Nursing Investigation Results -

Pennsylvania Department of Health
SUSQUEHANNA HEALTH SKILLED NURSING & REHABILITATION CENTER
Patient Care Inspection Results

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SUSQUEHANNA HEALTH SKILLED NURSING & REHABILITATION CENTER
Inspection Results For:

There are  64 surveys for this facility. Please select a date to view the survey results.

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SUSQUEHANNA HEALTH SKILLED NURSING & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance Survey, completed on April 12, 2019, it was determined that Susquehanna Health Skilled Nursing and Rehabilitation Center, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


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

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

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

Based on interviews with residents and staff and review of select facility documents, it was determined that the facility failed to adequately address residents' concerns regarding call bells on one of two floors (Second floor, Residents 29, 30, 73, 80, 105, and 107).

Findings include:

During a group interview with 12 residents on April 10, 2019, at 10:45 AM they revealed that staff are not answering their call bells in a timely manner. They indicated that this has been going on a long time and staff tell them, "We are working on it." The consensus of the 12 residents was that frequently it can take up to an hour for staff to answer a call bell. During meal time, there is only one staff member in the hall so if you ring your bell to be taken to the bathroom and you need a lift, you must wait until the meal is over. Staff tell you to ask for help to go back to bed, but you ring your bell, and nobody comes so you do it yourself. They take you into the bathroom and set you up to wash up and leave to do another resident's shower but when you put your call bell on, it takes a long time for them to return. One resident indicated that staff hides her call bell.

Review of the "Resident Council Meeting Minutes" revealed that between October 11, 2018, and March 4, 2019, residents voiced concerns regarding call bells in four of the last six meetings.

A random review of the facility's automated call bell report (a report that indicates the time a call bell is activated until the time it is answered) for February and March 2019, revealed the following times that were greater than 15 minutes in a 24 hour period:

The resident room shared by Residents 29 and 30 had 12 lasting more than 15 minutes with the longest being 26 minutes 43 seconds for February and 10 with the longest being 44 minutes 11 seconds in March.

The resident room shared by Residents 73 and 80 had 16 lasting more than 15 minutes with the longest being one hour 24 minutes and 37 seconds for February and 10 lasting more than 15 minutes with the longest being
48 minutes in March.

The resident room shared by Residents 105 and 107 had 50 lasting more than 15 minutes with the longest being one hour, 44 minutes, and 59 seconds and March had 37 lasting more than 15 minutes with the longest being 52 minutes.

An interview with the Director of Nursing on April 14, 2019, at 1:02 PM indicated that the facility's expectation is that staff will answer a resident's call bell within 15 minutes.

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

28 Pa. Code 201.29(i) Resident rights


 Plan of Correction - To be completed: 05/28/2019

Preparation and/or execution of this provider's plan of correction does not constitute admission or agreement of the truth of facts alleged, or conclusions set forth in the Statement of Deficiencies, as perceived by representatives of the Department of Health relative to the annual survey ending April 12, 2019. This provider's plan of correction is prepared because it conveys the sincere message of the governing body as follows:
All representative entities of the Susquehanna Health Skilled Nursing & Rehabilitation Center have been and will be committed to providing the highest quality of care and services to the elderly, in accordance with or exceeding all applicable local, state and federal laws/mandates regarding the operation of the long term care facility in the Commonwealth of Pennsylvania.
The following plan of correction comprises our allegations of compliance with regulatory requirements contained in 483, Subpart B Requirements for Long Term Care and Title 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

1. Residents 29, 30, 73, 80, 105, 107 will continue to have their needs met timely.

2. Facility will establish specialized call bell committee to review call bell times, plan of correction, and call bell goals. All residents are welcome with special invitation to residents identified as having call bell times greater than 15 minutes in the last 2 weeks prior to the meeting date if able to participate.

3. Staff education of expectations for call bell response time. Evaluation of IT solutions to assist with monitoring and escalation of call bell responses.

4. Call bell audits will be completed daily x 3 months with results reported at QAPI.



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 observation and staff interview, it was determined that the facility failed to distribute food in a manner to prevent the potential for food borne illness on one of two nursing units (Second floor, Residents 18, 58, 25, and 81).

Findings Include:

Observation on April 9, 2019, revealed that the following trays were passed from the second floor dining room to the hallway and resident rooms:

12:26 PM, the salad and pineapples were not covered on Resident 18's tray
12:27 PM, the salad and pineapples were not covered on Resident 58's tray
12:30 PM, the salad and pineapples were not covered on Resident 25's tray
12:31 PM, the salad and pineapples were not covered on Resident 81's tray

Interview with Employee 4, dietary, on April 9, 2019, at 12:43 PM revealed that there were no covers for cold food when trays are delivered to rooms.

The Nursing Home Administrator was made aware of the above findings on April 10, 2019, at 2:00 PM.

483.60(i)(1)(2) Food Procuement, Store/Prepare/Serve -Sanitary
Previously cited 5/11/18

28 Pa. Code 211.6 (c) Dietary services
Previously cited 5/11/18


 Plan of Correction - To be completed: 05/28/2019

Preparation and/or execution of this provider's plan of correction does not constitute admission or agreement of the truth of facts alleged, or conclusions set forth in the Statement of Deficiencies, as perceived by representatives of the Department of Health relative to the annual survey ending April 12, 2019. This provider's plan of correction is prepared because it conveys the sincere message of the governing body as follows:
All representative entities of the Susquehanna Health Skilled Nursing & Rehabilitation Center have been and will be committed to providing the highest quality of care and services to the elderly, in accordance with or exceeding all applicable local, state and federal laws/mandates regarding the operation of the long term care facility in the Commonwealth of Pennsylvania.
The following plan of correction comprises our allegations of compliance with regulatory requirements contained in 483, Subpart B Requirements for Long Term Care and Title 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.
1. Residents 18, 25, 58, 81 have all food items covered on hall trays.

2. Facility verified all food items on hall trays are covered.

3. Staff education regarding proper infection control process for hall tray delivery.

4. Weekly audits by Dietary Unit Leader or designee for 3 months on food coverage for hall trays and results reported at QAPI.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to initiate a restorative range of motion program for one of 12 residents reviewed (Resident 94).

Findings include:

The policy entitled "Restorative Nursing Policies (Referrals, Evaluation/Daily Record, Documentation, Refusal/Hold Discharge)" last reviewed without changes on March 11, 2019, indicates that if a resident is admitted to the hospital, he/she will be discharged from the restorative program. Upon return to the facility, the referral procedure will be followed.

Review of Resident 94's clinical record revealed that a program for active range of motion to both his shoulders, elbows, wrists, and fingers was implemented and being completed until November 9, 2018, when Resident 94 was admitted to the hospital. There was no evidence that the facility restarted Resident 94's restorative range of motion program after his hospital stay.

An occupational therapy note dated January 16, 2019, at 11:41 AM indicated that Resident 94 was concerned with his range of motion to his hands and that the occupational therapist thought he would benefit from range of motion exercises to increase mobility and use of his hands.

Occupational therapy discharged Resident 94 on January 25, 2019, with no referral for any restorative range of motion programs for his upper extremities after formal therapy was completed.

Interview with Employee 1, occupational therapist, on April 12, 2019, at 10:35 AM confirmed the above information and indicated that she was unaware that restorative programs need reordered after a hospital stay.

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 5/11/18


 Plan of Correction - To be completed: 05/28/2019

Preparation and/or execution of this provider's plan of correction does not constitute admission or agreement of the truth of facts alleged, or conclusions set forth in the Statement of Deficiencies, as perceived by representatives of the Department of Health relative to the annual survey ending April 12, 2019. This provider's plan of correction is prepared because it conveys the sincere message of the governing body as follows:
All representative entities of the Susquehanna Health Skilled Nursing & Rehabilitation Center have been and will be committed to providing the highest quality of care and services to the elderly, in accordance with or exceeding all applicable local, state and federal laws/mandates regarding the operation of the long term care facility in the Commonwealth of Pennsylvania.
The following plan of correction comprises our allegations of compliance with regulatory requirements contained in 483, Subpart B Requirements for Long Term Care and Title 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.
1. Resident 94 was evaluated and started on OT Caseload on 4/16/19 for 5x week for 4 weeks. Active ROM program for both UEs started on 4/23/19.
2. All Occupational and Physical Therapists will be educated on need for assessment for restorative range of motion programs upon return from hospital stay.
3. Automatic alert built into electronic medical record for a message to go directly to the therapy department and Restorative LPN upon resident readmission from a hospital stay to assess for necessity of ROM programs.
4. The Therapy Department Program Manager or designee will complete weekly audits of restorative range of motion programs for all readmissions for 3 months with results reported to QAPI.

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

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

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide an assistive device to prevent an accident for one of two residents reviewed (Resident 93).

Findings include:

Review of Resident 93's clinical record revealed a plan of care dated September 28, 2017, indicating that she required the use of a covered cup for fluids.

Review of the facility investigation dated April 7, 2019, at 6:04 PM indicated that dietary staff provided Resident 93 coffee with her dinner in a regular coffee mug with no cover. Resident 93 spilled the hot coffee on her thighs, sustaining a burn to her right thigh measuring 2 cm (centimeters) long by 1 cm wide, and a burn to her left thigh measuring 7 cm long by 3 cm wide.

Witness statements indicated that Resident 93 did not have the proper assistive device she needed to safely drink hot fluids. According to the facility's follow up report dated April 10, 2019, Resident 93 was to use a two handled spouted cup with a lid for all fluids. There was no documented evidence in the facility's incident investigation to indicate if staff were aware that Resident 93 was to use a covered cup for liquids, nor was there a statement from the staff member who provided Resident 93 with a regular coffee mug.

Observation of Resident 93's thighs on April 12, 2019, at 8:05 AM, revealed that a 1 cm in diameter reddened area that continued on her left thigh from the incident on April 7, 2019.

483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices
Previously cited 5/11/18

28 Pa. Code 201.18 (e)(1) Management
Previously cited 5/11/18

28 Pa. Code 211.10(d) Resident care policies
Previously cited 6/20/18 and 5/11/18


 Plan of Correction - To be completed: 05/28/2019

Preparation and/or execution of this provider's plan of correction does not constitute admission or agreement of the truth of facts alleged, or conclusions set forth in the Statement of Deficiencies, as perceived by representatives of the Department of Health relative to the annual survey ending April 12, 2019. This provider's plan of correction is prepared because it conveys the sincere message of the governing body as follows:
All representative entities of the Susquehanna Health Skilled Nursing & Rehabilitation Center have been and will be committed to providing the highest quality of care and services to the elderly, in accordance with or exceeding all applicable local, state and federal laws/mandates regarding the operation of the long term care facility in the Commonwealth of Pennsylvania.
The following plan of correction comprises our allegations of compliance with regulatory requirements contained in 483, Subpart B Requirements for Long Term Care and Title 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

1. Resident 93 has a covered cup with a lid for all fluids.

2. Facility verified that all residents with orders for covered cups have them in place.

3. Education to dietary staff on proper set up of assistive devices for meals.

4. Weekly audits by the Dietary Unit Leader or designee for 3 months on assistive devices matching plan of care during meals and results reported to QAPI.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

483.55(b) Nursing Facilities.
The facility-

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

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

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

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

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

Based on review of facility policies, observation, family and staff interview, and clinical record review, it was determined that the facility failed to provide dental services for one of three residents reviewed (Resident 16).

Findings include:

The facility policy entitled "Dental Services" last reviewed on March 11, 2019, revealed the purpose was to ensure residents received appropriate and timely dental care and services.

Interview with Resident 16 on April 10, 2019, at 12:37 PM revealed that he has not seen a dentist since admission to the facility. He stated that he would see a dentist if the service was offered.

Clinical record review revealed no documentation related to Resident 16 being seen by a dentist or being offered dental services.

On April 11, 2019, at 9:30 AM the Director of Nursing provided a printed document that indicated Resident 16 had a dental screening on September 28, 2018, October 5, 2018, and October 29, 2018. Interview with the Director of Nursing on April 11, 2019, at 3:00 PM revealed that there was no dental screening notes available as to the findings. She also indicated that a dental screening is done by the dental hygienist.

On April 12, 2019, at 10:15 AM a second printed document was provided to the surveyor that indicated Resident 16 refused his dental screen on September 21, 2018, and October 29, 2018. Concurrent interview with the Director of Nursing revealed that the facility could not provide documentation to indicate if Resident 16 had dental services provided by a Dentist or Dental hygienist or if he refused services.

The facility failed to provide evidence that Resident 16 was offered or received routine dental services.

28 Pa. Code: 211.15 (d) (1) Nursing services
Previously cited 11/7/18, 6/20/18, 5/11/18

28 Pa. Code 211.15 (d)(3) Nursing services
Previously cited 5/11/18

28 Pa. Code: 211.15 (a) Dental services


 Plan of Correction - To be completed: 05/28/2019

Preparation and/or execution of this provider's plan of correction does not constitute admission or agreement of the truth of facts alleged, or conclusions set forth in the Statement of Deficiencies, as perceived by representatives of the Department of Health relative to the annual survey ending April 12, 2019. This provider's plan of correction is prepared because it conveys the sincere message of the governing body as follows:
All representative entities of the Susquehanna Health Skilled Nursing & Rehabilitation Center have been and will be committed to providing the highest quality of care and services to the elderly, in accordance with or exceeding all applicable local, state and federal laws/mandates regarding the operation of the long term care facility in the Commonwealth of Pennsylvania.
The following plan of correction comprises our allegations of compliance with regulatory requirements contained in 483, Subpart B Requirements for Long Term Care and Title 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.
1. Resident 16 was offered and refused routine dental services.
2. Residents meeting criteria have been offered routine dental services.
3. Audit tool built in electronic medical record to capture routine dental services.
4. Assistant NHA or designee will audit monthly to ensure dental services are offered to those residents meeting criteria and report results to QAPI for 3 months.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on observation and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection on one of two nursing units (Second floor nursing unit, Resident 324).

Findings include:

Observation of incontinence care provided to Resident 324 on April 9, 2019, at 9:54 AM revealed that Employees 2 and 3, nurse aides, removed the urine soaked brief, and placed a lift pad under the resident. Employee 2 used the lift controls with her contaminated gloved hands and opened the resident's dresser with the same gloves. At 10:08 AM, Employee 2 put the lift at the end of the hallway without cleaning it after she touched it with her contaminated gloves.

The findings were discussed during an interview with the Nursing Home Administrator on April 11, 2019 at 11:00 AM.

28 Pa. Code 201.18(b)(1) Management
Previously cited 5/11/18

28 Pa. Code 211.10(d) Resident care policies
Previously cited 6/20/18 and 5/11/18








 Plan of Correction - To be completed: 05/28/2019

Preparation and/or execution of this provider's plan of correction does not constitute admission or agreement of the truth of facts alleged, or conclusions set forth in the Statement of Deficiencies, as perceived by representatives of the Department of Health relative to the annual survey ending April 12, 2019. This provider's plan of correction is prepared because it conveys the sincere message of the governing body as follows:
All representative entities of the Susquehanna Health Skilled Nursing & Rehabilitation Center have been and will be committed to providing the highest quality of care and services to the elderly, in accordance with or exceeding all applicable local, state and federal laws/mandates regarding the operation of the long term care facility in the Commonwealth of Pennsylvania.
The following plan of correction comprises our allegations of compliance with regulatory requirements contained in 483, Subpart B Requirements for Long Term Care and Title 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.
1. Hoyer lift was cleaned.
2. Facility lift audit completed for lift cleanliness.
3. Staff education on lift cleaning process and proper infection control practices during resident care.
4. Weekly observations of lift cleanliness after use for 3 months with results report to QAPI by Infection Preventionist or designee.

201.18(b)(1)-(3) LICENSURE Management.:State only Deficiency.
(b) The governing body shall adopt and enforce rules relative to:

(1) The health care and safety of the residents.

(2) Protection of personal and property rights of the residents, while in the facility, and upon
discharge or after death.

(3) The general operation of the facility.
Observations:

Based on closed clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to account for the disposition of personal property for one of three residents reviewed (Resident 124).

Findings include:

Review of the facility's policy entitled "Clothing/Article List and Clothing Labeling," last reviewed without changes on March 11, 2019, indicates that the facility will document receipt of personal articles upon discharge. On discharge from the facility for any reason, nursing will assist the resident or responsible party with gathering belongings. The Resident or authorized decision maker will sign the belonging sheet indicating that they have received all personal belonging to the resident.

Review of Resident 124's closed clinical record revealed that she was admitted to the facility on March 9, 2015. A handwritten note was in Resident 124's closed clinical record indicating that her family brought in personal possessions, that included two diamond rings, a wedding band, and several articles of clothing. Resident 124 was discharged from the facility on March 16, 2019. There was no documented evidence in Resident 124's closed clinical record to indicate that the facility completed a belonging sheet or returned all her belongings to the responsible party upon Resident 124's discharge.

Interview with the Director of Nursing on April 12, 2019, at 9:59 AM, confirmed the above findings.


 Plan of Correction - To be completed: 05/28/2019

Preparation and/or execution of this provider's plan of correction does not constitute admission or agreement of the truth of facts alleged, or conclusions set forth in the Statement of Deficiencies, as perceived by representatives of the Department of Health relative to the annual survey ending April 12, 2019. This provider's plan of correction is prepared because it conveys the sincere message of the governing body as follows:
All representative entities of the Susquehanna Health Skilled Nursing & Rehabilitation Center have been and will be committed to providing the highest quality of care and services to the elderly, in accordance with or exceeding all applicable local, state and federal laws/mandates regarding the operation of the long term care facility in the Commonwealth of Pennsylvania.
The following plan of correction comprises our allegations of compliance with regulatory requirements contained in 483, Subpart B Requirements for Long Term Care and Title 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.
1. Staff confirmed resident 124's family took belongings upon discharge.
2. Resident/Representative will sign disposition of personal property upon discharge.
3. Staff education with printing disposition of personal property form with discharge paperwork.
4. Weekly audits completed by RN Case Manager or designee for 3 months with results reported at QAPI.


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