Nursing Investigation Results -

Pennsylvania Department of Health
RIVERSIDE CARE CENTER
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
RIVERSIDE CARE CENTER
Inspection Results For:

There are  106 surveys for this facility. Please select a date to view the survey results.

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RIVERSIDE CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and an Abbreviated Survey in response to a complaint completed on April 9, 2019, it was determined that Riverside Care Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.60(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 review of facility policies, observations and staff interview, it determined the facility failed to maintain sanitary conditions to prevent the potential for cross contamination and failed to store products in a manner to prevent foodborne illness in the main kitchen and two of four pantries (activities and memory unit impaired pantries).

Findings include,

A review of facility policy "Dishwasher Procedure " last updated 1/21/19, indicated the manufacturer's instructions shall be followed for machine washing and sanitizing. For high temperature dishwashers with heat sanitization. The wash temperature shall be at minimum 150 degrees Fahrenheit. The surface of service ware must be at a minimum of 160 degrees Fahrenheit to verify the dishwasher is reaching the correct sanitizing temperature during operation.

A review of facility policy "Food Temperatures" last updated 1/21/19, indicated cold foods are maintained at 41 degrees Fahrenheit or below.

A review of the manufacturer's recommendations for the Manitowoc undercounter ice machine drain lines must not create traps.

A review of facility policy "Date marking and labeling" last updated 1/21/19, indicated items were to be dated when a commercially prepared item is opened.

During observations of the main kitchen dishwasher on 4/1/19, at 9:23 a.m. the wash temperature was observed to be between 140 to 145 degrees Fahrenheit. An observation of three test strips (test to determine the surface temperature of service ware is 160 degrees Fahrenheit) failed to indicate the water was at a minimum of 160 degrees Fahrenheit. Next the facility ran a thermometer through the dishwasher three times and it recorded sanitizing temperatures of 390, 158 and 158 degrees Fahrenheit. The main kitchen ice machine had two plastic lines draining from the machine both of which were in contact with the floor, one the lines was draining water creating a small puddle next to the drain. The milk cooler thermometer indicated the temperature was 46 degrees Fahrenheit.

A review of an outside contractors work order dated 4/1/19, indicated the contractor found the condenser (cools inside of refrigerator) on the milk cooler was dirty causing it to not cool properly.

During an interview on 4/3/19, at 9:19 a.m. the Dietary Director Employee confirmed the above observations, that the milk cooler needed repaired and that the facility failed to maintain sanitary conditions to prevent the potential for cross contamination and failed to store products in a manner to prevent the possibility of foodborne illness in the main kitchen.

During observation on 4/1/19, at 10:33 a.m. in the activity room pantry refrigerator there were open, undated containers of two chocolate syrups, lemon juice, thickened water (for residents with trouble swallowing), sugar and powdered creamer.

During an interview on 4/1/19, at 10:33 a.m. Activity Aide Employee E1 confirmed the above observations and that the facility failed to store products in a manner to prevent the possibility of foodborne illness in the activity room pantry refrigerator.

During observations on 4/1/19, at 10:38 a.m. of the memory unit impaired pantry refrigerator there were open, undated containers of apple juice, butter spray, grape juice and two thickened waters.

During an interview on 4/1/19, at 10:38 a.m. Registered Nurse Supervisor Employee E2 confirmed the above observations and that the facility failed to store products in a manner to prevent the possibility of foodborne illness in the memory unit impaired pantry refrigerator.

28 Pa. Code: 201.14(a) Responsibility of Licensee.
Previously cited 3/28/18.

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

28 Pa. Code: 207.2(a) Administrator's Responsibility



 Plan of Correction - To be completed: 05/21/2019

Air Gap
-The facility recognizes the responsibility to store, prepare, distribute and serve food under sanitary conditions. The facility has determined that all residents who receive food and beverages prepared in the kitchen have the potential of being effected by the alleged deficient practice.
-The drainage lines on the main ice machine in the kitchen were repaired to enable a proper air gap in accordance with professional standards for food safety.
-The Facility Administrator conducted a review of all other ice machines in the facility to ensure drainage lines included an acceptable air gap.
-The Dietary Manager and Maintenance Director conducted a review of all kitchen equipment to ensure professional standards for food service safety are met.
-The Maintenance Director or designee will complete a monthly audit of the kitchen equipment to ensure compliance with professional standards for food service safety.
-Results of the audits and actions will be documented by the Maintenance Director and reviewed at the facility QAPI meetings.


Dish Washer
-The facility recognizes the responsibility to store, prepare, distribute and serve food under sanitary conditions. The facility has determined that all residents who receive food and beverages prepared in the kitchen have the potential of being effected by the alleged deficient practice.
-Operation of the dish washer was terminated immediately. An outside vendor was contacted to repair the unit and protocol for utilization of disposable service ware initiated.
-Dietary staff was reeducated on the policy and procedure related to monitoring dish washer temperatures and the process of taking corrective action when temperatures are out of acceptable range.
-The Director of Dietary / Designee will audit the dish washer temperature log weekly x and then monthly x 3 months for proper temperature range and report results to monthly QAPI meetings for evaluation.


Pantries
Dating and Labeling & Activities Room
-The facility recognizes the responsibility to store, prepare, distribute and serve food under sanitary conditions. The facility has determined that all residents who receive food and beverages have the potential of being effected by the alleged deficient practice.
-Items identified were immediately discarded. All perishable and non-perishable foods were reviewed to ensure proper labeling and dating in all food storage areas.
-The Director of Dietary in-serviced dietary, nursing and activities staff regarding the facility's protocol for proper labeling and dating of food products to ensure food safety.
-Staff that fail to comply with the facility's policy will be provided with additional education and/or progressively disciplined as indicated.
-The Dietary Manager/Designee will complete daily audits x 2 weeks, then weekly audits x 1 month and monthly x 4 months to ensure foods are properly labeled and dated in all food storage areas.
-Results of the audits will be reviewed at the facility QAPI meetings and reviewed for compliance.


Milk Cooler
-The facility recognizes the responsibility to store, prepare, distribute and serve food under sanitary conditions. The facility has determined that all residents who receive food and beverages prepared in the kitchen have the potential of being effected by the alleged deficient practice.
-Operation of the milk cooler was terminated immediately and an outside vendor was contacted to repair the unit.
-Dietary staff was reeducated on the policy and procedure related to monitoring equipment temperatures and the process of taking corrective action when temperatures are out of acceptable range.
-The Director of Dietary / Designee will audit the milk cooler temperature log weekly x 4 and then monthly x 3 months for proper temperature range and report results to monthly QAPI meetings for evaluation.

483.10(g)(4)(i)-(vi) REQUIREMENT Required Notices and Contact Information:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(g)(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 facility document review, group interview, observations and staff interview, it was determined that the facility failed to display pertinent information to residents about contacting the Ombudsman, the State Department of Health, Adult Protective Services, and the Medicaid Fraud Control Unit as required on three of three nursing units and for seven of seven group residents (Resident R600, R601, R602, R603, R604, R605, and R606).

Findings include:

During the resident group meeting conducted on 4/2/19, at approximately 11:00 a.m. seven of seven residents (Resident R600, R601, R602, R603, R604, R605, and R606) expressed that they were unaware of where the Ombudsman's contact information was posted.

Observations conducted on 4/5/19, at 11:45 a.m. failed to reveal required postings of the Ombudsman's business email address, the Department of Health's business email address, contact information for Adult Protective Services, and contact information for the Medicaid Fraud Control Unit.

During an interview on 4/5/19, at 1:00 p.m. the Nursing Home Administrator confirmed that the facility does not have the required postings available to facility residents.

28 Pa. Code 201.18(a)(b)(e)(1) Management.
28 Pa. Code 201.29(a) Resident rights.







 Plan of Correction - To be completed: 05/21/2019

-The facility recognizes that the required posting for pertinent contact information for all agencies was not available on all nursing units.
-Resident 601,602, 603, 604, 605 and 606 have been provided information for contacting the ombudsman.
-The Nursing Home Administrator evaluated locations on nursing units for required postings to ensure locations had current contact information for pertinent agencies.
-Nursing Home Administrator/Social Services Director will monitor current locations of postings monthly for three months then quarterly thereafter.
-The facility will review results of the monitoring, identify trends, and report results to the Quality Assurance Performance Improvement Committee.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of 483.95(g).
Observations:

Based on review of facility staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education for nurse aides as required for seven of 25 nurse aides (Employees E5, E6, E7, E8, E9, E10 and E11).

Finding include:

Review of Nurse Aide (NA) Employee's E5, E6, E7, E8, E9, E10 and E11 education records with hire date greater than 12 months for the education period identified by the facility as 1/1/18, through 12/31/18, revealed the following:
NA Employee E5 has a hire date of 12/15/15, with 0.5 hours in-service education.
NA Employee E6 has a hire date of 4/24/03, with 6 hours in-service education.
NA Employee E7 has a hire date of 5/22/15, with 11.75 hours in-service education.
NA Employee E8 has a hire date of 8/1/16, with 4 hours in-service education.
NA Employee E9 has a hire date of 7/2/00, with 10.5 hours in-service education.
NA Employee E10 has a hire date of 5/13/16, with 6 hours in-service education.
NA Employee E11 has a hire date of 6/16/14, with 11.75 hours of in-service education.

During an interview on 4/8/19, at 3:01 p.m. the Nursing Home Administrator confirmed that the NA Employees E5, E6, E7, E8, E9, E10 and E11 have only received the listed education hours and the facility failed to provide the required 12 hours annual inservice education for NA Employee E5, E6, E7, E8, E9, E10 and E11.

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

28 Pa. Code: 201.20(c) Staff Development.








 Plan of Correction - To be completed: 05/21/2019

-The facility recognizes that seven of twenty five nursing assistants did not receive the entire twelve hours of inservice.
-Employees E5, 6, 7,8,9,10 and 11 will receive the remaining required inservices.
-The Director of Nursing or designee will monitor completion of nursing assistant twelve hours of required inservices monthly for three months and quarterly thereafter.
-The facility will review results of monitoring , identify trends and report results to the Quality Assurance Performance Improvement Committee.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:
Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to identify and investigate incidents of possible neglect and abuse for one of six residents (Residents R29).

Findings include:

The facility policy entitled "Abuse Definitions" dated January 2019, indicated that sexual abuse includes sexual harassment, sexual coercion or sexual assault.

The facility policy entitled "Abuse" dated January 2019, indicated that all staff will be educated on the types of abuse/neglect as defined in the state and federal regulations governing the facility to identify abuse/neglect. All allegations of abuse, neglect, exploitation or mistreatment of residents, including injuries of unknown origin, will be thoroughly investigated by the administrator and support staff.

Review of the Minimum Data Set (MDS- periodic assessment of care needs) dated 3/29/19, indicated that Resident R29 had diagnoses that included diabetes, schizophrenia and chronic obstructive lung disease.

Review of a progress note dated 3/8/19, at 12:54 a.m. indicated that Resident R29 stated that she had engaged in sexual intercourse with an male employee that she identified by a first name. The 3/8/19, progress note indicated that the Registered Nurse Supervisor and Social Services Director were notified.

During an interview on 4/5/19, at 10:24 a.m., the Nursing Home Administrator stated that he was notified of the allegations made by Resident R29 but did not complete an investigation as required.

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

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















 Plan of Correction - To be completed: 05/21/2019

-Resident 29 continues to reside at the facility and was evaluated by the psychiatrist on March 24, 2019.
-The Nursing Home Administrator was re-educated on investigation of allegations.
-Education to staff regarding abuse will be completed with a focus on reporting, preventing and investigating.
The Director of Nursing or designee will review the facilities 24 hour report, interdisciplinary progress notes and grievances for the past fourteen days to ensure that allegations of abuse have been investigated per policy.
-Event reports will be monitored by the Nursing Home Administrator or designee weekly for one month, monthly for three months and quarterly thereafter.
-The facility will review results of monitoring, identify trends and report results to the Quality Assurance Performance Improvement Committee.

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 facility policy, an observation and staff interviews it was determined that the facility failed to provide a dignified dining experience for one of three residents (Resident R106).

During an observation on 4/3/19, at 12:20 p.m. Registered Nurse (RN) Employee E3, was standing while feeding Resident R106 in the hallway then walked away leaving resident with the food tray unable to feed self.

During an interview on 4/3/19, at 12:36 p.m. RN Employee E3, confirmed standing and feeding Resident R106 in the hallway then walking away leaving the resident with food tray in front of him/her. RN Employee E3 confirmed that by doing so, he/she failed to provide Resident R106 with a dignified dining experience.

28 Pa. Code 201.18(a)(b)(e)(1) Management
28 Pa. Code 201.29(a) Resident rights










 Plan of Correction - To be completed: 05/21/2019

-Resident 106 was re-evaluated.
-Registered Nurse 3 was educated on resident rights.
-Staff will be re-inserviced on resident rights with a focus on resident feeding procedures.
-The Director of Nursing or designee will monitor resident dining areas daily for two weeks, then weekly for four weeks and monthly for three months thereafter.
-The facility will review results of monitoring, identify trends, and report results to Quality Assurance Performance Improvement Committee.

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 facility policy and clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for one of three dialysis residents. (Resident R55).

Findings include:

A review of the facility policy "Dialysis Care" dated 1/21/19, indicated that written communication will occur between the facility and dialysis center each day dialysis services are rendered.

A review of the clinical record revealed that Resident R55 was admitted to the facility on 12/6/16, with diagnoses that included end stage renal disease (advanced chronic kidney disease, where the kidneys no longer meet the body's needs) and dependence on renal dialysis (a process to mechanically clean the blood).

A review of the physician orders indicated that Resident R55 goes to dialysis on Monday, Wednesday and Friday.

A review of the clinical record did not include documentation or a communication form for seven of the prior 28 dialysis visits (2/6, 2/8, 2/11, 2/13, 2/18, 3/4 and 3/18 of 2019).

During an interview on 4/5/19, at 2:22 p.m. the Director of Nursing confirmed that the facility failed to make certain consistent dialysis communication was maintained for Resident R55.

28 Pa. Code: Clinical records.
28 Pa. Code: Management.
28 Pa. Code: Resident care policies.
28 Pa. Code: Nursing services.





 Plan of Correction - To be completed: 05/21/2019

-The facility acknowledges that the dialysis communication forms for R55 were not included in the clinical record.
-Nursing staff to review and complete the dialysis communication form prior to the resident leaving for dialysis and upon their return to ensure any information that may assist in the resident's care is included and reviewed.
-Education on F698 with a focus on providing the dialysis communication form and retaining it as part of the medical record.
-The Director of Nursing/Designee will complete random weekly X4 weeks, then monthly X3 months and quarterly thereafter.
-The facility will review results of monitoring, identify trends and report results to Quality Assurance Committee at the scheduled meetings.

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

Based on review of facility policies and clinical records, observations and staff interviews it was determined the facility failed to develop a resident-centered plan of care for the use of a lap belt for one resident (Resident R47.)

Findings include:

The facility "Restraint Use" policy last reviewed 1/21/19, indicated that the facility will use the least restrictive device only after proper evaluation and use of alternative interventions.

The clinical record indicated that Resident R47 was admitted to the facility on 11/15/18, with diagnoses that include intertrochanteric fracture (a break in the upper part of the thigh bone), mild intellectual disabilities and schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms, such as hallucinations or delusions and depression or mania).

During an observation on 4/1/19, at 10:50 a.m. Resident R47 was seated in her wheelchair, with a lap belt in place.

A review of Resident R47's clinical record failed to reveal a resident-centered plan of care with goals and interventions related to her lap belt.

During an interview on 4/5/19, at 9:54 a.m. the Director of Nursing DON confirmed the facility failed to develop a resident centered care plan for the use of a lap belt for Resident R47.

28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: Resident care policies










 Plan of Correction - To be completed: 05/21/2019

-R47's care plan has been updated to reflect the use of the lap belt in the chair.
-Any resident noted with lap belts on their chair following the evaluation from nursing will have their care plans updated accordingly.
-Therapy to inform nursing of any chair containing lap belts either for transport or other reasons and care plans will be updated accordingly.
-Education to be provided on F656 with a focus on care planning restraints following evaluations completed by therapy and nursing.
-The Director of Nursing/Designee will complete random audits weekly X4 weeks, then monthly X3 months and quarterly thereafter.
-The facility will review results of monitoring, identify trends and report results to Quality Assurance Committee at the scheduled meetings.

483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints: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) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with 483.12(a)(2).

483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:

Based on review of facility policies and clinical records, observations and staff interviews it was determined that the facility failed to identify a lap belt as a possible restraint, failed to assess the functional status of the individual resident to determine if the use of a lap belt is a restraint and failed to obtain physician's order for the use of a lap belt for one of two residents (Resident R47.)

Findings include:

The facility "Restraint Use" policy last reviewed 1/21/19, indicated that the facility will use the least restrictive device only after proper evaluation and use of alternative interventions.

The clinical record indicated that Resident R47 was admitted to the facility on 11/15/18, with diagnoses that include intertrochanteric fracture (a break in the upper part of the thigh bone), mild intellectual disabilities and schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms, such as hallucinations or delusions and depression or mania).

During an observation on 4/1/19, at 10:50 a.m. Resident R47 was seated in her wheelchair, with a lap belt in place.

Resident R47's clinical record did not include an assessment for the ability to release her lap belt, a physician's order for the lap belt or a care plan with goals and interventions related to her lap belt.

During an interview on 4/5/19, at 9:54 a.m. the Director of Nursing confirmed the facility failed to assess Resident R47 for a restraint, and failed to obtain a physician's order and develop a resident centered care plan for the use of a lap belt.

28 Pa. Code: 211.8(d)(e) Use of restraints.

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







 Plan of Correction - To be completed: 05/21/2019

-R47 has had an evaluation completed for the use of the lap belt when in her chair. Interview with staff and the therapy department it was noted that the resident is to use the lap belt for transport to and from Community Life Center Visits.
-Any other resident in the facility noted with a lap belt for any use including being used for transport to and from Community Life Center Visits will have an evaluation done for the use of the device and a monitoring schedule for the future.
-Therapy to notify nursing staff of any chair that have the lap belts present their schedule to be used so that nursing can complete an evaluation on the use of the device and orders can be obtained and the plan of care can be updated.
-Education on F606 with the focus on chair containing lap belts either for transport or other reasons in the facility.
-The Director of Nursing/Designee will complete random audits weekly X4 weeks, then monthly X3 months and quarterly thereafter.
-The facility will review results of monitoring, identify trends and report results to Quality Assurance Committee at the scheduled meetings

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

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

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

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

Findings include:

The facility policy "Grievance and Complaints" last reviewed 1/21/19, states that residents have the right to file an anonymous grievance.

During a resident group interview on 4/2/19, at 11:00 a.m. seven of seven alert residents (Resident R600, R601, R602, R603, R604, R605, and R606) living on the Intermediate and Skilled Nursing Units, were asked if they knew who was the Grievance Official and how to they would file a grievance anonymously. Seven of the seven identified the Nursing Home Administrator as the Grievance Official and were unclear on how to file an anonymous grievance and they were unaware of the location of Grievance/Concern Forms.

During observations on 4/5/19, at 11:14 a.m. with the Nursing Home Administrator (NHA) on the Intermediate, Skilled and Memory Impairment Nursing Units revealed there were no Grievance/Concern Forms visible on the units. The NHA confirmed the facility does not have a grievance process that allows a resident or resident representatives to file written grievances anonymously and the resident and/or representative would have to ask a staff member for a Grievance/Concern Form.

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

28 Pa. Code 201.29(i) Resident rights.

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






 Plan of Correction - To be completed: 05/21/2019

The following is being submitted for plan of correction purposes only and should not be construed as an admission.

-The facility's Grievance Official is the Social Service Director.
-The facility Grievance Official will attend Resident Council Meetings to ensure that the residents are aware of who the Grievance Official is and where she can be located and to review the process of completing a grievance.
-Grievance forms will be made available on all units and a secure device/box that the completed grievances can be placed in so that they may remain anonymous will be located in the lobby.
-Education will be provided on F585 with focus on the Grievance Official as well as the placement of the grievance forms and the devices to place them in.
-The Nursing Home Administrator /Designee will complete random audits weekly X4 weeks, then monthly X3 months and quarterly thereafter.
-The facility will review results of monitoring, identify trends and report results to Quality Assurance Committee at the scheduled meetings

51.3 (g)(1-14) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:
Based on review of facility policy, facility documents and staff interview, it was determined that the facility failed to make certain that all alleged violations involving abuse and/or neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made to the state agencies as required for two of six residents (Residents R43 and R29 ).

Findings include:

A review of facility policy "Abuse" last reviewed 1/21/19, indicated the facility will report all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, following federal and state regulations.

A review of the quarterly Minimum Data Set (MDS- periodic review of care needs) dated 2/13/19, indicated that resident R43 was admitted on 2/13/18, and current diagnosis included aphasia (difficulty speaking), right sided stroke, and seizures, and arthritis.

A review of an incident report dated 11/17/18, indicated Resident R43's leg was bleeding, but she stated that she did not know what she hit her leg on in the bathroom to cause the bleeding. Resident R43 was sent to the hospital for stitches. The report did not contain information that the state agencies were notified.

During an interview on 4/4/19, at 11:11 a.m. the Director of Nursing and Compliance Registered Nurse Employee E13, confirmed that the facility failed to notify the state agency as required.

Review of the MDS dated 3/29/19, indicated that Resident R29 had diagnoses that included diabetes, schizophrenia and chronic obstructive lung disease.

Review of a progress note dated 3/8/19, at 12:54 a.m. indicated that Resident R29 stated that she had engaged in sexual intercourse with a male employee that she identified by a first name. The 3/8/19, progress note indicated that the Registered Nurse Supervisor and Social Services Director were notified.

During an interview on 4/5/19, at 10:24 a.m., the Nursing Home Administrator confirmed that he was notified of the allegations made by Resident R29 but did not notify the state agency or other agencies as required.





 Plan of Correction - To be completed: 05/21/2019

-The completed reports for residents R43 and R29 were submitted to the state agency on April 2, 2019.
-The Nursing Home Administrator and Director of Nursing were re-educated on reporting requirements.
-Education to staff regarding abuse will be completed with a focus on reporting.
The Director of Nursing or designee will review the facilities 24 hour report, interdisciplinary progress notes and grievances for the past fourteen days to ensure that allegations of abuse have been investigated per policy.
-Event reports will be monitored by the Nursing Home Administrator or designee weekly for one month, monthly for three months and quarterly thereafter.
-The facility will review results of monitoring, identify trends and report results to the Quality Assurance Performance Improvement Committee.

211.9(c) LICENSURE Pharmacy services.:State only Deficiency.
(c) Medications and biologicals shall be administered by the same licensed person who prepared the dose for administration and shall be given as soon as possible after the dose is prepared.
Observations:

Based on facility policy, observation and staff interviews, it was determined that facility failed to ensure that medications were administered by the same licensed person who prepared the dose on one of two nursing units (Skilled Nursing Unit).

Findings include:

A review of the facility "Administration of Oral Medications" policy dated 1/21/19, indicated that licensed staff will administer physician ordered medications following acceptable standard of care.

During an observation on 4/3/19, at 12:20 p.m. on the Skilled Nursing unit Registared Nurse (RN) Employee E3 poured a red oral medication in a medication cup at the medication cart in the hallway. RN Employee E3 identifed resident who was to receive the medication then handed the medication to RN Supervisor Employee E4.

During an interview on 4/3/19, at 12:34 p.m. RN Supervisor Employee E4 confirmed that he/she administered the medication prepared by RN Employee E3.





 Plan of Correction - To be completed: 05/21/2019

-Registered Nurse 3 and 4 will be re-educated on administration of oral medications.
-Licensed staff will be re-inserviced on administration of oral medication.
-The Director of Nursing or designee will monitor medication administration randomly on 2 licensed staff daily for two weeks, then weekly for four weeks and then random observation monthly for three months.
-The facility will review results of monitoring, identify trends, and report results to Quality Assurance Performance Improvement Committee.


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