Pennsylvania Department of Health
 AVENTURA AT PROSPECT
Patient Care Inspection Results

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AVENTURA AT PROSPECT
Inspection Results For:

There are  155 surveys for this facility. Please select a date to view the survey results.

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AVENTURA AT PROSPECT - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey, completed on March 15, 2024, it was determined that Aventura at Prospect, was not in compliance with the 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 related to the health portion of the survey process.


 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 review of facility policy, resident council documents, resident council group interview, resident interview, and staff interview it was determined that the facility failed to respond to concerns from resident council and failed to respond to concerns in a timely manner for three out of nine months (November 2023, December 2023, January 2024, and February 2024).

Findings include:

Review of Resident council minutes dated November 2023, December 2023, January 2023 and February 2024 identified a request from council to address concerns about portions size during meals. The documentation did not indicate follow-up actions or communication from nursing home administration to address the portion size.

A resident group meeting was conducted on March 13, 2024, at 11:30 a.m. Residents R68, R12, R16, 35, 66, 51, 143 and 34 were present during the meeting.

During the resident council group interview on March 13, 2024, at 11:30 a.m. 8 of 8 residents voiced a concern with the facility administration not resolving their request for large portion during meals, residents stated they did not receive enough food during meals and they have asked for large portion size.

During an interview on March 13, 2024, at 1:18 p.m. the Nursing Home Administrator, Employee E1 confirmed that the facility failed to respond to concerns from resident council and failed to respond to concerns/requests in a timely manner for four months.

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





 Plan of Correction - To be completed: 04/24/2024

- Corrective action: All open concerns were addressed by SSD or designee by 4/24/24. All concerns from resident council were addressed by SSD or designee by 4/24/24
- Identified Others: Resident council was held on 3/27/24 all concerns were addressed in 72 hour time frame as stated in policy
- Measures implements: SSD was educated on grievance policy and concerns being resolved in timely manner and resident council concerns being addressed timely by administrator or designee by 4/24/24
- Monitoring: To monitor and maintain ongoing compliance, the Administrator/Designee will audit Resident Council Minutes & Concern log weekly x4 then monthly x2 to ensure timely follow-up. Results of audits will be reported at QAPI meeting to ensure compliance

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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.
§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

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

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

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

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

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

Based on the review of facility documentation, clinical records review and staff interviews, it was determined that the facility failed to provide necessary pharmaceutical services for six medication doses ordered for Resident R66 and13 medication doses ordered for Resident R68. (Resident R66 and Resident R68)

Findings include:

Interview with Resident R66 on March 13, 2024, at 12:30 p.m., stated facility often ran out of his medications. Facility staff did not order it on time and the pharmacy did not deliver enough supply of the medication. Resident R68 stated he was ordered ear drops 3 weeks ago and he did not receive the medication.

Review of physician order for Resident R66 dated February 22, 2024, revealed that the resident was ordered for Debrox Otic (safely removes excessive earwax through the power of microfoam cleansing) solution, 5 drops to both ears two times a day for 21 days.

Review of Medication Administration Record for Resident R66 for the month of February and March 2024 revealed that the resident did not receive the medication on twice on February 24, once on 25, 29, March 7, 9, at 9:00 p.m. The reason was documented as medication not available.

Interview with R68 on March 11, 2024, at 12:06 p.m., stated staff did not order medication appropriately and the facility often ran out of the supplies, and he missed several doses of medications.

Review of physician order for Resident R68 dated January 22, 2024, revealed that the resident was ordered for Zaditor ophthalmic solution every 8 hours to both eyes for allergic conjunctivitis.

Review of Medication Administration Record for Resident R68 for the month of February and March 2024 revealed that the resident did not receive the medication on February 3, 9, 13, 16, 26, March 1, 8, twice on March 9, 11, 13

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

28 Pa. Code: 211.9(a)(1)(f)(2)(4)(k) Pharmacy services.








 Plan of Correction - To be completed: 04/24/2024

- Corrective Action: Physician was notified of missed medication for R66, R68 and new orders were received and medication was ordered and verified administered by DON or designee by 4/24/24
- Other Residents: All residents medications were verified to be in the facility and available for administration by DON or designee by 4/24/24
- Measures Implemented: All nurses were educated on medication administration policy and reordering medication from pharmacy by DON or designee by 4/24/24
- Monitoring: To monitor and maintain ongoing compliance, the Administrator/Designee will audit medication passes weekly x4 then monthly x2 to ensure medication availability & accurate pass. Results of audits will be reported at QAPI meeting to ensure compliance

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:

Based on review of personnel files and staff interviews, it was determined that the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents for 5 of 5 nursing staff reviewed (Employee E13, E14. E15, E16 and E17)

Findings Include:

Review of facility documentation revealed that the facility provided care residents received intravenous therapy and tracheostomy care.

A request for competencies and skill sets related to the management of residents with tracheostomy, intravenous therapy and medication administration was made to the facility administration on March 12, 2024, for nursing staff Employee E13, E14. E15, E16 and E17

Facility did not submit staff competencies and skill sets related to the management of residents with restraints.

Interview with the Nursing Home Administrator, Employee E1, and Regional staff, Employee E2 on March 15, 2024, at 12:00 p.m. confirmed that there was no documentation available to show that licensed nursing staff had been evaluated for competencies.

28 Pa Code 201.20(b) Staff development.

28 Pa Code 201.20(d) Staff development.



 Plan of Correction - To be completed: 04/24/2024

- Corrective Action: Staff members with missing skills competencies were completed by DON or designee by 4/24/24
- Other Residents: All STNAs completed required skills competencies by DON or designee by 4/24/24
- Measures Implemented: Director of nursing was educated on routine required skills competencies for STNA by corporate nurse or designee by 4/24/24
- Monitoring: To monitor and maintain ongoing compliance, the Administrator/Designee will audit STNA skills competencies weekly x4 then monthly x2 to ensure completion. Results of audits will be reported at QAPI meeting to ensure compliance

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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)(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.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on review of clinical records, interviews with facility staff and review of facility policy, it was determined the facility failed to develop a comprehensive care that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one of 30 resident records reviewed (Resident R83).

Findings include:

Review of the facility's policy titled "Care Plans, Comprehensive Person-Centered revised on March 16, 2024, states the comprehensive person-centered care plan is developed and implemented to include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs.

Review of Resident R83's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated February 4, 2024, revealed the resident was cognitively intact diagnosed with heart failure, high blood pressure, schizophrenia (mental illness associated with loss of reality contact, delusions, and hallucinations) and history of an ileus (a painful obstruction of the ileum or other parts of the intestine with signs of nausea, vomiting, constipation and abdominal cramps).

Review of Resident R83's physician progress notes revealed on February 26, 2024, the resident complained of nausea and abdominal discomfort and had one episode of emesis (vomit). On March 1, 2024, the resident approached the physician and complained of constipation, nausea and abdominal pain and requested medication to help with his constipation. The same day the physician ordered a KUB (kidney ureter and bladder x-ray to assess the abdominal area) to rule out an ileus.

Review of Resident R83's care plan revealed the facility failed to care plan the resident for his history of an ileus and constipation.

Review of Resident R83's psychiatric note dated January 29, 2024, address the need to re-evaluate the resident's diagnosis of schizophrenia and psychotropic drug use since the staff reported episodes of patient eating cardboard and the resident having occasional auditory and visual hallucinations.

Further review of Resident R83's care plan did not reveal a plan of care for the resident's diagnosis of schizophrenia.

This was confirmed with the Director of Nursing on March 13, 2024, at 11:58 a.m.

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

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





 Plan of Correction - To be completed: 04/24/2024

- Corrective Action: Residents careplan was updated to reflect measurable and objective time frames to meet the residents medical, nursing, and mental and psychosocial needs by MDS or designee by 4/24/24.
- Other Residents: All residents careplans were reviewed and/or updated to include measurable and objective time frames to meet the residents medical, nursing, and mental and psychosocial needs by MDS or designee by 4/24/24
- Measures Implemented: MDS nurse, SSD, and Activity director were educated on developing an comprehensive care plan to include measurable and objective time frames to meet the residents medical, nursing, and mental and psychosocial needs by DON or designee by 4/24/24
- Monitoring: To monitor and maintain ongoing compliance, the Administrator/Designee will audit comprehensive careplan weekly x4 then monthly x2 to ensure appropriate measurable and objective time frames to meet the residents medical, nursing, and mental and psychosocial needs are reflected. Results of audits will be reported at QAPI meeting to ensure compliance

483.20(k)(1)-(3) REQUIREMENT PASARR Screening for MD & ID: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.
§483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability.

§483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with:
(i) Mental disorder as defined in paragraph (k)(3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission,
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
(B) If the individual requires such level of services, whether the individual requires specialized services; or
(ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission-
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
(B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability.

§483.20(k)(2) Exceptions. For purposes of this section-
(i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital.
(ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual-
(A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital,
(B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and
(C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services.

§483.20(k)(3) Definition. For purposes of this section-
(i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1).
(ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b)(3) or is a person with a related condition as described in 435.1010 of this chapter.
Observations:

Based on clinical record review, review of facility policies and staff interview determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for three of 30 residents reviewed related to PASRR assessments (Resident R83, R148 and R13)

Findings include:

The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability.

The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A Level II PASRR evaluation must be completed if the Level 1 PASRR determined that the person is a targeted person with mental illness or an intellectual disability. The Level II PASRR would determine if placement or continued stay in the requested or current nursing facility is appropriate.

Review of the facility's Admission policy revised August 2022 states the facility admits only resident who's medical and nursing care needs can be met. The same policy states that all new admissions are screened for mental disorders (MD) intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process.

Review of Resident R83's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated February 4, 2024, revealed that the resident was admitted to the facility on September 14, 2023, diagnosed with schizophrenia (mental illness associated with loss of reality contact, delusions, and hallucinations).

Review of Resident R83's PASRR Level I assessment, dated January 26, 2023, failed to include schizophrenia as the resident's mental disorder and the resident was not listed as having a serious mental illness.

Interview on March 12, 2024, at 12:54 p.m. Employee E7, Social Service Director, confirmed that Resident R83 PASRR assessment was not completed accurately and failed to include mental health diagnoses.

Review of Resident R148's Admission MDS dated February 14, 2024 revealed the resident was admitted to the facility on February 1, 2024 diagnosed with a neurological traumatic brain injury with a subdural hemorrhage and loss of consciousness.

Further review of Resident R148's clinical record revealed the resident's diagnosis of his neurological condition effected the resident's memory, attention, language, perception, and social cognition.

Review of Resident R148's PASRR dated February 1, 2024, was not accurately complete and failed to include the resident's neurocognitive disorder.

Interview on March 12, 2024, at 12:54 p.m. Employee E7, Social Service Director, confirmed that Resident R148's PASRR assessment was not accurately completed .


Review of Resident R13's clinical record revealed that the resident was admitted December 18, 2023 with the diagnoses of psychotic disorder with delusions due to known physiological condition; post-traumatic stress disorder; other recurrent depressive disorders; alcohol dependence with alcohol-induced anxiety disorder; delusional disorders; personal history of suicidal behavior and peripheral vascular disease.

Review of Resident R13 's clinical health record revealed a PASARR screen with another resident's name.

Interview on March 14, 2024 at 1:30 p.m. with the Director of Nursing, Employee E2 confirmed that it was the incorrect form. The facility was not able to provide evidence that a PASRR was completed for Resident R13.


28 Pa. Code 201.8(b)(1) Management

28 Pa. Code 201.8(e)(1) Management
















 Plan of Correction - To be completed: 04/24/2024

- Corrective action: Residents 83, 148, & 13 PASSARs were completed and submitted and filed appropriately by SSD or designee by 4/24/24.
- Other Residents: All residents PASSARs were audited to ensure they are completed and submitted and filed appropriately by SSD or designee by 4/24/24.
- Measures Implemented: SSD was educated on proper PASSAR completion and filing by Administrator or designee by 4/24/24
- Monitoring: To monitor and maintain ongoing compliance, the Administrator/Designee will audit PASSARs weekly x4 then monthly x2 to ensure appropriate completion. Results of audits will be reported at QAPI meeting to ensure compliance

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice: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(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:

Based on a review of clinical records and facility provided documentation, and interview with staff, it was determined that the facility failed to provide the required advanced notice, through a Notice of Medicare Non-Coverage (CMS 10123), regarding the termination of Medicare services for three of three residents sampled (Residents R355, R356 and R357)

Findings include:

The form "Notice of Medicare Non-Coverage (NOMNC) CMS-10123," is a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization to appeal. The Medicare provider must ensure that the notice is delivered at least two calendar days before covered services end.

Review of Resident R355's Notice of Medicare Non-Coverage (NOMNC) cms-10123 revealed that the Medicare skilled A services will end on November 18, 2023.

Review of Resident R356's Notice of Medicare Non-Coverage (NOMNC) cms-10123 revealed that the Medicare skilled A services will end on January 5, 2024.

Review of Resident R357's Notice of Medicare Non-Coverage (NOMNC) cms-10123 revealed that the Medicare skilled A services will end on January 26, 2024.

Interview with the Nursing Home Administrator on March 15, 2024, at 12:30 p.m. confirmed the facility did not ensure to that notice was delivered at least two calendar days before Resident R355, R356 and R357's covered services ended.

28 Pa Code 201.29(a) Resident rights




 Plan of Correction - To be completed: 04/24/2024

- Corrective Action: Resident were given their NOMNC by MDS nurse by 4/24/24
- Other residents: All residents with end of Medicare coverage for the last 30 days were verified by MDS nurse by 4/24/24 to have been given NOMNC per policy
- Measures Implemented: MDS was educated on NOMNC requirements by DON or designee by 4/24/24
- Monitoring: To monitor and maintain ongoing compliance, the Administrator/Designee will audit Residents with ending Medicare Coverage weekly x4 then monthly x2 to ensure NOMNC given timely. Results of audits will be reported at QAPI meeting to ensure compliance

483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions: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(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.
Observations:

Based on review of resident records, facility policy, and interviews with resident and facility staff, it was determined that the facility failed to ensure the resident was informed of his medical condition for one of 30 resident record reviewed. (Resident R83).

Finding includes:

Review of the facility's Resident Rights policy revised in August 2022, states all residents will be treated with kindness, and respect, and be informed of his/or her medical condition.

Review of Resident R83's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated February 4, 2024, revealed the resident was cognitively intact diagnosed with Heart failure, high blood pressure, schizophrenia (mental illness associated with loss of reality contact, delusions, and hallucinations) and history of an ileus (a painful obstruction of the ileum or other parts of the intestine with signs of nausea, vomiting, constipation and abdominal cramps).

Review of Resident R83's physician progress notes revealed on February 26, 2024, the resident complained of nausea, vomiting and and abdominal discomfort. On March 1, 2024, the resident complained of constipation, nausea and abdominal pain and the physician ordered an abdominal xray to rule out an ileus.

During an interview with Resident R83 on March 13, 2024, at 10:30 a.m. indicated no one told him the results of the abdominal exray, done almost two weeks ago.

Review of the results dated March 1, 2024, revealed no documented evidence the resident was informed of the results.

28 Pa Code 201.18(b)(2) Management

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




 Plan of Correction - To be completed: 04/24/2024

- Corrective Action: Resident was updated on medical condition by DON or designee by 4/24/24
- Identified Others: All resident with x-rays in the last 30 days were verified to have resident notification by DON or designee by 4/24/24 . No issues noted
- Measures Implemented: All nurses re-educated on the resident rights policy and educated to ensure residents are updated on medical changes
- Monitoring: To monitor and maintain ongoing compliance, the DON/Designee will audit x-ray results weekly x4 then monthly x2 to ensure resident notification. Results of audits will be reported at QAPI meeting to ensure compliance.

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

Based on observations and interviews with staff, it was determined that the facility failed to post how to file a complaint with the State Survey Agency as required for three of three nursing units. (First, Second and Third floor nursing)

Findings include:

Observation on March 13, 2024, at 1:18 p.m. of the main lobby area as well as the First and Second floor nursing units revealed that the complaint hotline number for the State Survey Agency was not posted.

Interview on March 13, 2024, at 1:18 p.m. the Nursing Home Administrator confirmed that the complaint hotline number for the State Survey Agency was not posted.

28 Pa Code 201.14(a) Responsibility of licensee

28 Pa Code 201.18(b)(2) Management



 Plan of Correction - To be completed: 04/24/2024

- Corrective Action: "How to file a complaint with sate survey agency" signage was posted by administrator by 4/24/24
- Other Residents: All residents were made aware of posting location of required posting by Administrator or designee by 4/24/24
- Measures Implemented: Administrator was educated on required posting "How to file a complaint with sate survey agency" on nursing units by corporate employee by by 4/24/24
- Monitoring: To monitor and maintain ongoing compliance, the Administrator/Designee will audit each nursing unit weekly x4 then monthly x2 to ensure required posting "how to report to state Survey Agency". Results of audits will be reported at QAPI meeting to ensure compliance

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

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

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

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

Based on review of select facility policy and the minutes from Residents' Council meetings and staff interviews, it was determined that the facility failed to put forth sufficient efforts to promptly resolve resident complaints/grievances expressed by a resident for one of 30 residents reviewed. (Resident R66)

Findings include:

Review of the facility policy "Resident Rights", dated August 2022, indicated that. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: u. voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; v. have the facility respond to his or her grievances."

A resident group meeting was conducted on March 13, 2024, at 11:30 a.m. Resident R68, R12, R16, 35, 66, 51, 143 and 34 were present during the meeting.

During the resident council group interview on March 13, 2024, at 11:30 a.m. 8 of 8 residents voiced a concern with the facility administration not resolving their grievances in a timely manner and residents stated they did not hear back from the staff after grievances were filed.

During the resident council group, Resident R66 stated he has raised some concerns to facility staff for few months and the issues were not resolved. Resident was interviewed after the meeting, he stated he voiced his concern to facility staff including nurses and supervisors for months and he did not hear any response from staff, or the issues were not resolved. Resident stated staff did not provide him medications as ordered by the physician and often times the medications were late. Resident stated he did not receive ensure as ordered by the physician.
Continued interview with the resident stated he voiced the concern to the social worker on March 8, 2024, and she gave him a concern form to fill out.

Interview with the social service director, Employee E7, on March 13, 2024, at 2:02 p.m. stated resident did want to raise concerns to the facility staff on March 8, 2024. Employee E7 stated she gave him a grievance form to fill out, however she did not have the concern form, or she did not know about the concerns. Employee E7 confirmed that she did not follow up with the resident about the grievance or his concerns and no immediate interventions were implemented to prevent any violations.


28 Pa. Code 201.18 (b)(1)(3)(2.1)(4) Management

28 Pa. Code 201.29 (a) Resident Rights




 Plan of Correction - To be completed: 04/24/2024

- Corrective action: All open concerns were addressed by SSD or designee by 4/24/24. All concerns from resident council were addressed by SSD or designee by 4/24/24
- Identified Others: Resident council was held on 3/27/24 all concerns were addressed in 72 hour time frame as stated in policy
- Measures implements: SSD was educated on grievance policy and concerns being resolved in timely manner and resident council concerns being addressed timely by administrator or designee by 4/24/24
- Monitoring: To monitor and maintain ongoing compliance, the Administrator/Designee will audit Resident Council Minutes & Concern log weekly x4 then monthly x2 to ensure timely follow-up. Results of audits will be reported at QAPI meeting to ensure compliance

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


Based on observation, review of resident records, interviews with staff and review of facility policies, it was determined that the facility failed to provide treatment and care in accordance with professional standards of practice, for failing to monitor bowel movements and failure to follow physician orders related to a neck collar for two of 30 residents reviewed. (Resident R83 and Resident R146)

Findings include:

Review of the facility's Bowel Protocol, not dated, states the facility will assist the residents to assure regular bowel elimination to avoid complications associated with constipation or diarrhea. Each residents' bowel elimination is monitored and checked by the unit manager daily. The protocol further list medication and interventions for bowel elimination and to notify the physician for additional instructions if a bowel movement does not occur. The policy further states that the unit manager will be responsible for ensuring appropriate interventions are on the plan of care with input from all applicable disciplines.

Review of Resident R83's quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated February 4, 2024, revealed the resident was cognitively intact and inlcuded the diagnoses of heart failure, high blood pressure, and history of an ileus (a painful obstruction of the ileum or other parts of the intestine with signs of nausea, vomiting, constipation and abdominal cramps).
Review of Resident R83's physician progress notes revealed on February 26, 2024, the resident complained of nausea and abdominal discomfort that started the night before and had one episode of emesis (vomit).

On February 29, 2024, physician note indicated the resident approached the physician and complained of constipation, nausea and abdominal pain. His last bowel movement was two days ago and requested medication to help with his constipation.

Further review of Resident R83's clinical record revealed no documentation the resident's bowel habits were monitored.

The Director of Nursing on March 13, 2024, at 11:58 a.m. confirmed nursing failed to monitor and document Resident R83 daily bowel habits.


Review of Resident R146's care plan, dated January 28, 2024, revealed that the resident had an nursing intervention to wear an Aspen Collar at all times related to chronic progressive disease, mobility deficit and spinal fusion.

Observation of Resident R146 on March 12, 2024, at 9:35 a.m., revealed resident resting in bed without the Aspen collar in place. Interview with the Employee E26, confirmed that resident did not have the aspen collar in place. It was also stated that the nurse thought that the Aspen Collar was 'on order'.

Review of resident's clinical record revealed an order for Aspen Collar at all times following a spinal fusion dated January 27, 2024. The order was scheduled to be documented every shift.

Continued review of Resident R146's February 2024 Treatment Administration Record noted under the Aspen Collar a code 16 'See Note' for February 4, 5, 6, 7, 10, 13, 19, 20, 21, 22, and 23, 2024 during the 11 p.m. to 7 a.m. shift

Interview on March 13, 2024, at 11:30 a.m., with the Director of Nursing, Employee E2 confirmed that the Aspen Collar was not on order. The Director of Nursing (DON) stated resident had been pulling at the collar and not wearing it. DON stated that it should have been discontinued by hospice.

28 Pa. Code 211.10 (c) Resident care policies

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





 Plan of Correction - To be completed: 04/24/2024

- Corrective Action: Resident 146 has expired. Resident 83's medical record updated with bowel habits monitoring in clinical documentation.
- Other Residents: No other resident's identified with aspen collar orders. All residents were reviewed to have bowel monitoring in clinical record.
- Measures Implemented: Nursing staff educated on bowel habit monitoring. Nursing staff educated on following doctor's orders to ensure quality of care related to aspen collar.
- Monitoring: To monitor and maintain ongoing compliance, the DON/Designee Rill audit weekly x4 then monthly x2 to ensure timely psychiatric services rendered.
- Results of audits will be reported at QAPI meeting to ensure compliance

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

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


Based on observation, interviews with facility staff and review of clinical records and facility policy and documentation determined that the facility failed to ensure a cognitively impaired resident (Resident R148) received adequate supervision to prevent reoccurring falls for one of 30 resident records reviewed.

Findings include:

Review of the facility's policy titled, Managing Falls and Fall Risk revised in August 2022, states that based on previous evaluations, and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. If falls reoccur, staff will implement additional or different interventions.

Review of Resident R148's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated February 14, 2024, revealed that the resident was admitted to the facility on February 2, 2024, diagnosed with neurological conditions, fracture, aphasia (non-verbal), hemiplegia (one sided paralysis) , traumatic brain injury incontinent of bowel and bladder and completely dependent on staff for all activities of daily living bed mobility and transfers.

Review of Resident R148's clinical records and facility documentation revealed three falls requiring emergency room evaluations. On February 2, 2024, at approximately 8:00 a.m. the resident had an unwitnessed fall , observed on the floor, on the right side of the bed. On February 16, 2024, the resident was transferred to the emergency room when at approximately 12:45 p.m. a nursing assistant (NA) was preparing to feed the resident lunch in his Geri-chair (reclining wheelchair) and turned away. The resident reached for his meal and fell to the floor, hitting the left side of his face and head. On February 17, 2024, the resident was transferred to the emergency room when he was found on the floor in the dinning room having a seizure. Resident R148's returned the same day and his care plan for falls was updated with new interventions that included 1:1 staff supervision while in his Geri-chair. On February 19, 2024, the resident had an unplanned transfer to the hospital when the resident was observed in the hallway lying face down on the floor at 4:25 p.m.

During an interview with the Director of Nursing (DON) on March 13, 2024 at 1:30 p.m. confirmed Resident R148 was not properly supervised on February 19, 2024, when he fell from his Geri-chair in the main hallway. The DON stated at the time of the fall he was to have 1:1 supervision and the unit clerk who was watching him was on the computer working at the nurse station. The resident has a habit of flipping and jerking his body. When the unit clerk looked up the resident was already on the floor. The DON also confirmed the facility's 1:1 supervision policy is to assign one staff per shift no other job assignments other than the responsibility to watch/supervise the resident.


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

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














 Plan of Correction - To be completed: 04/24/2024

- Corrective Action: Resident 148 Fall risk was updated resident and resident was evaluated by therapy by 4/24/24. Residents careplan was updated.
- Other Residents: All residents with a 1:1 for supervision and safety were verified to be in place and/or validate if still appropriate by DON or designee by 4/24/24
- Measures Implemented: All nurses and STNA were educated on safety and supervision and maintaining 1:1 if initiated by DON or designee by 4/24/24
- Monitoring: To monitor and maintain ongoing compliance, the Administrator/Designee will audit 1:1 staffing weekly x4 then monthly x2 to ensure in place as ordered. Results of audits will be reported at QAPI meeting to ensure compliance

483.40 REQUIREMENT Behavioral Health Services:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations:

Based on the review of clinical records and interviews with staff and resident, it was determined that the facility failed to ensure each resident received the necessary behavioral health services in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one of 30 residents reviewed (Resident 66).

Findings include:

Review of psychiatric consult note for Resident R66 dated January 29, 2024, revealed that the resident was re-evaluated for depression and bipolar disorder. Resident had a history of suicidal attempt in the past, multiple psychiatric hospitalizations were noted. Resident noted with clinical signs of depression, mood swings, verbal aggression. A recommendation was made for psychology consult.

Review of care plan for Resident R66 initiated on May 31, 2023, revealed evidence that the facility implemented a behavioral care plan for Resident R66 for suicidal ideation with intervention.

Further review of the entire clinical record revealed no evidence that the resident was seen by the psychology as recommended by the psychology on January 29, 2024.

Interview with Psychology practitioner, Employee E18 on March 13, 2024, at 2:10 p.m. stated she came to the facility at least weekly and saw residents as requested by the staff. Employee E18 stated she did not see Resident R66 and was not aware of the consult made on January 29, 2024.

Interview with the social service director, Employee E7, on March 13, 2024, at 2:02 p.m. stated resident did want to raise concerns to the facility staff on March 8, 2024. Employee E7 stated she gave him a grievance form to fill out, however she did not have the concern form, or she did not know about the concerns. Employee E7 confirmed that she did not follow up with the resident about the grievance or his concerns and no immediate interventions were implemented to prevent any violations.

Review of social service progress note dated March 8, 2024, revealed that the social worker met with the resident to address a statement from resident about a statement he made about harming himself. The resident stated that he made statement of harming himself because he was frustrated about some concerns. Further review of the progress note revealed that "social service department is in the process of addressing all the residents' concerns and notifying the appropriate departments." However, the note did not address the actual concerns resident had to make statement about harming himself or plans or interventions to address the concern


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






 Plan of Correction - To be completed: 04/24/2024

- Corrective Action: Resident 66 was consulted by psych on 3/19/24.
- Other Residents: All residents with psych consult orders were audited to ensure psychiatric services received.
- Measures Implemented: Nursing Staff educated on process to notify psych services when order received for consultation.
- Monitoring: To monitor and maintain ongoing compliance, the DON/Designee will audit weekly x4 then monthly x2 to ensure psychiatric services received. Results of audits will be reported at QAPI meeting to ensure compliance

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

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

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

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

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

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

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on clinical record reviews and staff interview, it was determined that the facility failed to ensure resident's medication regime was free from potential unnecessary medications for one of five residents reviewed (Resident R138).

Findings include:

Clinical record review for Resident 138 revealed a current physician's order dated February 23, 2024, for Clonazepam 1 milligrams to give 1 tablet by mouth every 8 hours as needed for anxiety for 14 Days only.

Further review of the physician orders revealed that the order was renewed on March 10, 2024

Review of psychiatric consult report dated March 1, 2024, revealed that the resident was on a short trial of Clonazepam. Further review of the consult did not reveal any documentation related to the duration expected for the Clonazepam trial.

Review of physician progress note dated March 11, 2024, revealed an order to continue Clonazepam twice daily. However, the physician progress did not include a reason for continuing Clonazepam as needed after 14 days and the expected duration of as needed order.


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












 Plan of Correction - To be completed: 04/24/2024

- Corrective Action: Resident 138's physician was notified of Clonazepam order and resident was seen by physician by 4/24/24 and required documentation including reasoning and duration of therapy were completed
- Other Residents: All residents on PRN psychotropics were reviewed with the physician and documented reasoning if continuing past 14 days and expected duration.
- Measures Implemented: Physician and DON were educated on unnecessary psychotropic medication policy and required documentation by corporate nurse or designee by 4/24/24
- Monitoring: To monitor and maintain ongoing compliance, the Administrator/Designee will audit PRN Psychotropic medications weekly x4 then monthly x2 to ensure Reason and expected duration of treatment are documented. Results of audits will be reported at QAPI meeting to ensure compliance

483.50(a)(1)(i) REQUIREMENT Laboratory Services:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.50(a) Laboratory Services.
§483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that laboratory studies were promptly obtained as ordered by the physician for one of one resident reviewed for laboratory services (Resident 66).

Findings include:

Review of laboratory report for Resident R66 dated October 27, 2023, revealed that a valproic acid (It can treat seizures and bipolar disorder) level was completed. The specimen was collected on October 27, 2023, and result was reported on the same day. The result showed the valproic acid level was below therapeutic range)

Further review of the clinical record revealed no evidence that the result was notified to the physician until October 30, 2023.

Review of Resident R2's physician progress note dated October 30, 2023, revealed that the resident's valproic acid level was below therapeutic range, and a recommendation was made to recheck valproic acid level in 1 week.

Review of clinical record for Resident R66 revealed no evidence that a valproic acid level test was completed after 1 week as ordered by the physician on October 30, 2023.

Review of laboratory report for Resident R66 dated March 8, 2024, revealed that a valproic acid level was completed. The specimen was collected on March 8, 2024, and result was reported on the same day. The result showed the valproic acid level was low (below therapeutic range)

Further review of the clinical record revealed no evidence that the facility staff obtained the result from laboratory system and notified the physician of the abnormal lab in a timely manner.

Interview with the Assistant Director of Nursing on March 15, 2024, at 11:15 a.m., confirmed that Resident R66's labs results were not notified to the physician in a timely manner.

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

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

28 Pa. Coded 211.12(d)(5) Nursing services







 Plan of Correction - To be completed: 04/24/2024

- Corrective Action: Physician for R66 was contacted regrading subtherapeutic valproic acid level.
- Other Residents: All residents with labs in the last 30 days were reviewed to make sure notification was made to physician by DON or designee by 4/24/24
- Measures Implemented: All nurses were educated on lab services and notification to physician timely by DON or designee by 4/24/24
- Monitoring: To monitor and maintain ongoing compliance, the DON/Designee will audit Lab orders and results weekly x4 then monthly x2 to ensure timely provider notification. Results of audits will be reported at QAPI meeting to ensure compliance

483.70(n)(2)(i)(ii)(3)-(5) REQUIREMENT Entering into Binding Arbitration Agreements:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.70(n) Binding Arbitration Agreements
If a facility chooses to ask a resident or his or her representative to enter into an agreement for binding arbitration, the facility must comply with all of the requirements in this section.

§483.70(n)(1) The facility must not require any resident or his or her representative to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility and must explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility.

§483.70(n)(2) The facility must ensure that:
(i) The agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands;
(ii) The resident or his or her representative acknowledges that he or she understands the agreement;

§483.70(n)(3) The agreement must explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it.

§483.70(n) (4) The agreement must explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility.

§483.70(n) (5) The agreement may not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman, in accordance with §483.10(k).
Observations:

Based on the review of facility documents and resident clinical record and staff interviews, it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement for one of three residents reviewed (Resident R99).

Findings Include:

Review of Resident R99's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated October 5, 2023, revealed the resident was admitted to the facility on September 28, 2023, and had a diagnosis of altered mental status and cocaine abuse.

Further review of the MDS, Section C - Cognitive Patterns (items in this section are intended to determine the resident's attention, orientation, and ability to register and recall new information - these items are crucial factors in many care-planning decisions), indicated that Resident R49 scored a 9 on the Brief Interview for Mental Status (BIMS), which indicated the resident had moderate cognitive impairment.

Review of physician progress note dated September 29, 2023, revealed that the resident was poor historian and forgetful. Resident was alert and oriented x 2 (person and time) which indicated that the resident was not completely oriented to person, time, place, and situation.

Review of psych consult dated October 5, 2023, revealed that resident was seen after he was seen by urinating in Styrofoam cup and drinking his urine. Resident was agitated and confused.

Review of Resident R99's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated the resident signed the document on September 28, 2023. Further review of the Binding Arbitration Agreement revealed it was also signed by facility employee, Admission Director, Employee 19.

Interview on March 15, 2024, at 12:00 p.m. with Employee E19, confirmed that he was not aware of the resident's mental status, and he usually ask the staff about residents mental status and he was not sure if there was any response he received of residents mental status.

28 Pa. Code 211.10 (d) Resident care policies




 Plan of Correction - To be completed: 04/24/2024

- Corrective Action: Facility has started pursuing guardianship for R99
- Other Residents: All residents Admission agreement was reviewed to ensure it is signed by competent resident or correct responsible party by admissions coordinator by 4/24/24
- Measures Implemented: Admissions Director was educated on Arbitration agreement and requirements for signing a binding agreement by administrator by 4/24/24
- Monitoring: To monitor and maintain ongoing compliance, the Administrator/Designee will audit Arbitration Agreements weekly x4 then monthly x2 to ensure competent party has signed. Results of audits will be reported at QAPI meeting to ensure compliance

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
Observations:

Based on the review of facility policy, observations and staff interviews it was determined that the facility failed to ensure a safe environment related to the oxygen storage for one of two nursing unit reviewed. (First floor)

Finding Include:

Observation of the facility first floor nursing unit n March 11, 204 at 11:00 a.m. revealed that there were around 12 oxygen cylinders stored on the hallway in an open area between resident room 100 and 101. There were no signs at the door indicating of the oxygen storage.

Interview with Nursing Assistant, Employee E20 on March 13, 2024, at 1:00 p.m. stated staff stored oxygen in the hallway space between room 100 and 101. She was not aware of the facility protocol of storing the cylinder in the locked oxygen storage room.

Interview with the Nursing Home Administrator on March 13, 2024, at 1:00 p.m. confirmed that the staff stored oxygen cylinders unsafely. Administrator stated he was aware of the problem but did not implement and educate the staff about safe oxygen handling. Administrator also stated staff was expected to store oxygen cylinder in the locked room with signage of oxygen storage outside the room.

28 Pa. Code. 207.2(a) Administrator's responsibility.




 Plan of Correction - To be completed: 04/24/2024

- Corrective Action: Oxygen was moved and stored appropriately by NHA on 3/15/24
- Other Residents: All oxygen was accounted for and verified to be stored properly by DON or designee by 4/24/24
- Measures Implemented: All staff were educated on proper O2 storing by DON or designee by 4/24/24
- Monitoring: To monitor and maintain ongoing compliance, the Administrator/Designee will audit Oxygen storage weekly x4 then monthly x2 to ensure stored properly. Results of audits will be reported at QAPI meeting to ensure compliance

483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides: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.
§483.95(g) Required in-service training for nurse aides.
In-service training must-

§483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

§483.95(g)(2) Include dementia management training and resident abuse prevention training.

§483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at § 483.70(e) and may address the special needs of residents as determined by the facility staff.

§483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
Observations:

Based on a review of facility documentation and staff interview, it was determined that the facility failed to ensure its nurse aide staff was receiving in-service training to be proficient and competent and that the training be no less than 12 hours annually for five of five nurse aide staff training information reviewed (Employees E21. E22, E23, E24 and E25).

Findings Include:

A request for nurse aides annual in-service training record for nurses' aides Employee E21, E22, E23, E24 and E25 was requested on March 13, 14, and 15, 2024 to ensure compliance with compliance with requirement of no less than 12 hours annual in service.

Facility did not provide training record for the requested staff until at the end of survey.

An interview with the Nursing Home Administrator on March 15, 2024, at 12:00 p.m. confirmed that the facility did not have the in-service training record for their nurses' aides Employee E21, E22, E23, E24 and E25 and confirmed that the facility documentation did not contain evidence of that the training for E21, E22, E23, E24 and E25 met the twelve hours of annual training requirement.

28 Pa. Code 201.14(a) responsibility of licensee.




 Plan of Correction - To be completed: 04/24/2024

- Corrective Action: Staff E21, E22, E23, E24, & E25 with missing 12 hours of annual training were completed by by DON or designee by 4/24/24
- Other Residents: All STNAs files were audited for completed 12 hours of annual training on by DON or designee by 4/24/24
- Measures Implemented: Director of nursing was educated on 12 hours of annual training required for STNA by DON or designee by 4/24/24
- Monitoring: To monitor and maintain ongoing compliance, the Administrator/Designee will audit STNA required 12 hours of annual training weekly x4 then monthly x2 to ensure completion. Results of audits will be reported at QAPI meeting to ensure compliance

§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on a review of nursing schedules, staffing information provided by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 20 residents on the day shift for four of 21 days. (March 7, 8, 10, 11, 2024)

Findings Include:

Review of facility census data indicated that on March 7, 2024, the facility census was 150, which required 12.50 (150 residents divided by 12) NA's during the day shift. Review of the nursing time schedules revealed 12 NA's provided care on the day shift on March 7, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 8, 2024, the facility census was 149, which required 12.42 (149 residents divided by 12) NA's during the day shift. Review of the nursing time schedules revealed 12 NA's provided care on the day shift on March 7, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 10, 2024, the facility census was 148, which required 12.33 (148 residents divided by 12) NA's during the day shift. Review of the nursing time schedules revealed 11 NA's provided care on the day shift on March 10, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 11, 2024, the facility census was 151, which required 12.58 (158 residents divided by 12) NA's during the day shift. Review of the nursing time schedules revealed 11 NA's provided care on the day shift on March 11, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

This information during an interview with the Nursing Home Administrator and Director of Nursing Home on March 26, 2024, at 9:37 a.m.




 Plan of Correction - To be completed: 04/24/2024

Facility will ensure that all CNA staff members will meet state average staffing levels per census.

Education provided to staffing scheduler related to the staffing requirements.
Staffing requirements will be monitored by staffing scheduler daily to ensure staffing requirements are met. Results will be reported at QAPI meeting to ensure compliance


§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse per 25 residents during the day on six of 21-day shifts reviewed. (December 19, 20,21, 2023 and March 10, 11, 13, 2024)

Findings include:

Review of nursing staff care hours provided by the facility revealed the following licensed practical nurse (LPN)scheduled for the following resident census:

Day shift:

December 19, 2023, 6 LPN for a census of 154 required 6.16 LPN (FTE- 154 divided by 25)
December 20, 2023, 6 LPN for a census of 151 required 6.04 LPN (FTE- 151 divided by 25)
December 21, 2023, 6 LPN for a census of 152 required 6.08 LPN (FTE- 152 divided by 25)
March 10, 2024, 4 LPN for a census of 148 required 5.92 LPN (FTE- 148 divided by 25)
March 11, 2024, 6 LPN for a census of 151 required 6.04 LPN (FTE- 151 divided by 25)
March 13, 2024, 6 LPN for a census of 152 required 6.08 LPN (FTE- 152 divided by 25)

This information during an interview with the Nursing Home Administrator and Director of Nursing Home on March 26, 2024, at 9:37 a.m.




 Plan of Correction - To be completed: 04/24/2024

Facility will ensure that all LPN staff members will meet state average staffing levels per census.

Education provided to staffing scheduler related to the staffing requirements.
Staffing requirements will be monitored by staffing scheduler daily to ensure staffing requirements are met. Results will be reported at QAPI meeting to ensure compliance



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