Nursing Investigation Results -

Pennsylvania Department of Health
RESTORE HEALTH AT UNIVERSITY CITY
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
RESTORE HEALTH AT UNIVERSITY CITY
Inspection Results For:

There are  117 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
RESTORE HEALTH AT UNIVERSITY CITY - 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 and an Abbreviated Survey in response to a complaint, completed on May 29, 2019, it was determined that Restore Health at University City, was not in compliance with the requirements of the 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:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected 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 a review of medical records and facility documentation and interviews with staff, it was determined that the facility failed to provide the appropriate assistance to one resident while drinking a hot beverage which resulted in actual harm, related to a burn, for one of 34 residents reviewed (Resident R68).

Findings include:

Review of medical records for Resident R68 revealed diagnoses, including but not limited to, dementia (a broad category of brain diseases most notable for decline in memory and other mental abilities), absolute glaucoma (this is the end stage of all types of glaucoma where the eye has no vision) and paresis (muscular weakness caused by nerve damage or disease-a state of partial paralysis).

Further review of Resident R68's medical records revealed an Occupational Therapy (OT) discharge summary dated August 13, 2018 to August 29, 2018. The discharge summary indicated that Resident R68's baseline for self-feeding as of August 29, 2018, was contact guard assistance (there is a high probability of the resident needing assistance and the helper should have a hand on the resident but not give assistance unless needed) while trying the task herself.

Interview with the Director of Rehabilitation Services (DRS) on May 28, 2019, at 11:34 a.m. confirmed that Resident R68 was discharged from therapy on August 29, 2018, with recommendations to nursing staff which included assistance with eating and self-feeding which meant the resident required cueing (the caregiver provides verbal and tactile reminders to facilitate safe functional mobility to perform the task) and contact guard assistance. The DRS confirmed that recommendations made by the therapy department are expected to be adopted by the nursing and do not require a physician's order to implement the adaptations to care.

Review of facility documentation revealed that Resident R68 sustained a burn during a daytime activity involving a hot drink on September 11, 2018. The burn formed three fluid filled blisters along the right hip and right lateral (side) thigh measuring 34.5 cm (centimeter) by 5.4 cm, 3.5 cm by 2.0 cm and 1.7 cm by 1.5 cm.

Interview with the Director of Nursing (DON) on May 28, 2019, at 11:04 a.m. revealed that one nursing assistant poured a drink of hot tea for Resident R68 during a group activity on September 11, 2018 and continued around the table pouring hot drinks for other residents. Another nursing assistant arrived and notified the first nursing assistant that there was water on the floor under Resident R68's wheelchair and an empty hot beverage cup with the lid on, lying next to the resident's right leg in the wheelchair, along the edge of the chair.

Interview with the DON on May 29, 2019, at 11:00 a.m. confirmed that Resident R68 was left alone with a hot beverage on September 11, 2018, and that two nursing assistants found the same container between the resident's right leg and the arm of the wheelchair with a puddle of water under the wheelchair.

The facility failed to provide the appropriate level of assistance to one resident during an activity involving a hot drink that resulted in actual harm in the form of a burn.

28 Pa. Code 201.18(b)(1)(3) Management
Previously cited 06/14/18, 05/09/17

28 Pa. Code 201.18(e)(1) Management
Previously cited 06/14/18

28 Pa. Code 201.29(j) Resident rights
Previously cited 06/14/18

28 Pa Code 211.10(d) Resident care policies
Previously cited 06/14/18, 05/09/17

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 06/14/18, 05/09/17







 Plan of Correction - To be completed: 07/24/2019

1. Resident R68 was assessed and treated, the Physician and Resident Representative were notified.

2. The facility will audit the current Residents for adaptive equipment and level of assistance with meals with the dining process.

3. The Facility Educator will rein-service the staff on providing the appropriate level of assistance to residents.


4. The dining process will be audited weekly times 4 and monthly x 2 to ensure Residents have their adaptive equipment and level of assistance with meals are provided.

5. The Dining Process Audits will be reviewed in QA Meeting monthly times 3.

6. The Director of Dietary Services or Designee will be responsible for implementing acceptable POC.
483.10(g)(4)(i)-(vi) REQUIREMENT Required Notices and Contact Information:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(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 observation, interviews with residents and staff, it was determined the facility failed to post in a prominent location and in a large print easy to read format 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 Pennsylvania Department of Health Hot Line, the Long-Term Care Ombudsman Program located within the Local Area Agency on Aging, the protection and advocacy agency, the local contact agency for information about returning to the community, the Medicaid Fraud Control Unit and the local Legal Services Program to which residents may address grievances on both clinical nursing units (first-floor and second-floor).

Findings include:

Observations on May 24, 2019, at 8:32 a.m. with the Nursing Home Administrator (NHA) revealed that the information for the Pennsylvania Department of Health Hot Line was posted on the first-floor nursing unit in a very small font size high up on the notice board which was not accessible to most residents; the telephone number was not posted on the second-floor nursing unit. The NHA also revealed confirmation of the telephone number for the Long-Term Care Ombudsman Program located within the Local Area Agency on Aging telephone number, information for the local contact agency for information about returning to the community, the Medicaid Fraud Control Unit and the local Legal Services Program to which residents may address grievances were not posted on both the first-floor and second-floor clinical nursing units.

Interview on May 24, 2019, at 10:30 a.m. with a group of seven alert and oriented (as identified by a facility employee) Resident Council residents who provided representation from both clinical nursing units revealed that all seven residents did not know how to file a grievance or know the location of information for the Pennsylvania Department of Health Hot Line, the telephone number of the Long-Term Care Ombudsman Program located within the Local Area Agency on Aging and the telephone number of the local Legal Services Program to which residents may address grievances.

The facility failed to post in a prominent location and in a large print easy to read format 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 Pennsylvania Department of Health Hot Line, the Long-Term Care Ombudsman Program located within the Local Area Agency on Aging, the protection and advocacy agency, the local contact agency for information about returning to the community, the Medicaid Fraud Control Unit and the local Legal Services Program to which residents may address grievances.

42 CFR 483.10(g)(4) Required Notices and Contact Information
Previously cited 06/14/18

28 Pa. Code 201.18(a) Management
Previously cited 06/14/18, 05/09/17

28 Pa. Code 201.18(b)(1)(3) Management
Previously cited 06/14/18, 05/09/17

28 Pa. Code 201.18(e)(1) Management
Previously cited 06/14/18

28 Pa. Code 201.29(a) Resident rights
Previously cited 06/14/18

28 Pa. Code 201.29(b) Resident rights

28 Pa. Code 201.29(d) Resident rights
Previously cited 06/14/18

28 Pa. Code 201.29(i) Resident rights
Previously cited 06/14/18

28 Pa. Code 201.29(j) Resident rights
Previously cited 06/14/18



 Plan of Correction - To be completed: 07/24/2019

1. The facility posted in prominent locations and in a large print easy to read format 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 Pennsylvania Department of Health Hot Line, the Long-Term Care Ombudsman Program located within the Local Area Agency on Aging, the protection and advocacy agency, the local contact agency for information about returning to the community, the Medicaid Fraud Control Unit and the local Legal Services Program to which residents may address grievances, on the first-floor and second-floor clinical nursing units.

2. The facility informed Resident's at Resident Council Meeting, the facility posted in a prominent locations and in a large print easy to read format 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 Pennsylvania Department of Health Hot Line, the Long-Term Care Ombudsman Program located within the Local Area Agency on Aging, the protection and advocacy agency, the local contact agency for information about returning to the community, the Medicaid Fraud Control Unit and the local Legal Services Program to which residents may address grievances, on the first-floor and second-floor clinical nursing units.

3. An audit will be completed weekly times 4 and monthly times 3 by the Director of Maintenance or Designee to ensure postings are present.

4. The Required Notices and Contact Information will be review in QA Meeting monthly times 3.

5. The Director of Maintenance or Designee will be responsible for implementing acceptable POC.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:

Based on observations and interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly.

Finding include:

Initial tour of the Food Service Department conducted on May 23, 2019 at 8:25 a.m. with Employee E3, Food Service Director (FSD), revealed the following:

Observations in the loading dock and receiving area revealed a dumpster for recycling cardboard with the top lid open, the ground around the dumpsters was littered with debris including paper and plastic refuse along with and old linen steamer, a dunnage rack, a lobby style dust pan and milk crates all scattered around the dumpsters.

Observations of the biohazard storage area revealed biohazard labeled cardboard boxes with the lids open haphazardly stacked leaning against the biohazard storage shed.

During the tour of the dumpster and receiving area the double entry doors were both propped open with no one in the area to monitor for the entrance of unauthorized people or unwanted pests.

Interview with FSD at 8:35 a.m. on May 23, 2019 confirmed the above findings.

The facility failed to maintain the outside dumpster area in a safe and sanitary condition.

28 Pa. Code 201.18(b)(3) Management
Previously cited: 06/14/18, 05/09/17, 11/17/16

28 Pa. Code 207.2(a) Administrator's responsibility
Previously cited: 05/09/17



 Plan of Correction - To be completed: 07/24/2019

1. The loading dock and receiving area were cleared of refuse and debris, also the dumpster lid was closed.

2. The biohazard labeled cardboard boxes were removed and the storage shed is properly secured.

3. The double entry doors were closed.

4. The Facility Educator or Designee will rein-service the staff on properly disposing garbage and refuse.

5. The facility will perform dietary audits to ensure the proper garbage and refuse disposal weekly times 4 and monthly times 2.
6. The Dietary Audits will be reviewed in QA Meeting monthly times 3.

7. The Unit Manager or Designee will be responsible for implementing acceptable POC.


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on observation, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Findings include:

Review of an undated policy, "Food Safety and Sanitation" stated, The Food and Nutrition Department will follow the regulations of the official health agencies with jurisdiction over the facility. The undated "Sanitation of Dishes/Dish Machine" Policy had a chart which listed the acceptable level for sanitation on a low temperature dish machine using chemicals to sanitize was 50 PPM (parts per million).

Initial tour of the Food Service Department conducted on May 23, 2019 at 8:25 a.m. with Employee E3, Food Service Director (FSD), revealed the following:

Observations in the loading dock and receiving area revealed a dumpster for recycling cardboard with the top lid open, the ground around the dumpsters was littered with debris including paper and plastic refuse along with and old linen steamer, a dunnage rack, a lobby style dust pan and milk crates all scattered around the dumpsters. During the tour of the receiving area the double entry doors were both propped open with no one in the area to monitor for the entrance of unauthorized people or unwanted pests.

Observations in the refrigerator revealed yellow pastries plated on small Styrofoam plates covered with plastic wrap with a note saying lemon bars. Interview with FSD on May 23, 2019 at 8:25 a.m. confirmed that the lemon bars were for the lunch meal and were plated on disposable plates because they were waiting on a delivery of china.

Observation of the stacked convection ovens revealed a heavy build-up of black baked on food debris and grime on the inside surfaces of the ovens especially on the bottom surfaces, the ovens under the stove cooktops were similarly soiled.

Observation of the refrigerator revealed an open bottle of water with "Cindy" written on the lid.

Interview with FSD at 8:35 a.m. on May 23, 2019 confirmed the above findings.

A follow-up tour of the kitchen was conducted on May 24, 2019 at 8:20 a.m. included an observation of the breakfast tray line which revealed that the hot cereal was being placed in disposable Styrofoam bowls with disposable lids. Interview with FSD on May 23, 2019 at 8:35 a.m. confirmed that disposable bowls are used when they run out of regular insulated bowls and that they still had more than four carts to load.

Additional observations on the follow-up tour in the kitchen area revealed four trash cans (two near tray line, one near pot and pan area and one near the dish room) with no lid open to the air.

Continued observations on the follow-up tour in the pot and pan area revealed the sanitizer in the third sink, when asked to test the sanitizer concentration the FSD used a test strip that was out of the container and had no color chart to compare the results, and when asked what the level was he compared it to a sign on the wall which explains how the sanitizer works, and said the level was 500 parts per million. The same sign indicated that the acceptable level was 150-400 ppm for EcoLab Oasis 146 Sanitizer.

Further observations on the follow-up tour in the dish room revealed a two-tank conveyor type dish machine set up for chemical sanitizer. When the sanitizer level was tested with a test strip the level was 25 ppm chlorine. Interview with FSD, on May 23, 2019 at 8:40 a.m. prior to the test revealed that when asked what the acceptable level of chlorine was, he replied 100 ppm, and when the test strip level was 25 ppm he stated he had to contact EcoLab to check the machine and sanitizing equipment.

Interview with FSD and the EcoLab Representative, on May 28, 2019 at 2:05 p.m. confirmed that the EcoLab rep had repaired the dish machine's chemical squeeze tubes which deliver the chlorine to the dish machine and is now reaching an acceptable level between 50 and 100 PPM, confirming that anything over 100 PPM was not acceptable. When the rep was asked about the acceptable level of Oasis 146, a quaternary ammonium sanitizer, he confirmed the 150 - 400 PPM posted on the sign above the pot sink, and he stated that anything over 400 PPM was not good.

The facility failed to store, prepare and serve food in accordance with professional standards for food service safety.


28 Pa. Code: 2014(a) Responsibility of licensee
Previously cited 06/14/18, 05/09/17, 11/17/16.

28 Pa. Code: 201.18(b)(3) Management
Previously cited 06/14/18

28 Pa. Code: 207.2(a) Administrator's responsibility
Previously cited 05/09/17




 Plan of Correction - To be completed: 07/24/2019


1. The facility updated it's "Sanitation of Dishes/Dish Machine" Policy.

2. The loading dock and receiving area were cleared of refuse and debris, also the dumpster lid was closed.

3. The delivery of china has been received.

4. The double entry doors were closed.
5. The yellow pastries plated on small Styrofoam plates covered with plastic wrap with a note saying lemon bars were removed.

6. The stacked convection ovens were cleaned.

7. The ovens under the stove cooktops were cleaned.

8. The open bottle of water with "Cindy" written on the lid was discarded.

9. The bowls were ordered and received.

10. The four trash cans (two near tray line, one near pot and pan area and one near the dish room) have lids.

11. Resident R31 did not experience an adverse reaction as a result of being served a slice of white bread with her meal.

12. The Facility Educator or Designee will rein-service the staff on serving the menu items on the posted menu, ensuring residents are receiving their food preferences and providing foods conforming to the resident's diet order.

13. The facility performs dietary audits to ensure the facility is serving the menu items on the posted menu, ensuring residents are receiving their food preferences and providing foods conforming to the resident's diet order weekly times 4 and monthly times 2.

14. The Dietary Audits will be reviewed in QA Meeting monthly times 3.

15. The Food Service Director or Designee will be responsible for implementing acceptable POC.


483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e)

This includes:
483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who-
(i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is:
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.
Observations:

Based on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services and a qualified dietitian of seven personnel records reviewed (Employees E3 and E4).

Findings include:

During the initial tour of the food and nutrition services department on May 23, 2019, at 8:25 a.m., the Food Service Director (FSD) stated that his responsibilities included oversight of ordering, receiving, storing, preparation and service of food.

An interview on May 28, 2019, at 10:40 a.m. with the Employee E4, Dietitian, confirmed that she was RD Eligible, having completed her Dietetics degree and her Internship, but had not taken the RD (Registered Dietitian) Exam and was not a Registered Dietitian with the Commission on Dietetic Registration. A review of Employee E4's personnel records revealed that she did have a bachelor's degree granted by a regionally accredited university, and that she had completed her supervised practice by completing an accredited dietetic internship, but there was no evidence of her being a licensed or registered dietitian.

An interview on May 28, 2019, at 11:10 a.m. with the Employee E3, Food Service Director (FSD), confirmed that he was not a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; or had an associate's or higher degree in food service management or hospitality from an accredited institution; and that he had not received frequently scheduled consultations from a qualified dietitian.

An interview on May 29, 2019, at 1:45 p.m. with the Employee E1, Nursing Home Administrator (NHA), confirmed that he understood that neither Employee E3 (FSD) or Employee E4 (Dietitian) possessed the regulatory required qualifications for their positions.

The NHA was unable to provide evidence that the FSD was receiving frequently scheduled consultation from a qualified dietitian to ensure that adequate guidance was provided to the FSD and staff of the dietary department.

Refer to F806, F810, F812, F814

28 Pa. Code 211.6 (c)(d) Dietary services



 Plan of Correction - To be completed: 07/24/2019

1. Food Service Director is registered for Food Service Director Certification.

2. The facility secured contract with a Registered Dietician to start consultative services effective 7/24/2019.

3. An audit of Consultant Registered Dietician Services will be completed by Nursing Home Administrator or Designee monthly.

4. Re-education with facility Dietician and Food Service Director on Regulatory Requirement of F801 by 7/24/2019.

5. Nursing Home Administrator will be responsible for ensuring the Registered Dietician Consultant provides services to the facility until the Food Service Director is certified.


483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

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

Based on observations and interviews with staff, it was determined that the facility failed to maintain resident rooms and bathrooms in a homelike condition on two of two clinical nursing care units (first-floor unit and second-floor unit).

Findings include:

Observation of the end-portion of the second-floor nursing unit main clinical care hallway on May 23, 2019, at 8:41 a.m. revealed four mattresses stored directly on the floor.

Observation of the bathroom sink/basin in Room 251 on the second-floor on May 23, 2019, at 8:44 a.m. revealed the sink/basin was well attached to the section of wall it was screwed to, but that section of wall had detached from the main portion of wall, causing the sink/basin to be angled downwards and wobble when touched.

Interview with Employee E12, Nursing Assistant (NA), on May 23, 2019, at 8:45 a.m. confirmed that the bathroom sink/basin in Room 251 was wobbly.

Observations in Room 167 on the first-floor at 9:00 a.m. on May 23, 2019, during initial screening of residents, revealed that the wall on the right side as you enter the room was all scraped with the paint coming off revealing the white center of the wall board and black scuff marks and in the bathroom, there were two dirty basins stacked on top of sink, so the sink was not accessible.

Further observations on May 23, 2019, during initial screening of residents, in room 177 revealed a hole in the wall behind the door where the handle meets the wall and the area behind the toilet in the bathroom was not painted and had the bare wall board exposed.

An interview with Resident R82 on May 23, 2019, during initial screening of residents, in room 177 revealed that the hole in the wall and the unpainted wall behind the toilet had been like that since he was admitted in January.

Observation in Room 254 on the second-floor unit on May 23, 2019, at 9:02 a.m. revealed no trash can in the room or bathroom and the toilet was constantly running.

Observation in Rooms 256 and 258 on the second-floor unit on May 23, 2019, at 9:23 a.m. revealed no arm chairs in the rooms.

Interview with the Director of Maintenance on May 29, 2019, at 11:01 a.m. in Room 254 confirmed that the toilet was constantly running.

Observation in Room 255 on the second-floor on May 28, 2019, at 9:45 a.m. revealed the window was open about two feet.

Interview with Employee E16, Registered Nurse and Nurse Manager, on May 28, 2019, at 9:47 a.m. revealed confirmation that the window in Room 255 was open too far and the device that prevented the window from opening fully had been removed.

The facility failed to maintain a homelike environment for the residents.

42 CFR 483.10(i) Safe/Clean/Comfortable/Homelike Environment
Previously cited 9/18/18, 5/9/17

28 Pa. Code 207.2(a) Administrator's responsibility
Previously cited: 5/9/17



 Plan of Correction - To be completed: 07/24/2019


1. The four mattresses stored directly on the floor, on the second-floor nursing unit main clinical care hallway have been removed.

2. The bathroom sink/basin and wall in Room 251 on the second-floor has been repaired.

3. The wall in Room 167 has been repaired and the basins were removed.

4. The wall behind the door in Room 177 has been repaired, the unpainted wall behind the toilet has been painted.

5. In Room 254 on the second-floor unit, a trash can has been provided and the toilet was repaired.

6. Rooms 256 and 258 on the second-floor unit have been provided with arm chairs.

7. The window in Room 255 on the second-floor was repaired to only open up to 4 inches.

8. The Staff Educator will rein-service the staff on maintenance rounds.

9. The Maintenance Department will audit resident rooms and bathrooms to monitor for and ensure a Safe/Clean/Comfortable/Homelike Environment.

10. The Maintenance Audit will be reviewed by the IDT Team weekly x4 and monthly x2.

11. The Maintenance Audit will be reviewed in QA meeting monthly times 3

12. The Director of Maintenance or Designee will be responsible for implementing acceptable POC.


483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes: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(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;
Observations:

Based on observation, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to serve the food items as posted on the menu for several meals, failed to ensure residents were receiving their food preferences and failed to provided food conforming to the residents' diet order for three of 34 residents reviewed (Residents R31, R59 and R106).

Findings include:

Interview with a group of seven alert and oriented residents as identified by the Director of Rehabilitation Services (DRS) on May 24, 2019, at 10:30 a.m. revealed that residents do not always receive food from the menu that is posted and do not always receive their specific food preferences.

Observation in the second-floor dining room on May 23, 2019, at 12:19 p.m. revealed Resident R106 with a meal ticket that read, "no concentrated sweets", but was served a full sugar fruit punch drink containing high fructose corn syrup. Resident R31's meal ticket read, "dislikes: white bread", and was served a slice of white bread with her meal. Resident R59's meal ticket read, "honey liquids", referring to the consistency of fluids but was served regular consistency hot tea.

Observation in the first-floor dining room on May 23, 2019, at approximately 12:30 p.m., revealed residents being served corn, bread and lemon bars while the menu posted in the dining room called for baby carrots, wheat rolls and toffee bars.

Observation of the first-floor dining room on May 24, 2019, at approximately 8:40 a.m., revealed residents being served pancakes when the menu posted in the dining room called for waffles.

Interview with Employee E3, Food Service Director, on May 24, 2019, at approximately 8:45 a.m. confirmed that the above menu changes were due to not having the posted food items and substitutions were made. No evidence was available to review that the menu changes were approved or reviewed by a qualified dietitian.

The facility failed to serve the menu items on the posted menu for several observed meals, and the facility failed to ensure residents were receiving their food preferences, and the facility failed to provided food conforming to their diet order.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited: 06/14/18, 05/09/17, 11/17/16

28 Pa. Code 201.29(j) Resident rights
Previously cited: 06/14/18, 04/21/16

28 Pa. Code 211.6(c) Dietary services



 Plan of Correction - To be completed: 07/24/2019

1. Resident R106 did not experience an adverse reaction as a result of being served a full sugar fruit punch drink.

2. Resident R31 did not experience an adverse reaction as a result of being served a slice of white bread with her meal.

3. The Facility Educator or Designee will rein-service the staff on serving the menu items on the posted menu, ensuring residents are receiving their food preferences and providing foods conforming to the resident's diet order.

4. The facility will perform dietary audits to ensure the facility is serving the menu items on the posted menu, ensuring residents are receiving their food preferences and providing foods conforming to the resident's diet order weekly times 4 and monthly times 2.

5. The Dietary Audits will be reviewed in QA Meeting monthly times 3.

6. The Food Service Director or Designee will be responsible for implementing acceptable POC.


483.21(b)(1) 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.
Observations:

Based on a review of clinical records, facility policy and procedures and staff interviews, it was determined that the facility failed to develop comprehensive person-centered care plans regarding medications (Resident R33), respiratory equipment (Resident R5 and R113), Wanderguard devices (Resident R80) and failed to implement a care plan related to fall prevention (Resident R23) for five of 34 residents reviewed.

Findings include:

Review of facility policy, "Care Planning," dated April 2019, revealed that "A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident." Continued review revealed "The care plan interventions are derived from a thorough analysis of the information gathered as part of the resident's comprehensive assessment... The comprehensive, person-centered care plan will include measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, [and] incorporate identified problem areas ... Identify problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process."

A review of Resident R33's clinical record revealed that the resident was admitted to the facility on January 17, 2019, with a diagnosis including, but not limited to, bipolar mood disorder ( a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), seizures, anxiety, depression, agitation and delirium (serious disturbance in mental abilities that results in confused thinking and reduced awareness of surrounding).
Further review revealed that the resident was moderately impaired in decision making skills. The resident could self-propel in the wheelchair on the nursing unit.

A review of physician orders dated March 6, 2019, revealed an order for Quetiapine (an antipsychotic medication used to treat schizophrenia, bipolar disorder and depression) 100 milligrams, by mouth every night at bedtime and Quetiapine 50 milligrams, one tablet by mouth every morning also ordered on March 6, 2019. The potential long-term side effects of Quetiapine, which can include tardive dyskinesia (a condition caused by long term use of antipsychotic medication, symptoms include: repetitive, involuntary movements, usually the smacking of the lips, and blinking the eyes fast), increased blood sugar, and weight gain

A review of care plans for Resident R33, revealed no comprehensive, person center care plan had been developed related to the use of an antipsychotic medication Quetiapine.

Interview with the second floor nursing manager on May 29, 2019, at 8:35 a.m. confirmed that the resident did not have a comprehensive care plan developed for the use of an antipsychotic medication.

A review of Resident R5's clinical record revealed that the resident was admitted to the facility on August 21, 2018, with diagnoses, including but not limited to, acute respiratory tract infection and lung abscess due to Hemophilus influenza (bacteria that is capable of spreading from the nasal tissues and upper airway, where it is usually found, to the chest).

Review of Resident R5's physician orders dated January 31, 2018, revealed orders to apply CPAP (Continuous Positive Airway Pressure- respiratory device used to treat sleep apnea)at bedtime and remove in the morning, with settings 6-20 CM attached to oxygen at 2 liters per minute (O2 at 2 L/min).

Review of Resident R5's care plan revealed no indication that the resident had a CPAP machine, nor any interventions related to the care and maintenance of a CPAP machine.

Interview on May 28, 2019, at 10:45 a.m., Employee E7, ADON (Assistant Director of Nursing), confirmed that there was nothing in Resident R5's care plan to indicate that the resident had a CPAP machine.

A review of Resident R113's clinical record revealed that the resident was admitted to the facility on August 21, 2018, with a diagnosis, including but not limited to, chronic obstructive pulmonary disease (COPD - involving constriction of the airways and difficulty or discomfort in breathing).

Review of physician orders for Resident R113 revealed orders dated March 8, 2019, to apply BI-PAP at bedtime and remove in the morning, with settings 15/5, without oxygen, if resident cannot tolerate use without oxygen, use oxygen at 2 liters per minute (O2 at 2 L/min).

Review of Resident R113's care plan revealed that there was no indication that the resident had a BI-PAP (Bilevel Plosive airway pressure-respiratory device ) machine, nor any interventions related to the care and maintenance of a BI-PAP machine.

Interview on May 28, 2019, at 11:05 a.m., Employee E7, ADON (Assistant Director of Nursing), confirmed that there was nothing in Resident R113's care plan to indicate that the resident had a BI-PAP machine.

Interview with a group of alert and oriented residents as selected by the Director of Recreation on May 24, 2019, at 10:30 a.m. revealed that Resident R80 had received a Wanderguard (device designed to trigger an alarm if the person wearing the device moves outside a defined area) device after he expressed interest in going to a convenience store across the street to buy snacks.

Observation of Resident R80 on May 24, 2019, at 10:30 a.m. and 12:45 p.m. and May 29, 2019, at 9:39 a.m. revealed the resident was wearing a Wanderguard bracelet.

Review of medical records for Resident R80 revealed no comprehensive person-centered care plans related to the wandering prevention device and elopement.

Interview with the Director of Nursing on May 24, 2019, at 12:30 p.m. revealed confirmation that Resident R80 did not have a person-centered care plan related to wandering or eloping.

Review of medical records for Resident R23 revealed the resident was non-verbal due to having a tracheostomy (a surgically created hole in your trachea that allows for breathing).

Review of medical records for Resident R23 revealed a care plan for the resident being at a high risk of falling with an intervention to ensure the bed was always left in the lowest and locked position when care was not being provided to the resident.

Observation of Resident R23 on May 28, 2019, at 9:40 a.m. revealed the resident lying in bed, unattended, with the bed in the highest locked position possible. The resident's call light button was out of reach and the resident was unable to call for assistance verbally due to having a tracheostomy to have the bed lowered.

Interview with Employee E18, Nursing Assistant (NA), on May 28, 2019, at 9:41 a.m. revealed confirmation that Resident R23's bed was in a high locked position.

The facility failed to develop comprehensive person-centered care plans regarding antipsychotic medications, CPAP, BI-PAP, Wanderguards and failed to implement a care plan related to fall prevention.

28 Pa. Code 211.11(d) Resident care plan

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 06/14/18, 05/09/17




 Plan of Correction - To be completed: 07/24/2019


1. R33 has a comprehensive, person center care plan related to the use of an antipsychotic medication Quetiapine.

2. R5's care plan includes the resident's CPAP machine including its care and maintenance.

3. R113's care plan includes the indication for a BI-PAP (Bilevel Plosive airway pressure-respiratory device) machine, with interventions related to its care and maintenance.


4. R80 has a person-centered care plan related to wandering or eloping.

5. R23 has a person-centered care plan related to falls.

6. The Facility Educator or Designee will rein-service the staff on comprehensive person-centered care plans regarding antipsychotic medications, CPAP, BI-PAP, Wander Guards and fall prevention.

7. The facility will audit current Residents for comprehensive person-centered care plans regarding antipsychotic medications, CPAP, BI-PAP, Wander Guards and fall prevention weekly x4 and monthly x2.

8. The Care Plan Audits will be reviewed in QA Meeting monthly times 3.

9. The Unit Manager or Designee will be responsible for implementing acceptable POC.



483.21(a)(1)-(3) REQUIREMENT Baseline 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 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

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

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

Based on observations, interviews with residents and staff, review of facility policies and clinical records, it was determined that the facility failed to develop a baseline care plan related to a midline intravenous catheter for one resident (Resident R114), a peripherally inserted central catheter for another resident (Resident R16) and nutrition for a resident (Resident R44) for three of 34 residents reviewed.

Findings include:

Review of the facility policy, "Baseline Care Plan," dated April 2019, revealed, "To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission."

Clinical record review revealed that Resident R114 was admitted to the facility on February 11, 2019, with diagnoses including, but not limited to, cerebral vascular accident (CVA - a bleed on the brain or blockage of oxygenating blood in the brain causing death of brain tissue) and sepsis (infection of the blood stream).

Review of progress notes dated February 12, 2019, at 7:15 a.m. revealed that on admission, Resident R114 had a right upper extremity (right arm) midline IV (a hollow plastic tube inserted into the vein that is used to deliver antibiotics throughout the body).

Review of Resident R114's care plans dated February 11, 2019, revealed no baseline care plan was developed within the first 48-hours after admission for the care and maintenance of the midline IV.

Interview with the Director of Nursing on May 29, 2019, at 11:25 a.m. revealed confirmation that Resident R114 did not have a baseline care plan for a midline IV within 48-hours of her initial admission to the facility.

Interview with Resident R44 on May 23, 2019, at 10:26 a.m. revealed the resident felt as though the facility did not understand his dietary restrictions because within the first two-days of his admission to the facility, the facility served him meat-based products when he was a staunch vegetarian. The resident stated that he had informed the facility immediately that he eats a lot of fish but no other meat-based products.

Observation and interview with Resident R114 on May 23, 2019, at lunchtime revealed a notation printed on the meal ticket that read, "no fish". The resident confirmed this was incorrect and he loved fish. The resident also confirmed this problem had existed since he was first admitted to the facility and it was a mistake.

Review of medical records for Resident R44 revealed he was admitted to the facility on May 15, 2019, and the facility did not create a baseline care plan related to nutrition or food preferences for the resident within 48-hours of admission to the facility.

Review of physician orders for Resident R16 revealed orders dated May 8, 2019, to measure the external catheter length of the resident's PICC line (a PICC line - peripherally inserted central catheter - a thin soft tube inserted in a vein in the arm with the tip of the tube positioned in a large vein that carries blood to the heart) with each dressing change and as needed. Continued review revealed another order, dated May 23, 2019, to contact an outside infusion company for supplies and information regarding the resident's infusion services.

Interview on May 28, 2019, at 10:57 a.m., Resident R16 stated that an outside infusion company performs his daily infusions through his PICC line and that the nurses at the facility only flush the PICC line. Observation, at the time of the interview, revealed that the resident had an access device for infusions on his left chest.

Review of Resident R16's care plan revealed that no indication that the resident had a PICC line or any interventions developed related to the care and maintenance of the PICC line.

Interview on May 29, 2019, at 11:00 a.m., Employee E6, Unit Manager, confirmed that there was nothing in Resident R16's care plan to indicate that the resident had a PICC line, that he received daily infusions from an outside infusion company, or how facility staff are supposed to manage the resident's PICC line.

The facility failed to develop baseline care plans that included the instructions needed to provide effective and person-centered care that met professional standards of quality care.

28 Pa. Code 211.11(d) Resident care plan



 Plan of Correction - To be completed: 07/24/2019


1. Resident R114 no longer resides at the facility.

2. Resident R44 has a baseline care plan.

3. The Facility Educator or Designee will rein-service the staff on Baseline Care Plans that include the instructions needed to provide effective and person-centered care that meets professional standards of quality care.

4. The facility will audit the current Residents for Baseline Care Plans.

5. The Care Plan Audits will be reviewed weekly x4 and monthly x2 by the Interdisciplinary Team.

6. Upon admission care plans will be reviewed to ensure baseline care plans are in place.

7. The Care Plan Audits will be reviewed in QA Meeting monthly times 3.

8. The Unit Manager or Designee will be responsible for implementing acceptable POC.


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

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

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

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

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

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

Based on observations, a review of facility documentation and policies, and interviews with staff and residents, it was determined that the facility did not ensure voting rights for three of 34 residents reviewed (Residents R17, R22 and R28), did not ensure dignity for residents related to feeding and dining for one of two dining rooms (first-floor dining room) and did not ensure that residents had the right to self-determination related to the use of Wanderguards for one of 34 resident reviewed (Resident R80).

Findings include:

Review of a facility policy titled, "Voting," dated January 2019, revealed that "The center strongly respects the voting rights of each resident and supports the residents in the effort to vote in local and national elections. The center provides the opportunity for residents to vote in their polling station or by completing an absentee or provisional ballot." Further, the policy revealed, "The resident will be asked to if they wanted to vote."

Review of the census report provided by the Director of Recreation revealed that all residents as of April 29, 2019, had either a handwritten "NA", "Refused", a check mark or "Not Registered" next to their name. The report showed Resident R17 as "NA", Resident R22 as "Not Registered" and Resident R28 as "Refused".

Interview with the Director of Recreation on May 28, 2019, at 11:30 a.m. revealed as stated that "NA" meant either not available to vote or not able to vote based on his determination of the Brief Interview for Mental Status (BIMS - a brief screening tool that aids in detecting cognitive impairment) score of the resident and his impression of their cognitive level and ability to understand the voting process.

Interviews with Residents R17, R22 and R28 on May 28, 2019, at 10:00 a.m. revealed that Resident R17 wanted to vote but was not asked if he wanted an absentee ballot, Resident R22 was not asked if he wanted an absentee ballot and Resident R28 wanted to vote and did not refuse the absentee ballot.

The facility failed to ensure voting rights for residents.

Dining observations in the first-floor dining room on May 23, 2019, at 12:30 p.m. revealed that Employee E8, Restorative Nursing Assistant, was feeding two residents at the same time, one resident on each side of her. Further observation revealed that Employee E8 placed the plate for the resident to her left in front of her while she fed the male resident. When the DON asked her why she had the plate in front of herself, she said that the resident would "dig" into the food on the plate.

Further dining observations in the first-floor dining room on May 23, 2019, at 12:30 p.m. revealed that residents were served cold beverages and water in disposable plastic cups and the dessert, lemon bars, were served on disposable Styrofoam plates.

Dining observations on May 24, 2019, at 8:30 a.m. in the first-floor dining room revealed that residents were served hot cereal in disposable Styrofoam bowls and cold beverages in disposable plastic cups.

Interview with the DON on May 28, 2019, at 2:15 p.m. confirmed the dining observations.

The facility failed to ensure dignity for residents related to feeding and dining.

Review of facility policy, "Wanderguard/Watchmate (a device that triggers an alarm to prevent a resident from leaving an area) Policy," dated January 2019, revealed that "Once a resident has been identified at risk for elopement (the act leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment), as per Elopement Assessment form, a Wanderguard/Watchmate will be obtained and placed on the resident ... The responsible representative and the resident physician will be notified a Wanderguard/Watchmate is in use."

Interview with a group of alert and oriented residents as selected by the Director of Recreation on May 24, 2019, at 10:30 a.m. revealed that Resident R80 had received a Wanderguard (device designed to trigger an alarm if the person wearing the device moves outside a defined area) device after he expressed interest in going to a convenience store across the street to buy snacks. Further interview with Resident R80 revealed that he expressed concern that he had to wear the wanderguard device.

Review of medical records for Resident R80 revealed a BIMS score of 15 which indicated that the resident was cognitively intact and able to make his own decisions.

Observation of Resident R80 on May 24, 2019, at 10:30 a.m. and 12:45 p.m. and May 29, 2019, at 9:39 a.m. revealed the resident was wearing a Wanderguard bracelet.

A request for elopement and/or wander risk assessments for Resident R80 to the Nursing Home Administrator and Director of Nursing on May 24, 2019, at 12:50 p.m. was not fulfilled. In the paper and electronic medical record that was accessible for review, there was no observable elopement and/or wander risk assessment for Resident R80.

Review of physician orders for Resident R80 revealed an order for Wanderguard that was discontinued on May 24, 2019, at 12:00 p.m. Further review of physician orders revealed a new order for Wanderguard starting May 27, 2019, at 10:00 p.m.

Interview with Resident R80 on May 29, 2019, at 9:39 a.m. revealed the resident had continued to wear the Wanderguard bracelet over the weekend, even when there was no physician order to wear it and he did not know why he had to wear it.

The facility failed to ensure that residents had the right to a dignified existence and self-determination related to the use of Wanderguards.

42 CFR 483.10(a)(1) Resident Rights/Exercise of Rights
Previously cited 06/14/18

28 Pa. Code 201.29(a) Resident rights
Previously cited 06/14/18

28 Pa. Code 201.29(d) Resident rights
Previously cited 06/14/18

28 Pa. Code 201.29(j) Resident rights
Previously cited 06/14/18



 Plan of Correction - To be completed: 07/24/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations, the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the
center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated.


1. Residents R17, R22 and R28 were provided information on voting.

2. The Staff Educator will rein-service the TR staff on voting rights and the voting process.

3. The Director of Recreation or Designee will complete facility wide audit to identify residents who are interested in voting.

4. Residents who are interested in voting and are not yet registered will complete a voter registration application with the assistance from TR staff. An audit of Resident's BIMS will be completed to identify Residents with a BIMS of 10-15.

5. Residents with a BIMS of 10-15, who are interested in voting and are not yet registered will complete a voter registration application with assistance from TR staff.


6. The Director of Recreation or Designee or designee will verify voter registration status for Residents who expressed interest in voting and or have a BIMS of 10-15 using the PA Department of State voter database.

7. The Director of Recreation or Designee will maintain proof of registration for current Residents with an active voter registration in a binder in the recreation office. Copy of completed applications will be kept in a binder in the recreation office.

8. The Director of Recreation or Designee will be responsible for implementing acceptable POC.



1. There were no negative outcomes to Residents regarding the food plates being placed in front of E8 or being served cold beverages and water in disposable plastic cups and the dessert, lemon bars, were served on disposable Styrofoam plates and hot cereal in disposable Styrofoam bowls.

2. The Facility Educator or Designee will in-service the staff on placing the Resident's meals in front of them, serving beverages, food and snacks with dishware.

3. The dining process will be audited weekly x 4, monthly x2, to ensure Resident's meals are being placed in front of them and beverages, food and snacks are being served with dishware.

4. The Dining Process Audits will be reviewed in QA Meeting monthly times 3.

5. The Director of Dietary Services or Designee will be responsible for implementing acceptable POC.









1. An elopement assessment was conducted on Resident R80 and he was provided a Wander Guard.

2. The Resident Representative and Physician were notified.

3. The Staff Educator will in-service the staff on the Wander Guard process.

4. The facility will audit Residents with Wander Guards to ensure an Elopement Risk Assessment was performed, The Physician and Resident Representative were notified, a Physician's order for the Wander Guard was obtained and the Wander Guard was care planned.

5. The Wander Guard Audit will be reviewed by the IDT Team weekly x4 and monthly x 2.

6. The Wander Guard Audit will be reviewed in QA meeting monthly times 3

7. The Unit Manager or Designee will be responsible for implementing acceptable POC.





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 interviews with staff and resident representatives , review of facility policies and clinical records, it was determined that the facility failed to provide a resident's representative the opportunity to choose a treatment option related to a Wanderguard device for one of 34 residents reviewed (Resident R265).

Findings include:

Review of facility policy, "Wanderguard/Watchmate (a device that triggers an alarm to prevent a resident from leaving an area) Policy," dated January 2019, revealed that "Once a resident has been identified at risk for elopement (the act leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment), as per Elopement Assessment form, a Wanderguard/Watchmate will be obtained and placed on the resident ... The responsible representative and the resident physician will be notified a Wanderguard/Watchmate is in use."

Interview on May 23, 2019, at 9:43 a.m., with Resident R265's Representative revealed that on May 22, 2019, the resident had tried to leave the facility and that the resident was irrational, agitated and combative. Resident R265's Representative stated that she wanted the resident's behaviors to be evaluated by a physician.

Clinical record review for Resident R265 revealed a nursing progress note dated May 22, 2019, 6:50 a.m. which indicated that the resident was in bed until 5:45 a.m., at which time he came out of his room to the hallway with his rolling walker and his belongings and was noted to be looking for an exit to go home.

Continued record review revealed an additional nursing progress note dated May 22, 2019, at 7:46 a.m. which stated that the resident "was seen in the dining room eating breakfast, wander guard activated and placed on right ankle." Further record review revealed a nursing progress note dated May 23, 2019, at 2:00 p.m. which stated that "called in to residents room by his wife, who alerted me that the resident had removed his device off of his leg... I spotted the base of the Wanderguard on the dresser. I asked the resident if he could hold the piece in his pocket. Resident asked for me to hold the piece. I told him and his wife that I would leave it in his wheelchair pocket."

Interview on May 24, 2019, at 11:27 a.m., with Employee E6, Unit Manager, and Employee E7, Assistant Director of Nursing, confirmed that there was no documentation available in the clinical record that the resident's representative was informed of treatment options related to Resident R265's exit seeking behavior and that the Wanderguard device had been placed on the resident.

Follow up interview on May 29, 2019, at 11:47 a.m., with Resident R265's Representative confirmed that she was never informed by the facility that the Wanderguard device had been placed on the resident and stated that she became aware of the device when the resident broke it off from his leg. Resident R265's Representative also stated that the facility never discussed with her other treatment options available to manage the resident's behaviors.

The facility failed to inform a resident's representative that a Wanderguard had been placed on a resident and failed to inform the representative of available treatment options to manage the resident's behaviors.

28 Pa. Code 201.29(d) Resident rights
Previously cited 06/14/18

28 Pa. Code 201.29(j) Resident rights
Previously cited 06/14/18



 Plan of Correction - To be completed: 07/24/2019

1. Resident R265 no longer resides at the facility.

2. The Staff Educator will rein-service the staff on the Wander Guard process.


3. The facility will audit Residents with Wander Guards to ensure an Elopement Risk Assessment was performed, The Physician and Resident Representative were notified, a Physician's order for the Wander Guard was obtained and the Wander Guard was care planned.

4. The Wander Guard Audit will be reviewed by the IDT Team weekly 4 and monthly x 2.

5. The Wander Guard Audit will be reviewed in QA meeting monthly times 3

6. The Unit Manager or Designee will be responsible for implementing acceptable POC.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on interviews with residents and staff, and clinical record review, it was determined that the facility failed to ensure reasonable accommodation of resident needs and preferences related to showering for one of 34 residents reviewed (Resident R102).

Findings include:

Interview on May 23, 2019, at 10:45 a.m., with Resident R102 revealed that the resident would prefer to receive showers in the evening. Resident R102 stated that since her admission to the facility on April 25, 2019, that she has only had a shower twice, and that she is not offered by staff to take a shower on a regular basis.

Review of Resident R102's care plan, dated initiated May 14, 2019, revealed that the resident has limited physical mobility related to weakness and deconditioning and for staff to provide supportive care and assistance with mobility as needed.

Review of Resident R102's admission MDS assessment (Minimum Data Set - a mandatory periodic resident assessment tool), dated May 2, 2019, revealed that the resident expressed that it is "very important" to her to "chose between a tub bath, shower, bed bath or sponge bath" and that she is totally dependent for bathing requiring the physical assistance of one person.

Review of Resident R102's clinical record related to bathing revealed that the resident received a shower on May 1, 2019, only once since her admission to the facility.

Interview on May 29, 2019, at 10:42 a.m., Employee E7, Assistant Director of Nursing, confirmed that the resident had only one documented shower since admission.

The facility failed to ensure reasonable accommodation of resident needs and preferences related to showering.

42 CFR 483.10(e)(3) Reasonable Accommodation of Needs/Preferences
Previously cited 06/14/18

28 Pa. Code 201.29(j) Resident rights
Previously cited 06/14/18



 Plan of Correction - To be completed: 07/24/2019


1. Resident R102 no longer resides at the facility.

2. The Staff Educator will rein-service the staff on ensuring reasonable accommodation of resident needs and preferences related to showering.

3. The facility will complete a facility wide audit of Resident's bathing activity. Bathing preference will be reviewed during resident care plan meetings.

4. The Bathing Activity Audit will be reviewed by the IDT Team weekly x4 and monthly x2.

5. The Bathing Activity Audit will be reviewed in QA meeting monthly times 3.

6. The Unit Manager or Designee will be responsible for implementing acceptable POC.


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:

Based on interviews with staff and resident representatives and review of facility policies and clinical records, it was determined that the facility failed to notify the physician in a timely manner of a resident who exhibited exit seeking behaviors and the application of a Wanderguard device to one of 34 residents reviewed (Resident R265).

Findings include:

Review of facility policy, "Notification of Physician," dated February 2019, revealed that "The resident physician or covering physician/NP (nurse practitioner) should be notified if... any change in condition that affects the health of the resident... a change in behavior that places a resident at a danger to himself/herself or others."

Review of facility policy, "Wanderguard/Watchmate (a device that triggers an alarm to prevent a resident from leaving an area) Policy," dated January 2019, revealed that "Once a resident has been identified at risk for elopement (the act leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment), as per Elopement Assessment form, a Wanderguard/Watchmate will be obtained and placed on the resident. The medical record will be updated to identify location of the Wanderguard/Watchmate, to check placement every shift ... The responsible representative and the resident physician will be notified a Wanderguard/Watchmate is in use."

Interview on May 23, 2019, at 9:43 a.m., Resident R265's representative revealed that yesterday (May 22, 2019) the resident tried to leave the facility and that the resident was irrational, agitated and combative. Resident R265's representative stated that she wants the resident's behaviors to be evaluated by a physician.

Clinical record review for Resident R265 revealed a nurse's note, dated May 22, 2019, 6:50 a.m., which indicated that the resident was in bed until 5:45 a.m., at which time he came out of his room to the hallway with his rolling walker and his belongings and was noted to be looking for an exit to go home.

Continued record review revealed another nurse's note, dated May 22, 2019, at 7:46 a.m., which stated that the resident "was seen in the dining room eating breakfast, wander guide activated and placed on right ankle."

Further clinical record review for Resident R265 revealed that there were no physician orders for the Wanderguard device available in the record, no documentation that the device was being checked for placement every shift by staff, no documentation that the physician had been notified that the resident exhibited exit seeking behaviors, no documentation that the physician had been notified that a Wanderguard device had been applied to the resident, and no documentation that an elopement assessment had been completed prior to the application of the Wanderguard device.

Interview on May 24, 2019, at 11:27 a.m., with Employee E6, Unit Manager, and Employee E7, Assistant Director of Nursing, confirmed that there was no documentation available in the clinical record to indicate if the resident had been assessed for elopement risk, that there were no physician orders in the record related to the Wanderguard device, no documentation that the resident's physician was notified of the resident's exit seeking behaviors or that the Wanderguard device was applied to the resident.

The facility failed to notify the physician in a timely manner of a resident who exhibited exit seeking behaviors and the application of a Wanderguard device to that resident.

28 Pa. Code 211.2(a) Physician services

28 Pa. Code 211.10(a) Resident care policies
Previously cited 5/9/17

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 6/14/18, 5/9/17


 Plan of Correction - To be completed: 07/24/2019


1. Resident R265 no longer resides at the facility.

2. The Staff Educator will rein-service the staff on the Wander Guard process.

3. The facility will audit Residents with Wander Guards to ensure an Elopement Risk Assessment was performed, The Physician and Resident Representative were notified, a Physician's order for the Wander Guard was obtained and the Wander Guard was care planned.

4. Residents with exit seeking behaviors will be reviewed by the Unit manager to ensure Physicians and Resident Representatives are notified timely and an elopement assessment is completed prior to applying a Wander Guard device.

5. The Wander Guard Audit will be reviewed by the IDT Team weekly x4 and monthly x2.

6. The Wander Guard Audit will be reviewed in QA meeting monthly times 3.

7. The Unit Manager or Designee will be responsible for implementing acceptable POC.


483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on observation, medical record review and staff interview, it was determined that the facility failed to update care plans related to assistive feeding devices for one of 34 residents reviewed (Resident R68).

Findings include:

Review of medical records for Resident R68 revealed diagnoses, including but not limited to, dementia (a broad category of brain diseases most notable for decline in memory and other mental abilities), absolute glaucoma (the end stage of all types of glaucoma where the eye has no vision) and paresis (a condition of muscular weakness caused by nerve damage or disease - a state of partial paralysis).

Review of facility documentation revealed that Resident R68 obtained a burn during a daytime activity involving a hot drink on September 11, 2018. The burn formed three fluid filled blisters along the right hip and right lateral (side) thigh measuring 34.5 cm (centimeter) by 5.4 cm, 3.5 cm by 2.0 cm and 1.7 cm by 1.5 cm.

Observation of Resident R68 on May 23, 2019, at 12:37 p.m. revealed the resident had a purple one-handled mug containing a hot beverage with her lunch. This observation was confirmed by Employee E12, Nursing Assistant (NA). Repeat observation of Resident R68 on May 29, 2019, at 8:20 a.m. revealed the resident had a purple one-handled mug containing a hot beverage with her breakfast. This observation was confirmed by Employee E13, Licensed Practical Nurse (LPN).

Review of facility documentation provided by the Director of Rehabilitation Services (DRS) revealed that Resident R68 had an order in September 2018 for a "bilateral mug with handles for all meals" after the resident obtained a serious burn to her right leg on September 11, 2018.

Interview with the DRS on May 28, 2019, at 11:34 a.m. revealed that Resident R68 received occupational and physical therapy consultations in September 2018 related to assessing and developing the resident's abilities to drink safely and the recommendation for a bilateral handled mug was still in effect.

Review of medical records for Resident R68 on May 23, 24, 28 and 29, 2019, revealed the resident did not have a care plan to use bilateral-handled mugs for consuming beverages.

Interview with the Director of Nursing on May 29, 2019, at 1:00 p.m. revealed confirmation that Resident R68 did not have an updated care plan to include the use of the September 2018 assistive feeding devices updates.

The facility failed to update care plans.

28 Pa. Code 211.11(d) Resident care plan




 Plan of Correction - To be completed: 07/24/2019


1. Resident R68 has an updated care plan.

2. The Facility Educator or Designee will rein-service the staff on updating care plans.

3. The Unit Manager or Designee will audit current Residents that have assistive devices to ensure they are addressed on the care plan.

4. Annual, quarterly and with change of condition, Residents care plans will be reviewed and revised as applicable to ensure assistive devices are included on the care plan.

5. The Care Plan Audits will be reviewed weekly x 4, montly x2 by the Interdisciplinary Team.

6. The Care Plan Audits will be reviewed in QA Meeting monthly times 3.

7. The Unit Manager or Designee will be responsible for implementing acceptable POC.


483.21(c)(1)(i)-(ix) REQUIREMENT Discharge Planning Process:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(c)(1) Discharge Planning Process
The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and-
(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident.
(ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
(iii) Involve the interdisciplinary team, as defined by 483.21(b)(2)(ii), in the ongoing process of developing the discharge plan.
(iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.
(v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.
(vi) Address the resident's goals of care and treatment preferences.
(vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community.
(A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose.
(B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities.
(C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.
(viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences.
(ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.
Observations:

Based on interviews with residents and staff and clinical record review, it was determined that the facility failed ensure that a discharge plan was developed for one of 34 residents reviewed (Resident R83).

Findings include:

Interview with Resident R83 on May 23, 2019, at 12:27 p.m., revealed that he was admitted to the facility for a short-term stay, that he has not received any discharge planning since his admission and that he would like to go home.

Review of physician orders revealed that Resident R83 was admitted to the facility on April 20, 2019, and that he was prescribed to receive occupational therapy for six weeks.

Review of Resident R83's care plan revealed no documentation in the record that the resident was a short-term stay or that a discharge plan had been established.

Interview on May 29, 2019, at 9:30 a.m., Employee E9, Social Worker, confirmed that a discharge care plan had not been developed for Resident R83. Employee E9 also confirmed that there were no notes available in the clinical record related to discharge planning for this resident.

The facility failed ensure that a discharge plan was developed for a short-term rehabilitation resident.

28 Pa. Code 201.25 Discharge policy

28 Pa. Code 211.11(d)(e) Resident care plan



 Plan of Correction - To be completed: 07/24/2019


1. Discharge planning has been initiated for R83.

2. The Facility Educator or Designee will rein-service the staff on the discharge planning process.

3. The facility will audit the last 30 days of short term rehab Residents to ensure discharge plans are in place.

4. The Discharge Planning Audits will be reviewed weekly x4, monthly x2 by the Interdisciplinary Team and revised as needed.

5. Short stay Residents will be reviewed in morning meeting, post admission to ensure Residents have a discharge plan.

6. The Discharge Planning Audits will be reviewed in QA Meeting monthly times 3.

7. The Social Worker or Designee will be responsible for implementing acceptable POC.


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

Based on interviews with residents and staff and review of clinical records, it was determined that the facility failed to ensure that discharge summaries included the information necessary for post discharge care for two of five discharged residents reviewed (Residents R96 and R16).

Findings include:

Interview with Resident R96 on May 23, 2019, at 9:27 a.m., revealed that the resident was scheduled to be discharged home tomorrow and that she would be discharged with a "team of homecare staff." Resident R96 stated that she did not know which homecare company would be providing services to her, what services would be provided or how to contact the homecare company.

Review of Resident R96's discharge summary revealed that the resident was discharged home on May 24, 2019 at 8:00 a.m. Continued review of the discharge summary revealed that no contact information was provided to the resident for the referred homecare company. Further review of the discharge summary revealed that the resident takes a blood thinning medication and needed to have blood work drawn following her discharge to monitor the medication. There was no indication on the discharge summary of how or where the resident was supposed to receive the recommended blood work.

Interview on May 24, 2019, at 10:30 a.m., Employee E6, Unit Manager, confirmed that no contact information for the homecare company was included in the discharge summary and that no information was provided on how the resident would have her blood work completed.

Interview on May 23, 2019, at 12:22 p.m., Resident R16 stated that he was scheduled for a discharge planning meeting Friday and that he wants to go home.

Review of Resident R16's discharge summary revealed that Resident R16 was discharged home on May 28, 2019, at 1:00 p.m. Continued review of the discharge summary revealed that the resident was scheduled for two follow-up appointments with specialist physicians. There was no phone number provided on the discharge summary for either of the specialist physicians. Further review of the discharge summary revealed that no medication list or evidence of medication reconciliation was provided to the resident.

Review of the clinical record revealed a nurse's note, dated May 28, 2019, at 6:29 p.m., which indicated that Resident R16 was given his remaining medications upon discharge. There was no documentation in the record to indicate which medications or the quantities of the medications that the resident received.

Interview on May 29, 2019, at 11:15 a.m., Employee E6 confirmed that no phone numbers for the specialist physicians and no comprehensive medication list was provided to the resident on the discharge summary.

The facility failed to ensure that discharge summaries included necessary information.

28 Pa. Code 201.25 Discharge policy



 Plan of Correction - To be completed: 07/24/2019


1. R96 no longer resides in facility. Social Worker followed up with R96 to provide them with information of how or where the resident was supposed to receive the recommended blood work

2. R16 no longer resides in facility. Social Worker followed up with R16 to provide them with information of the two follow-up appointments with specialist physicians with the phone numbers. A medication list with medication reconciliation was provided to the resident.

3. The Facility Educator or Designee will rein-service the staff on the discharge planning process and that that discharge summaries included in the discharge planning process.

4. The Social Worker will audit discharges in the last 30 days for evidence of a discharge summary.

5. The Discharge Planning Audits will be reviewed weekly by the Interdisciplinary Team times 4 weeks and monthly times 2 months.

6. Planned discharges for the week will be reviewed at morning meeting, discharge recapitulation will be completed by Social Service.

7. The Discharge Planning Audits will be reviewed in QA Meeting monthly times 3.

8. The Social Worker or Designee will be responsible for implementing acceptable POC.


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 observations, interviews with staff and clinical record review, it was determined that the facility failed to follow physician orders for two of 34 residents reviewed regarding blood glucose results and an assistive device for a contracture (Residents R51 and R65).

Findings include:

A review of Resident R51's clinical record revealed that the resident was admitted to the facility on August 20, 2018, with diagnoses, including but not limited to, of intraventricular hemorrhage (described as bleeding inside or around the ventricles in the brain. The ventricles are the spaces in the brain that contain the cerebral spinal fluid) and cerebral infarction (an area of necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain).

Further review of the clinical record revealed that the resident had a tracheostomy (a tube inserted through the neck to assist breathing), a percutaneous endoscopic gastrostomy (a tube that is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate). The resident was also noted with a contracture (a condition of shortening and hardening of muscles, tendons or other tissues, often leading to deformity and rigidity of joints) of the left hand.

A review of physician's orders dated October 1, 2018, revealed an order for a resting hand splint- restorative nursing: left resting hand splint: wear 7:00 a.m. to 7:00 p.m. (on at a.m. off at p.m.) as tolerated. Passive range of motion (involves someone moving a joint for the patient) pre and post splint wear with skin checks pre and post wear. Daily at 9:00 a.m. and daily at 5:00 p.m..

Observations of the resident on May 23, 2019 at 10:00 a.m. revealed that the resident did not have the splint on his left hand. Observations of the resident on May 24, 2019 at 9:00 a.m. and 11:00 a.m. revealed that the resident did not have the splint on his left hand.

The facility failed to follow physician orders regarding the application of a splint for a contracture.

A review of Resident R65's clinical record revealed that the resident was admitted to the facility on August 13, 2018 with a diagnosis, including but not limited to, diabetes (a disease that affects the way the body processes's blood sugar (glucose). Further review revealed that the resident is severly cognitively impaired in decision making skills.

A review of physician orders dated March 26, 2019, revealed an order for blood glucose checks, two times a day at 6:30 a.m. and 4:00 p.m., if blood glucose is under 80 milligrams per deciliter or greater than 350 milligrams per deciliter notify the physician.

A review of blood glucose monitoring sheets for April 2019 and May 2019, revealed that on April 20, 2019 the resident blood glucose was recorded as 78 milligrams per deciliter. There was no documentation available for review that the physician was notified. And on May 21, 2019, the resident blood glucose was measured at 68 milligrams per deciliter. There was no evidence available for review that the physician was notified.

An interview with the nursing manager on the second floor on May 29, 2019, at 9:00 a.m. confirmed that the physician had not been notified.

The facility failed to follow physician orders regarding a splint for a contracture and notifying the physician regarding blood glucose results.

28 Pa. Code 211.12 (1)(2)(5) Nursing services
Previously cited 06/14/18



 Plan of Correction - To be completed: 07/24/2019


1. R51 is wearing his left-hand splint appropriately.
2. The physician has been notified of Resident R65's blood sugars for April 20, 2019 and May 21, 2019.

3. The Facility Educator or Designee will rein-service the staff on physician's order for splints and accu-checks.

4. An audit will be conducted of current Residents to ensure Physician orders were followed regarding splints and ensure the Physician was notified of applicable blood glucose results.

5. The Unit Manager or Designee will conduct random audits to ensure Physician orders were followed regarding splints and the Physician was notified of applicable blood glucose results weekly times 4 and monthly times 2

6. The Quality of Care Audits will be reviewed weekly by the Interdisciplinary Team.

7. The Quality of Care Audits will be reviewed in QA Meeting monthly times 3.

8. The Unit Manager or Designee will be responsible for implementing acceptable POC.


483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on observations, interviews with residents and staff, review of facility policies and review of clinical records, it was determined that the facility failed to obtain physician orders for oxygen therapy and tracheostomy tubes and failed to properly maintain respiratory equipment related to oxygen concentrators for four of 34 residents reviewed (Residents R6, R23, R83 and R96).

Findings include:

Review of facility policy, "Oxygen Administration," dated January 2019, indicated "Verify that there is a physician's order for this procedure... check the mask, tank, humidifying jar, etc., to be sure they are in good working order."

Review of facility policy, "Tracheostomy Care," dated May 25, 2019, revealed that "In order to provide safe nursing care for residents with a tracheostomy (a surgically created hole in your trachea that allows for breathing), licensed nurses need to know the following information: the rational for the creation of the tracheostomy, the date the tracheostomy was placed, the type and size of the tracheostomy, inner cannula type, cuffed or non-cuffed, and the amount of supplemental oxygen to be delivered."

Observation of Resident R6's respiratory equipment on May 23, 2019, at 11:32 a.m., revealed that he had a spare 8.0 Portex trach with a cuff (type and size of tracheostomy tube) available at his bedside. Continued observation revealed that the resident was receiving five liters of oxygen to his tracheostomy from an oxygen concentrator machine. The filter on the machine was observed to be a whitish color covered with dust and debris.

Clinical record review for Resident R6 revealed that there were no physician orders and no care plan pertaining to Resident R6's tracheostomy tube, it's size or type, when it was inserted, or how often the tube should be changed available for review.

Medical record review for Resident R23 revealed physician orders and care plans to care for a tracheostomy but no orders or care plans stipulated what type and size of tracheostomy the resident should have in use or as backup in case of emergency.

During a tour conducted on May 24, 2019, at 1:15 p.m., with Employee E7, the Assistant Director of Nursing, confirmed that Resident R6 had an 8.0 cuffed Portex tracheostomy tube and confirmed that no physician orders or care plans were available related to the size, type and maintenance of the tracheostomy tube. Additionally, Employee E7 confirmed that Resident R23 had a number 6 cuffed Shiley tracheostomy and confirmed there were no physician orders or care plans available related to the size and type of Resident R23's tracheostomy.

Observation on May 23, 2019, at 9:27 a.m., Resident R96 was noted to be wearing oxygen via a nasal cannula from an oxygen concentrator machine. The filter on the machine was observed to be a whitish color covered with dust and debris.

Observation on May 23, 2019, at 12:27 p.m., Resident R83 was noted to have an oxygen concentrator machine in his room. Interview at the time of the observation, Resident R83 stated that he sometimes uses the oxygen at night when he feels short of breath and that he used it last night. The filter on the machine was observed to be a whitish color covered with dust and debris.

Clinical record review for Resident R83 revealed that there were no physician orders and no care plan pertaining to the resident's oxygen therapy available for review.

Continued observation on May 24, 2019, at 10:04 a.m., revealed that Resident R6's oxygen concentrator filter was still noted to be a whitish color covered with dust and debris.

Further observation on May 28, 2019, at 10:58 a.m., revealed that Residents R6, R83 and R96's oxygen concentrator filters were still noted to be a whitish color covered with dust and debris.

Interview on May 28, 2019, at 11:05 a.m., Employee E7 confirmed that the oxygen concentrator filters for Residents R6, R83 and R96 were covered with dust and debris and needed to be cleaned. Continued interview with Employee E7 also confirmed that there were no physician orders available for review related to Resident R83's oxygen therapy.

The facility failed to obtain physician orders for oxygen therapy and tracheostomy tubes and failed to properly maintain respiratory equipment related to oxygen concentrators.

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 06/14/18, 05/09/17

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 06/14/18, 05/09/17

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 06/14/18, 05/09/17



 Plan of Correction - To be completed: 07/24/2019


1. Resident R6's concentrator filter has been cleaned. Resident R6's trach tube is included in their physician's orders and care plan. Resident R23 has orders and a care plan stipulating what type and size of tracheostomy the resident should have in use or as backup in case of emergency. Resident R96 concentrator filter has been cleaned. Resident R83 concentrator filter has been cleaned and he has a Physician and care plan for his PRN oxygen.

2. The Facility Educator or Designee will rein-service the staff on cleaning oxygen concentrator filters, physician's orders and care plans for Residents with trachs and Residents on oxygen.

3. The facility will audit current Residents on oxygen and Residents with trachs for physician orders, care plans and clean oxygen filters.

4. The Unit Manager or Designee will conduct random audits on Residents with oxygen and Residents with trachs for physician orders, care plans and clean oxygen filters.

5. The Audits will be reviewed weekly x 4 weeks, monthly x2, by the Interdisciplinary Team.

6. The Audits will be reviewed in QA Meeting monthly times 3.

7. The Unit Manager or Designee will be responsible for implementing acceptable POC.

483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on review of clinical records, facility documentation and interviews with residents and staff, it was determined that the facility failed to provide medications to dialysis residents as ordered by the physician and to maintain ongoing communication between the facility and a dialysis provider for two of 34 residents reviewed (Residents R5 and R83).

Findings include:

Review of facility Policy "Dialysis Care" dated November 2018, revealed that the nurse will have pharmacy schedule medication administration around the resident's dialysis (the process of removing waste products and excess fluid from the body) time.

Review of facility documentation, "Outpatient Dialysis Coordination Agreement," dated June 28, 2017, revealed that the dialysis center will provide to the facility information on all aspects of the management of a resident's care related to the provision of dialysis services.

Review of Resident R5's clinical record revealed that the resident has dialysis treatments three times per week on a Monday, Wednesday and Friday schedule with a 10:45 a.m. pick up and a 11:45 a.m. chair time. Further review of Resident R5's Medication Administration Record (MAR- list of medications ordered and given with times and boxes for staff to indicate if medication was given) revealed orders for: Diclofenac 1% Gel (topical gel for the relief of the pain in joints, such as the knees and those of the hands) ordered for 5 a.m., 1 p.m., and 9 p.m., with records indicating that the 1 p.m. dose of medication was not administered as ordered on 9 days from May 1 to May 23, 2019; Ondansetron 4 mg tablet (used to prevent nausea and vomiting caused by cancer drug treatment and radiation therapy) ordered for 9 a.m., 1 p.m., and 5 p.m., with records indicating that the 1 p.m. dose of medication was not administered as ordered on 9 days from May 1 to May 23, 2019; Renvela 800mg 2 Tablets (is used to lower high blood phosphorus (phosphate) levels in patients who are on dialysis) ordered for 7:45 a.m., 11:30 a.m., 5:45 p.m., and 9 p.m. with records indicating that the 11:30 a.m. dose of medication was not administered as ordered on 9 days from May 1 to May 23, 2019.

Continued record review revealed that four of 22 dialysis communication log sheets were missing from Resident R5's dialysis communication binder.

Interview with Employee E7, Assistant Director of Nursing (ADON) on May 28, 2019 at 10:30 a.m. confirmed the above findings.

Clinical record review for Resident R83 revealed a physician's order dated April 20, 2019, for the resident to attend dialysis three times per week on Mondays, Wednesdays and Fridays and that he would be picked up at the facility at 2:00 p.m. on those days. Continued review revealed additional physician orders, dated April 22, 2019, for the resident to be seen by a psychologist and a psychiatrist (physicians that specialize in mental health) related to depression.

Continued clinical record review revealed that there was no documentation available in the record to indicate that Resident R83 was seen by either a psychologist or a psychiatrist.

Review of Resident R83's MARs for April 2019, revealed orders for: Furosemide 80mg (used to removed excess water from the body) ordered for 7:30 a.m. and 5:00 p.m., with records indicating that the 5:00 p.m. dose was not administered as ordered on two days from April 20 to April 30, 2019; Renvela 800mg 3 tablets ordered for 7:45 a.m., 12:00 p.m., and 5:45 p.m., with records indicating that the 5:45 p.m. dose was not administered as ordered on three days from April 20 to April 30, 2019; and Ketoconazole 2% cream (used to treat fungal infections) ordered for 9:00 a.m. and 5:00 p.m., with records indicating that the 5:00 p.m. dose was not administered as ordered once from April 20 to April 30, 2019.

Review of Resident R83's MARs for May 2019, revealed that the resident did not receive the 5:00 p.m. dose of Furosemide as ordered four times from May 1 to May 27, 2019; did not receive the 5:45 p.m. dose of Renvela five times from May 1 to May 27, 2019; and did not receive the 5:00 p.m. dose of Ketoconazole cream as ordered four times from May 1 to May 27, 2019.

Further clinical record review for Resident R83 revealed that the resident was scheduled to receive dialysis 15 times between April 22 through May 24, 2019, and that there were no completed dialysis communication sheets available for review.

Interview on May 28, 2019, at 11:10 a.m., Employee E7 confirmed that Resident R83 had not been seen by either a psychologist or a psychiatrist and stated those services are provided on Wednesday afternoons, when Resident R83 is at dialysis.

Interview on May 28, 2019, at 11:20 a.m., Employee E6, Unit Manager, confirmed that there were no completed dialysis communication sheets available for review.

Interview on May 28, 2019, at 1:04 p.m., the Director of Nursing confirmed that Resident R83 missed medication doses and that the resident's medication administration times were not adjusted for the days that the resident has dialysis.

The facility failed to provide medications as ordered due to dialysis schedules and maintain ongoing communication between the facility and a dialysis provider.

28 Pa. Code 211.5(f) Clinical records
Previously cited 06/14/18

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 06/14/18, 05/09/17



 Plan of Correction - To be completed: 07/24/2019


1. Resident R5's medication regimen was adjusted around his dialysis times. Communication was obtained from the dialysis center.

2. Resident R83 was seen by the psychiatrist.

3. The Facility Educator or Designee will rein-service the staff scheduling medication regimens, appointments and consults around dialysis times. Also, the staff will be re-educated on ensuring the dialysis log sheets are filed in the dialysis communication binder.

4. The facility will audit Residents on dialysis to ensure medication, appointments and consults are scheduled around dialysis times and the dialysis logs are current, weekly x 4, monthly x2.

5. The Dialysis Audits will be reviewed in QA Meeting monthly times 3.

6. The Unit Manager or Designee will be responsible for implementing acceptable POC.



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

483.45(h) Storage of Drugs and Biologicals

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

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

Based on observation and staff interview, it was determined that the facility failed to store medications securely on one of two clinical nursing units (second-floor nursing unit).

Findings include:

Observation on May 23, 2019, at 12:02 p.m. revealed a pot of crushed medications sitting on a bathroom sink in Resident R59's room while Employee E15, Licensed Practical Nurse (LPN), was administering medications to Resident R59.

Interview with Employee E15 on May 23, 2019, at 12:03 p.m. confirmed that the medications in Resident R59's bathroom belonged to a resident in another room, Resident R12. Employee E15 revealed that she was storing the medications for Resident R12 in Resident R59's bathroom because Resident R12 had refused his medications and she needed somewhere to store them while doing medication administration for Resident R59.

Interview with the Director of Nursing and Employee E16, Registered Nurse (RN) and Nurse Manager, confirmed that storing medications for one resident in another resident's bathroom was an unacceptable practice.

Observation on May 29, 2019, at 8:24 a.m. revealed an unlocked medication cart in a clinical care hallway with residents sitting near the medication cart.

Interview with Employee E17, Director of Medical Records, on May 29, 2019, at 8:24 a.m. confirmed that the medication cart on the second-floor clinical nursing unit by the nursing station was unlocked and could be accessed by residents.

The facility failed to store medications securely.

42 CFR 483.45(g)(h) Label/Store Drugs & Biologicals
Previously cited 09/05/18, 06/14/18

28 Pa. Code 211.9(a) Pharmacy services
Previously cited 09/05/18

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 06/14/18, 05/09/17



 Plan of Correction - To be completed: 07/24/2019


1. Employee E15 has been re-educated on medication storage.

2. The Facility Educator or Designee will rein-service the staff on medication storage.

3. The Unit Manager or Designee will audit medication storage to ensure the safe storage of medications weekly times 4 and monthly times 2.

4. The Medication Storage Audits will be reviewed by the Interdisciplinary Team.

5. The Medication Storage Audits will be reviewed in QA Meeting monthly times 3.

6. The Unit Manager or Designee will be responsible for implementing acceptable POC.


483.60(g) REQUIREMENT Assistive Devices - Eating Equipment/Utensils: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.
483.60(g) Assistive devices
The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.
Observations:

Based on observations, medical record review and staff interviews, it was determined that the facility failed to provide residents with assistive feeding equipment for two of 34 residents reviewed (Residents R13 and R68).

Findings include:

Observation of Resident R13 on May 23, 2019, at 12:32 p.m. and May 29, 2019, at 8:15 a.m. revealed Resident R13 in the dining room eating lunch and breakfast respectively. On both observations Resident R13 had a meal ticket with the instructions for a scoop plate (a plate with high rims that allows food to be trapped and pushed easily onto utensils) for all meals and on both occasions did not receive a scoop plate.

Interview with Employee E11, Licensed Practical Nurse (LPN), on May 29, 2019, at 8:16 a.m. confirmed that Resident R13 did not receive her breakfast on a scoop plate.

Review of medical records for Resident R68 revealed diagnoses, including but not limited to, dementia (a broad category of brain diseases most notable for decline in memory and other mental abilities), absolute glaucoma (this is the end stage of all types of glaucoma where the eye has no vision) and paresis (a condition of muscular weakness caused by nerve damage or disease-a state of partial paralysis).

Review of facility documentation provided by the Director of Rehabilitation Services (DRS) revealed that Resident R68 had an order in September 2018 for a "bilateral mug with handles for all meals".

Interview with the DRS on May 28, 2019, at 11:54 a.m. confirmed that the order for a blue two-handled hot beverage mug was active and the resident should receive that with all meals.

Observation of Resident R68 on May 23, 2019, at 12:37 p.m. revealed the resident had a purple one-handled mug containing a hot beverage with her lunch. This observation was confirmed by Employee E12, Nursing Assistant (NA). Repeat observation of Resident R68 on May 29, 2019, at 8:20 a.m. revealed the resident had a purple one-handled mug containing a hot beverage with her breakfast. This observation was confirmed by Employee E13, LPN.

Interview with Employee E13, LPN, on May 29, 2019, at 8:20 a.m. revealed that Resident R68 should receive a double-handled mug for hot beverages with all meals.

The facility failed to provide residents with assistive feeding equipment.

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 6/14/18, 5/9/17



 Plan of Correction - To be completed: 07/24/2019

1. Resident R13 has been provided her scoop plate.

2. Resident R68 has been reassessed and a bilateral mug with handles for all meals is no longer appropriate for the Resident

3. The facility will audit current Residents for adaptive equipment during the dining process.

4. The Facility Educator or Designee will rein-service the staff on adaptive equipment with the dining process.

5. The dining process will be audited to ensure Residents have their adaptive equipment provided weekly times 4 and monthly times 2.

6. The Dining Process Audits will be reviewed in QA Meeting monthly times 3.

7. The Unit Manager or Designee will be responsible for implementing acceptable POC.


483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable 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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:

Based on medical record review and resident and staff interviews it was determined that the facility failed to ensure an accurate resident record for one of 34 resident records reviewed (Resident R78).

Findings include:

Review of the entire electronic medical record including the last annual and last three quarterly Minimum Data Set (MDS - a periodic review of the resident's needs) submissions to the Centers for Medicare and Medicaid Services (CMS) revealed that Resident R78's first name was spelled incorrectly.

Interview and observation with Resident R78 on May 24, 2019, at 10:30 a.m. revealed that his identifying wrist band was also spelled with the incorrect spelling of his first name. Resident R78 stated that he had requested staff to update his name on multiple occasions over the preceding six months or more and that staff had not complied with his request.

Interview with Employee E14, Registered Nurse Assessment Coordinator (RNAC), on May 23, 2019, at 1:31 p.m. confirmed that Resident R78's name was spelled incorrectly throughout his medical records and in the four most recent MDS submissions to CMS.

The facility failed to ensure accurate medical records.

28 Pa. Code 211.5(f) Clinical records
Previously cited 06/14/18



 Plan of Correction - To be completed: 07/24/2019

1. The spelling of Resident R78's name has been corrected on the MDS.

2. The facility will audit current Residents for the correct spelling of their names in the MDS.

3. The MDS will be audited weekly times 4 and monthly times 2 to ensure Residents names are spelled correctly.

4. The Facility Educator or Designee will rein-service the MDS coordinators to verify accurate spelling of Resident's names on the MDS and re-educate Licensed Nurses to verify spelling of Residents name on the name band.

5. The Audits will be reviewed in QA Meeting monthly times 3.

6. The MDS Coordinator or Designee will be responsible for implementing acceptable POC.


483.90(g)(2) REQUIREMENT Resident Call System: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(g) Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area.

483.90(g)(2) Toilet and bathing facilities.
Observations:

Based on observations and interviews with staff, it was determined that the facility failed to ensure that a call bell was available for one of 34 residents reviewed (Resident R6).

Findings include:

Observation on May 23, 2019, at 11:41 a.m., revealed that there was no call bell or communication system available that would allow for a resident, family member or staff member to call for assistance in Resident R6's room.

Interview on May 23, 2019, at 11:45 a.m., the Director of Nursing confirmed that there was no call bell available in Resident R6's room and stated that there should be.

The facility failed to ensure that a resident had a call bell available in their room.

28 Pa. Code 205.67(j) Electric requirements for existing and new construction



 Plan of Correction - To be completed: 07/24/2019

1. R6's room was provided a call bell.

2. The facility audited Resident rooms for call bells.

3. The Facility Educator or Designee will rein-service the nursing staff on call bells.
4. The call bells will be audited by the Director of Maintenance or Designee weekly times 4 and monthly times 2 to ensure Residents have them available.

5. The Call Bell Audits will be reviewed in QA Meeting monthly times 3.

6. The Director of Maintenance or Designee will be responsible for implementing acceptable POC.

211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.
Observations:


Based on a review of staffing schedules and interviews with staff, it was determined that the facility failed to meet the minimum number of general nursing care hours for each 24-hour period for three of 21 days reviewed.

Findings include:

A review of nursing schedules from February 10, 2019, through February 16, 2019, revealed that on two days the facility failed to meet the minimum number of general nursing hours of 2.7 hours of direct resident care for each resident.

A review of nursing schedules from May 22, 2019 through May 28, 2019, revealed that on one day the facility failed to meet the minimum number of general nursing hours of 2.7 hours of direct resident care for each resident.

On February 13, 2019, the calculated direct nursing care hours provided was 2.61 hours per resident.
On February 14, 2019, the calculated direct nursing care hours provided was 2.55 per resident.
On May 24, 2019, the calculated direct nursing care hours provided was 2.51 per resident.

An interview with the Nursing Home Administrator on May 31, 2019, at 3:15 p.m. confirmed that the facility had been short staffed.

The facility failed to meet the minimum number of general nursing care hours for each 24-hour period.



 Plan of Correction - To be completed: 07/24/2019

1. There were no Resident issues identified related to the staffing levels on February 13, 2019, February 14, 2019 or May 24, 2019.

2. The facility re-educated the Staffing Coordinator on the minimum number of general nursing hours of 2.7 hours of direct resident care for each resident.

3. Staffing will be audited weekly times 4 and monthly times 2 to ensure staffing levels meet state requirement.


4. The Staffing Audits will be reviewed in QA Meeting monthly times 3.

5. The Director of Nursing or Designee will be responsible for implementing acceptable POC


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port