliance will be 3/15/2024.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Observations:
Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and address weight loss in a timely manner for two of four residents reviewed for nutrition (Residents 105 and 112).

Findings include:

Review of facility policy, "Weight Assessment and Intervention," undated, revealed: "Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing."

Review of Resident 105's clinical record revealed on October 11, 2023, the resident was recorded as weighing 334.6 pounds (lbs.) On November 1, 2023, the resident was recorded as weighing 305 lbs., a 29.6 lb., or 8.85% weight loss in three weeks. Further review of Resident 105's weights revealed the next available weight was recorded on November 8, 2023, at 293.3 lbs.

Review of Resident 105's progress notes revealed a Weight Note on November 17, 2023, where the dietitian, Employee E5, requested a reweight be obtained.

Further review of Resident 105's weights revealed the next weight obtained was on November 21, 2023, with the resident recorded as weighing 278.6 lbs.

Further review of Resident 105's progress notes revealed the physician was notified of Resident 105's weight loss on December 6, 2023, and requested the resident's fluid restrictions be discontinued and the resident started on comfort measures.

The delay in obtaining a reweight to verify Resident 105's weight loss and the delay in the dietitian and physician being made aware of Resident 105's significant weight loss was discussed with the dietitian, Employee E5, on February 15, 2024, at approximately 11:15 a.m.

Review of Resident 112's clinical record revealed that on December 20, 2023, the resident weighed 135.2 lbs. On December 27, 2023, the resident weighed 127.3 pounds which is a 5.84 % loss in one week. Further review of Resident 112's weights revealed the next recorded weight was January 2, 2024, where the resident was recorded as weighing 124.9 lbs.

Review of Resident 112's progress notes revealed the Dietitian, Employee E5, did not address the resident's weight loss until January 9, 2024, where they documented that the resident was currently on antibiotic therapy for a urinary tract infection.

Further review of Resident 112's progress notes revealed the next Weight Note was on January 26, 2024, where the Dietitian, Employee E5, stated that Resident 112 had a 6.5% weight loss since December 20, 2023. The dietitian recommended nursing notify the physician and that Resident 112 be started on a supplement.

The delay in obtaining a reweight for Resident 112 and the delay in addressing Resident 112's significant weight loss was discussed with the dietitian, Employee E5, on February 15, 2024, at approximately 11:15 a.m.

28 Pa. Code 211.5(f) Clinical Records

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

28 Pa Code: 211.10(c) Resident care policies

Plan of Correction - To be completed: 03/15/2024

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required.

1.Physician notified of weight loss for Resident R112. Recommended supplement was started on 1/29/24. Physician aware of weight loss for Resident R105. Resident on comfort measures and MD discontinued weights.

2.Audit was completed to identify current residents with weight changes to ensure proper MD notification was completed and re-weights obtained with interventions put into place if required.

3.DON/Designee will educate dietician & nursing staff on the components of this regulation with an emphasis of ensuring the resident weights are obtained and the follow-up related to reweights and implementing occurs.

4.DON/Designee will perform weekly audits of 5 residents with significant weight changes x 4 weeks then monthly audits x 6 months to ensure residents with significant weight changes have had the proper assessments, notifications & interventions put in place.
The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services /Designee.

5.Date of Compliance will be 3/15/2024.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on clinical record review and staff interview it was determined that the facility failed to ensure that the pharmacy provided medications timely for one of two residents reviewed (Resident 80) and failed to provide record of disposition of a controlled drug for one of three closed records reviewed (Resident 130).

Findings include:

Review of Resident 80's clinical medical record revealed the following diagnoses: Encephalopathy Unspecified (a disease that affects brain structure or function. It causes altered mental state and confusion.), Methicillin-resistant staphylococcus aureus (MRSA- Infections caused by specific bacteria that are resistant to commonly used antibiotics), Sepsis (occurs when the body's immune response to an infection causes widespread inflammation, damaging its own tissues and organs.), UTI (urinary tract infection).

Review of Resident 80's comprehensive assessment Minimum Data Set (MDS - periodic assessment of resident care needs) dated January 1, 2024, in section O (special treatments, procedures, and programs) revealed Resident 80 was receiving IV medications (intravenous injection is an injection of medication or another substance into a vein and directly into the blood stream). Further review revealed Resident 80 was also receiving antibiotics (medicines that fight bacterial infections in people).

Additional review of Resident 80's clinical record revealed an order for "Vancomycin (antibiotic used to treat bacteria) 500 mg (milligrams) IV Q8 (every 8 hours) for 7 days with a start date of December 29, 2023, and an end date of January 4, 2024.

Review of Resident 80's clinical medical record revealed a progress note dated December 31, 2023, stating "as per md (medical doctor) extended iv vancomycin through January 5, 2024, due to missed doses regarding to pharmacy."

Further review of Resident 80's progress notes revealed a note dated January 5, 2024, stating "Vancomycin HCl Intravenous Solution Use 500 mg intravenously every 8 hours for MRSA urine until January, 5, 2024, 11:59 p.m. SASH protocol with med (medications) administration unavailable."

Review of Resident 80's eMAR (electronic medication administration record) revealed Resident 80 missed two doses of Vancomycin. The first missed dose was on December 31, 2023, and the second dose was on January 5, 2024.

Review of closed record revealed Resident 130 was admitted to Manatawny Center for Rehabilitation and Nursing on November 11, 2023, and expired on January 16, 2024.

Review of Resident 130's clinical medical record revealed an order for Morphine Sulfate (medication used to treat moderate to severe pain) solution 20 ML (milliliters) with a start date of January 16, 2024.

Further review of Resident 130's clinical medical record failed to find documentation of disposition (disposal) of Resident 130's morphine Sulfate.

Interview conducted with the Director of Nursing (DON) on February 15, 2024, at 11: 50 a.m. confirmed the above information.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

28 Pa. Code: 211.9 (a)(1) Pharmacy services

Plan of Correction - To be completed: 03/15/2024

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required.

1.Facility is unable to retroactively correct for Resident R80. Resident R130's morphine was returned to the pharmacy unopened.

2.An audit will be conducted of current residents by the DON/Designee to ensure that ordered medications are present in the facility. An audit will be conducted by the DON/Designee of discharged residents for the past 30 days to ensure that medication has been discarded per regulation.

3.DON/Designee will educate licensed staff on the components of this regulation with an emphasis on ensuring that medications are available as ordered with notification to facility administration if there are delays from pharmacy and on ensuring that discharged residents' medication is discarded of appropriately.

4.DON/Designee will perform audits of 5 residents x 4 weeks then monthly audits x 6 to ensure residents are receiving medications as prescribed and to ensure that discharged residents' medications have been discarded appropriately.
The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services/Designee.

5.Date of Compliance will be 3/15/2024.

483.50(a)(1)(i) REQUIREMENT Laboratory Services:

§483.50(a) Laboratory Services.
§483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter.

Observations:

Based on clinical record review and staff interview it was determined the facility failed to obtain laboratory services as ordered for one of 24 residents reviewed. (Resident 21)

Findings Include:

Review of Resident 21's physician orders revealed an order dated January 25, 2024 for a PT/INR (blood test to determined how fast blood clots) every Thursday for monitoring Coumadin (blood thinner).

Review of the clinical record revealed there was no PT/INR drawn on Thursday February 8, 2024.

Interview with the Director of Nursing on February 14, 2023 at 11:30 a.m. confirmed resident 21 did not have a PT/INR drawn on Thursday February 8th, 2024 as ordered.

28 Pa. Code 211.12(c)(d) (1)(3)(5) Nursing services

Plan of Correction - To be completed: 03/15/2024

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required.

1.Resident R21 was reassessed to ensure there were no unfavorable outcomes related to the facilities alleged deficient practice.

2.An audit was completed by the DON/Designee of current residents with coumadin orders to ensure that PT/INRs have been drawn as ordered.

3.DON/Designee will educate licensed staff on the components of this regulation with an emphasis on ensuring that residents who receive coumadin have the appropriate labs obtained.

4.DON/Designee will complete audits of residents with Coumadin orders to ensure PT/INRs are completed as ordered weekly x 4 weeks then monthly x6 months.
The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / Designee.

5.Date of Compliance will be 3/15/2024.

483.50(a)(2)(i)(ii) REQUIREMENT Lab Srvcs Physician Order/Notify of Results:

§483.50(a)(2) The facility must-
(i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws.
(ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders.

Observations:

Based on clinical record review and staff interview it was determined the facility failed to report results of laboratory studies to the physician for one of 24 residents reviewed. (Resident 21)

Findings Include:

Review of Resident 21's progress notes revealed a nursing entry dated January 23, 2024 at 9:43 p.m. stating INR 5.5 (lab resulting indicating how long it takes for blood to clot) new order obtained to hold warfarin (blood thinner) dose and recheck on January 25, 2024.

Review of Resident 21's labs revealed a PT/INR was drawn on January 25th 2024 and the results were reported to the facility on the same day.

Review of Resident 21's clinical record revealed the results of the PT/INR drawn on January 25, 2024 were not reported to the physician until January 29, 2024.

Interview with the Director of Nursing on February 14, 2023 at 11:30 p.m. confirmed the lab result from January 25, 2024 were not reported to the physician until January 29, 2024.

28 Pa. Code 211.12(c)(d) (1)(3)(5) Nursing services

Plan of Correction - To be completed: 03/15/2024

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required.

1.Physician made aware of lab results on 1/29/24 for Resident R21.

2.An audit was conducted by the DON/Designee of current residents with lab orders for the last 30 days to ensure that results have been obtained as ordered and reported to the physician.

3.DON/Designee will educate licensed staff on the components of this regulation with an emphasis on ensuring that laboratory results are reported to the physician in a timely manner.

4.DON/Designee will complete audits of 5 residents with laboratory orders to ensure that labs have been obtained and reported to the physician as appropriate in a timely manner, weekly x4 weeks then monthly x6 months.
The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services/Designee.

5.Date of Compliance will be 3/15/2024.

§ 201.18(d.1)(2) LICENSURE Management.:

(2) There is a plan in the event of an emergency when the administrator is not working.

Observations:
Based on closed record review and staff interview it was determined that the facility failed to return personal property to the family within 30 days after the death of a resident (Resident 130).

Findings include:

Review of Resident 130's closed record revealed Resident 130 expired on January 16, 2024.

Further review of Resident 130's closed record failed to find documentation regarding the returning of Resident 130's personal property to her family.

Interview conducted with the Director of Nursing (DON) on February 15, 2024, at 11:50 a.m. revealed the facility did not possess any documentation showing Resident 130's personal belongings were returned to her family.

Plan of Correction - To be completed: 03/15/2024

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required.

1.Facility is unable to retroactively correct for Resident R130.

2.An audit was conducted by the DON/Designee of resident discharges for the past 30 days to ensure resident personal property has been returned and documented in the medical record.

3.DON/Designee will educate licensed staff on the component of this regulation with an emphasis on ensuring that resident personal property is returned after discharge and documented in the medical record.

4.DON/Designee will audit 4 discharged residents weekly x 4 weeks then monthly x 6 months to ensure that personal property is returned after discharge and documented in the medical record.
The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services/Designee.

5.Date of Compliance will be 3/15/2024.

§ 211.5(f)(i)-(xi) LICENSURE Medical records.:

(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a resident ' s medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death.

Observations:
Based on a review of closed clinical records and interviews with facility staff, it was determined that the facility failed to ensure that a discharge summary, with the physician's final diagnosis, was completed for one out of three discharged residents reviewed (Resident 130)

Findings include:

Review of Resident 130's closed clinical record revealed the resident was admitted to the facility on November 6, 2023. The resident expired on January 16, 2024.

Review of the resident's closed clinical record on February 15, 2024, revealed the resident's record did not contain a physician's discharge summary with the resident's final diagnosis.

Interview with the Director of Nursing (DON) on February 15, 2024, at 11:50 a.m. confirmed the facility could not provide documentation a physician discharge summary completed for Resident 130.

Plan of Correction - To be completed: 03/15/2024

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required.

1.Facility is unable to retroactively correct for Resident R130.

2.An audit of resident discharges for the past 30 days was conducted by Medical Records/Designee to ensure that physician discharge summaries were present.

3.DON/Designee will educate facility physicians on the components of this regulation with an emphasis on ensuring that discharge summaries with the resident's final diagnosis upon discharge is completed.

4.DON/Designee will audit 4 discharged residents weekly x 4 weeks then monthly x 6 months to ensure the physician discharge summary is completed.
The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services/Designee.

5.Date of Compliance will be 3/15/2024.

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