Nursing Investigation Results -

Pennsylvania Department of Health
MISERICORDIA NURSING & REHABILITATION CENTER
Patient Care Inspection Results

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MISERICORDIA NURSING & REHABILITATION CENTER
Inspection Results For:

There are  54 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
MISERICORDIA NURSING & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid, State Licensure and Civil Rights survey completed on January 24, 2019, it was determined that Misericordia Nursing and Rehabilitation Center 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.


 Plan of Correction:


483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination: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(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:


Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide resident choice for one of 14 residents reviewed (Resident 29).

Findings Include:

Review of Resident 29's clinical record revealed diagnoses that included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) and adult failure to thrive (a gradual decline in health without an immediate explanation. It can be caused by factors such as: unknown medical problems, chronic disease, medication interactions, physical decline, poor appetite, or poor diet). Review of Resident 29's current physician orders revealed an order for a regular diet, nectar thick, pureed, with special instructions to use a teaspoon and may have pleasure foods with family present. Resident 29 is a total assist for meals.

Surveyor observation on January 22, 2019, at 12:15 p.m. revealed Resident 29's family member, who is not the Power of Attorney (POA), feeding Resident 29 yogurt and a banana. At that time, a staff member asked Resident 29's family member if Resident 29 wanted her lunch and the family member stated no. A staff member proceeded to bring Resident 29's plate of lunch to her and Resident 29's family member became upset because she didn't want Resident 29 to have anything to eat. The Food Service Director (FSD) attempted to explain to Resident 29's family member that the facility needed to serve Resident 29 what was on her meal ticket but the family member was angry and stated she wanted the ticket changed. Surveyor observation revealed that nobody acknowledged Resident 29 or asked her if she wanted her lunch.

Review of Resident 29's meal ticket, dated January 22, 2019, revealed that Resident 29 was to have fruit juice, pureed oriental mixed vegetables, tea, milk, and custard and that she is to get yogurt and applesauce with all meals.

During an interview with the Nursing Home Administrator (NHA) on January 23, 2019, at 9:40 a.m. she stated that Resident 29's family member is only at the facility for lunch. The NHA stated that the family member calls the puree food "slop" and doesn't want Resident 29 to have meat, so she will give her yogurt for protein. The NHA stated that Resident 29 will eat the meals she is served when the family member is not present.

Surveyor observation on January 23, 2019, at 12:11 p.m. revealed Resident 29's family member feeding her peaches and yogurt. At 12:27 p.m., Resident 29's family member was offered orange sherbet for Resident 29 but the family member declined. The staff member did not offer it directly to Resident 29 or ask Resident 29 if she wanted any sherbet. Surveyor observation in the dining room at that time failed to reveal that the staff offered Resident 29 her meal. Review of Resident 29's meal ticket for lunch on January 23, 2019, revealed that Resident 29 was to get pureed lasagna with meat sauce, pureed seasoned green peas and pureed bread.

Review of Resident 29's progress note dated November 16, 2018, revealed that Resident 29 was having lunch in the dining room, being assisted by a nurse aide (NA). Resident 29's family member arrived in the dining room and threw Resident 29's plate across the table and said "You're not eating this s***!" The family member then proceeded to get a banana and applesauce to assist Resident 29 with eating.

Review of Resident 29's progress note dated December 19, 2018, at 11:56 a.m. revealed that Resident 29's family member was "very upset" because she missed the care plan meeting for Resident 29. Staff explained to the family member that she was not the medical POA. The family member "stated she wants her wishes followed and she does not want [Resident 29] to have meat as 'she came here to die'. Explained that Resident [29] has the right to choose for herself and she is able to verbalize her response." Staff discussed with the family member the need for Resident 29 to have protein for wound healing and the family member stated "She doesn't need protein. She came here to die."

Review of Resident 29's progress note, dated December 28, 2018, revealed Resident 29's family member "was yelling at kitchen staff at start of lunch because resident was served pureed food per her diet order." Family member "yelled 'She don't eat this slop, she eats what I say'."

During staff interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on January 23, 2019, at 2:50 p.m. they stated that there have been multiple conversations with Resident 29's family member regarding the food. The DON stated that a while back they had a winter picnic with hot dogs and baked beans. The DON asked Resident 29 if she wanted that and she said yes. The DON stated that if the family member was present at that time, Resident 29 would not have been given the hot dog and baked beans. He stated that Resident 29 is able to say what she wants and say yes and no but the family member dictates what Resident 29 gets to eat. At that time, the NHA stated that the facility makes sure Resident 29 gets protein, such as yogurt and that Resident 29 eats breakfast and supper, when the family member is not present.


28 Pa. Code 201.29(j) Resident Rights







 Plan of Correction - To be completed: 03/13/2019

This facility will take, or has already taken, the actions stated in the following plan of correction to remain in compliance with all federal and state regulations. The following plan of correction constitutes the facility's allegation of compliance of all alleged deficiencies cited herein by the dates indicated. The center is committed to all necessary actions to remain in substantial compliance with state and federal regulations. This plan of correction states our intention to provide the necessary care and services to promote the highest practicable physical, mental, and psychosocial well-being of our residents.

The facility will continue to work to promote the resident right for self-determination through the support of resident choice.

To correct the deficiency as it relates to the individual, nursing staff present at lunchtime on January 22, 2019 and January 23, 2019 were instructed regarding the resident right for self-determination and the need for residents to be given a choice as to meal selection. The Social Services Director and the Administrator met with Resident 29's daughter on January 28, 2019 to explain the resident right for self-determination and that staff is required to give her mother a choice as to meal selection at each meal.

To protect residents in similar situations, a communication was provided to all staff on January 25, 2019 by the Administrator regarding the requirement to give each resident a choice regarding meal selection at each meal.

To ensure that the problem does not recur, the Social Services Director will inservice all staff regarding residents' rights and self-determination.

To monitor performance to ensure that the solution is permanent, audits of meal service will be conducted by the nursing supervisor/designee weekly for 4 weeks for all 3 meals and then weekly for 4 weeks for 1 meal to monitor that the resident right of self-determination is being met. Findings will be presented at least quarterly to the QAA Committee for further review and evaluation.

The facility alleges substantial compliance by March 13, 2019.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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(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 and staff interviews it was determined that the facility failed to store food in accordance with professional standards for food service safety in the main facility kitchen and in the downstairs dry storage room.

Findings include:

During entrance tour of the facility main kitchen on January 22, 2019, at 9:12 a.m., while accompanied with Dietary Manager (DTM) 1, there was observed in the walk-in freezer a plastic zip bag with a small amount of chicken breast and also turkey breast approximately one pound wrapped in foil with neither item displaying a label for identification of product or dates placed in freezer and/or to use by. Also observed was a package of ham loaf labeled with a use by date of April 28, 2018; a plastic bag with bulk hamburger and one with bulk ground turkey of approximately three to four pounds each without label for product identification and/or placement in freezer or use by dates and a plastic zip bag of bratwurst approximately two pounds without labeling to identify date placed in freezer and/or use by date. In the walk-in refrigerator was observed a beef loin approximately seven pounds and bag of bacon approximately three pounds without labeling to identify date placed in refrigerator and/or use by date.

In dry cupboard in kitchen was observed a case box bottom from syrup product which contained one packet of Ken's dressing (individual use) and individual 13 serving containers of syrup and four individual containers of jelly. DTM 1 identified that the syrup in the box was not original to the box. Review of the products revealed no use by dates on them. Also revealed in this pantry was a closed plastic container storing rice. It was noted that a piece of the original packaging bag for the rice was being used as the "label" for writing the open date of the rice package. Also observed in this cupboard was small packet of pudding mix and a plastic bag containing an opened bag of Tri-colored spirelli in it with no received and/or use by dates.

During an observation during this tour also revealed in the reach-in meat/vegetable freezer a plastic bag of meatballs with no received/opened dates and/or use by dates. Observation in the reach-in refrigerator revealed four, approximately one pound packages, and one log, five pounds, of American cheese without received and/or use by dates.

During same entrance tour it was observed in downstairs dry storage area at 10:18 a.m. the facility ice cream chest freezer . It was observed that the freezer presented with no built-in temperature device on the outside surface nor was there present any type temperature device on the inside. It was also observed that there was significant ice build-up in the bottom of the freezer and significant frosting on the inner sides. In addition it was observed that there was icing on the inside lid and that the insulating material on the inside lid was exposed. Also observed in the dry storage area was a five pound bag of breadcrumbs with a use by date of May 3, 2018, and a five pound bag of ziti in a plastic zip bag and an out of case box sleeve of oatmeal cookies with no received and/or use by dates.

During interview with DTM 1 while progressing through entrance tour, DTM 1 confirmed that the unidentified and/or undated food products should have had labeling to identify product and/or receive and/or use dates.

Review of facility Food Receiving and Storage Policy with revision date of December 2008, revealed "All foods stored in the refrigerator or freezer will be covered, labeled and dated [use by date]). Review of this policy revealed no guidelines for dating/labeling of dry food storage products.

During an interview with the Nursing Home Administrator (NHA) on January 22, 2019, at approximately 3:00 p.m. the NHA revealed the expectation that food items should be properly stored.

During an interview with the NHA on January 23, 2019, at approximately 3:00 p.m. the NHA revealed that the facility will be acquiring information to replace the dry storage chest freezer.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. code 201.18(b)(3) Management


























 Plan of Correction - To be completed: 03/13/2019

To correct the deficiency for the residents and to protect the residents, all items that were expired were discarded on 1/22/19. Also on 1/22/19, labels that could be appropriately revised were revised, and bulk individual food packets were stored properly in storage containers. Also, a thermometer was placed in the chest freezer as soon as it was noted on 1/22/19 that a thermometer was needed.


To ensure the problem does not recur, the Food Service Director revised the Food Receiving and Storage Policy and will inservice his staff on the new policy. Also, a new freezer is being ordered by the Food Service Direcor to replace the current chest freezer.

To monitor performance to make sure that the solutions are permanent, the Food Service Director/designee will conduct weekly audits of proper food storage and freezer temperature documentation 2 times a week for 4 weeks, then 1 time a week for 4 weeks thereafter. Findings will be presented to the QAA Committee for further review and evaluation.

The facility alleges substantial compliance by March 13, 2019.


483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:



Based on record review, and interview, it was determined that the facility failed to follow physician orders for one of 14 residents reviewed (Resident 9).

Findings include:

Review of Resident 9's clinical record revealed diagnoses that included: nausea with vomiting; and dysphagia pharyngeal phase (difficulty swallowing, starting of the swallowing and squeezing food down the throat).

Review of Resident 9's physician orders revealed: Senexon-S (a medication used to treat constipation, a stimulant and stool softener) 8.6 mg (a unit of measure) tablet, 2 tablets twice a day, hold for loose stools, start date October 8, 2018; Miralax powder (a medication used to treat constipation), 17 grams (a unit of measure) once a day every other day, start date January 18, 2019; Miralax powder (a medication used to treat constipation) 17 grams(a unit of measure) if no Bowel Movement after 6 shifts, mix in 4 - 8 ounces (a unit of measure) of fluid for constipation as needed, start date February 27, 2018; Dulcolax suppository (a medication used to treat constipation), 10mg (a unit of measure) rectal if no bowel movement after 7 shifts, perform rectal check and give suppository, gastrointestinal assessment must be documented in progress notes every 72 hours as needed, start date February 27, 2018; and Fleet Enema (a medication used to treat constipation) 19-7 grams/18 milliliters (a unit of measure) rectal if no results after 8 shifts and having been given Dulcolax Suppository with no results, then give Fleets enema, gastrointestinal assessment must be documented in progress notes, if no results after fleets enema at end of 8th shift call doctor for further orders, start date February 27, 2018.

Review of Resident 9's point of care history of control with bowel function revealed Resident 9 didn't have a bowel movement on the following days and number of shifts, and the as needed Miralax was not given per physician order:
January 3, 2019 at 9:18 p.m. through January 7, 2019 at 6:38 a.m. (12 shifts);
January 18, 2019, 2:19 a.m. through January 21, 2019, at 4:02 a.m.(8 shifts);
November 16, 2018 at 7:59 p.m. through November 19, 2018 at 2:06 a.m. (8 shifts);
November 28, 2018 at 9:52 p.m. through December 1, 2018 at 1:46 a.m.(10 Shifts) and;
October 20, 2018 at 9:27 p.m. through October 24, 2018 at 1:55 a.m. (11 shifts).

Review of Resident 9's Medication Administration History (record of medications that were administered) for January 2019 revealed that: Miralax ordered to be given every other day was given day shift on January 18th, 20th, 22 nd, and 24th; Miralax ordered to be given as need for no bowel movement in 6 shifts was given day shift on January 7th, 11th, 14th, 16th; and as needed suppository was given day shift January 24th.

Review of Resident 9's Medication Administration History (record of medications that were administered) for December 2018 revealed that: Miralax ordered to be given as need for no bowel movement in 6 shifts was given day shift on December 4th, 12th, 18th, 21st, and 24th.

Review of Resident 9's Medication Administration History (record of medications that were administered) for November 2018 revealed that: Miralax ordered to be given as need for no bowel movement in 6 shifts was given day shift on November 1st, 5th, 7th, 11th, 14th, 16th, 19th, and 26th; as needed Dulcolax suppository was given November 12th; and as needed Fleets enema was given November 2nd.

Review of Resident 9's Medication Administration History (record of medications that were administered) for October 2018 revealed that: Miralax ordered to be given as need for no bowel movement in 6 shifts was given day shift on October 3rd, 11th, 18th, 24th, and 25th, and evening shift on the 19th; Dulcolax suppository given 24th on evening shift, and Fleet enema given on night shift/morning of the 25th.

During an interview with the Nursing Home Administrator on January 24, 2019, at approximately 2:15 p.m. revealed that the bowel protocol should have been followed unless resident refused.

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








 Plan of Correction - To be completed: 03/13/2019

This facility will take, or has already taken, the actions stated in the following plan of correction to remain in compliance with all federal and state regulations. The following plan of correction constitutes the facility's allegation of compliance of all alleged deficiencies cited herein by the dates indicated. The center is committed to all necessary actions to remain in substantial compliance with state and federal regulations. This plan of correction states our intention to provide the necessary care and services to promote the highest practicable physical, mental, and psychosocial well-being of our residents.

The facility will continue to work to provide treatment and care in accordance with professional standards of practice by following physician orders.

To correct the deficiency as it relates to the individual, Resident 9's current bowel medication regimen for the past 3 months was reviewed in depth and has been individualized to help promote bowel regularity.

To protect residents in similar situations, a written communication by the Administrator on January 25, 2019 to the professional nurses instructed them of the need to follow the facility bowel medication protocol.

To ensure that the problem does not recur, the DON analyzed the cause. Subsequently, the bowel medication protocol is being revised. The DON/designee will inservice professional nurses regarding the new protocol to ensure the physician orders are being followed.

To monitor performance to ensure that solutions are permanent, the DON/designee will conduct weekly audits for 4 weeks of 5 residents and then monthly audits for 2 months of 2 residents to ensure that the bowel medication protocol is being followed according to physician orders. Findings will be presented at least quarterly to the QAA Committee for further review and evaluation.

The facility alleges substantial compliance by March 13, 2019.



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


Based on observation, clinical record review, as well staff and resident interview, it was determined that the facility failed to ensure the care plan was reviewed and revised for six of 17 residents reviewed (Residents 8, 9, 21, 23, 25, and 39).

Findings include:

Review of Resident 8's clinical record revealed diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and dysphagia (difficulty swallowing).

Surveyor observation on January 22, 2019, at 10:09 a.m. revealed that Resident 8 had a catheter. Review of Resident 8's current physician orders revealed an order for a Foley catheter (a flexible tube that a clinician passes through the urethra and into the bladder to drain urine).

Review of Resident 8's current care plan revealed that Resident 8 is incontinent of bowel and bladder. Further review of Resident 8's care plan failed to reveal that Resident 8 has a Foley catheter.

On January 24, 2019, at approximately 1:00 p.m. the facility provided the surveyor with an updated care plan for Resident 8's catheter, with a start date of January 24, 2019.

Review of Resident 9's clinical record revealed diagnoses that included: Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors).

Review of Resident 9's January 2019, Physician orders failed to reveal an order for a Foley catheter. However, there was an order to use a straight catheter as needed for urine specimen if unable to void, with a start date of February 27, 2018.

Review of Resident 9's care plan on January 24, 2019, at approximately 9:00 a.m. revealed "Resident requires an indwelling urinary catheter related to urinary retention," with a start date of June 15, 2018.

Interview with the Nursing Home Administrator on January 24, 2019, at approximately 10:57 a.m. revealed that Resident 9 was admitted with a catheter and it was discontinued on April 23, 2018, it was also revealed that the care plan should have been updated when the indwelling catheter was discontinued.

Review of Resident 21's clinical record revealed diagnoses that included Peripheral Vascular Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and Obesity (a disorder involving excess body fat and increases the risk of health problems).

Further review of Resident 21's clinical record on January 22, 2019, at 2:45 p.m. revealed a care plan for "Potential for skin breakdown R/T: incontinence, limited mobility, L side weakness, R shoulder pain, dystonia", this care plan had a problem start date of June 28, 2018, a long-term goal target date of September 28, 2018, and a "last reviewed/revised date" of June 28, 2018.

Further review of Resident 21's clinical record revealed quarterly assessments were completed on September 12, 2018, and December 5, 2018, and the care plan was not reviewed or revised after either one.

Review of Resident 23's clinical record revealed diagnoses that included muscle weakness (the condition when full effort doesn't cause muscle contraction or movement) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).

Further review of Resident 23's clinical record on January 22, 2019, at 2:55 p.m. revealed a care plan for "resident requires an indwelling urinary catheter R/T urinary retention, Dx prostate cancer", this care plan had a problem start date of June 28, 2018, a long-term goal target date of September 28, 2018, and a "last reviewed/revised date" of June 28, 2018.

Further review of Resident 23's clinical record on January 22, 2019 at 2:55 p.m. revealed a care plan for "potential for alteration in comfort/pain due to: stage 4 sacral ulcer, prostate cancer", this care plan had a problem start date of June 28, 2018, a long-term goal target date of September 28, 2018, and a "last reviewed/revised date" of June 28, 2018.

Further review of Resident 23's clinical record revealed quarterly assessment completed on September 12, 2018 and annual assessment completed on December 5, 2018, and the care plan was not reviewed or revised after either one.

Interview with Nursing Home Administrator on January 24, 2019, at 11:15 a.m. revealed that she would have expected the care plans to be reviewed and revised, at minimum, after each assessment.

Review of Resident 25's January 2019, physician orders revealed diagnoses that included Left Femur (the bone of the thigh or upper hind limb) fracture and abnormal gait (a person's manner of walking) and mobility(the ability to move or be moved freely and easily).

An observation on January 22, 2019, at 10:11 AM in Resident 25's room, revealed bilateral enabler devices attached to her bed.

Review of the facility's document titled "Facility Order," dated November 20, 2018, reads "Two UPPER Siderails, Assist Rails, Grab Bars or Enablers, assigned to Resident 25.

Review of Resident 25's interdisciplinary plan of care, addressing her potential for falls, revealed none developed to address the bilateral bars attached to her bed.

An interview with the Licensed Practical Nurse Assessment Coordinator (LPNAC) 1, on January 23, 2019, at 1:32 PM confirmed she could not locate Resident 25's enablers on the interdisciplinary plan of care.

Review of Resident 39's clinical record revealed diagnoses that included Alzheimer's disease (a type of dementia that causes problems with memory, thinking and behavior) and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome).

Surveyor observation on January 22, 2019, at 12:29 p.m. revealed Resident 39 with a catheter. Review of Resident 39's current physician orders revealed an order for a Foley catheter.

Review of Resident 39's current care plan revealed that Resident experiences bladder incontinence. Further review of the care plan failed to reveal any mention of the Foley catheter.

As of January 24, 2019, at 1:00 p.m. no additional information was provided by the facility.

42 CFR 483.21(b) Comprehensive Care Plans
Previously cited 3/2/17, 1/10/17, 4/12/16

28 Pa. Code 211.11(d)(e) Resident care plan
Previously cited 3/2/17, 1/10/17, 2/11/16

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/2/17, 1/10/17, 2/11/16, 3/26/15










 Plan of Correction - To be completed: 03/13/2019

This facility will take, or has already taken, the actions stated in the following plan of correction to remain in compliance with all federal and state regulations. The following plan of correction constitutes the facility's allegation of compliance of all alleged deficiencies cited herein by the dates indicated. The center is committed to all necessary actions to remain in substantial compliance with state and federal regulations. This plan of correction states our intention to provide the necessary care and services to promote the highest practicable physical, mental, and psychosocial well-being of our residents.

The facility will continue to work to review and revise resident care plans in a timely manner according to regulatory requirements.

To correct the deficiency as it relates to the individuals, the care plans for Residents 8, 9, 21, 23, 25, and 39 were reviewed and updated.

To protect residents in similar situations, the care plans for all in-house residents will be audited by the DON/designee to ensure that all have been reviewed and revised as needed after their most recent quarterly or comprehensive assessment. Any necessary revisions and updates will be made at that time.

To ensure that the problem does not recur, the DON/designee will inservice the interdisciplinary care team about the requirement to complete reviews and revisions to care plans after each quarterly and comprehensive assessment.

To monitor performance to make sure that solutions are permanent, the DON/designee will complete weekly audits for 4 weeks according to the weekly care conference schedule of all residents scheduled for review.

The facility alleges substantial compliance by March 13, 2019.

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

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

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

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

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

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:


Based on surveyor observation and staff interviews, it was determined that the facility failed to promote care for residents in a manner and environment that enhances each resident's dignity for two of four residents observed in the dining room (Residents 8 and 20).

Findings Include:

Surveyor observation on January 22, 2019, at 12:20 p.m. revealed Residents 8, 20, 37 and 42, all sitting at a table in the dining room. Resident 37 and Resident 42 were being assisted with eating their lunch meal by a staff member. Resident 8 and Resident 20 were sitting at the table, still waiting to be served lunch. At 12:25 p.m., Resident 20 was served her lunch and she required no assistance with eating. At 12:26 p.m., Resident 8 was served and received assistance with eating.

During an interview with the Nursing Home Administrator on January 24, 2019, at 11:30 a.m. she stated that the dining room gets busy at lunchtime and it is hard to serve everyone at once.

28 Pa. Code 201.29(j) Resident Rights








 Plan of Correction - To be completed: 03/13/2019

This facility will take, or has already taken, the actions stated in the following plan of correction to remain in compliance with all federal and state regulations. The following plan of correction constitutes the facility's allegation of compliance of all alleged deficiencies cited herein by the dates indicated. The center is committed to all necessary actions to remain in substantial compliance with state and federal regulations. This plan of correction states our intention to provide the necessary care and services to promote the highest practicable physical, mental, and psychosocial well-being of our residents.

The facility will continue to work to promote care for residents in a manner and environment that enhances each resident's dignity.

To correct the deficiency as it relates to the individuals, the staff who assisted Residents 8, 20, 37, and 42 in serving and eating lunch on January 22, 2019 were instructed regarding the residents' right for dignity for residents sitting at the same table to be served and assisted with their meals at the same time.

To protect residents in similar situations, a communication was provided to all staff by the Administrator on January 25, 2019 regarding residents' right for dignity for residents sitting at the same table to be served and assisted with their meals at the same time.

To ensure that the problem does not recur, the Director of Nursing/designee will inservice all staff on residents' rights for dignity and the protocol for residents at the same table to be served and assisted with their meals at the same time.

To monitor performance to ensure that the solution is permanent, audits of dining room meal service will be conducted weekly for 4 weeks for all 3 meals by the nursing supervisor/designee, then weekly for 4 weeks for 1 meal to monitor for meal service that enhances each resident's dignity. Findings will be presented at least quarterly to the QAA Committee for further review and evaluation.

The facility alleges substantial compliance by March 13, 2019.

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

483.45(h) Storage of Drugs and Biologicals

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

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


Based on surveyor observation, facility policy review, and staff interview, it was determined that the facility failed to discard expired biologicals for one of one medication rooms observed (Fayfield medication room).

Findings Include:

Review of facility policy titled, Insulin Injections, effective July 1, 2018, with a revision date of October 11, 2018, Section 6 revealed a chart indicating that Lantus insulin (a medication of diabetes) should be discarded 28 days after opening.

Review of Aplisol (medication used to determine the presence of Tuberculin bacteria) medication information sheet on FDA.gov revealed on page 5, Dosage and Administration section that "Vials in use for more than 30 days should be discarded."

Observation of the Fayfield medication room on January 23, 2019, at 1:06 p.m. revealed one open vial of Lantus insulin with an open date of December 20, 2018.

Further observation of Fayfield medication room on January 23, 2019, at 1:06 p.m. revealed one open vial of Aplisol with an open date of November 30, 2018.

Further observation of the Fayfield medication room on January 23, 2019, at 1:06 p.m. revealed 98 3cc syringes with an expiration date of April 2018.

During a staff interview on January 23, 2019, at 2:20 p.m. the Director of Nursing revealed that he would expect that the expired medications and supplies would have been disposed of properly or stored separately from other medications until disposed of per the facility policy.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.9(a)(1)(i) Pharmacy services.
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services







 Plan of Correction - To be completed: 03/13/2019

This facility will take, or has already taken, the actions stated in the following plan of correction to remain in compliance with all federal and state regulations. The following plan of correction constitutes the facility's allegation of compliance of all alleged deficiencies cited herein by the dates indicated. The center is committed to all necessary actions to remain in substantial compliance with state and federal regulations. This plan of correction states our intention to provide the necessary care and services to promote the highest practicable physical, mental, and psychosocial well-being of our residents.

The facility will continue to work to discard expired medications, biologicals, and supplies in a timely manner.

To correct the deficiency for the residents and to protect residents in similar situations, on 1/24/19 the DON examined every medication, biological, and supply in both medication rooms and discarded all expired items.

To ensure that the problem does not recur, the DON/designee will inservice the professional nurses regarding the facility policy for disposing of expired medications, biologicals, and supplies.

To monitor performance to ensure that solutions are permanent, the DON/designee will audit a medication room once a week for 4 weeks to ensure that all expired medications, biologicals, and supplies have been discarded. Findings will be presented at least quarterly to the QAA Committee for further review and evaluation.

The facility alleges substantial compliance by March 13, 2019.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(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 clinical record review and staff interview it was determined that the facility failed to inform the physician of significant weight loss for one of 14 residents reviewed (Resident 9).

Findings include:

Review of Resident 9's clinical record revealed diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), nausea and vomiting, and dysphagia pharyngeal phase (difficulty swallowing, starting of the swallowing and squeezing food down the throat).

Review of Resident 9's January 2019, Physician orders revealed the following: No Concentrated Sweets diet with thin liquids and regular consistency, pudding at breakfast, sugar free ice cream at lunch, and sugar free pudding at supper, start date of November 10, 2018; diet chocolate health shakes three times a day, start date of August 23, 2018; Zofran (a medication used to treat nausea) 4 mg (milligrams - a unit of measure) ever 6 hours as needed for nausea with vomiting, start date of November 14, 2018.

Resident 9's weight variance report revealed the following weight history:
January 13, 2019 = 142.7 lb (pounds - a unit of measure) (an 8 lb loss over the past month = 5% )
January 1, 2019 = 143.8 lb (a 7 lb loss over the past 30 days = 4.8% )
December 3, 2018 = 151 lb
November 2, 2018 = 155 lb
October 2, 2018 = 160.8 lb
September 3, 2018 = 161 lb
August 1,2018 = 161 lb
July 6, 2018 = 157 lb

Per Registered Dietitian's note dated January 15, 2019, it was revealed that Resident 9 had a 5% significant weight loss from December 2018 to January 2019. It was also revealed that Resident 9 meal consumption is 25-50%, and that he is eating a small amount of food and consuming mainly liquids due to becoming nauseated and having emesis on January 13th and 15th.

Further review of Resident 9's progress notes revealed Resident 9 was nauseated and/or had emesis on the following days: January 19th, 16th, 15th; December 30th, 29th, 8th, 5th, 2nd; and November 28th, 14th, 4th, and 1st.

Review of Speech Therapy screen completed for Resident 9 on November 14, 2018, due to recent emesis with meals, revealed that: resident stated he is tolerating chewing/swallowing without difficulty, has occasional emesis when nauseated, nursing staff educated on history of esophageal dilatation (stretching/widening of the esophagus) and possible follow up, Resident 9 and his wife are against any alteration is diet as they don't feel it is a swallowing issue.

During an interview with the Nursing Home Administrator on January 24, 2019, at approximately 1:00 p.m. it was revealed that there is no documentation the Physician is aware that Resident 9 has had incurred a significant weight loss over the past 30 days. It was also revealed that on January 14, 2019, Resident 9's wife completed an application for the use of a public transportation service which would enable Resident 9 to see an out of facility medical provider to assess the need for and/or complete an esophageal dilatation. The application was faxed to the public transportation company on January 15, 2019.

An e-mail received from the Nursing Home Administrator on January 24, 2019, at approximately 6: 25 p.m. revealed that Resident 9 has an appointment for an out of facility Gastroenterology consult on January 25, 2019, at 11:30 a.m.

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








 Plan of Correction - To be completed: 03/13/2019

This facility will take, or has already taken, the actions stated in the following plan of correction to remain in compliance with all federal and state regulations. The following plan of correction constitutes the facility's allegation of compliance of all alleged deficiencies cited herein by the dates indicated. The center is committed to all necessary actions to remain in substantial compliance with state and federal regulations. This plan of correction states our intention to provide the necessary care and services to promote the highest practicable physical, mental, and psychosocial well-being of our residents.

The facility will continue to work to inform physician of significant resident weight changes.

To correct the deficiency as it relates to the individual, the physician was notified of Resident 9's weight loss.

To protect residents in similar situations, a weight variance report will be reviewed by the DON/designee for all in-house residents to ensure that the physician has been notified for any resident showing a significant weight change.

To ensure that the problem does not recur, the DON/designee will inservice the professional nurses and the dietician of the policy for significant weight change, which includes the requirement to notify the physician.

To monitor performance to ensure that solutions are permanent, the DON/designee will conduct weekly audits for 4 weeks according to the weekly care conference schedule of all residents scheduled for review. Findings will be presented at least quarterly to the QAA Committee for further review and evaluation.

The facility alleges substantial compliance by March 13, 2019.




483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary: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(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of 483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to include reconciliation of all pre-discharge medications with the resident's post-discharge medications in the resident's discharge summary, for one of three closed records reviewed (Resident 26).

Findings Include:

Review of the Review of the clinical record for Resident 26 revealed diagnoses that included hypertension (elevated blood pressure) and gastroesophageal reflux disease (GERD). Resident 26 was discharged to home on January 3, 2019.
Review of Resident 26's discharge summary, dated January 3, 2019 revealed that Resident 26's pre-discharge medications were not included as part of the discharge summary.

During an interview with the Nursing Home Administrator on January 24, 2019, at 12:55 p.m. she acknowledged that the pre-discharge medications were not reconciled on the discharge summary.

28 Pa. Code 201.25 Discharge policy
28 Pa. Code 211.5(d)(f) Clinical records



 Plan of Correction - To be completed: 03/13/2019

This facility will take, or has already taken, the actions stated in the following plan of correction to remain in compliance with all federal and state regulations. The following plan of correction constitutes the facility's allegation of compliance of all alleged deficiencies cited herein by the dates indicated. The center is committed to all necessary actions to remain in substantial compliance with state and federal regulations. This plan of correction states our intention to provide the necessary care and services to promote the highest practicable physical, mental, and psychosocial well-being of our residents.

The facility will continue to work to provide a reconciliation of all pre-discharge medications with all post-discharge medications in the discharge summary.

Regarding the deficiency as it relates to Resident 26, Resident 26 discharged on 1/3/19. A medication reconciliation is not warranted at this time.

To protect residents in similar situations, a written communication was made by the Administrator to all professional nurses on January 25, 2019 indicating the requirement that a medication reconciliation of pre-discharge and post-discharge medications (both prescribed and over-the-counter) must be conducted and documented in the discharge summary.

To ensure that the problem does not recur, the DON/designee will inservice the professional nurses on the protocol for reconciling pre-discharge and post-discharge medications and documenting the reconciliation in the discharge summary.

To monitor performance to ensure that solutions are permanent, the DON/designee will conduct weekly audits for 4 weeks or until at least 7 discharges have occurred (due to the minimal number of discharges at our 50-bed facility) to ensure that the medication reconciliation is completed and documented. Findings will be presented at least quarterly to the QAA Committee for further review and evaluation.

The facility alleges substantial compliance by March 13, 2019.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards in regards to pressure ulcers for two of four residents reviewed (Residents 8 and 29).

Findings Include:

Review of Resident 8's clinical record revealed diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and dysphagia (difficulty swallowing).

During staff interview on January 22, 2018, at approximately 1:00 p.m. the Director of Nursing and Licensed Practical Nurse (LPN) 1 stated that Resident 8 and Resident 29 did not currently have a pressure ulcer. LPN 1 stated that she was taught that once an area is called a skin tear, excoriation, etcetera, it cannot be reclassified to a pressure ulcer. It will stay named a skin tear, excoriation, etcetera, until it is healed.

Review of Resident 8's facility form "Skin Condition Report" revealed weekly skin assessments done by LPN 1, for a skin tear (a wound caused by shear, friction, and/or blunt force resulting in separation of skin layers) to the right buttock. Review of Resident 8's Registered Nurse (RN) progress note dated January 22, 2019, at 3:04 p.m. revealed that Resident 8 "had a skin tear injury back in December of 2017 to her right buttock. Over time, it has deteriorated...Upon observation this morning, this wound should be reclassified as a Stage IV [full -thickness skin and tissue loss] area. While the initial injury was a skin tear, pressure to the area from the ischial tuberosity [the part of pelvis that supports a person while sitting] most likely contributed to the significant deterioration so it is more correctly classified as a pressure injury."

Review of Resident 29's clinical record revealed diagnoses that included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) and adult failure to thrive (a gradual decline in health without an immediate explanation. It can be caused by factors such as: unknown medical problems, chronic disease, medication interactions, physical decline, poor appetite, or poor diet).

Review of Resident 29's facility form "Skin Condition Report" revealed weekly skin assessments done by LPN 1 for excoriation (a place where your skin is scraped or abraded) to the left buttock. Review of Resident 29's RN progress note, dated January 22, 2019, at 6:16 p.m. revealed "Participated in wound rounds this morning. [Resident] has an area to her left buttock that originally presented as an excoriation on 6/27/18. Over time, pressure contributed to challenges of healing so that the area is more correctly staged as a pressure injury at this time."

During an interview with the Director of Nursing on January 23, 2019, at 1:20 p.m. he stated that LPN 1 did not reclassify wounds. He stated that if a wound presented as a skin tear or an excoriation, that is what it would be called until it healed. At that time, the Director of Nursing stated that Resident 8's skin tear and Resident 29's excoriation should have been reclassified as a pressure ulcer prior to January 22, 2019.

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









 Plan of Correction - To be completed: 03/13/2019

This facility will take, or has already taken, the actions stated in the following plan of correction to remain in compliance with all federal and state regulations. The following plan of correction constitutes the facility's allegation of compliance of all alleged deficiencies cited herein by the dates indicated. The center is committed to all necessary actions to remain in substantial compliance with state and federal regulations. This plan of correction states our intention to provide the necessary care and services to promote the highest practicable physical, mental, and psychosocial well-being of our residents.

The facility will continue to work to provide care and services that meet professional standards of quality.

To correct the deficiency as it relates to the individuals, Resident 8 and 29's skin tear was reclassified on January 22, 2019 to pressure ulcer.

To protect residents in similar situations, all residents with a current skin condition will be assessed by the DON/RN designee to ensure that care and services are being provided in accordance with professional standards.

To ensure that the problem does not recur, the DON/RN designee will inservice all professional nurses regarding the facility policy for skin care including classification of skin conditions.

To monitor performance to ensure that solutions are permanent, the DON/designee will conduct weekly audits for 4 weeks and then monthly audits for 2 months of any newly identified skin condition to ensure that professional standards of care and services are being met. Findings will be presented at least quarterly to the QAA Committee for further review and evaluation.

The facility alleges substantial compliance by March 13, 2019.



483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive 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(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:

Based on surveyor observations, clinical record review and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan to maintain the highest practicable well-being for two of 14 residents reviewed (Residents 8 and 39).

Findings Include:

Review of Resident 8's clinical record revealed diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and dysphagia (difficulty swallowing).

Review of Resident 8's current care plan revealed an approach for Resident 8 to have a multipodus boot (helps in the healing and prevention of heel and toe ulcers and safeguards against foot drop) to the right foot when out of bed. Review of Resident 8's "NursingAssistant Care Plan/ Cardex" revealed "blue boots on feet with gray foam position aid."

Surveyor observation on January 22, 2019, at 10:07 a.m. revealed Resident 8 in the activity room in her chair with a blue boot to the left foot and gray foam under the left foot. Resident 8 did not have any boot on her right foot. Surveyor observation on January 23, 2019, at 12:01 p.m. revealed Resident 8 had a blue boot to her left foot with gray foam underneath but nothing was on or under her right foot.

During an interview with the Director of Nursing on January 24, 2019, at 11:37 a.m. he stated that the care plan and orders did not match for the boots. He stated it has been updated. No additional information was provided to the surveyor in regards to the correct use of the boots.

Review of Resident 39's clinical record revealed diagnoses that included Alzheimer's disease (a type of dementia that causes problems with memory, thinking and behavior) and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome).

Review of Resident 39's current care plan revealed that Resident 39 "May not have knife at meals." "Fork and spoon only." Review of Resident 39's meal tickets, dated January 22 and January 23, 2019, revealed "May not have a knife. Fork and spoon only."

Surveyor observation on January 22, 2019, at 12:14 p.m. revealed Resident 39 sitting in the dining room, eating lunch, and had a knife. Surveyor observation on January 23, 2019, at 12:13 p.m. revealed Resident 39 had a knife with her lunch. Surveyor observed Nurse Aide (NA) 1 pick up Resident 39's knife, cut Resident 39's lasagna, and then place the knife back on Resident 39's plate and walk away.

During an interview with the Nursing Home Administrator (NHA) on January 23, 2019, at 2:37 p.m. she stated that if Resident 39 was care planned to not have a knife, she should not have had a knife.

During an additional interview with the NHA on January 24, 2019, at 9:11 a.m. she stated that Resident 39 was trying to cut her wanderguard off with a knife and that is why she was care planned to not have one.

28 Pa. Code 211.11 (d) Resident care plan








 Plan of Correction - To be completed: 03/13/2019

This facility will take, or has already taken, the actions stated in the following plan of correction to remain in compliance with all federal and state regulations. The following plan of correction constitutes the facility's allegation of compliance of all alleged deficiencies cited herein by the dates indicated. The center is committed to all necessary actions to remain in substantial compliance with state and federal regulations. This plan of correction states our intention to provide the necessary care and services to promote the highest practicable physical, mental, and psychosocial well-being of our residents.

The facility will continue to work to develop and implement a comprehensive care plan for each resident.

To correct the deficiency as it relates to the individuals, the care plans for Residents 8 and 39 were updated during the survey.

To protect residents in similar situations, a communication by the Administrator to the professional nurses and interdisciplinary care team on January 25, 2019 indicated the need for care plans to be current, reviewed, and revised in a timely manner.

To ensure that the problem does not recur, the DON/designee will inservice the professional nurses and interdisciplinary care team regarding the policy for comprehensive care plans to be developed and implemented to maintain the highest practicable well-being of the residents.

To monitor performance to ensure that solutions are permanent, the DON/designee will conduct weekly audits for 4 weeks of 5 care plans to ensure that care plans reflect the current needs of the residents. Findings will be presented at least quarterly to the QAA Committee for further review and evaluation.

The facility alleges substantial compliance by March 13, 2019.


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 that the facility failed to develop a baseline care plan for each resident within 48 hours of resident's admission for two of 16 residents reviewed (Resident 29 and 36).

Findings include:

Review of Resident 29's clinical record revealed diagnoses that included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) and adult failure to thrive (a gradual decline in health without an immediate explanation. It can be caused by factors such as: unknown medical problems, chronic disease, medication interactions, physical decline, poor appetite, or poor diet).

Further review of Resident 29's clinical record revealed that she was admitted to the facility on June 27, 2018. Review of Resident 29's baseline care plan revealed a date of July 4, 2018.

As of January 24, 2019, at 1:00 p.m. the facility was unable to provide surveyor with a baseline care plan for Resident 29 completed within 48 hours of Resident 29's admission to the facility.

Review of the clinical record for Resident 36 revealed diagnoses that included rheumatoid arthritis (chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility and scoliosis (abnormal lateral curvature of the spine).

Further review of the clinical record revealed that Resident 36 was admitted to the facility on December 20, 2018, with a pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure on the skin). Review of the current care plan revealed that on January 2, 2019, a care plan was developed that addressed the pressure ulcer.

During an interview with the Director of Nursing on January 23, 2019, at 3:05 p.m. he confirmed that the care plan was developed on January 2, 2109.

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

 Plan of Correction - To be completed: 03/13/2019

This facility will take, or has already taken, the actions stated in the following plan of correction to remain in compliance with all federal and state regulations. The following plan of correction constitutes the facility's allegation of compliance of all alleged deficiencies cited herein by the dates indicated. The center is committed to all necessary actions to remain in substantial compliance with state and federal regulations. This plan of correction states our intention to provide the necessary care and services to promote the highest practicable physical, mental, and psychosocial well-being of our residents.

The facility will continue to work to develop and implement a baseline care plan for each resident within 48 hours of admission.

To correct the deficiency as it relates to the individuals, the care plans for Residents 29 and 36 were reviewed to ensure that the care plans reflected the Residents' current care needs.

To protect residents in similar situations, a communication was made by the Administrator to the professional nurses and the interdisciplinary care team on January 25, 2019 of the requirement to develop a baseline care plan within 48 hours of admission.

To ensure that the problem does not recur, the DON/designee will inservice the professional nursing staff and the interdisciplinary care team regarding the requirement for developing a baseline care plan within 48 hours of admission that includes minimum healthcare information to provide effective, proper, person-centered care.

To monitor performance to ensure that solutions are permanent, the DON/designee will conduct audits weekly for 4 weeks or for at least 7 new admissions (due to the minimal number of admissions in our 50-bed facility) to ensure that an appropriate baseline care plan for newly-admitted residents is developed within 48 hours of admission. Findings will be presented at least quarterly to the QAA Committee for further review and evaluation.

The facility alleges substantial compliance by March 13, 2019.


483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

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

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

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

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


Based on clinical record review and staff interviews, it was determined that the facility failed to notify the office of the state ombudsman of facility-initiated transfers for two of 17 residents reviewed (Residents 51 and 52).

Findings include:

Review of Resident 51's clinical record revealed diagnosis that included Congestive Heart Failure (failure of the heart to pump sufficient amount of blood to meet the need of the body tissue)

Further review of Resident 51's clinical record revealed a transfer to the hospital on December 14, 2018, where she was admitted with acute cholecystitis (inflammation of the gallbladder).

Further review of Resident 51's clinical record revealed that no letter was provided to the resident/resident representative regarding the transfer with included the required contents; reason for the transfer, effective date of the transfer, location to which the resident was transferred to, a statement of the resident's appeal rights, and contact and address information of the Office of the State Long-Term Care Ombudsman.

An interview with the Nursing Home Administrator on January 24, 2019, at 12:30 p.m. revealed that she could not find any documented letter containing the above-mentioned contents was provided to the resident or resident representative.

Review of Resident 52's clinical record revealed diagnosis that included of Alzheimer's Hypoxemia (abnormally low concentration of oxygen in the blood) and generalized anxiety disorder (a disorder characterized by excessive or unrealistic anxiety about two or more aspects of life).

Further review of Resident 52's clinical record revealed a transfer to the hospital on October 4, 2018, where she was admitted with a hyponatremia (the condition of low sodium levels in the blood).

Further review of Resident 52's clinical record revealed that no letter was provided to the resident/resident representative regarding the transfer with included the required contents; reason for the transfer, effective date of the transfer, location to which the resident was transferred to, a statement of the resident's appeal rights, and contact and address information of the Office of the State Long-Term Care Ombudsman.

An interview with the Nursing Home Administrator on January 24, 2019, at 12:30 p.m. revealed that she could not find any documented letter containing the above-mentioned contents was provided to the resident or resident representative.

28 Pa. Code 201.29(h) Resident Rights
28 Pa. Code 201.14 (a) Responsibility of License


















 Plan of Correction - To be completed: 03/13/2019

This facility will take, or has already taken, the actions stated in the following plan of correction to remain in compliance with all federal and state regulations. The following plan of correction constitutes the facility's allegation of compliance of all alleged deficiencies cited herein by the dates indicated. The center is committed to all necessary actions to remain in substantial compliance with state and federal regulations. This plan of correction states our intention to provide the necessary care and services to promote the highest practicable physical, mental, and psychosocial well-being of our residents.

The facility will continue to work to provide proper notice of transfer and discharge.

Resident 51 transferred to a hospital on 12/14/18. She did not return to the facility. She expired in the hospital on 12/19/18. Resident 52 transferred to a hospital on 10/4/18. She returned to the facility on 10/10/18. She expired in the facility on 10/25/18.

To correct residents in similar situations, the Administrator instructed the Social Services Director of the requirement to notify the Office of the State Long-Term Care Ombudsman of all transfers and discharges and the need to document the provision of the required notification to the resident/resident representative regarding the reason for transfer/discharge, effective date of transfer/discharge, location to which the resident is transferred/discharged, appeal rights, and contact/address information for the Office of the State Long-Term Care Ombudsman.

To ensure that the problem does not recur, the Director of Nursing/designee will inservice the professional nursing staff and the Social Services Director on the regulatory notice requirements for transfer/discharge.

To monitor performance to ensure that the solutions are permanent, audits of transferred/discharged residents will be completed by the Administrator/designee weekly for 4 weeks or until at least 7 transfers/discharges have occurred (due to the minimal number of transfers/discharges that occur at our 50-bed facility). Findings will be presented at least quarterly to the QAA Committee for further review and evaluation.

The facility alleges substantial compliance by March 13, 2019.



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