Nursing Investigation Results -

Pennsylvania Department of Health
MANORCARE HEALTH SERVICES-POTTSVILLE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MANORCARE HEALTH SERVICES-POTTSVILLE
Inspection Results For:

There are  110 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.
MANORCARE HEALTH SERVICES-POTTSVILLE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance survey completed on January 18, 2019, it was determined that Manorcare Health Services - Pottsville 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:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Based on review of clinical records, facility event summary reports and information submitted by the facility and staff interview, it was determined that the facility failed to implement sufficient supervisory measures to prevent falls with serious injuries (fractured hip and head injury) for two of five residents reviewed with falls (Resident 45 and Resident 65).

Findings include:

A review of the clinical record review revealed that Resident 45 was admitted from the hospital to the facility on October 15, 2018, with diagnoses, which include pneumonia (infection that inflames the air sacs in one or both lungs) and sepsis (life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs). The resident resided in a personal care home prior to the resident's hospitalization on October 6, 2018.

A review of a hospital history and physical report dated October 6, 2018, revealed that the resident had a past medical history of a subdural hematoma (blood collects between the layers of tissue that surround the brain; the bleeding in a subdural hematoma is under the skull and outside the brain, as blood accumulates, the pressure on the brain increases. The pressure on the brain causes a subdural hematoma's symptoms) but unsure of the date of occurrence.

An Admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment completed at specific intervals to identify resident care needs) dated October 22, 2018, indicated that the resident was severely cognitively impaired and required extensive assistance with two persons for transfers between surfaces and for toileting.

The resident was identified at risk for falls due to weakness and difficulty walking as per his care plan dated October 15, 2018, with planned approaches that included to encourage the resident to transfer and change positions slowly, have commonly used articles within easy reach and reinforce need to call for assistance.

Nursing documentation dated November 20, 2018, at 6:56 PM indicated that the resident was found on the foot of his wheelchair with a lump noted to the right side of his head. The resident's pupils were unequal, but reactive. The resident was sent to emergency room at that time. A CT scan (computerized tomography (CT) scan combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones, blood vessels and soft tissues inside your body. CT scan images provide more detailed information than plain X-rays do) was performed and was negative.

Following this fall, there was no documented evidence that the facility had evaluated the adequacy of the existing care plan addressing the resident's fall risk and/or had developed and implemented additional interventions to prevent future falls.

Nursing documentation dated November 23, 2018, at 9:17 PM indicated that the resident was very restless and was attempting to self-transfer and walk with poor ambulatory skills at this time. It was noted that he required 1:1 supervision (one staff member assigned to resident for supervision) for four hours for his safety.

On November 26, 2018, at 4:53 PM nursing documentation indicated that the resident slipped out of his chair and sustained a 5 cm hematoma (collection of blood under the skin caused by an injury) to the right side of his forehead.

As the result of this fall, the facility revised the resident's care plan on November 27, 2018, noting that the resident would wear non-skid footwear when he allowed it and physical therapy was to evaluate the resident.

Nursing documentation dated December 2, 2018, at 2:10 PM indicated that the resident attempted, three times, to self ambulate and get up out of his Broda chair (a chair used for positioning and mobility), but the staff was able to ambulate him.

A review of nursing documentation dated November 5, 2018, at 2:29 PM revealed that the resident's family requested a CT Scan of the resident's head due to his history of a subdural hematoma and falls in the past.

A CT scan was completed on December 10, 2018, which revealed a thin subdural collection of blood along the right parietal convexity (right area of the brain surface) measuring 3 mm (millimeter) in thickness. According to the CT scan report, there was a prior right frontoparietal (frontoparietal region is the portion of the left frontal and parietal lobes that overlap) craniotomy (a surgical operation in which a bone flap is temporarily removed from the skull to access the brain) with burr hole (hole surgically created to remove collection of blood). The reported revealed no evidence of a new hemorrhage examination since study of September 12, 2018 (performed prior to the resident's admission to the facility).

Nursing documentation dated December 14, 2018, indicated that the resident was very restless and frequently attempted to get out of his Broda chair, which continued on December 15, 2018.

Nursing documentation dated December 19, 2018, at 2:24 PM indicated that the resident was attempting to ambulate on his own while staff assisted him. He attempted to sit back down on the Broda chair legs, which were extended. The resident flipped the Broda chair and the resident fell to the floor, hitting the right side of his head off another resident's chair. The resident sustained a laceration (injury to skin or tearing of the tissue) measuring 1.5 cm x 0.2 cm with a small amount of bleeding.

In response to this fall, an immediate intervention was to trial a rock and go wheelchair
(a wheelchair that features a rocking motion designed to comfort the resident) and increase restorative ambulation.

The resident's care plan was updated on December 19, 2018, to trial the rock and go wheelchair, which has a design feature that has been shown to ease agitation in dementia.
The resident's care plan also indicated that restorative ambulation was to be completed by staff, ambulating the resident with a rollator walker to and from the dining room and the bathroom for at least 35 feet twice a day and for periods of restlessness.

However, at the time of the survey ending January 18, 2019, there was no documentation indicating that this restorative ambulation was provided to the resident as planned.

Nursing documentation dated December 29, 2018, at 1:30 AM indicated Employee 2, LPN (licensed practical nurse) witnessed the resident standing in the hallway in front of his room. Staff went to help resident, but he fell on the carpeted floor in the hallway onto his right side. Staff did not observe the resident hit his head according to nursing documentation.

Nursing documentation dated December 30, 2018, at 6:00 AM indicated that the resident was found in another resident's bed and was verbally abusive to staff.

Nursing documentation dated December 31, 2018, at 1:05 AM revealed that that this resident on the floor of his room, lying on his right side. The resident was unresponsive to painful stimuli. The resident was noted to have agonal breathing (irregular gasping breaths can be one breath every five to six seconds) and a lump to the back of his head with nonreactive pupils (no response of the pupil (the round black part of the eye) to constrict when stimulated with light or expand when exposed to a reduction of light). The resident also had a 3 cm laceration to the right temporal area of his head. The resident was sent to the emergency room at that time and admitted at 6:50 AM with a cerebral hemorrhage (bleeding in the brain).

A CT scan completed at the hospital at 3:13 AM on December 31, 2018, revealed a large 23 mm right parietal scalp hematoma with suspected active bleeding, an approximately 7 mm right to left midline shift (midline shift refers to when a person's brain actually shifts beyond the center line of the brain. The shift is normally caused by a traumatic event involving the brain or head) at the level of the septum pellucidum (a thin membrane located at the midline of the brain between the two halves of the brain), bilateral 5-8 mm frontal parietal subdural hematoma, right greater than the left, moderate 8 mm subdural hematoma along the posterior clivus (bony part of skull base) and multifocal areas of subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain).

The hospital emergency department report indicated that the resident was critically ill with a poor prognosis and comfort care was recommended. The resident expired at at 1:45 PM on December 31, 2018.

Interview with the Director of Nursing (DON) on January 17, 2018, at approximately 11:15 AM confirmed that the facility had identified this resident to be at risk for falls and a known history of subdural hematoma. The DON verified that there was no evidence that the facility had provided adequate and increased supervision at the frequency and level required and/or effective safety measures to promote this resident's safety and prevent repeated falls and serious head injury.

A review of Resident 65's clinical record revealed that the resident was admitted to the facility on October 4, 2018, with diagnosis to include dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems).

The resident's admission physician orders dated October 4, 2018, included Seroquel (an antipsychotic medication, a group of drugs that are used to treat serious mental health conditions) 25 mg tablet, 1/2 tab, 12.5 mg by mouth at bedtime for depression.

A review of an admission MDS Assessment dated October 11, 2018, indicated that the resident had a BIMS score of 3 (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 0 to 7 indicates severe cognitive impairment). The resident required staff assistance with activities of daily living (daily tasks of self-care) and required supervision of one person physical assistance walking in his room and in the corridor on the unit.

A physician's order dated December 11, 2018, was noted to increase the resident's dose of Seroquel, to 12.5 mg at 9:00 AM and 12.5 mg at 9:00 PM, for depression.

On December 13, 2018, the resident was involved in a behavioral incident with his roommate, which resulted in Resident 65's admission to a psychiatric hospital from December 13, 2018, through December 27, 2018.

Upon readmission the resident's readmission to the facility on December 27, 2018, the physician's ordered Divalproex Sodium (an anticonvulsive, which may be used for mood disorder with potential side effects to include dizziness and drowsiness) 250 mg by mouth at 9:00 AM and 500 mg by mouth at 9:00 PM, as a mood stabilizer and Seroquel 12.5 mg (potential side effects include dizziness, drowsiness and lack of strength) by mouth at 9:00 AM and 50 mg by mouth at 9:00 PM for hallucinations.

A physician order dated December 31, 2018, was noted to discontinue Seroquel 12.5 mg at 9 AM daily and start 25 mg daily at 9:00 AM for depression.

A review of an incident report dated January 1, 2019, at 12:20 PM indicated that Resident 65 was observed lying on the floor next to the resident's bed, with his pillow under his head. His head was at the foot of the bed, the bed sheets were lying on the floor and the mattress was pushed off the bed. The resident was found saturated of urine with no visible injury noted. The intervention planned following this incident, according to the report, was to toilet the resident when he awakes from a nap, but this intervention was not added to the resident's care plan.

A review of information dated January 1, 2019, at 4:40 PM submitted by the facility, revealed that Resident 65 sustained a fall in the hallway and he complained of pain in his left hip. The resident was transferred to the hospital with a fracture of the left hip, which required surgery.

A review of the resident's significant change MDS Assessment dated November 21, 2018, section G (functional status) revealed that the resident required supervision of two persons physical assist, while walking in the corridor. However, a review of progress notes from November 21, 2018, through January 1, 2019, revealed multiple entries noting that the resident was often walking independently throughout the unit and wandering aimlessly.

There was no indication that staff was assisting the resident with ambulation in the hallway when he fell on January 1, 2019, at 4:40 PM.

A review of progress notes from the resident's admission to the facility on October 4, 2018 until his fall on January 1, 2019, revealed that he wandered about the unit. The resident's care plan, dated October 4, 2018, indicated that the resident was at risk for falls due to poor mobility and resistance to staff education regarding safety. The interventions planned to minimize the resident's risk for falls included to encourage the resident to transfer and change positions slowly; have commonly used articles within easy reach and reinforce need to call for assistance. The facility did not plan approaches to monitor the resident's whereabouts and activities and to supervise the resident's at the level and frequency required to prevent falls.

During interview with the Director of Nursing (DON) on January 18, 2019, at 11:10 AM the DON acknowledged that upon the resident's return to the facility from the psychiatric unit, the resident's was receiving additional psychoactive medications that may increase the resident's risk for falls and that the facility failed to review and revise the resident's fall prevention plan and implement measures necessary to prevent his fall with serious injury on January 1, 2019, at 4:40 PM.

483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices
Previously cited 7/14/17

28 Pa Code 211.12(a) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(c) Nursing services
Previously cited 12/27/18, 8/27/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(d)(1) Nursing services
Previously cited 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(d)(3) Nursing services
Previously cited 8/27/18, 6/25/18, 5/23/18, 2/9/18, 7/14/17

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17





































 Plan of Correction - To be completed: 03/06/2019

1. R45 no longer resides in the facility. R65 no longer resides in the facility.
2. A 30 day (1.7.2019 2.7.2019) look back of residents with actual falls will be completed by the DON/designee to verify appropriate interventions by the date of compliance 3.6.2019.
3. Nursing staff will be educated on the "falls practice guide" by the DON/designee by the date of compliance 3.6.2019.
4. Using the "Fall" QAPI tool 5 residents/week x4 weeks will be audited by the DON/designee to verify appropriate interventions are in place. Results will be reviewed with QA&A.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

483.10(f)(6) The resident has a right to participate in family groups.

483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:

Based on resident and staff interview, review of select facility policy and minutes from Resident Council Meetings, it was determined that the facility failed to demonstrate timely and adequate efforts to resolve resident grievances regarding untimely call bell response and staff's failure to meet residents' needs for assistance timely, which were brought forth at resident group meetings as evidenced by four out of at six residents attending the group meeting (Residents 96, 79, 73 and 135).

Findings include:

A review of the facility policy "Call Light" last reviewed by the facility on October 30, 2018, revealed that all staff is required to answer call lights in a prompt, calm manner. The call light should be left on until the residents' request is met.

A review of the minutes from the Resident Council Meetings held from October 2018 through December 2018, revealed that residents in attendance voiced concerns that staff's response to call bells is slow and that they fell that there is not enough staff to address their needs. The Resident Council Meeting minutes contained no further details as to the specific resident care needs, which were re not being met, approximately how long the residents wait for their call bells to be answered or needs met, or if there was a specific shift during which the wait for staff response to call bells and requests for assistance are most lengthy.

During a group meeting held on January 16, 2019, at 10:00 AM with seven alert and oriented residents, four residents (Residents 96, 79, 73 and 135) out of the seven residents in attendance stated that untimely staff response to call bells continues to be a problem. The residents stated that they often wait up to 60 minutes for their call bells to be answered and for staff to assist the residents with their care. The resident stated that it is a problem on all shifts. The residents stated that staff frequently turns the residents' call bell off and inform the resident that they will return soon, but then staff does not return for an additional 20 minutes. The residents stated that when they have raised the issue of long waits for staff to respond to call bells and requests for assistance at their Resident Council Meetings in the past, the facility staff tell them that they, "we will look into it" or "we are working on hiring staff."

Interview with the Director of Nursing on January 17, 2019, at 10:00 AM confirmed that residents have repeatedly complained that staff are not responding timely to residents' call bells or providing the requested assistance in a timely manner and the facility was unable to provide evidence of sufficient efforts to resolve this ongoing complaint.

483.10(f)(5)(i)-(iv)(6)(1) Resident/Family Group and Response
Previously cited 7/14/17

28 Pa. Code 201.18(e)(1) Management
Previously cited 12/27/18, 7/14/17

28 Pa. Code 201.18(e)(4) Management

28 Pa. Code 201.29(i) Resident Rights

28 Pa. Code 201.29(j) Resident Rights
Previously cited 2/9/18

28 Pa Code 211.12(a) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(c) Nursing services
Previously cited 12/27/18, 8/27/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(d)(1) Nursing services
Previously cited 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(d)(3) Nursing services
Previously cited 8/27/18, 6/25/18, 5/23/18, 2/9/18, 7/14/17

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17







 Plan of Correction - To be completed: 03/06/2019

1.Resident group meeting is scheduled for 2.8.2019, led by the Grievance officer/designee - to inform residents R96, R79, R73 and R135 about the grievance/concern process and to review the call light response performance improvement plan.
2.Current residents are invited to attend group meeting led by the Grievance officer/designee to discuss the concern/grievance process and the call light response procedure. New admissions will be educated on the call light procedure during the admission process.
3.The interdisciplinary team will be educated by the NHA/designee on the concern/grievance process and the call light procedure by date of compliance 3.6.2019.
4.Random resident interviews of 10/week x4 weeks will be completed by the NHA/designee to audit call light response. Trends will be reviewed with QA&A.

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ: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.
483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
Observations:

Based on observation and staff interview and review of clinical records and investigative reports it was determined that the facility failed to maintain a safe and sanitary environment for residents residing on the Arcadia (locked dementia) unit and individuals accessing ice from the ice machine.

Findings Include:

A review of the clinical record of Resident 65 indicated that the resident had been observed to urinate on the ice machine, which was housed in an alcove on the locked Arcadia dementia (group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) unit. Facility documentation indicated that the resident had a pattern of urinating in appropriate places on the unit such as the in hallway, dining room and other resident rooms. Further review of the resident's clinical record revealed that Resident 65 urinated in the ice machine on October 22, 2018, October 29, 2018, and attempted to urinate in the ice machine on November 19, 2018, but was redirected.

An observation of the ice machine on January 15, 2019, revealed that the ice machine was operational.

A review of a facility investigation dated January 16, 2019, indicated that when Resident 65 urinated in the ice machine he was redirected and it was clean. However, there was no evidence that the facility developed and implemented preventative measures to ensure that Resident 65 did not urinate in the ice machine as the resident independently ambulated throughout the unit.

The facility was aware of this resident's behaviors since October 2018 and maintenance staff was made aware on December 27, 2018. Maintenance suggested that a gate could possibly provide a means of preventing the resident' access to the ice machine. However, the facility did not initiate contact with a vendor for this purpose until January 16, 2019, in response to surveyor inquiry.

28 Pa. Code 207.2(a) Administrator's responsibility
Previously cited 7/14/17

28 Pa Code 211.12 (a)(c) Nursing services
Previously cited 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(d)(3) Nursing services
Previously cited 8/27/18, 6/25/18, 5/23/18, 2/9/18, 7/14/17

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17










 Plan of Correction - To be completed: 03/06/2019

1. R65 no longer resides in the facility.
2. The Ice machine was removed from service on the Arcadia by the maintenance director of 1.17.2019.
3. The IDT team will be educated by the NHA/designee on "Focus on F tag 921" by the date of compliance on 3.6.2019.
4. Environmental rounds will be completed by the NHA/designee weekly x4 to ensure safe/sanitary conditions. Trends will be reviewed by QA&A.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:

Based on clinical record review and staff interview it was determined that the facility failed to assure that one resident was free from a significant medication error out of 27 residents sampled. (Resident 8).

Findings include:

A review of the clinical record revealed that Resident 8 was admitted to the facility on April 11, 2012, and had diagnoses that included hypertension, diabetes and depression.

Resident 8 had a physicians order dated June 20, 2017 for Sertraline (used to treat depression) 50 milligrams (mg) orally once daily for depression.

On May 16, 2018, the pharmacist recommended a dose reduction of Sertraline. The physician accepted the recommendation to decrease Sertraline to 25 mg orally once daily for depression on May 17, 2018.

There was no indication that the Sertraline had been decreased to 25 mg on May 17, 2018, and Resident 8 continued to receive Sertraline 50 mg until January 17, 2019, when it was brought to the facility's attention during this survey.

During interview with the Director of Nursing on January 17, 2019, at 9:00 AM, she confirmed the medication error.

Refer F756

28 Pa Code 211.12(a) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(c) Nursing services
Previously cited 12/27/18, 8/27/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(d)(1) Nursing services
Previously cited 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17






 Plan of Correction - To be completed: 03/06/2019

1. R8 was evaluated and the medication was reviewed with the doctor with no change noted.
2. January's medication regimen reviews for current residents will be audited to ensure appropriate follow up by the DON/designee by the date of compliance.
3. Licensed nurses and the facility pharmacist will be educated by the DON/designee on Medication Regimen reviews and Focus on F tag 760 by the date of compliance.
4. Pharmacist initiated Medication Regimen reviews will be audited by the DON/designee weekly x4 to ensure appropriate follow up with irregularities. Trends will be reviewed with QA&A.


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 affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.45(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 interview, it was determined that the facility failed to attempt dose reductions of psychotropic medications for three of eight residents sampled (Resident 39, 40, and 71).

Findings include:

A review of the clinical record revealed that Resident 39 was admitted to the facility on April 21, 2015 and had diagnoses that included psychosis (mental disorder characterized by a disconnection from reality), depression, and anxiety. The resident had a physician's order from March 11, 2016 for Valproic Acid (anticonvulsant used to treat seizures and bipolar disorder 500 milligrams (mg) via peg tube every 8 hours for dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) with psychosis.

A review of physician progress notes and "Medication Regimen Reviews" conducted by the pharmacist from January 2018 through December 2018, revealed no indication of a gradual dose reduction attempt of Valproic Acid 500 mg during this past year.

A review of the clinical record revealed that Resident 40 was admitted to the facility on June 6, 2016 and had diagnoses that included bipolar disorder and depression. The resident had a physician's order from admission for Trazodone (used to treat depression) 100 mg at bedtime.

A review of physican progress notes and "Medication Regimen Reviews" conducted by the pharmacist from admission June 2018 through December 2018, revealed no indication of a gradual dose reduction attempt of Trazodone 100 mg.

A review of the clinical record revealed that Resident 71 was admitted to the facility on December 29, 2017, and had diagnoses that included depression and anxiety. The resident had a physician's order from admission for Xanax (used to treat anxiety and panic attacks) 0.25 mg twice daily.

On April 23, 2018, the physician increased the dose of Xanax to 0.25 mg three times daily, which continued to the time of the survey ending January 18, 2019.

A review of physician progress notes and "Medication Regimen Reviews" conducted by the pharmacist from January 2018 through December 2018, revealed no indication of a gradual dose reduction attempt of Xanax. 25 mg TID

During an interview with the Director of Nursing (DON) on January 17, 2019, at 9:00 AM the DON confirmed that gradual dose reductions of the above psychoactive drugs was not recommended by the pharmacist or ordered by the physician for these residents.

483.45(c)(3)(e)(1)-(5) Free from Unnecessary Psychotropic Meds/PRN Use
Previously cited 2/9/18

28 Pa. Code 211.9(k) Pharmacy services
Previously cited 5/23/18, 2/9/18, 7/14/17

28 Pa Code 211.12(a) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(c) Nursing services
Previously cited 12/27/18, 8/27/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(d)(1) Nursing services
Previously cited 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(d)(3) Nursing services
Previously cited 8/27/18, 6/25/18, 5/23/18, 2/9/18, 7/14/17

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17







 Plan of Correction - To be completed: 03/06/2019

1. R39 psychoactive medications will be reviewed with the physician by the unit manager/designee by the date of compliance. R40 psychoactive medications will be reviewed with the physician by the unit manager/designee by the date of compliance. R71 psychoactive medications will be reviewed with the physician the Unit manager/designee by the date of compliance..
2. January's medication regimen reviews for current residents will be audited to ensure appropriate follow up by the DON/designee by the date of compliance.
3. Licensed staff and the facility pharmacist will be educated on "Focus on F-tag 758" and "Medication Regimen Review" by the DON/designee by the date of compliance 3.6.2019.
4. GDR recommendations from the facility pharmacist will be reviewed weekly x4 by the DON/designee to ensure appropriate follow up by the DON/designee. Trends will be reviewed with QA&A.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.45(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

483.45(c)(2) This review must include a review of the resident's medical chart.

483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on review of clinical records and staff interview, it was determined that pharmacist failed to identify drug irregularities in residents' drug regimen and the physician failed to act upon pharmacy recommendations timely for two of 27 sampled residents (Residents 16 and Resident 8).

Findings include:

A review of the clinical record revealed that Resident 16 was admitted to the facility on December 16, 2016, with diagnoses that included major depression and anxiety. A physician order dated November 10, 2017, was noted an order for Zoloft (an anti-depressant) 75 mg one tablet every evening for depression.

A review of pharmacy "Medication Regimen Review" dated May 17, 2018 and July 7, 2018, revealed the pharmacist made the recommendation to the physician to consider a gradual dose reduction (GDR) of Zoloft 75 mg.

Further review of the resident's clinical record revealed no physician documentation addressing the pharmacist's recommendation for a GDR.

Interview with the director of nursing on January 17, 2019, at 1:30 PM failed to provide documented evidence that the physician had acted upon the pharmacist's recommendation to consider a GDR of the antidepressant drug, Zoloft.

Clinical record review revealed that Resident 8 was admitted to the facility on April 11, 2012, and had diagnoses that included hypertension, diabetes and depression. Resident 8 had a physicians order dated June 20, 2017 for Sertraline (used to treat depression) 50 milligrams (mg) orally once daily for depression.

The pharmacy made a recommendation on May 16, 2018, for a dose reduction on this Sertraline. The physician accepted the recommendation to decrease this Sertraline to 25 mg orally once daily for depression on May 17, 2018.

There was no indication the facility made the change, and Resident 8 continued to receive Sertraline 50 mg until January 17, 2019. There was no indication the Pharmacist recognized that the dosage reduction was not put in place from May 17, 2018 to January 17, 2019.

Interview with the Director of Nursing on January 17, 2019, at 9:00 AM she confirmed the medication continued to be given until January 17, 2019 and that the Pharmacist never picked up the error.


Cross reference F760

28 Pa. Code 211.5(g) Clinical records
Previously cited 11/29/17, 7/14/17

28 Pa. Code 211.9(k) Pharmacy services.
Previously cited 5/23/18, 2/9/18, 7/14/17

28 Pa Code 211.12(a) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(c) Nursing services
Previously cited 12/27/18, 8/27/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(d)(1) Nursing services
Previously cited 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(d)(3) Nursing services
Previously cited 8/27/18, 6/25/18, 5/23/18, 2/9/18, 7/14/17

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17
























 Plan of Correction - To be completed: 03/06/2019

1. R16 medication regimen was reviewed with MD by unit manager. R8 medication regimen was reviewed and the MD was notified of the discrepancy by the Unit Manager.
2. January's medication regimen reviews for current residents will be audited to ensure appropriate follow up by the DON/designee by the date of compliance of 3.6.2019.
3. Licensed nursing staff and the facility pharmacist will be educated by the DON/designee on "Focus on F-tag 756" and the "Medication Regimen Review" by the date of compliance 3.6.2019.
4. Pharmacist initiated Medication Regimen reviews will be audited by DON/designee weekly x4 to ensure appropriate follow up with irregularities. Trends will be reviewed with QA&A.

483.30(c)(1)-(4) REQUIREMENT Physician Visits-Frequency/Timeliness/Alt NPP: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.
483.30(c) Frequency of physician visits
483.30(c)(1) The residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter.

483.30(c)(2) A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required.

483.30(c)(3) Except as provided in paragraphs (c)(4) and (f) of this section, all required physician visits must be made by the physician personally.

483.30(c)(4) At the option of the physician, required visits in SNFs, after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist in accordance with paragraph (e) of this section.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that two of 27 sampled residents were seen timely by a physician (Resident 39 and 71).

Findings include:

A review of the clinical record of Resident 39 revealed that the resident was admitted to the facility April 21, 2015. A review of the physician's progress notes revealed that the resident was seen by the physician on November 1, 2018, but not seen again until January 17, 2019; 77 days between physician visits.

A review of the clinical record of Resident 71 revealed admission to the facility December 29, 2017. A review of the physician's progress notes revealed that the resident was seen by the physician on March 21, 2018, but not seen again until the facility's medical director saw the resident on June 19, 2018; 90 days between visits by a physician.

Further review of the physician's progress notes revealed that Resident 71 was seen by the physician on October 27, 2018, but not seen again until January 8, 2019; 73 days between physician visits.

Interview with the Director of Nursing on January 18, 2019, at 1:15 PM confirmed that the physician did not visit Resident 39 and Resident 71 every 60 days.

28 Pa. Code 201.18(e)(3) Management
Previously cited 7/14/17

28 Pa. Code 211.2(a) Physician services
Previously cited 5/23/18, 2/9/18

28 Pa. Code 211.2(d)(2) Physician services
Previously cited 5/23/18, 7/14/17

28 Pa Code 211.12(d)(3) Nursing services
Previously cited 8/27/18, 6/25/18, 5/23/18, 2/9/18, 7/14/17

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17









 Plan of Correction - To be completed: 03/06/2019

1. R39 and R71 had a physician visit
2. A comprehensive audit was completed on current residents to review physician visit records by the medical records clerk on 2.4.2019.
3. Medical records will be educated by the NHA/designee on the "Focus on F-tag 712" and the "clinical record guideline" By the date of compliance 3.6.2019. Physicians will be educated by the Medical Director on F 712 and timely visits by the date of compliance 3.6.2019.
4. Physician Monitoring visit report in the electronic record will be audited weekly x4 by the medical records clerk. Results will be reviewed with QA&A.


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 review of the clinical records and facility procedural guides and staff interview it was determined that the facility failed to provide necessary care and services in accordance with professional standards of practice for monitoring a resident after repeated falls with potential head injury for one out of five residents reviewed who had sustained falls (Resident 45).

Findings include:

A review of the facility's procedure guide entitled Neurological Evaluation (an assessment brain functions) dated as reviewed October 30, 2018, indicated that the purpose of a neurological evaluation is used to establish a baseline neurological status upon which subsequent evaluations may be compared and changes in neurological status may be determined. The reason this type of evaluation is used following a witnessed fall when a resident hits their head or following an unwitnessed fall when a head injury may be suspected. The procedure indicates after the completion of the initial neurological evaluation with vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a resident's essential body functions), the evaluations should be conducted every 30 minutes for 4 times, then every one hour for four times, then every 8 hours for 9 times for the next 72 hours. This includes evaluating level of consciousness, level of orientation, evaluation of the pupils, movement of extremities, evaluation of communication and vital signs. The results of the evaluations should be documented on a neurological flow record to determine any changes or declines in status.

A review of the clinical record of Resident 45 revealed admission to the facility on October 15, 2018, with a history subdural hematoma (blood collects between the layers of tissue that surround the brain; the bleeding in a subdural hematoma is under the skull and outside the brain, as blood accumulates pressure on the brain increases, which causes subdural hematoma's symptoms) according to a CT (computerized tomography (CT) scan combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones, blood vessels and soft tissues inside your body. CT scan images provide more detailed information than plain X-rays do) dated September 12, 2018, which revealed a history of subdural hematoma with surgical evacuation, date unknown.

Further review of the resident's clinical record revealed that the resident was identified at risk for falls upon admission to the facility. The resident sustained falls on November 20, 2018, November 23, 2018, December 14, 2018 and December 31, 2018, during which the resident sustained impact to the right side of his head. A review of nursing documentation for each 72 hour period following each of the above falls revealed only sporadic neurological evaluations had been conducted following each fall. There was no documentation of consistent neurological evaluations completed as per the facility procedure guide which encompassed a 72 hour period. The limited nursing documentation noted did not include the specific examinations as indicated in the facility's procedure guide

Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on January 18, 2019, at 2:15 PM revealed that the facility's nursing staff failed to consistently conduct neurological evaluations in accordance with professional standards of care following a fall with potential head injury and according to facility procedures.

483.25 Quality of Care
Previously cited 6/25/18, 7/14/17

28 Pa. Code 211.5(f) Clinical records
Previously cited 2/9/18, 7/14/17

28 Pa. Code 211.5(g) Clinical records
Previously cited 11/29/17, 7/14/17

28 Pa. Code 211.5(h) Clinical records
Previously cited 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(a) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(c) Nursing services
Previously cited 12/27/18, 8/27/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(d)(3) Nursing services
Previously cited 8/27/18, 6/25/18, 5/23/18, 2/9/18, 7/14/17

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17







 Plan of Correction - To be completed: 03/06/2019

1. R45 no longer resides in the facility.
2. A 7-day look back of new admits from and patients 2.1.2019 2.7.2019 with actual falls will be completed by the DON/designee to ensure appropriate interventions and evaluations for falls were completed by the date of compliance 3.6.2019.
3. Licensed staff will be educated by the DON/designee on the "Falls Practice Guideline" and the "Neurologic Evaluation" by the date of compliance 3.6.2019.
4. Using the "fall" QAPI tool - the DON/designee will audit 5 falls/week x 4 weeks to ensure appropriate interventions and evaluations post fall were are completed. Trends will be reviewed with QA&A.

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, a review of clinical records and the facility's activities calendar and interviews with 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 who reside on the dementia unit of the facility.

Findings include:

Observations of the Arcadia unit (a locked unit that houses residents with dementia/severe cognitive impairment) revealed a posted calendar of daily events scheduled for the residents weekly. A review of this calendar revealed that the facility provided between four to six activities throughout the day, starting at 10:00 AM with the last activity scheduled for 3:00 PM. The calendar included an activity titled "Hydration Station" offered to the residents twice daily at both 11:00 AM and 3:00 PM.

Further review of this activity calendar revealed a scheduled activity of " I Believe" at 10:30 AM on January 15, 2019. Observation of this activity on January 15, 2019, at 10:30 AM revealed five residents seated at a table watching television. Three residents were seated at another table as the activity aide asked one resident if she "believed in angels." Continued observation revealed that this question was the extent of the scheduled activity conducted.

Observation of the activity "Hydration Station" scheduled for 11:00 AM, on January 15, 2019, conducted at 11:19 AM January 15, 2019, revealed nine residents seated in the activity/dining room. A half pint carton of milk was placed in front of three residents. One resident was observed with his head on the table and appeared to be asleep. Another resident had placed a large checker token in his mouth. The activity aide was not observed to converse or engage with the residents during this activity.

The activities calendar also included bingo and word games planned for the residents of dementia unit. There was no evidence that the facility developed and implemented a program of activities to meet the functional needs, abilities, preferences and interests of the residents who reside in the dementia unit of the facility and those with cognitive impairment.

Throughout the days of the survey from January 15, 2019, through January 18, 2019, residents were observed walking around the dementia unit and seated in the dining/activity area sleeping without evidence of diversional activities, sensory stimulation, individual activities ties or self-directed activities

During an interview with the Nursing Home Administrator and Director of Nursing on January 18, 2019, it was confirmed that the activities offered to the residents on the dementia unit were limited and not all activities provided were specifically designed and appropriate to the meet the needs and level of functioning of severely cognitive impaired residents.

483.24(c)(1) Activities Meet Interest/Needs each Resident
Previously cited 2/9/18

28 Pa. Code 201.29(a) Resident rights
Previously cited 12/27/18, 2/9/18, 7/14/17

28 Pa. Code 201.29(j) Resident Rights
Previously cited 2/9/18











 Plan of Correction - To be completed: 03/06/2019

1. Activities will be implemented that meet the needs of residents with dementia by the activities department by the date of compliance 3.6.2019.
2. Current residents and new admissions to the dementia unit will be assessed for historical interests and hobbies by the activities department/designee by the date of compliance 3.6.2019. An activity calendar will be developed to meet the needs of residents with dementia by the activities department/designee bu the date of compliance 3.6.2019.
3. Activities staff will be educated on creating and implementing activities that meet the needs of residents with dementia by the Activities consultant/designee by the date of compliance 3.6.2019.
4. Activities on the dementia unit will be monitored weekly x4 by the NHA/designee utilizing the Activities QAPI tool. Trends will be reviewed with QA&A.

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

Based on review of clinical records, observations and staff interviews it was determined that the facility failed to develop a comprehensive plan of care to meet the specific needs of three out of 27 residents reviewed (Residents 8, 40, and 65).

Findings include:

A review of Resident 8's clinical record revealed that the resident was admitted to the facility on April 11, 2012, and had diagnoses that included hypertension, diabetes and depression.

Observation of Resident 8 on January 15, 2019, at 9:30 AM and again January 16, 2019, at 11:15 AM revealed the resident was in bed with the bed in the highest (elevated) position. Interview with Resident 8 on January 16, 2019, at 11:15 AM revealed that the resident stated that she liked the bed in that position because it made it easier for her to view the television. The resident stated that the facility staff were aware of her preference for the bed in the highest position for ease of television viewing.

A review of the resident's comprehensive care plan dated June 7, 2017, revealed that the resident's preference for bed positioning was not included in the resident's care plan. Resident 8 is a low risk for falls and from the October 14, 2018 quarterly MDS (MDS -a federally mandated standardized assessment completed at specific intervals to define resident care needs) she has a BIMS of 15, she is extensive assistance two person physical assist (3/3) for bed mobility, and total dependence two person physical assist (4/3) for transfers.

Interview with the Director of Nursing on January 15, 2019, at 1:15 PM she indicated Resident 8 was educated on the risks verses the benefits of the bed being in the highest position, but could not provide documentation about it.

A review of Resident 40's clinical record revealed that the resident was admitted to the facility on June 6, 2018, with diagnoses that included chronic pain, depression and quadriplegia (paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs and torso).

Review of a Occupational therapy discharge communication form dated October 28, 2018, indicated restorative nursing staff were to apply bilateral (both) splints to his upper extremity as tolerated for wrist support for functional tasks and provide active range of motion (AROM
resident performs the exercise to move the joint without any assistance to the muscles surrounding the joint) to his upper extremities during activities of daily living (ADLs - daily self-care activities).

Review of a physical therapy discharge communication form dated November 22, 2018, indicated that restorative nursing staff were to provide Resident 40 with passive range of motion to (PROM - staff or equipment moves the joint through the range of motion with no effort from the resident) bilateral lower extremities during ADLs.

A review of Resident 40's plan of care dated November 2, 2018, revealed that the application of bilateral splints, AROM and PROM during ADLs was not incorporated into the resident's comprehensive plan of care.

During an interview with the Director of Nursing (DON) on January 17, 2019, at 9:00 AM the DON confirmed that Resident 8's preferred bed position and Resident 40's restorative nursing services were not included on the residents' care plans.

Review of Resident 65's clinical record revealed the resident sustained two falls on January 1, 2019. A review of the resident's current plan of care October 4, 2018, revealed no documented evidence that the facility had reviewed and/or revised the resident's plan care after these falls, which was confirmed by the Director of Nursing during interview on January 17, 2019, at 12:00 PM.

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

28 Pa Code 211.12(a) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(c) Nursing services
Previously cited 12/27/18, 8/27/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(d)(3) Nursing services
Previously cited 8/27/18, 6/25/18, 5/23/18, 2/9/18, 7/14/17

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17





























 Plan of Correction - To be completed: 03/06/2019

1. R8's care plan was updated to include her preference of her bed height on 1.17.2019 by the mobile educator. R40's care plan was updated to include his restorative care plan on 1.29.2019 by the DON. R65 no longer resides in the facility.
2. A comprehensive audit will be completed by the mobile educator/designee on current residents and the plan of care will be reviewed to validate it reflects the current status by the date of compliance 3.6.2019.
3. Licensed staff will be educated on "Creating and maintaining care plans QRG" by the DON/designee by the date of compliance 3.6.2019.
4. Audits of care plans will be completed with care conferences weekly x4. Trends will be reviewed with QA&A.

483.10(j)(1)-(4) REQUIREMENT Grievances: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(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 observations, review of select facility policy and resident and staff interviews, it was determined that the facility failed to make information available regarding the facility's grievance/complaint process and the residents' rights to file a grievance in prominent locations on the nursing units, which consisted of three nursing units.

Findings include:

During a group interview conducted on January 16, 2019, at 10:00 AM with seven alert and oriented residents (Residents 96, 60, 33, 79, 41, 73 and 135) the residents relayed that grievance forms can be obtained from the nurses station kept in a folder. All seven residents in attendance stated they were not aware of postings in the facility, regarding the facility's grievance process, they were unaware of who the grievance official is, how to file a grievance anonymously, that they can obtain a written notice, or contact information to file a complaint outside of the facility.

Observations conducted on the days of survey of all three nursing units, from January 15, 2019, through January 18, 2019, revealed no evidence of postings that contained procedural information, including how to file anonymously, where to obtain grievance forms, the right to obtain a written decision regarding his or her grievance and a reasonable expected time frame for completing the review of the grievance.

There was no evidence provided by the facility of a facility established grievance policy/procedure which was confirmed by the Director of Nursing during interview on January 15, 2019, at 10 AM.

During an interview with the Nursing Home Administrator (NHA) on January 15, 2019, at 10:00 AM the NHA confirmed that the residents do not currently have means to anonymously file grievance forms and that postings throughout the facility, do not include all pertinent information regarding the facility's grievance process.


28 Pa. Code 201.18(e)(1) Management
Previously cited 12/27/18, 7/14/17

28 Pa. Code 201.29(a) Resident rights
Previously cited 12/27/18, 2/9/18, 7/14/17

28 Pa. Code 201.29(b)(i) Resident rights









 Plan of Correction - To be completed: 03/06/2019

1.A resident group meeting is scheduled for 2.8.2019 and led by the grievance officer/designee to inform residents R96, R79, R73 and R135 about the grievance/concern process including who the grievance official is, how to file a grievance anonymously, that they can obtain written notice, or contact information to file a complaint outside of the facility and where the posters are located in the facility.
2.Current residents are invited to attend the resident group meeting led by the Grievance officer to discuss the concern/grievance process including who the grievance official is, how to file a grievance anonymously, that they can obtain written notice, or contact information to file a complaint outside of the facility by whom and when. New admissions will be educated on the grievance process during the admission process. "The Grievance process will be posted in the facility on each nursing unit and will be added to the monthly activity calendar for residents to review."
3.The interdisciplinary team will be educated by the Grievance officer/designee on the "Concern/grievance form process" and the "QAPI manual" by the date of compliance 3.6.2019.
4.The "resident Interview" tool from the QAPI manual will be utilized to randomly interview 10 residents/week x 4 weeks on call lights, interviews will be conducted by the NHA/designee. Trends will be reviewed with QA&A.

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 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)(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 review of the clinical record, facility policies and procedures, and staff interview, it was determined that the facility failed to consult with the physician regarding a change in condition for one of five residents with nutritional concerns (Resident 78).

Finding include:

A review of the facility policy entitled "Weight Management Guideline" dated as reviewed by the facility March 2018, revealed that the key to effective weight management is to appropriately identify weight variances and initiate nutrition strategies to reduce nutrition related complications. If a patient experiences a change in condition and develops signs and symptoms for weight change, then the RD (Registered Dietitian) is contacted and re-evaluates the patient and the physician and family are notified of the changes in condition.

Review of Resident 78's clinical record revealed that on November 7, 2018, the resident's weight was recorded at 167.2 pounds. The resident's weight on December 3, 2018, was noted to have decreased to 157.8 pounds, a loss of 9.4 pounds in one month or 5.62% loss of body weight. It was noted that on January 1, 2019, the resident's weight had further decreased to 154.8 lbs; a loss of an additional 3 pounds.

There was no documented evidence that the physician had been notified of the resident's significant weight loss.

Interview with the Director of Nursing (DON) on January 18, 2019, at 9:30 AM confirmed that the physician was not notified of the resident's significant weight loss.

Cross refer F692

28 Pa Code 211.12(a) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(c) Nursing services
Previously cited 12/27/18, 8/27/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(d)(3) Nursing services
Previously cited 8/27/18, 6/25/18, 5/23/18, 2/9/18, 7/14/17

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17













 Plan of Correction - To be completed: 03/06/2019

1. R -78 MD was made aware of the weight change in November, December and January and the current plan of care by the Unit Manager/designee.
2. A comprehensive weight change audit will be completed for current residents to identify any 5% in 30day or 10% in 180day and the MD will be notified accordingly by the Dietician/designee.
3. Licensed nursing staff and the dietician will be educated by the DON/designee on the "weight management guideline" and the "Focus on F tag 580 Notification of Change" by date of compliance 3.6.2019.
4. Audits of weight changes of 5% or greater will be completed by the dietician weekly x4 with notification to the MD by the nursing department. Trends will be reviewed with QA&A.


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

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

Based on a review a closed resident record and staff interview, it was determined the facility failed to provide Notice of Medicare Provider Non-Coverage and for the appeal process for one of three records reviewed (Resident CR1).

Finding include:

A review of the form "Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123," (a notice that informs the recipient when care receive from skilled nursing facility is ending and how you can contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed.

Review of the list of discharged residents, provided by the facility, from a Medicare covered Part A stay with benefit days remaining in the past six months revealed no indication that Resident CR1 or his representative was given at least a two day notice, informing the beneficiary that skilled nursing services will end (last covered day) in two days.

Clinical record review revealed that Resident CR1 Medicare Part A skilled services started on October 31, 2018 and the last covered day of Part A services was November 20, 2018.

There was no evidence that the resident or representative had been notified verbally or in writing 48 hours prior to the last covered day of Medicare Part A skilled services.

An interview with the Nursing Home Administrator (NHA) on January 18, 2019, at 12:38 PM confirmed that there was no documented evidence that Resident CR 1 resident/representative received verbal or written notice 48 hours prior to the last covered day of Medicare Part A skilled services .

The facility failed to provide notice to beneficiary or representative at least 48 hours prior to the last covered day of Medicare Part A skilled services.

28 Pa. Code 201.18(e)(1) Management
Previously cited 12/27/18, 7/14/17

28 Pa. Code 201.29(a) Resident rights
Previously cited 12/27/18, 2/9/18, 7/14/17











 Plan of Correction - To be completed: 03/06/2019

1. CR1 no longer resides in the facility.
2. Current residents who require a notice of Medicare non-coverage will be presented the NOMNC according to federal guidelines by social service representative/designee.
3. Social Services and the Business office personnel and MDS nurses will be educated by the NHA/designee on "Focus on F-tag 582 Medicaid/Medicare Coverage/Liability Notice" and the "Social Service Manual discharge documentation" by the date of compliance 3.6.2019.
4. Audits of current residents requiring notification of non-coverage will be completed weekly x4 by the NHA/designee. Trends will be reviewed with QA&A.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(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 review and staff and resident interview, it was determined that the facility failed to provide restorative nursing services for two of three residents reviewed (Resident 40 and Resident 45).

Findings include:

A review of Resident 40's clinical record revealed that the resident was admitted to the facility on June 6, 2018, with diagnoses that included chronic pain, depression and quadriplegia (paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs and torso).

Review of a Occupational therapy discharge communication form dated October 28, 2018, indicated restorative nursing staff were to apply bilateral (both) splints to his upper extremity as tolerated for wrist support for functional tasks and provide active range of motion (AROM
resident performs the exercise to move the joint without any assistance to the muscles surrounding the joint) to his upper extremities during activities of daily living (ADLs - daily self-care activities).

Review of a physical therapy discharge communication form dated November 22, 2018, indicated that restorative nursing staff were to provide Resident 40 with passive range of motion to (PROM - staff or equipment moves the joint through the range of motion with no effort from the resident) bilateral lower extremities during ADLs.

There was no documented evidence that the resident was receiving the restorative nursing services as indicated upon the resident's discharge from skilled occupational and physical therapy.

During an interview with Resident 40 on January 18, 2019, at 10:30 AM the resident stated that the last "exercise program" he had "was down in therapy a few months ago." The resident stated that nursing was not applying his splints on a regular basis and they were not providing any active range of motion to his bilateral upper extremities or ensuring the passive range of motion exercises to his bilateral lower extremities during ADLs.

Interview with the Director of Nursing on January 18, 2019, at 10:30 AM confirmed that there was no documented evidence Resident 40 had been receiving the restorative nursing services as recommended upon discharge from skilled occupational and physical therapy to maintain the resident's functional abilities.

Resident 45 was admitted to the facility on October 15, 2018, diagnosis which include pneumonia (infection that inflames the air sacs in one or both lungs) and sepsis (life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs). The resident had a history of falls and a history of subdural hematoma (in a subdural hematoma, blood collects between the layers of tissue that surround the brain. The outermost layer is called the dura. In a subdural hematoma, bleeding occurs between the dura and the next layer, the arachnoid. The bleeding in a subdural hematoma is under the skull and outside the brain, not in the brain itself. As blood accumulates, however, pressure on the brain increases. The pressure on the brain causes a subdural hematoma's symptoms. If pressure inside the skull rises to very high level, a subdural hematoma can lead to unconsciousness and death) but not sure of the date of occurrence.

An Admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment completed at specific intervals to identify resident care needs) dated October 22, 2018, indicated the resident was severely cognitively impaired and required extensive assistance with two persons for transfers between surfaces and for toileting. The resident was identified at risk for falls due to weakness and difficulty walking as per his care plan dated October 15, 2018.

Nursing documentation dated December 19, 2018, at 2:24 PM indicated that the resident was attempting to ambulate on his own while staff assisted him. He attempted to sit back down on the Broda chair legs, which were extended. The resident flipped the Broda chair and the resident fell to the floor, hitting the right side of his head off another resident's chair. The resident sustained a laceration (injury to skin or tearing of the tissue) measuring 1.5 cm x 0.2 cm with a small amount of bleeding.

In response to this fall, an immediate intervention was to trial a rock and go wheelchair
(a wheelchair that features a rocking motion designed to comfort the resident) and increase restorative ambulation.

The resident's care plan was updated on December 19, 2018, to trial the rock and go wheelchair, which has a design feature that has been shown to ease agitation in dementia.
The resident's care plan also indicated that restorative ambulation was to be completed by staff, ambulating the resident with a rollator walker to and from the dining room and the bathroom for at least 35 feet twice a day and for periods of restlessness.

However, at the time of the survey ending January 18, 2019, there was no documentation indicating that this restorative ambulation was provided to the resident as planned. The absence of evidence of the provision of restorative nursing services was verified by interview with the Nursing Home Administrator on Januray 17, 2019, at 9:00 AM

28 Pa. Code 211.5(f) Clinical records
Previously cited 2/9/18, 7/14/17

28 Pa Code 211.12(a) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(c) Nursing services
Previously cited 12/27/18, 8/27/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17

















 Plan of Correction - To be completed: 03/06/2019

1. R40 restorative plan was implemented by a DON on 1.29.2019. R45 no longer resides in the facility.
2. Comprehensive audit of current residents was completed on 1.29.2019 by a DON to ensure the recommended restorative program has been implemented and appropriate follow up if needed.
3. Nursing staff will be educated on the "Restorative practice guide" and the "Focus on F tag 688 by the DON/designee by the date of compliance 3.6.2019.
4. Using the "ADL/Restorative" QAPI tool 5residents/week on a restorative plan will be audited weekly x 4 by the DON/designee to ensure recommended restorative programs are in place. Trends will be reviewed with QA&A.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to thoroughly assess and evaluate bladder function and implement individualized approaches to restore normal bladder function to the extent possible for one resident with urinary incontinence (Resident 8) out of one sampled resident.

Findings include:

Review of Resident 8's clinical record indicated that the resident was admitted to the facility on May 27, 2017, and had diagnosis that included hypertension, diabetes and chronic kidney failure.

An annual Minimum Data Set Assessment (MDS -a federally mandated standardized assessment completed at specific intervals to define resident care needs) dated July 14, 2018, and a quarterly MDS Assessment dated October 14, 2018, both indicated that the resident was cognitively intact, dependent on staff for activities of daily living (ADLs-tasks of daily self-care) and was frequently incontinent of urine. The resident was cognitively intact with a BIMS (brief interview for mental status - a score of 13-15 indicates intact cognition).

Review of Resident 8's plan of care for urinary incontinence initially dated June 27, 2017, revealed that this resident was on an individual toileting plan with toileting between 8:00 AM-10:00 AM, 10:00 AM.-12:00 PM, 12:00 PM-2:00 PM, 2:00 PM-4:00 PM, 4:00 PM-6:00 PM, 6:00 PM-8:00 PM, 8:00 PM-10:00 PM, 10:00 PM-12:00 AM, and as needed and when awake at night.

There was no documented evidence that the facility had evaluated this toileting plan from January 1, 2018, to the time of the survey ending January 18, 2019.

Review of the Resident 8's toileting records revealed that the toileting times noted were not consistent with the scheduled toileting times noted above.

Further review of the resident's toileting revealed that from March 2018 to December 2018, the resident displayed patterns of incontinence at all times on the toileting sheet, without documented evidence that the facility had revised the toileting plan to decrease episodes of incontinency.

There was no indication that the facility identified the patterns of incontinence reflected in the resident's toileting tracking and revised the resident's toileting plan to restore normal bladder function to the extent possible for Resident 8.

Interview with the Director of Nursing on January 17, 2019, at 9:00 AM confirmed that no changes were made to Resident 8's toileting plan since its implementation June 27, 2017.

28 Pa. Code 211.10(a) Resident care policies
Previously cited 8/27/18, 7/14/17

28 Pa. Code 211.10(d) Resident care policies
Previously cited 8/27/18, 5/23/18, 7/14/17

28 Pa Code 211.12(a) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(c) Nursing services
Previously cited 12/27/18, 8/27/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(d)(1) Nursing services
Previously cited 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(d)(3) Nursing services
Previously cited 8/27/18, 6/25/18, 5/23/18, 2/9/18, 7/14/17

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17











 Plan of Correction - To be completed: 03/06/2019

1. R8 will be assessed by the DON/designee for bladder function and care plan adjusted accordingly by the date of compliance 3.6.2019.
2. A comprehensive review of current residents with bladder incontinence was completed by a DON/designee to validate and update their plan of care is reflective of their current needs by the date of compliance 3.6.2019.
3. Nursing staff will be educated on the "Incontinence practice guide" and "Focus on F 690" by the DON/designee by the date of compliance 3.6.2019.
4. Residents with a decline in urinary incontinence on submitted MDS's will be audited weekly x4. Results will be reviewed with QA&A.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on a review of clinical records and select facility policy and staff interviews it was determined that the facility failed to timely assess weight changes and implement interventions to deter further weight loss and/or gain for two of five residents reviewed for nutrition. (Residents 81 & 78).

Findings include:

A review of the facility policy entitled "Weight Management Guideline" dated as reviewed by the facility March 2018, revealed that the key to effective weight management is to appropriately identify weight variances and initiate nutrition strategies to reduce nutrition related complications. If a patient experiences a change in condition and develops signs and symptoms for weight change, then the Registered Dietitian (RD) is contacted and re-evaluates the patient and the physician and family are notified of the changes in condition.

A review of the clinical record revealed that Resident 81 was admitted to the facility on April 15, 2018, with diagnoses that included adult failure to thrive (describes a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments. Manifestations of this condition include weight loss, decreased appetite, poor nutrition, and inactivity) and dementia (general term for a decline in mental ability severe enough to interfere with daily life).

A nutritional risk evaluation dated November 26, 2018, revealed that the resident weighed 163.2 pounds (lb) upon admission to the facility. The evaluation indicated that the resident was meeting his nutritional needs, was on diuretic therapy (drugs to reduce the amount of salt and water in the body by increasing urine), the resident's diet remained appropriate and continue to monitor weight.

A review Resident 81's nutritional care plan dated November 15, 2018, revealed a problem/need of the resident's nutritional status relating to the resident's therapeutic diet, diagnoses and diuretic therapy. The care plan interventions at the time included to review weights and notify physican and responsible representitive (RR) of significant weight changes.

A review of the resident's "Weights and Vitals Summary" report revealed that the resident's weight was noted as 188.6 lb on December 13, 2018, (representing a 25.5 lb or 15.5 % weight gain in less than one month).

In an interview conducted on January 18, 2019, at approximately 9:28 AM with the Director of Nursing (DON) and Nursing Home Administrator (NHA), the DON and NHA confirmed that the physican and family representative were not notified of the resident's weight gain and that there was no nutritional progress note until January 5, 2019, addressing the resident's weight gain and/or weight fluctuations.

A review of the clinical record of Resident 78 revealed admission to the facility on April 19, 2018, with diagnosis, which included cancer of the bladder and colon (the last part of the gastrointestinal tract and of the digestive system) with a colostomy (is a surgical procedure in which an opening [stoma] is formed by drawing the healthy end of the large intestine or colon through an incision this opening, in conjunction with the attached stoma appliance, provides an alternative channel for feces to leave the body) and esophageal reflux disease (when stomach acid frequently flows back into the tube [esophagus] connecting your mouth and stomach, this backwash [acid reflux] can irritate the lining of the esophagus).

According to the resident's plan of care dated April 23, 2018, the facility planned to review the resident's weight and notify physician and responsible party of significant weight change. The resident's weight as of November 7, 2018, was noted as 167.2 pounds and on December 3, 2018, the resident's weight had decreased to 157.8 pounds; a weight loss of 9.4 pounds in one month or 5.62% loss of body weight. On January 1, 2019, the resident's weight was recorded as 154.8 lbs, a loss of an additional 3 pounds.

The last progress note written by the facility's dietitian was dated November 24, 2018, and indicated that the resident did not have a significant weight loss.

There was no documentation that facility staff notified the dietitian of the 9.4 pound weight loss on December 3, 2018, and no nutritional support interventions were developed and implemented in response to this resident's significant weight loss in one month.

Interview with the DON on January 18, 2019, at 9:30 AM confirmed that the dietitian was not made aware of the resident's significant weight loss and no interventions were put in place to address this weight loss.

Cross refer F580

28 Pa Code 211.6(d) Dietary services.

28 Pa Code 211.12(a) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(c) Nursing services
Previously cited 12/27/18, 8/27/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17

28 Pa Code 211.12(d)(3) Nursing services
Previously cited 8/27/18, 6/25/18, 5/23/18, 2/9/18, 7/14/17

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 12/27/18, 8/27/18, 6/25/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17















 Plan of Correction - To be completed: 03/06/2019

1. R 81 no longer resides in the facility. R -78 MD was made aware of the weight change in November, December and January and the current plan of care by the Unit Manager.
2. A comprehensive weight change audit will be completed for current residents to identify any 5% in 30D or 10% in 180D changes and plans of care will be updated by the Dietician/designee by the date of compliance 3.6.2019.
3. The Dietician and licensed nursing staff will be educated by the DON/designee on the "weight management guideline" on or before the date of compliance 3.6.2019.
4. Using the "Weight change" audit tool, the dietician will audit 5 residents/week who were weighed during that week to validate any significant change. Audits will be completed weekly x4. Results will be reviewed by QA&A.

201.19 LICENSURE Personnel policies and procedures.:State only Deficiency.
Personnel records shall be kept current and available for each employe and contain sufficient information to support placement in the position to which assigned.
Observations:

Based on a review of employee personnel files and staff interviews, it was determined that the facility failed to ensure that personnel records contained sufficient information to support placement in the position to which staff was assigned for one employee out of five reviewed (Employee 1).

Findings include:

A review of the personnel file revealed that Employee 1 was hired by the facility on December 11, 2018 as Medical Records Director.

According to interview with the Nursing Home Administrator on January 17, 2019, at 11:00 AM. Employee 1 was assigned the position of Medical Records Director as of December 11, 2018.

The job description indicated educational requirements were a bachelor's degree in Health Information Administration preferred. Registered Health Information Administrator (RHIA) or Registered Health Information Technician) (RHIT) credential preferred.

Employee 1's personnel record did not contain documented evidence that this employee was qualified for this position according to the definition in the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations (a person who is certified or eligible for certification as a registered records administrator (RRA) or a health information technologist/accredited record technician by the American Health Information Management Association (AHIMA) and who has the number of continuing education credits required for each designation by the AHIMA.

An interview with the Nursing Home Administrator (NHA) confirmed that Employee 1's personnel record did not contain sufficient information to support placement in the position to which she was assigned.








 Plan of Correction - To be completed: 03/06/2019

1. A Health records professional who meets the regulations has been contracted by the NHA to supervise and audit the medical records team of the facility.
2. A review of non-nursing licensed/certified positions will be completed by the HR representative/designee to ensure compliance with regulations by the date of compliance.
3. HR, NHA, and DON will be educated by the Quality Assurance Consultant/designee on the requirements and job descriptions for non-nursing licensed/certified positions in the facility.
4. The Human Resources Director will review new hires to non-nursing positions that require license/certification to ensure regulatory compliance weeklyx4 and results reviewed with QA&A.

211.5(i) LICENSURE Clinical records.:State only Deficiency.
(i) The facility shall assign overall supervisory responsibility for the clinical record service to a medical records practitioner. Consultative services may be utilized, however, the facility shall employ sufficient personnel competent to carry out the functions of the medical record service.
Observations:

Based on review of an employee job descriptions and staff interviews, it was determined that the facility failed to assign supervisory responsibility of the clinical record service to a qualified medical records practitioner.

Findings include:

Review of the facility's job description for "Medical Records Director" revealed the person in this position would plan, develop, and administer medical record systems for the nursing facility in accordance with state and federal regulations as well as professional standards of practice and company and facility policies and procedures. A bachelor's degree in Health Information Administration preferred. registered health information administrator (RHIA) or registered health information technician (RHIT) credential preferred.

A review of the qualifications defined in the 28 PA Code Pennsylvania State Licensure Regulations revealed that a medical record practitioner is a person who is certified or eligible for certification as a registered records administrator (RRA) or a health information technologist/accredited records technician by the American Health Information Management Association (AHIMA) and who has the number of continuing education credits required for each designation by the AHIMA.

Interviews with the Nursing Home Administrator (NHA) on January 17, 2019, at 11:30 AM revealed that supervisory responsibility of the facility's medical records service was assigned to Employee 1 on December 11, 2018. A review of this employee's personnel file revealed the employee was not qualified for this position. Employee 1 lacked the necessary medical records certification. This employee was not supervised by an individual who was certified as a medical records practitioner

The NHA stated during interview on January 17, 2019, at 11:30 AM the facility does not have a contract with a certified medical record practitioner and confirmed the overall responsibility for the clinical record service was not assigned to a qualified medical record practitioner.












 Plan of Correction - To be completed: 03/06/2019

1. A Health records professional who meets the regulations has been contracted by the NHA to supervise and audit the medical records team of the facility.
2. A review of non-nursing licensed/certified positions will be completed by the HR representative to ensure compliance with regulations.
3. HR, NHA, and DON will be educated by the Quality Assurance Consultant/designee on the requirements and job descriptions for non-nursing licensed/certified positions in the facility.
4. The Human Resources Director will review new hires to non-nursing positions that require license/certification to ensure regulatory compliance weekly x4 with results reviewed with QA&A.



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