Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT ORANGEVILLE, THE
Patient Care Inspection Results

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GARDENS AT ORANGEVILLE, THE
Inspection Results For:

There are  56 surveys for this facility. Please select a date to view the survey results.

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GARDENS AT ORANGEVILLE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on March 5, 2019, it was determined that The Gardens at Orangeville was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 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 observations, resident interview and a review of grievances lodged with the facility it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a clean resident environment and availability of necessary hygiene products.

Findings include:

Review of grievances lodged with the facility revealed that on December 20, 2018, Resident 86 filed a grievance because brown splattered stains were on the in the interior surface of the resident's bathroom door. The grievance also noted that the floor between the beds in the resident's room was dirty and dust accumulated on the floor.

On January 10, 2019, Resident 86 and Resident 18 filed a grievance that they frequently do not have paper towels, tissues and toilet paper.

On January 14, 2019, Resident 91 filed a grievance stating that the nurse aides drop gloves after care and don't clean them up and they receive basins/bins that are soiled with mouth wash and soap.

On February 18, 2019, Resident 75 filed a grievance reporting that the resident's room had not been cleaned since his admission, the resident's bathroom was "filthy" and there was a sticky spot on the floor "since he got there."

Observation on March 5, 2019, at 12:30 p.m. of Resident 70's dresser, top surface of the wardrobe, television, and window sill revealed that surfaces were coated with lint, dust and cob webs.

Observation on March 5, 2019 at 11:25 a.m. and 11:32 a.m. respectfully, of Resident 13, and Resident 14's rooms revealed lint and dust balls on the tops of the residents' wardrobes.

Interview with the administrator on March 5, 2019, at approximately 1:30 p.m., confirmed that the environment was to be maintained in a clean and orderly manner.



28 Pa. Code 207.2(a) Administrator's Responsibility.
Previously cited 7/13/18




 Plan of Correction - To be completed: 04/05/2019

Resident 86, 91, 18, 75 issues were all addressed at the time of the grievance being filed. Resident 70, 13 and 14 were all cleaned immediately.
All residents rooms were audited for cleanliness and to ensure all were equipped with toilet paper, paper towels and tissues.
Housekeeping staff will be re-educated on appropriate cleaning of residents rooms to include high dusting and window sills, bathrooms and ensuring tissues, paper towels toilet paper are available at all times. Nursing staff will be re-educated on cleanliness of facility, appropriate use of trash cans and cleanliness of residents basins/bins.
Audit of resident areas will be completed 2x week by the housekeeping director and NHA x4 weeks, then weekly.
Results of audits to QA for review and recommendations.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs: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.
483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

483.55(b) Nursing Facilities.
The facility-

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

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

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

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

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

Based on review of clinical records and staff interview, it was determined that the facility failed to timely obtain routine dental services for one Medicaid payor sources out of six residents sampled (Resident 100) for dental services.

Findings include:

Review of Resident 100's clinical record indicated that the resident saw a dentist on November 9, 2018. The dentist identified a broken tooth, but it was not repaired because the resident needed an order from her physician indicating that she may receive an anesthetic prior to the composite filling.

At the time of the survey ending March 5, 2019, there was no evidence that the resident's physician was notified of the resident's dental needs and/or an order obtained to proceed with the tooth repair.

Interview with the Director of Nursing on March 5, 2019 at 12:30 p.m. confirmed that the resident's tooth had not yet been repaired as identified during the dental service on November 9, 2018.



28 Pa. Code 211.12(c)(d)(3)(5) Nursing services
Previously cited 7/13/18.

28 Pa. Code 211.15(a) Dental services




 Plan of Correction - To be completed: 04/05/2019

Resident 100 will have her tooth repaired April 16, 2019.
All dental consults for the last 3 months will be reviewed for appropriate follow up.
Licensed staff will be re-educated on follow through for consultant recommendations with primary care physicians.
Audit of 25% of dental consults by DON/designee weekly x4, then monthly x2.
Results of audits to QA for review and recommendations.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:

Based on interviews with residents and staff and a review of grievances lodged with the facility, it was determined that the facility failed to consistently serve palatable food to the residents, including Residents 72, CR2, 34, 35, CR3, 78, 70, 74, 95, 72, 43, 93, CR4).

Findings include:

On December 12, 2018, Resident 72 filed a grievance that mashed potatoes are served too frequently and they are too salty. The resident received a mechanical soft diet and sometimes the hamburger served to him chopped, sometimes its served whole and some other foods he receives are pureed. The grievance noted that the foods are usually cold at most meals.

On December 28, 2018, Resident CR2 filed a grievance noting that he did not like any food on his lunch tray and he wants coffee with his meal.

On December 28, 2018, Residents 34 and 35 filed a grievance indicating that the potatoes were not cooked enough to chew and the chicken was pink and not cooked enough at the lunch meal.

On December 31, 2018, Resident CR3 complained that the potatoes salad and scalloped potatoes were hard and undercooked and the resident was unable to eat. The grievance indicated that the food is luke warm and the resident had not had a hot meal since admission. Resident CR3 complained that the chilli was too spicy hot so she requested a hot dog as an alternate, but did not receive it.

On December 31, 2018, Resident 74 complained that she was tired of not having appropriate foods available to her and a lot of nights alternates are not available and she rarely gets soda that with her meals.

A third grievance filed on December 31, 2018, indicated that Resident 95 complained that there were no foods available to him that he can eat; all items that he checked on the menu he did not receive on his meal tray.

A grievance filed on January 1, 2019, by Resident 72 indicated that at the resident's lunch meal, he did not get receive his cup of soup, his peas were cold and possibly never cooked, his hot dog was salty and he didn't get any sauerkraut. The resident stated that he has had a problem with his meals "everyday and is tired of it."

On January 16, 2019, Resident 43 filed a grievance that dietary (staff) had not met with her to determine her preferences. The resident stated that she was receiving food she does not like. When asking for an alternative, she was offered a hot dog or hamburger and she accepted the hot dog. When the aide went to the kitchen there were no not dog buns and the kitchen sent up the hot dog on a dinner roll. The hot dog was not on a plate or napkin, the aide was holding it in her hand and it was handed to the resident that way.

On February 12, 2019, Resident 93 filed a grievance that she was unhappy with the meal served on February 11, 2019, complaining that the "meat was hard and the portions were too small."

On February 13, 2019, Resident CR4 filed a grievance that she requires a low fat, low salt, diabetic diet and she was receiving "carbs and salt." The resident complained that she was getting juices that tasted like "pure sugar" and no one had met with her about her food preferences. The resident stated that she receives coffee and would like tea and that she has asked several times about having someone from dietary meet with her.

During interview with Resident 78 on March 5, 2019 at 10:45 a.m. she complained that the meats served were either overcooked or undercooked. In addition, the resident stated that alternates were not always available at meals.

Interview with Resident 70 on March 5, 2019, at 12:30 p.m. revealed that the resident complained that the meats served were either overcooked or undercooked and were tough to chew.

Interview with the NHA on March 5, 2019, at approximately 1:30 p.m. confirmed that the facility had received multiple complaints from residents regarding the palatability, temperature and quality of food served.



28 Pa. Code: 211.16(c)(d) Dietary Services.
Previously cited 7/13/2018

28 Pa. Code: 201.29(i) Resident Rights.
Previously cited 7/13/2018





 Plan of Correction - To be completed: 04/05/2019

Residents 72,34, 35, 74, 95, CR2 and CR4 issues were all addressed at the time of the grievance being filed. Dietary manager/Dietician met with resident 70 and 78 to discuss dietary concerns.
Residents were invited to a special food committee meeting held with dietary manager/dietician to discuss any current concerns/issues.
Dietary staff re-educated on proper cooking, temperature, serving and presentation of all resident meals.
Audit of 10% of meal trays will be completed by dietary manager/dietician 2x week x4 weeks, then weekly to ensure food preparation is palatable, attractive, and at a safe and appetizing temperature.
Results of audits to QA for review and recommendations.


483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

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

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

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

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

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

Based on a review of clinical records, information submitted by the facility and a facility incident investigation and staff interviews , review of an Event Report and facility investigation and staff interview, it was determined that the facility failed to maintain complete and accurate clinical records for one of 15 resident's sampled (Resident 54).

Findings include:

A review of the clinical record of Resident 54 revealed admission to the facility on February 4, 2019, with diagnoses of hypertension, bipolar, and depression. Review of information dated March 1, 2019, submitted by the facility revealed that on February 23, 2019 at 9:00 p.m. staff found two Percocet (narcotic medication) tablets in an cigarette pack in Resident 54's dresser drawer while looking for pajamas.

Further review of the clinical record revealed that Resident 54 had physicians orders dated February 18, 2019, for Oxycodone (a narcotic pain reliever for moderate to severe pain) 2.5 milligrams (mg) every 4 hours as needed for pain rated 4-6 (on a scale of 1-10) and Oxycodone 5 mg every 4 hours as needed for pain rated 7-10. The resident did not have a physician order for Percocet at the time the drug was found in the resident's room.

Review of the facility investigation revealed that on February 23, 2019 at 9:00 p.m. the administrator was made aware that 11 loose pills, later identified as Percocet, were found in Resident 54's room in an empty cigarette pack. Employee 1 (CNA) had gone into the dresser drawer to retrieve pajamas and observed two yellow pills laying in the drawer next to a cigarette pack and 9 pills in the pack. The facility's investigation indicated that the resident's room was searched and no other issues were noted.

The facility interviewed Resident 54 on February 25, 2019, regarding the incident and the resident stated that his pain was not relieved with the "oxy" (Oxycodone) that he was receiving at the facility and that the Percocet he brought in from home helps him more.

On March 1, 2019, the police and representatives of the local Area Agency on Aging were in the building to investigate an anonymous complaint that Resident 54 had given Resident 97, Percocet.

A review of Resident 54's clinical record revealed no documented evidence of the above incident, the subsequent interview with the resident, involvement of the police and AAA and evidence of physician notification and consultation regarding the resident's pain management and report that Oxycodone was ineffective.

Interview with the Administrator and Director of Nursing on March 5, 2019 at 11:30 a.m. confirmed that there was no documentation in this resident's clinical record, the investigation by other agencies and law enforcement and physician notification of the incident and consultation regarding the resident's pain management regimen.


28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.
Previously cited: 7/13/18

28 Pa. Code 211.5 (f) Clinical records.
Previously cited: 7/13/18







 Plan of Correction - To be completed: 04/05/2019

A late entry note was placed in resident 54's medical record for medications being found in dresser, MD response to pain management, investigation by Area on Aging representative and police involvement. Incident report completed.
Review of 24 hour reports for the past 30 days to ensure any incidents are reflected in the medical record.
Licensed staff re-educated on ensuring all incidents are reflected in the medical record with physician notification and complete an incident report as required.
Audit of 10% of clinical records will be completed by DON/designee 2x week x4 weeks, then weekly to ensure any incident is documented in the clinical record Results of audits to QA for review and recommendations.

201.14(e) LICENSURE Responsibility of licensee.:State only Deficiency.
(e) The administrator shall notify the appropriate division of nursing care facilities field office as soon as possible, or, at the latest, within 24 hours of the incidents listed in Section 51.3 and subsection (d).
Observations:

Based on a review of clinical records and information submitted by the facility and staff interviews it was determined that the facility failed to timely report an incident with the potential to compromise resident safety to the State Licensing Agency as evidenced by one resident out of 14 sampled (Resident 54).

Findings include:

A review of the clinical record revealed that Resident 54 was admitted to the facility on February 4, 2019, with diagnoses of hypertension, bipolar, and depression.

Review of information dated March 1, 2019, submitted by the facility revealed that on February 23, 2019 at 9:00 p.m., while staff were looking for pajamas in Resident 54's dresser drawer, an open cigarette pack containing two Percocet tablets was found. The resident reported that a friend had brought the narcotic medications into the facility from a previous prescription.

Further review of the clinical record revealed that Resident 54 had physicians orders dated February 18, 2019, for Oxycodone (a narcotic pain reliever for moderate to severe pain) 2.5 milligrams (mg) every 4 hours as needed for pain rated 4-6 (on a scale of 1-10) and Oxycodone 5 mg every 4 hours as needed for pain rated 7-10. The resident did not have a current physician order for Percocet at the time the drug was found in the resident's room.

Review of the facility investigation revealed that on February 23, 2019, at 9:00 p.m. that the administrator was made aware that 11 loose pills, later identified as Percocet, were found in Resident 54's room in an empty cigarette pack. Employee 1 (CNA) had gone into the dresser drawer to retrieve pajamas and observed two yellow pills laying in the drawer next to a cigarette pack and 9 pills in the pack. The facility's investigation indicated that the resident's room was searched and no other issues were noted.

The facility did not report this event to the State Licensing Agency until March 1, 2019, after the Area Agency on Aging and police arrived at the facility on March 1, 2019, in response to an anonymous report that Resident 54 was distributing narcotics to residents.

Interview with the Administrator on March 5, 2019 at 11:30 a.m. confirmed that the facility failed to timely notify the State Survey Agency, Department of Health, Division of Nursing Care Facilities of the incident with the potential to compromise resident safety.





 Plan of Correction - To be completed: 04/05/2019

Event report was submitted on 3/1/19.
Review of 24 hour reports for the past 30 days to ensure any incidents that meet the definition of a reportable event was completed.
NHA and DON reviewed event report guidelines on timely notification of incident with potential to compromise resident safety.
Audit of 10% of clinical records will completed by DON/designee 2x week x4 weeks, then weekly to ensure any incident that meets the definition of a reportable event has been completed.
Results of audits to QA for review and recommendations.



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