Nursing Investigation Results -

Pennsylvania Department of Health
ARISTACARE AT MEADOW SPRINGS
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ARISTACARE AT MEADOW SPRINGS
Inspection Results For:

There are  142 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.
ARISTACARE AT MEADOW SPRINGS - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to two complaints, completed on May 16, 2019, it was determined that Aristacare at Meadow Springs, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.






 Plan of Correction:


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

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

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

Based on observation, review of facility documentation, policy and procedure and staff interview, it was determined that the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety.

Findings include:

Review of facility policy "Sanitation - General Kitchen", dated September 1, 2018, indicated, "The kitchen will be clean and sanitize food preparation areas, food-contact surfaces, dining facilities and equipment". "After each use, clean and sanitize tableware, kitchenware and food contact surfaces and equipment".

Observation of the dietary department on May 13, 2019, starting at 11:40 a.m. and than following on the same date, at 1:45 p.m. revealed the following observations:

The loading dock area had an accumulation of plastic strip debris and numerous cigarette butts covering this area.

Continued observation of the loading dock area revealed two industrial size trash cans that had loose debris and were without lids.

Observation of the central supply area revealed 12 cases of Jevity 1.5 were sitting directly on the floor.

Observation of the emergency supply storage closet revealed that five 50 gallon water containers were coated with a layer of dust. Additionally, the closet contained a floor buffer head and a leaf rake.

Two separate observations were made of small buckets of sanitizer solution sitting in areas of food prep.

Observation of two sugar and one flour bin revealed that the bins were cracked and were without covers.

The three tier plate warmer was observed to have a heavy coating of dried-on food particles lined the inside of each plate warmer tier, with a stack of clean plates in each tier.

Two circulating fans were observed to be running which were coated with a thin layer of dust and debris.

Observation of the dry food storage closet revealed each of the shelves holding food were coated with a heavy layer of dust and spilled on food debris and the floor in this area was dirty with dry food debris. Continued observation of this area revealed multiple bags of bread and rolls, that were opened were not dated to when they were opened.

The ceiling in the dry storage room revealed it was cracked with loose debris near the ceiling vent.

An area of the floor by the door of the dry storage room was covered with water. The source of the water at the time of the observation was unknown.

The floor drain near the mop storage area was observed to be heavily coated with food debris, particles of trash and stagnant water. Observation of the floor drain near the ice machine also appeared to be heavily coated with food debris, particles of trash and stagnant water.

Observation of the walk-in refrigerator and freezer revealed boxes were stored close to the ceiling, not allowing air circulation to flow properly.

Continued observation of the walk-in freezer revealed in the right hand corner was a large amount of dry spillage, which at the time of the observation, Employee E8, Dietary director, indicated the spillage was not food related, rather it was coming from somewhere else.

Observation of the entire floor within the dietary department revealed it had not been swept and/or mopped recently.

Upon asking Employee E8, Dietary manager, for copies of recent completed cleaning tasks for the dietary department, at the end of the follow up observation of the dietary department, it was revealed to the surveyor, "They could not be located".

Interview with Employee E8, dietary manager, on May 13, 2019, at 3:15 p.m. confirmed no recent completed dietary cleaning documentation was available for review. During the same interview, Employee E8, confirmed that the dietary department was not being maintained in accordance with professional standards for food service safety.

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

42 CFR 483.60(i) Food safety requirements.
Previously cited 8/30/18

28 Pa. Code: 211.6(b) Dietary services.

28 Pa. Code: 207.2(a) Adminstrator's responsibility
Previously cited 8/30/18








 Plan of Correction - To be completed: 07/10/2019


Debris cleaned on loading dock and trash cans were removed due to not being used during time of survey. Small buckets of sanitizer were removed immediately by FSD and put in utility area in kitchen. Sugar and flour were properly sealed and dated. Cracked and lidless containers were discarded. All tasks added to "Task List" completed by morning and evening dietary supervisor to ensure proper , sanitation and placement/quality of equipment. Audits to be completed monthly for 6 months. Results of audits will be reported through QA Steering Committee and frequency determined by committee.

Shelves in dry storage were added to Food Service Director tasks and will be completed weekly. FSD director or designee will audit monthly for six months. Results of audits will be reported through QA Steering Committee and frequency determined by committee.

The following were cleaned during time of survey: floor drains by mop storage and near ice-machine, three-tier plate warmer, dry food storage closet and floor and floors throughout entire kitchen. All tasks are currently tasks to be performed by kitchen staff. FSD will re-Inservice the importance of completing the tasks assigned. Audits will be completed monthly for six months. Results of audits will be reported through QA Steering Committee and frequency determined by committee.

Two circulating fans were cleaned at time of survey and add as a maintenance task every 6 months to be completed. Audits to be completed every six months for a year. Results of audits will be reported through QA Steering Committee and frequency determined by committee.

Boxes in walk-in refrigerator and freezer were taken down to allow air circulation to flow. Mark will be installed in refrigerator and an additional freezer will be purchased to ensure proper air circulation. Audits will be completed monthly for six months. Results of audits will be reported through QA Steering Committee and frequency determined by committee.


Ceiling in dry storage was repaired at time of survey.

Water at time of survey was cleaned up. Source of issue will be fixed to minimize condensation from pipes.

During time of survey facility received the weekly shipment for supplies for environmental, dietary and central supply. Supplies were in the process of being put away. Central Supply director in-serviced that no supplies are to be put on the floor. Audits will be completely monthly for six months. Results of audits will be reported through QA Steering Committee and frequency determined by committee.

Water containers were dusted during time of survey. Containers to be wrapped with plastic to protect containers from getting dusty. Monthly audits for six months to be completed. Results of audits will be reported through QA Steering Committee and frequency determined by committee.







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

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

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

Based on review of clinical records, facility documentation, observation and staff interviews, it was determined that the facility failed to ensure that three of three resident reviewed received their Restorative Nursing Program (RNP - a program that provides appropriate services to increase range of motion) as ordered (Resident's R55, R66 and R72).

Findings include:

Review of facility policy, "Restorative (Functional Maintenance Program) Adaptive Equipment "stated "Rehab will initially discharge resident to Restorative Nursing Program. Eventually, some resident's range of motion and splinting programs will be transferred to the Floor Maintenance Program conducted by floor C.N.A.s. (Certified Nursing Assistant)".

Review of Resident R55's clinical record revealed that he was admitted to the facility on November 13, 2018 with diagnose,s including but not limited to, Amyotrophic lateral sclerosis (progressive nervous system disease that weakens muscles and impacts physical function), dependence on a ventilator (machine used to assist breathing) and Respiratory failure.

Review of Resident R55's quarterly Minimum Data Set, (MDS - periodic assessment of needs) dated March 10, 2019, revealed that Resident R55's "functional limitation in Range of Motion for upper extremity (shoulder, elbow, wrist and hand)" was impaired on both sides. Further review of the clinical record revealed a physician order dated January 01, 2019 which stated, "splints to bilateral hands soft pro-palmer (Large finger platform comfortably supports and protects hand and fingers) up to 6 hours per day". A review of the resident Kardex for quick reference kept at the nurse's station revealed that splints were to be administered by the A.M.-3p.m. shift.

Observation of Resident R55 on May 12, 2019, at 1:30 p.m. and 4:47 p.m., May 13 at 2: 47 PM. and May 14 at 11:05 a.m. revealed that Resident R55 was not wearing the bilateral hand splints as ordered. Review of "C.N.A documentation history detail" for the months of March 2019, April 2019, and May 2019 showed no evidence that the hand splints were applied as ordered by the physician. Additionally, there was no documentation of the reason why the splints were not being applied as ordered.

Interview with Employee E2, director of nursing, on May 15, 2019, at approximately 3:00 p.m. confirmed that there was no documented evidence that the facility had applied the hand splints as ordered to prevent the worsening of the resident's limited range of motion to the extent possible.

Resident R66 was admitted to the facility on December 21, 2016, with diagnoses, including but not limited to, cerebral palsy (congenital disorder of movement, muscle tone or posture due to abnormal brain development), dependence on ventilator (machine used to assist with breathing) and anemia(a reduction of red blood cells). Review of Resident's quarterly Minimum Data Set dated March 30, 2019 revealed that the resident was totally dependent on staff for all activity of daily living; impaired upper and lower extremities bilaterally and cognitive impairment. Further review of the clinical record revealed a physician's order dated April 22, 2019 to apply bilateral hand roll carrots for 4 hours.

Observation of Resident R66 on May 14, 2019, at approximately 9:00 AM moving arms and left leg in bed. Fingers in both hands were contracted and observed clenched into a tight fist. No splint or hands rolls were noted in place. Observed resident again, out of bed at 3:34 PM, no splint or hand rolls were noted in place. Observed resident on May 16, 2019, at 9:24 AM, in bed, no hand roll in place.

Review of Certified Nurse's Aide Documentation History (electronic documentation by CNAs of completion of resident care tasks) indicated that from April 23, 2019 to May 15, 2019, the task was performed by the CNA on 3 of 24 possible days.

This was confirmed by the Director of Nursing on May 16, 2019, at approximately 3:30 PM>

Clinical record review for Resident R72 revealed a physician order dated May 1, 2019, which indicated diagnoses of: anoxic brain damage, (internal condition that decreases the oxygen supply for the brain), convulsions, (neurological disorder that causes brief episodes of spasms and /or unresponsiveness), muscle spasm, (involuntary muscle contraction of sudden onset) and low back pain.

Continued review of Resident R72's clinical record reveal a physician order's dated, November 13, 2017, indicating Resident R72, was to receive BLE PROM/AAROM, (bilateral passive range of motion/active assistive range of motion - to move joints through its full range of motion), in bed/chair, Hip/knee/ankle all planes, all directions, 5 to 6 times a week. Further review of Resident R72's physician orders dated May 1, 2019, revealed a second order dated May 23, 2018, indicating an order for RNP (physical exercise program that provides appropriate services to increase range of motion), for bilateral upper extremities, (both arms), 10 reps (repetitions) x 3 sets or as tolerated, daily.

Review of facility documentation "Resident CNA Documentation History Detail" (signed documentation by CNA indicating that a physcian order was completed as ordered) from January 1 - May 16, 2019, revealed that Resident R72 had not been receiving RNP as ordered by the physician. Continued review of the documentation, dated January 1 to May 16, 2019, a period of approximately 20 weeks, revealed that Resident R72 had received the the RNP on 31 of the 100 times ordered by the physician.

Interview with Employee E5, Licensed nurse, on May 16, 2019, at 11:40 a.m. confirmed that Resident R72 has not been receiving the RNP as ordered by the physician.

The facility failed to ensure that three residents received their Restorative Nursing Program as ordered.

28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services
Previously cited 7/24/2017

28 Pa. Code: 201.18 (b)(2) Management

28 Pa. Code: 211.10 (d) Resident care policies





 Plan of Correction - To be completed: 07/10/2019

R55, R66, R72 re-evaluated by Therapy Services. Results of evaluations determined no decline.

In-service to be conducted on the importance of proper documentation within residents EMR to nursing staff. Nursing staff will also complete new competencies on RNP that will be created will be created which will include implementation.

Audits will be conducted to ensure documentation present. Residents who do not have documentation will be re-assessed by Therapy Department. Once discharged by Therapy orders for RNP will be followed if applicable and the following audits will ensure resident's have received their RNP.

Clinical Program Coordinator will audit documentation in resident's EMR monthly for three months to ensure completion of documentation.

Results of audits will be reported through QA Steering Committee and frequency determined by committee.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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.
483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:

Based on staff interview, review of clinical records, facility documentation and facility policy, it was determined that the facility failed to ensure that one of thirty-eight residents reviewed was protected from neglect, related to a fall (Resident R98).

Findings include:

Reviewed of facility policy "Abuse", dated October 27, 2017 revealed that neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Review of the clinical record for Resident R98 revealed that the resident was admitted to the facility on January 17, 2019, with diagnoses, including but not limited to, anoxic brain damage (oxygen deprivation resulted in the brain not functioning correctly) and dependence on ventilator ( machine used to assist with breathing). Observation of Resident R98 on May 14, 2019, at approximately 10:52 AM revealed that the resident was in bed with a tracheostomy tube (inserted through the neck to assist breathing) and a gastrostomy tube (inserted in the abdomen to provide nutrition).

Review of the clinical record revealed a nurse's note dated March 26, 2019 at 7:37 PM which indicated that Resident R98 was found on the floor in room by the geri-chair at 4 PM. No injuries or bruising noted. Resident was agitated and restless. Further review of the clinical record revealed the quarterly Minimum Data Set (MDS- periodic assessment of the resident's needs) dated April 22, 2019 indicated that the resident required total assistance with all activities of daily living, had functional limitation in range of motion for bilateral (both sides)extremities and severe cognitive impairment. There was a physician's order written on February 13, 2019: for posey belt for chair.

On May 16, 2019 at approximately 7:46 AM, interview with the Director of Nursing revealed that the resident had orders for a posey belt before the fall because the resident had non- purposeful movement in and out of bed. On March 26, 2019 the resident fell out of the geri-chair. The resident did not have the belt in place at the time of the fall. The nurse aide did not know that the resident wore a belt in the geri-chair and he did not read the resident's care plan.

On May 16, 2019 at approximately 11:08 a.m., interviewed Employee E5, the unit manager. Employee E5 stated that the nurse aides received information regarding the resident from the assignment sheet, the written Kardex which is kept at the nursing station and the electronic kiosk which is accessed by the nurse aide. Safety measures and resident's care needs are listed on the Kardex and in the kiosk system.

Review of the investigation regarding the fall revealed that the nurse aide assigned to the resident wrote the statement that he was new to the assignment and did not know that the resident had a belt on his chair. The Director of Nursing's written conclusion was that the resident did not have a posey belt in place resulting in a fall. Nurse aide said that he was new to the assignment and failed to review the resident's care card.

The facility failed to ensure that one resident received the necessary care and services to prevent a fall.

28 Pa. Code: 201.14 (a) Responsibility of licensee.
Previously cited 7/24/17

28 Pa. Code 201.18 (B)(1) (2)(3)(e)(1) Management.
Previously cited 7/24/17

28 Pa. Code 211. 12 (d)(1)(5) Nursing services
Previously cited 7/24/17










 Plan of Correction - To be completed: 07/10/2019

Certified Nursing Assistant involved received education at time of incident regarding safety interventions to be implemented as ordered as well as the importance of reading all residents care card before providing care

Audits will be conducted to ensure resident's who have a physician order for a restraint is in place. Audit content will be added to facilities 'Non-Clinical Rounds', which are completed weekly by department heads or designee.

Results of audits will be reported through QA Steering Committee and frequency determined by committee.








483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

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

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

483.12(a) The facility must-

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

Based on observation, review of clinical records, facility documentation and facility policy and staff interview, it was determined that the facility failed to ensure that one of five residents reviewed remained free of unnecessary physical restraints (Resident R113).


Findings include:

Review of facility policy "Use of Restraints", undated, indicated "Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully". ... and ... "Physical Restraints" are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body". "Examples of physical restraint is a soft ties, such as a posey belt".

Continued review of the policy revealed that "Resident or resident's responsible party shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use". "Should a resident not be capable of making a decision, the resident's responsible party may exercise the right of the use of non-use of a resident".

Observation of Resident R113 on May 13, 2019, at 1:45 p.m. revealed the resident sitting in a wheelchair with a posey belt, (a clothe belt-like device applied around the waist and tied behind the wheelchair to prevent the individual from moving and/or sliding out of the wheelchair) secured around the resident's waist. Interview with Resident R113, at the time of the observation, revealed that he could not answer any questions related to the posey belt being in place.

A second observation of Resident R113, on May 14, 2019, at approximately 3:00 p.m. while receiving therapy services revealed that Resident R113, had a Posey belt in place around his waist. Additionally, it was noted that the resident had a seat belt fastened to the wheelchair thereby creating a double restraint for R113.

Interview with Employee E10, Occupational Therapist, on may 14, 2019, at the time of the observation, revealed that the employee was unaware that Resident R113 had a doubled restraint around his waist.

Further observation of Resident R113 on May 14, 2019, at 3:20 p.m. in the presence of the Director of Nursing and Employee E5, Licensed nurse, confirmed that Resident R113 was not properly restrained thereby creating a double restraint, with the Posey belt in place and with a seatbelt fastened to the wheelchair being clipped around R113's waist.

Clinical record review for Resident R113, revealed a physician order, dated, May 1, 2019, which indicated the following diagnoses, respiratory failure, (when not enough oxygen passes from your lungs into your blood), seizure disorder, history of sudden cardiac arrest, non-displaced fracture (broken bone) of 2nd cervical vertebrae and fracture of T11 and T12 vertebra. Continued review of the physician order's dated May 1, 2019, revealed an order dated February 20, 2019, which indicated, "Posey Belt while in chair" and Bilateral Hand Mitts, (glove like device that goes over one's hands, permitting them from being able to use hands) as needed.

Review of Resident R113's quarterly, MDS, (Minimum Data Set - periodic assessment of needs) dated, April 28, 2019, indicated R113 is severly cognitively impaired, requires complete extensive care with all activities of daily living and is impaired on both sides of lower extremities.

Review of facility document "Nursing - Physical Restraint Assessment", dated completed February 26, 2019, revealed an Initial Restraint Assessment for Resident R113 related to the use of a Posey Belt and Hand Mitts. Continued review of the assessment revealed that the section about Resident/family Informed, explained Risks and Benefits of the Posey Belt and/or Hand Mitts restraints was not completed as required by facility staff.

Interview with Employee E5, Licensed nurse, on May 16, 2019, at 10:50 a.m. confirmed that there was no documentation to indicate that Resident R113 and/or family were informed and/or that the risks and/or benefits of the restraints had been explained. Employee E5 further indicated that no documentation was available for review to indicate that the facility re-evaluated the continued need for the Posey Belt and/or Hand Mitts and/or that the restraints were being released every two hours as indicated in the facility policy.

Further interview with the Director of Nursing and Employee E5, Licensed nurse, on May 15, 2019, at 10:50 a.m. indicated that the certified nurse aide, (CNA) assigned to Resident R113 on May 14, 2019, did improperly restrain Resident R113 by placing both a posey belt and a seat belt on Resident R113.

The facility failed to properly use, obtain consent and re-evaluate the need for the continued use of a physical restraint for one resident.

28 Pa. Code: 211.5(f) Clinical records

28 Pa. Code: 211.8(a)(f) Use of restraints

28 Pa. Code: 211.10(d) Resident care policies

28 Pa. Code: 211.12(d)(1)(5) Nursing services
Previously cited 7/24/17

28 Pa. Code: 201.14(a) Responsibility of licensee
Previously cited 7/24/17

28 Pa. Code: 201.18(b)(1)(3) Management.
Previously cited 7/24/17

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


















 Plan of Correction - To be completed: 07/10/2019

Risks and benefits re-reviewed with the resident's responsible party and documented in the resident's EMR. After review of resident's chart, resident continues to require a physical restraint to ensure the resident's safety.

Audits to be completed to ensure residents' who have physician order for hand-mitt and/or posey pelvic belt have had risks and benefits discussed with resident/resident responsible party as well that a Quarterly Restraint Review has been completed by nursing staff which ensures the continue need for the restraint

Also, posey pelvic belt and hand-mitt orders will be updated to reflect that every two-hour documentation is required for release of the restraint and skin check completed.

Nursing staff will be in-serviced that the new standard order for posey pelvic belts and hand-mitts will include and require documentation every two hours that the restraint was released and skin checks were completed.

DON or designee will audit any order for hand-mitt and posey seat belt to ensure proper documentation in the resident's EMR. Audits will be completed weekly for a month and then monthly for three months.

'Ensure proper restraint use' use will be added to 'Non-clinical Rounds' that are completed weekly by department heads or designees. Audit is to ensure residents are not double restrained or improperly restrained.Data from rounds is captured in QA Steering Meeting.

Audit results for both risk and benefits documentation of restraint documentation and documentation that restraints were released and skin checks were completed will be reported through QA Steering Committee and frequency determined by committee.

483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on review of clinical records, review of facility documentation and facility policy and interviews with staff, it was determined that the facility failed to report suspected incidents of abuse, neglect or mistreatment to the State Agency in a timely manner for one of thirty-eight residents reviewed. (Resident R98).

Findings

Review of facility policy "Abuse" dated October 27, 2017, revealed in the section "Reporting and Response" that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported immediately, but not later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, not later than 24 hours... If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency. A follow-up investigation will be submitted to the State Agency within five (5 working days).

Review of the clinical record revealed that Resident R98 was admitted to the facility on January 17, 2019 with diagnoses, including but not limited to, anoxic brain damage (oxygen deprivation resulted in the brain not functioning correctly) and dependence on ventilator
(machine used to assist with breathing).

Further review of the clinical record revealed in a nurse's note dated March 26, 2019 at 7:37 PM that the Resident R98 was found on the floor in his room by geri-chair at 4 PM. No injuries or bruising noted. Resident was agitated and restless. Upon further review of the clinical record, the quarterly Minimum Data Set (MDS- periodic assessment of the resident's needs) dated April 22, 2019 revealed that the resident required total assistance with all activities of daily living; functional limitation in range of motion for bilateral extremities and severe cognitive impairment. Continued review of the clinical record revealed a physician's order dated February 13, 2019 which directed staff to apply a posey belt (clothe type strap used to secure an individual in place) for chair.

Review of the facility's fall investigation revealed that the nurse aide assigned to the resident wrote that he was new to the assignment and did not know that the resident had a belt on his chair. The Director of Nursing's written conclusion was that the resident did not have a posey belt in place resulting in a fall. Additionally, it was noted that the nurse aide said that he failed to review the resident's care card.

This incident was not reported to the State Agency within 24 hours and the conclusion of the investigation was not reported. This was confirmed by the Administrator on May 16, 2019 at approximately 12 PM.

The facility failed to reported that the nurse aide neglected to read the resident's care card and provide posey belt as prescribed.

28 Pa. Code 201.14 (a) Responsibility of licensee.
Previously cited 7/24/17

28 Pa. Code 201.18 (b)(1)(2)(3) Management.
Previously cited 7/24/17

28 Pa. Code 211.12 (d)(1)(3) Nursing services.
Previously cited 7/24/17




















 Plan of Correction - To be completed: 07/10/2019

Incident referring to deficiency was during the time of previous NHA who is no longer employed by the company.


Current NHA has been educated and trained on the federal regulation regarding reportable incidents.

NHA will conduct a monthly audit for six months on incidents to ensure compliance of reporting investigations. Results of audits will be reported through QA Steering Committee and frequency determined by committee.



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

Based on observation, review of facility documentation, facility policy and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for one of one residents reviewed with a cervical collar (Resident R103).

Findings include:

Review of the facility policy, "Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates", dated November 27, 2017, indicated, "The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care."

Observation of Resident R103, during the initial tour of the facility on May 13, 2019, revealed that the resident was wearing a cervical collar. At the time of the observation Resident R103 was unable to communicate why he was wearing the cervical collar. Further observation of Resident R103 revealed he had limited range of motion with both his upper and lower extremities, (arms and legs).

Clinical record review for Resident R103, revealed a physician order dated May 1, 2019, which indicated the following diagnoses; complete lesion at C4 level of cervical spinal cord, (injury of nerves and spinal cord at neck level), quadriplegia, (paralysis of all four limbs), dependence on respirator, (ventilator -a machine designed to mechanically move breathable air into and out of the lungs, to provide the mechanism of breathing for a patient who is physically unable to breathe, or breathing insufficiently) and absence of spleen, (with out an organ found in virtually all vertebrates, acts primarily as a blood filter, spleen plays important roles in regard to red blood cells and the immune system. It removes old red blood cells and holds a reserve of blood, which can be valuable in case of shock, and also recycles iron).

Continued review of Resident R103's physician orders revealed an order dated, March 2, 2019, which indicated that Resident R103, "Must wear neck brace at all times". Additionally, the order further directed "Every day 7:00 am - 7:00 pm; 7:00 pm - 7:00 am.

Review of Resident 103's Plan of Care's revealed that there were no interventions in place to address Resident R103 having a cervical collar in place, 24 hours a day, 7 days a week.

Interview with Employee E5, Licensed nurse, on May 16, 2019, at 10:00 a.m. confirmed no care plan was developed and/or implemented related to Resident R103, having a cervical collar in place.

The facility failed to develop or implement a comprehensive care plan related to a resident wearing a cervical collar.

28 Pa. Code: 211.11(a)(d) Resident care plan.

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

28 Pa. Code: 211.12(d)(1)(5) Nursing services.
Previously cited 7/24/17











 Plan of Correction - To be completed: 07/10/2019

Comprehensive care plan added to resident's EMR during time of survey including daily skin checks around site of cervical collar.

Audit will be completed to ensure a comprehensive cervical collar care plan which includes skin checks is present for all residents who have a physician order for cervical collar/brace to ensure appropriate measures are in place.

Skin checks will be added to any cervical collar/brace physician order. This change will be in-serviced to all nursing staff. Checkmark item will be added to facility's Admission/Re-Admission Checklist which is completed on every resident who newly admits or re-admits by DON or designee.

Audits will be completed by DON or designee monthly for 6 months to ensure care plan present.
Results of audits will be reported through QA Steering Committee and frequency determined by committee.


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

483.45(h) Storage of Drugs and Biologicals

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

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

Based on observation and staff interview, it was determined that the facility failed to appropriately store medications and failed to discard expired medications for one of six medication carts inspected (the NLC medication cart D).

Findings include:

Observation of the NLC medication cart D on May 15, 2019, at 9:07 a.m., with Employee E3, Licensed Nurse, revealed the presence of the following:

An opened 10 ML (milliliter) vial of Novolog insulin (used to treat Diabetes) with an opened date as February 17, 2019, which should have been discarded after 28 days of opening.

An opened 3 ML vial of Humulin R insulin without any opened date marked.

An opened 16 fl (fluid) oz (ounce) bottle of Geri-Dryl Liquid Allergy Relief (used to relieve symptoms of allergy) which was dated expired on March 2019.

A 50 ML bottle of Ondansetron (used to prevent nausea and vomiting ) oral solution which was expired on February, 2019.

A bottle of Acidophilus Capsules (Probiotics-form of good bacteria used as a supplement) which was opened on April 15, 2019, that should have been refrigerated after opening.

Interview with Employee E3, Licensed Nurse, at the time of the observation, confirmed that the expired medications, including the Acidophilus Capsules which was not refrigerated after opening, should have been discarded.

The facility failed to ensure that all drugs and biologicals used in the facility were stored appropriately and not expired.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 7/24/17

28 Pa. Code 211.9(g)(h) Pharmacy services.

28 Pa. 211.12(d)(1)(5) Nursing services.
Previously cited 7/24/17








 Plan of Correction - To be completed: 07/10/2019

Medications that were found to be not stored or dated properly were destroyed immediately. Also expired medication was discarded immediately.

Audits of all medication carts to be completed to ensure no medications are incorrectly labeled, stored improperly or expired

Medication audits will be completed monthly to ensure no medications are incorrectly labeled, stored improperly or expired for six months.

Results of audits will be taking to QA Steering Committee who will then decide frequency of audits.

211.6(b) LICENSURE Dietary Services.:State only Deficiency.
(b) Sufficient food to meet the nutritional needs of the residents shall be prepared as planned for each meal. There shall be at least 3 days' supply of food available in storage in the facility at all times.
Observations:

Based on observation, review of facility documentation and interview with facility staff, it was determined the facility did not maintain a three day emergency food supply on hand in the event of an emergency.

Findings include:

Observation of the designated storage area for the dietary department on May 13, 2019, at 12:30 p.m. revealed the area identified for three day emergency supply of food, in the presence of Employee E8, Dietary Manager, did not have a sufficient supply of food for three days in the event of an emergency.

A review of the three day emergency menu revealed that many of the food items listed, were not available in the event of an emergency.

At the time of the observation Employee E8, confirmed that an insufficient supply of three day emergency food was in place.

Continued observation of the food items available in the event of an emergency, revealed that no use by date and/or expiration date was indicated on the food items. Further observation of emergency food supply revealed a small plastic container of b'gan grape jelly had the hand written date of 12/17 in black magic marker on the lid. Continued observation of the grape jelly revealed that Employee E8 could not identify the use by date and/or expiration date on the grape jelly.

A follow-up interview with Employee E8, on May 15, 2019, at 1:45 p.m. revealed a letter received from the food provider indicating that the grape jelly was a kosher product with the use-by date indicated in Hebrew, (H-22-R). Further interview with Employee E8, confirmed that he did not know the use by date on any of the food items that were currently in stock within the dietary department.

The facility failed to maintain a three day emergency food supply.





 Plan of Correction - To be completed: 07/10/2019

Jelly discarded. All food in emergency supply was re-checked to ensure all food was not expired. All food also was checked to ensure that all items on emergency supply menu were in emergency food supply.

Audits to be completed monthly for a year to ensure expiration dates are properly written on items, food is not expired and every item on emergency food menu is in supply.

Results of audits will be reported through QA Steering Committee and frequency determined by committee.

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