Nursing Investigation Results -

Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT LAKESIDE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
KADIMA REHABILITATION & NURSING AT LAKESIDE
Inspection Results For:

There are  46 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.
KADIMA REHABILITATION & NURSING AT LAKESIDE - 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 Abbreviated Complaint Survey completed on March 8, 2019, it was determined that The Gardens at Lakeside was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.10(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 observation of the facility's stock room and staff interview, it was determined that the facility failed to maintain clean resident care equipment and failed to store resident care equipment and supplies in a sanitary and orderly manner.


Findings include:

Observations of the facility's stock room on March 6, 2019, at approximately 1 PM revealed that the door to the room was unlocked. The floor was dirty and paper debris, styrofoam cups and plastic cups littered the floor of the stock room.

On the top shelf of a tiered, metal shelving unit was a large, open bag of cotton balls.

On the floor behind the entrance door was a large cobweb.

The door to the stock medication closet (located inside of this room) was open. The closet contained multiple cardboard boxes stacked on top of each other, to include outdated cleansing wipes, a case of insulin syringes, two cases of tracheostomy care kits and several used, dirty tube feeding and intravenous pumps.

In an additional storage closet (located within this room) multiple clean, bagged oxygen concentrators were observed. Stored next to the clean oxygen concentrators were two broken, dirty oxygen concentrators.

On a shelf in the stock room there were multiple boxes of outdated dressings and dressing supplies, oxygen supplies.

These observations were confirmed at the time of the observations by Employee 1 (central supply/medical records staff).

During an interview March 6, 2019, at approximately 2 PM the Nursing Home Administrator confirmed that the facility failed to store resident care equipment in a sanitary manner.

An observation of Resident 4's room on March 8, 2019, at approximately 11 AM revealed the resident's geri-chair along with multiple cushions and blankets on the chair used by the resident while seated in the chair. There was a strong urine-like odor emanating from the chair at the time of this observation, which was confirmed at that time by the Director of Nursing.

F584
previously cited 2/23/18

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





 Plan of Correction - To be completed: 04/02/2019

1. The facility's stock room was immediately deep cleaned to address the cobweb and debris. Open, outdated and broken items were immediately discarded. The stock room was immediately re-organized to ensure resident care equipment and supplies were maintained in a clean and orderly manner. Resident 4 had just been provided incontinence care. The room and geri-chair were deep cleaned immediately.
2. A facility wide audit was completed to identify other areas throughout the facility that house resident equipment needing cleaning or re-organization. These areas were addressed appropriately. A facility wide audit was completed to identify other wheelchairs needing deep cleaning.
3. The Central Supply Clerk and Environmental Services Director were re-educated on maintaining and storing resident care equipment and supplies in a sanitary and orderly manner. A wheelchair cleaning schedule will be followed. The NHA and Environmental Services Director will do weekly environmental rounds.
4. The NHA or designee will conduct an audit of the facility stock room and wheelchair cleanliness weekly x 4 weeks then monthly x 2 months to ensure resident care items and supplies are stored in a sanitary and orderly manner. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(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 clinical record review, observation and staff interview, it was determined that the facility repeatedly failed to follow physician orders for oxygen therapy for one of 12 residents (Resident 4).

Findings include:

A review of the clinical record revealed that Resident 4 was admitted to the facility on September 7, 2016, with diagnosis to include acute respiratory distress syndrome and had a tracheostomy ( a medical procedure - either temporary or permanent - that involves creating an opening in the neck in order to place a tube into a person ' s windpipe. The tube is inserted through a cut in the neck below the vocal cords. This allows air to enter the lungs. Breathing is then done through the tube, bypassing the mouth, nose, and throat).

The resident's current monthly recapped physicians orders for March 2019, dated February 21, 2019, included humidified oxygen at 3 L via the trach collar, every shift, continuously.

An observation on March 6, 2019, at 11:15 AM and March 7, 2019, at 9:30 AM revealed Resident 4 was seated in a reclining geri-chair in the resident dining room during an activity. On both occasions this resident was receiving unhumidified oxygen.

The observations were confirmed during an interview March 7, 2018, the Director of Nursing, confirmed that resident should have humidified oxygen at all times.

F695
previously cited 2/23/18

28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services
Previously cited 2/10/17







 Plan of Correction - To be completed: 04/02/2019

1. The facility is unable to retroactively provide humidified oxygen during the observation.
2. There are no other residents receiving humidified oxygen.
3. The Licensed Nursing Staff was re-educated on following physician orders for oxygen therapy. The RN Supervisor will conduct rounds each shift to ensure Resident 4's oxygen is humidified.
4. The DON or designee will conduct an audit of residents receiving oxygen therapy weekly x 4 weeks then monthly x 2 months to ensure physician orders are being followed.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

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

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

Based on clinical record and staff interview, it was determined that the facility failed to consistently provide restorative nursing services as planned and evaluate the effectiveness and continued appropriateness of restorative services designed to maintain the functional abilities of one resident out of 12 residents sampled (Resident 4).

Findings include:

A review of the facility policy, dated as reviewed by the facility October 5, 2018, for Restorative Nursing Program revealed that residents will be assessed to determine, at least quarterly, for an appropriate restorative nursing program to attain, maintain and prevent decline in activities of daily living. The guidelines included, a licensed nurse will be responsible for developing and supervising the nurse aide and restorative aide staff in providing education and supervision of the restorative program, assessing the need for continuation or change in the program, assuring restorative nursing program is documented in the electronic documentation program, quarterly assessments and the residents care plan and developing and expanding the restorative program, in conjunction with the Director of Nursing and the rehabilitation department.

A review of the clinical record revealed that Resident 4 was admitted to the facility on September 7, 2016, with diagnosis to include, acute respiratory distress syndrome, Down syndrome (Down syndrome (DS or DNS), is a genetic disorder associated with physical growth delays, mild to moderate intellectual disability and characteristic facial features), dementia, seizures and a gastrostomy feeding tube (fed through a tube directly into the stomach). The resident was non-ambulatory and had severe foot drop (the inability to lift the front part of the foot).

A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 6, 2019, indicated that the resident was severely cognitively impaired and was dependent on staff for all activities of daily living (ADLs- the basic tasks of everyday life, such as eating, bathing, dressing, toileting and transferring), was at risk for pressure sores and was on a passive range of motion, restorative nursing program.

A review of a nursing plan of care for RNP (restorative nursing program) dated September 22, 2016, revealed the plan for a RNP to both lower extremities, daily. The noted goal was that the resident will tolerate her passive range of motion (PROM) exercises to both lower extremities over the next 90 days. the interventions included preform PROM to both lower extremities in all planes x 20 reps each to the residents tolerance.

A review of RNP documentation for January 2019, February 2019 and March 2019 revealed that the resident's restorative nursing program was not consistently provided to the resident daily as planned. The documentation that was present for the provision of the program, which included the number of minutes each RNP session lasted, failed to identify the number of repetitions completed at each session as per the plan of care.

A review of nursing documentation dated February 25, 2019, at 5:30 PM Employee 3 (Restorative RN) documented "Resident 4 is on a RNP for passive range of motion, she is tolerating her PROM exercises with no further decline or contracture formation."

There was no documented evidence at the time of the survey that the resident's restorative nursing program were reviewed and evaluated at planned intervals to ensure consistent implementation by staff, the resident's participation and response and continued appropriateness of the established program or if revisions were necessary to meet the resident's goals.



28 Pa. Code 211.5(f)(h) Clinical records
Previously cited 2/23/18

28 Pa. Code 211.10(a)(c)(d) Resident care policies

28 Pa. Code 211.12(a)(c)(d)(5) Nursing services
Previously cited 2/23/18















 Plan of Correction - To be completed: 04/02/2019

1. Resident 4's restorative nursing program was reviewed by the IDT for appropriateness. Resident 4's Task List was updated to include the number of repetitions completed.
2. A facility wide audit was completed to identify other residents on Restorative Nursing Programs. Their programs were reviewed for appropriateness by the IDT and their Task Lists were updated to include the number of repetitions.
3. The Restorative RN was re-educated on planning and evaluating the effectiveness and continued appropriateness of the restorative services designed to maintain the functional abilities of residents.
4. The DON or designee will conduct an audit of 25% of residents with restorative nursing programs weekly x 4 weeks then monthly x 2 months to ensure the programs are planned and evaluated appropriately.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to timely assess and treat a pressure sore (Resident 4) and implement interventions planned to prevent pressure sore development (Resident 21) for two of 12 sampled residents.

Findings include:

A review of a the facility policy for skin and wound healing program, last reviewed by the facility October 5, 2018, revealed that wound care, physician led program is multifaceted with an interdisciplinary team approach, focused on the treatment and healing of acute and chronic wounds. This is to include a complete and thorough wound assessment and staging, scheduled assessments to monitor staging and individualized care planning and wound care treatment approach.

A review of the clinical record revealed that Resident 4 was admitted to the facility on September 7, 2016, with diagnoses to include, acute respiratory distress syndrome, Down syndrome (Down syndrome (DS or DNS), also known as trisomy 21, is a genetic disorder typically associated with physical growth delays, mild to moderate intellectual disability, and characteristic facial features) dementia, seizures and gastrostomy feeding tube feed (a tube directly into the stomach).

A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 6, 2019, indicated that the resident was severely cognitively impaired and was dependent on staff for all activities of daily living (ADLs- the basic tasks of everyday life, such as eating, bathing, dressing, toileting and transferring) and was at risk for pressure sores.

A review of a facility incident investigation report dated February 6, 2019, at 7 AM revealed that Resident 4 was found with a ruptured blister to the top of her right foot. There was no additional description of the area including drainage, size or surrounding skin noted. The root cause noted for the development of this area was friction from the bed sheets. The investigation revealed that the area initially presented as a dislodged flake of skin related to xerosis (abnormally dry skin). The resident is also noted to cross her left foot over her right foot at times.

A review of a Wound Consultant Physician report dated February 11, 2019, revealed that Resident 4 had a shear wound of the right, dorsal (top of the foot) foot. There was light serous (serous fluid or serosal fluid is used for various bodily fluids that are typically pale yellow and transparent and of a benign nature) drainage. The area measured 3 cm x 2 cm x 0.1 cm. The noted treatment was Xeroform (a sterile wound dressing that is non-adherent , which means it won't stick to the wound so dressing changes are less painful and trauma to the wound is minimized. Xeroform is also an occlusive dressing which means the dressing prevents air from reaching the wound) dressing daily.

There was no documented evidence that the facility had conducted a complete assessment of the skin impairment on the resident's foot at the time the area was initially discovered.

The complete assessment was completed by the Wound Care Physician, conducted five days after facility staff had identified the pressure sore.

During an interview March 7, 2019, at approximately 1:30 PM the Director of Nursing stated that the wound assessments, including measurements and descriptions are completed when the consultant wound care Physician is in the facility. The DON confirmed that facility's nursing staff did not conduct a clinical assessment of the resident's wound prior to the wound physician's assessment five days after identification of the resident's skin breakdown.

A review of Resident 21's clinical record and incident report dated January 31, 2019, revealed that a nurse aide who had been providing daily care to the resident observed a darkened area measuring 3 cm x 3 cm on the resident's left heel.

A review of the resident's care plan dated January 22, 2019, revealed interventions in place to include bilateral heel float boots on at all times, turn and reposition with skin care every two hours and off load heels.

Further review of the resident's clinical record revealed no documented evidence that the facility had implemented the planned interventions to prevent pressure sore development.

During an interview with the Director of Nursing on March 8, 2019, at 11:45 AM, confirmed there was no documented evidence to indicate that the facility had implemented the planned interventions to prevent Resident 21's pressure sore.


28 Pa Code 211.11 (a)(c) Resident care plan
previously cited 2/23/18

28 Pa Code 211.12 (a)c)(d)(1)(3)(5) Nursing services
previously cited 2/23/28

28 Pa Code 211.10 (a)(d) Resident care policies












 Plan of Correction - To be completed: 04/02/2019

1. Residents 4 and 21's pressure ulcers have been healed.
2. A facility wide audit was completed to ensure residents with pressure ulcers had measurements taken and interventions in place as appropriate.
3. The Registered Nurses were re-educated on providing timely assessment and treatment of a pressure sore. The Licensed Nursing Staff were re-educated on implementing interventions planned to prevent pressure sore development. Wounds will be reviewed at a weekly CQI meeting to ensure timely assessment, treatment and interventions are in place.
4. The DON or designee will conduct an audit of 25% of residents with pressure ulcers weekly x 4 weeks then monthly x 2 months to ensure timely assessment, treatment and interventions. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

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

Based on clinical record review and staff interview, it was determined that the facility failed to follow physician orders for medication administration for one resident out of 12 sampled (Resident 10)

Findings include:

A review of the clinical record revealed that Resident 10 was admitted to the facility with diagnoses that included depression, atherosclerotic cardiovascular disease (hardening and thickening of the walls of the arteries) and hypertension (elevated blood pressure).

Physician's orders dated November 23, 2018, called for staff to administer the medication metoprolol tartrate (a medication used to treat hypertension) 12.5 milligrams (mg) twice a day and to hold the medication when the resident's systolic blood pressure is less than 90 mmHg (millimeters of mercury) or when the heart rate is less than 50 beats per minute. [Systolic blood pressure (SBP) - occurs when the heart is contracting causing maximum arterial pressure during contraction of the left ventricle of the heart and the systolic blood pressure, for example, is the first number recorded as 120/80 mmHg (the SBP is the 120 mmHg).

A review of the resident's medication administration record for the months of Janaury 2019, February 2019 and until March 6., 2019, revealed no documented evidence that nursing staff had obtained the resident's blood pressure and/or heart rate prior to administering metoprolol tartrate 12.5 mg to the resident to ensure the necessity of administration based on the physician prescribed parameters.

Interview with the nursing home administrator and director of nursing on March 7, 2019, at approximately 1:18 p.m. confirmed that there was no documented evidence on the aforementioned months, indicating that staff had obtained the resident's blood pressure and heart rate prior to administering the prescribed medication according to physician orders.


28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services.
Previously cited 2/23/18
































 Plan of Correction - To be completed: 04/02/2019

1. The facility is unable to retroactively obtain the resident's blood pressure and heart rate prior to administering Metoprolol tartrate 12.5 mg. The supplemental documentation on the order was discontinued in error by the former DON.
2. A facility wide audit was completed to identify other residents with supplemental documentation needs prior to medication administration. Orders were updated as appropriate.
3. The Licensed Nursing Staff were re-educated on following physician orders for medication administration. The DON will complete an order listing summary review daily to ensure orders with supplemental documentation are entered appropriately.
4. The DON or designee will conduct an audit of 25% of residents with parameter orders weekly x 4 weeks then monthly x 2 months to ensure supplemental documentation. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

483.24(c)(2)(i)(ii)(A)-(D) REQUIREMENT Qualifications of Activity Professional: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.
483.24(c)(2) The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who-
(i) Is licensed or registered, if applicable, by the State in which practicing; and
(ii) Is:
(A) Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or
(B) Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or
(C) Is a qualified occupational therapist or occupational therapy assistant; or
(D) Has completed a training course approved by the State.
Observations:

Based on staff interviews and a review of employee personnel records it was determined that the facility's activities program was not directed by a qualified professional.

Findings included:

Interview with Employee 2 (activity director ) on March 6, 2019, at approximately 10:30 a.m. revealed that the employee had been working as the facility's Activity Director since August 2016.

During an interview with the nursing home administrator on March 7, 2019, at approximately 12:00 p.m. it was determined that Employee 2 was not a qualified therapeutic recreation specialist or an activities professional.

A review of Employee 2's personnel record confirmed that the employee did not possess the regulatory required qualifications for the position of director of activities.



28 Pa. Code 201.3 Definitions.

28 Pa. Code 201.18(e)(6) Management










 Plan of Correction - To be completed: 04/02/2019

1. The Activities Director meets the Activity Director Certified (ADC) requirements under NCCAP guidelines. An application was submitted to the NCCAP to privilege to test. A temporary Qualified Activities Director Consultant was contracted until the current Activities Director received her certification.
2. The residents of the facility's activity programming could be impacted by this deficiency.
3. The NHA or designee will be re-educated by facility ownership on providing activities programming that is directed by a qualified professional.
4. A Qualified Activities Director Consultant will conduct an audit of activities programming weekly until the current Activities Director receives her certification. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident: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.
483.24(c) Activities.
483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
Observations:

Based on observation, review of the facility's activities calendar and the facility's Activity Policy and interviews with residents and staff, it was determined that the facility failed to design and provide an ongoing program of activities to meet the functional needs, abilities, preferences and interests of the residents to include evening activities for residents as desired by residents, including Residents 12, 22, 1, 19 and 28.

Findings include:

Review of the facility's policy entitled "Activity/Recreation Programs," last reviewed by the facility on October 5, 2019, revealed that the facility will provide small, large and individualized programs designed to meet the residents needs. programming reflects the schedules, choices and the rights of the residents within the facility and are offered on weekends, holidays, evenings (at least 2) and are scheduled at hours, which are convenient to the residents.

A review of the facility's monthly activities calendars for January 2019 and February 2019, revealed an activity titled "News," which consists of the staff reading the newspaper to the residents who choice to partake. This activity was offered twice a week at 5:30 PM. There was no activities offered to the residents later in the evening, after supper to meet residents needs/choices.

A review of the facility's monthly activities calendar for March 2019, revealed that the 5:30 PM News activity was no longer offered to the residents.

During a group interview with five residents (Residents 12, 22, 1, 19 and 28), who also regularly attend the monthly Resident Council meetings, the resident stated that they are not offered an evening activity after their supper meal. The resident's stated that they would enjoy participating in an evening activity, especially Bingo. All residents in attendance at the group meet stated that activity staff has never asked them if they would like an activity program offered to them during the evening hours.

During an interview with the Nursing Home Administrator on March 7, 2019, it was confirmed there was no ongoing program of activities to meet the functional needs, abilities, preferences and interests of the residents to include evening activities for residents of the facility.




28 Pa. Code 201.29(a)(j) Resident rights
Previously cited 2/23/18














 Plan of Correction - To be completed: 04/02/2019

1. Residents 1, 12, 19, 22 and 28's activity care plans were updated to reflect preference to participate in evening activities.
2. A Resident Council Meeting was held to discuss evening activities and identify those residents who would like to participate. Residents that did not attend the Resident Council Meeting were visited 1:1 by the Activities Director to be offered an evening activity.
3. The Activities Director was re-educated on providing an ongoing program of activities to meet the functional needs, abilities, preferences and interests of the residents to include evening activities as desired. The NHA will attend Resident Council Meetings, with the resident's permission, to discuss the upcoming month's activity programming and calendar.
4. The NHA or designee will conduct an audit of the monthly resident activity calendar monthly x 6 months to ensure activity programming meets the resident's needs and preferences.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to afford residents the right to formulate advance directives (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) as evidenced by three out of 12 residents sampled (Resident 31, 9 and 4).

Findings include:

A review of the clinical record revealed that Resident 31 was admitted to the facility on Janaury 9, 2019. Further review of the above resident's clinical record failed to indicate whether the resident had an advance directive. The resident's clinical record did not include documented evidence of discussions of the resident's right to formulate an Advance Directive or how to go about formulating an Advanced Directive if the residents wished to do so.

A review of the clinical record revealed that Resident 9 was admitted to the facility on September 27, 2019. Further review of the above resident's clinical record failed to indicate whether the resident had an advance directive. The resident's clinical record did not include documented evidence of discussions of the resident's right to formulate an Advance Directive or how to go about formulating an Advanced Directive if the residents wished to do so.

A review of the clinical record revealed that Resident 4 was admitted to the facility on September 7, 2016. Further review of the above resident's clinical record failed to indicate whether the resident had an advance directive. The resident's clinical record did not include documented evidence of discussions of the resident's right to formulate an Advance Directive or how to go about formulating an Advanced Directive if the residents wished to do so.

An interview with the nursing home administrator (NHA) on March 8, 2019, at approximately 8:25 a.m. failed to provide evidence that each resident was provided information on the right to formulate an advance directive or how to formulate an advanced directive if they wished to do so.




28 Pa. Code 211.5 (f) Clinical records
Previously cited 2/23/18

28 Pa. Code 201.29 (a)(d)(i) Resident rights
Previously cited 1/12/18, 9/16/18















 Plan of Correction - To be completed: 04/02/2019

1. Residents 4, 9 and 31 were given advanced directives information on admission; however, it was not documented by the Social Worker. The facility is unable to retroactively document evidence of discussions of the resident's right to formulate an advanced directive.
2. A facility wide audit was completed to ensure documentation of the resident's right to formulate an advanced directive. Assistance was provided to those residents that chose to proceed with implementing an advanced directive.
3. The Social Worker will be re-educated on Resident Rights as it pertains to their right to formulate an advanced directive. The NHA will review Social Services documentation after a resident admits to the facility to ensure advanced directive formulation rights are afforded.
4. The NHA or designee will conduct an audit of new admissions social services progress notes weekly x 4 weeks then monthly x 2 months to ensure discussion of the resident's right to formulate an advanced directive is documented and assistance is provided if desired. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

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 staff interview and review of clinical records and select facility policy, it was determined that the facility failed to timely consult with the physician regarding significant weight changes for one resident out of 12 sampled (Resident 23).

Findings include:

A review of a facility policy entitled "Resident Weights" reviewed by the facility on October 5, 2018, revealed that residents with notable weight change will be re-weighed at the discretion of the dietitian within 72 hours. Further review of the policy indicated that if the weight change is significant (an unplanned weight loss or gain of 5% in a month) the physican, dietitian and family will be notified.

Review of the facility's "Vital Records Report" dated March 7, 2019, revealed that the resident weighed 172 pounds on December 1, 2019, 182.5 pounds (representing a weight gain of 10.5 pounds or 6.1 % in one month) and 181 pounds on February 1, 2019.

There was no documented evidence that the physician was notified of the resident's significant weight gain when identified on February 1, 2019.

Interview with the nursing home administrator on March 8, 2019, at approximately 9:43 a.m., confirmed that the facility failed to timely notify the physcian of Resident 23's weight gain.


28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services.
Previously cited 2/23/18

























 Plan of Correction - To be completed: 04/02/2019

1. Resident 23's Physician was immediately notified of weight gain upon observation.
2. A facility wide audit was completed to ensure physicians of residents with weight gains in the past 30 days were notified.
3. Licensed nursing staff will be re-educated on the Resident Weights policy as it relates to physician notification of weight gains. The CDM will conduct a weekly audit to ensure physician notification occurs with weight changes.
4. The NHA or designee will conduct an audit of resident weight gains weekly x 4 weeks then monthly x 2 months to ensure physician notification occurred. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

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

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

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

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

Based on clinical record review and staff interview, it was determined the facility failed to ensure that a written notice of transfer to the hospital was provided to the resident and the residents' representative for three of 12 residents reviewed (Residents 29, 25 and 22).

Findings include:

A review of the clinical record revealed that Resident 29 was transferred and admitted to the hospital on December 19, 2018.

A review of the clinical record revealed that Resident 25 was transferred and admitted to the hospital on Janaury 22, 2019, and returned to the facility on January 25, 2019.

A review of the clinical record revealed that Resident 22 was transferred and admitted to the hospital on Janaury 21, 2019, and returned to the facility on January 24, 2019.

Further review of the clinical records of the above residents revealed no documented evidence that written notice was provided to these residents and the resident representatives regarding the transfers that included the required contents: contact and address information for the Office of the State Long-Term Care Ombudsman, and if applicable, information for the agency responsible for the protection and advocacy of individuals with developmental disabilities.

Interview with the Nursing Home Admistrator on March 7, 2019, at approximately 9:45 a.m. verified that the facility does not send written notices to the resident and residents' representative with information, applicable to the information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. The facility was unaware of some the notification requirements at the time of this survey, but does sent a monthly notice to the State Ombudsman.


28 Pa. Code 201.29(h) Resident rights.

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



























 Plan of Correction - To be completed: 04/02/2019

1. The facility is unable to retroactively provide residents 22, 25 and 29 with a written notice of transfer to the hospital that includes information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. These individuals did not meet this criterion; therefore, the contact information was not provided at the time the written notice was provided.
2. A facility wide audit was completed to identify residents transferred to the hospital in the past 30 days and updated letters went provided to residents/responsible parties.
3. The NHA and BOM will be re-educated by facility ownership on providing written notice of transfer to the hospital that includes information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. The BOM will provide the written notices as soon as practicable.
4. The NHA or designee will conduct an audit of resident transfers to the hospital weekly x 4 weeks then monthly x 2 months to ensure an appropriate written notice of transfer was given to the resident/responsible as soon as practicable. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

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

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

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

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

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

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

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

Based on a review of clinical records and staff interviews, it was determined that the facility failed to attempt a gradual dose reduction of of a psychoactive medication for one out of five sampled residents (Resident 20).

Findings include:

Review of Resident 20's clinical record revealed a physician order dated August 31, 2017, for Lorazepam (an anti-anxiety medication) 0.5 mg two times a day related to generalized anxiety disorder.

A review of a pharmacy recommendation dated January 4, 2018, revealed that the physician requested that the physician consider an attempted dose reduction or trial discontinuation of the Ativan. The physician's response was that he disagreed, solely indicating that a gradual dose reduction may result in destabilization.

During an interview with the Nursing Home Administrator and Director of Nursing on march 8, 2019, the NHA confirmed there was no attempt of a gradual dose reduction for the Ativan for Resident 20.



28 Pa. Code 211.2(a) Physician Services
Previously cited 2/23/18

28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services
Previously cited 2/23/18

28 Pa. Code 211.5 (f)(g)(h) Clinical Records

28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services







 Plan of Correction - To be completed: 04/02/2019

1. Resident 20's Lorazepam was successfully GDR'ed.
2. A facility wide audit was completed to determine other residents receiving psychotropic medications that were due for a GDR.
3. The Psychotropic Reduction Committee was re-educated on ensuring a GDR on each psychoactive medication is attempted per regulation. The Psychotropic Reduction Committee will meet quarterly to review psychoactive medication use.
4. The NHA or designee will conduct an audit of 25% of residents receiving psychotropic medications weekly x 4 weeks then monthly x 2 months to ensure a GDR was attempted.


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