Nursing Investigation Results -

Pennsylvania Department of Health
ELKINS CREST HEALTH & REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ELKINS CREST HEALTH & REHABILITATION CENTER
Inspection Results For:

There are  147 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.
ELKINS CREST HEALTH & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed June, 7th, 2019, it was determined that Elkins Crest Health and Rehabilitation Center, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.


 Plan of Correction:


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 a group interview, resident interview, clinical record review, review of activity calendars and observation, it was determined that the facility failed to provide an on-going activity program to meet the needs of two of four sampled residents. (Resident 58, 65)

Findings include:

During a group interview on June 5, 2019, at 10:30 a.m., five of nine alert and oriented residents stated that the activities were not satisfactory due to repetitiveness, lack of variety and being non-stimulating. (Residents 12, 41, 43, 89, 109)

Review of the monthly activity calendars from January 2019, through June 2019, revealed that the activities offered on a daily/weekly basis were repetitive and lacking variety especially on the weekends.

Clinical record review revealed that Resident 58 had diagnoses that included heart disease, anxiety, depressive episodes and difficulty walking. The Minimum Data Set (MDS) assessment dated October 12, 2018, indicated in the activities section that books, newspapers, music and getting fresh air when the weather was good were all activities that were somewhat important to the resident. The assessment further indicated that the resident was the source of the information. A nursing note dated May 21, 2019, revealed that the resident was alert and able to make his needs known. Observation on June 4, 2019, at 1:27 p.m., revealed that the resident was in his room seated on his bed. Observation again on June 6, 2019, at 11:00 a.m., revealed that the resident was in his room seated on his bed. On June 6, 2019, at 11:00 a.m., observation revealed that there was a music event being held on the second floor. Resident 58 stated at this time that "he would have liked to have attended the activity but staff did not ask him to go and he was unaware of the music event being held on the second floor ".

Clinical record review revealed that Resident 65 had diagnoses that included cognitive communication deficit, heart disease, suicidal ideations and limitations of activity due to disability. The MDS assessment dated April 2, 2019, indicated that the resident had no memory impairment. The activities section of the assessment indicated that books, listening to favorite music, animals, being in groups, participating in favorite activities, getting fresh air when the weather was good and religion were all activities that were very important to the resident. The assessment further indicated that the resident was the source of the information. Observation on June 4, 2019, at 12:45 p.m., revealed that the resident was in his room by himself. He stated that "he was often bored and not interested in the activities listed on the activity calendar". Observation on June 5, 2019, at 12:40 p.m., revealed that the resident was again seated in his room by himself and he stated that "he was often bored and really only had his television to watch". Observation on June 6, 2019, at 11:05 a.m., revealed that the resident was again in his room by himself watching television. He was awake and alert and oriented. Observation at 11:05 a.m., revealed that there was a music event being held on the second floor. Resident 65 stated that "he would have liked to have attended the activity, but staff did not ask him to go and he was unaware of the music event being held on the second floor." There was no documented evidence that the aforementioned residents had been offered or participated in activities of their preference or interest.








 Plan of Correction - To be completed: 07/02/2019




1. R12, 41, 43, 89, 109 were interviewed to identify their preferences for facility activities. R58 and 65 were personally invited to the current activity when it was identified they were not in attendance.

2. All residents have the potential to be affected. The NHA and/or delegate held a special Resident Council meeting on 6/25/2019 to determine what group activities center residents would like to have offered. Where possible, activities will be included on the upcoming Activities Schedule.


3. To prevent the potential for reoccurrence the NHA and/or delegate will announce activities 5 minutes before they begin. Residents will be reminded of this change at the next Resident Council Meeting. The NHA and/delegate will educate the Activities Director on including population sensitive activities in the Activities Calendar.

4. To monitor and maintain ongoing compliance the NHA and/or delegate will request monthly visitation; for 3 months, to Resident Council to discuss current facility activities and how they are received. Results of audit will be presented to QAPI committee for further review and

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(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, it was determined that the facility failed to maintain sanitary conditions in the dietary department.

Findings include:

Observation during the environmental tour of the dietary department on June 4, 2019, at 10:56 a.m., revealed that the top convection oven was soiled on the doors on the inside and outside and on the bottom of the top part of the oven. Observation of the dish machine room revealed that there was a black substance on the ceiling tile over the top of the clean dish area where the clean dishes came out of the machine. In addition, in this same room, both doors were heavily marred and scratched. The wall on the right side of the room had multiple tiles that were cracked and damaged. The grouting and flooring in the dishmachine area was cracked and was missing areas of grouting throughout the dishmachine area.

483.60(i)(1)(2) Food Procurement Store/Prepare/Serve Sanitary
Previously cited 3/28/19, 6/5/18

28 Pa. Code 201.18(b)(1)(3) Management

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







 Plan of Correction - To be completed: 07/02/2019

1. The convention oven door was deep cleaned. Observed stained ceiling tiles in kitchen were replaced. Kitchen wall tiles replaced and regrouted. Kitchen door painted.

2. All residents have the potential to be affected. The NHA and/or delegate audited all kitchen ceiling tiles, wall tiles, doors, and appliances for needed housekeeping or maintenance. Where necessary corrections were accommodated.

3. To prevent the potential for reoccurrence the NHA and/or delegate educated all employees on how to fill out a maintenance request slip.

4. To monitor and maintain ongoing compliance the NHA and/or delegate will observe the kitchen for maintenance and housekeeping concerns 3 times weekly for 3 months. Results of audit will be presented to QAPI committee for further review and recommendation.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:


Based on clinical record review and observation, it was determined that the facility failed to ensure that a resident had her call bell accessible in order to ask for assistance from staff for one of 27 sampled residents. (Resident 56)

Findings include:

Clinical record review revealed that Resident 56 had diagnoses that included cerebral infarction, anxiety and muscle weakness. The Minimum Data Set assessment dated December 12, 2018, indicated that the resident had some memory impairment and required extensive assistance from staff for most activities of daily living. Review of a current care plan revealed the resident was at risk for falls due to unsteady gait and there was an intervention for staff to re-inforce the need to call for assistance. Observation on June 4, 2019, at 12:05 p.m., and 1:41 p.m., on June 5, 2019, at 10:25 a.m., and 1:22 p.m., and again on June 6, 2019, at 10:41 a.m., revealed that the resident was in her room in bed and the call bell was wrapped around the bed enabler rail and located behind the head board and was completely out of her reach.

Pa. Code 211.12(d)(1)(5) Nursing services.








 Plan of Correction - To be completed: 07/02/2019

1. The call light button for R56 was moved to their dominant side.

2. All residents have the potential to be affected. The Director of Nursing (DON) and/or delegate conducted an audit of all residents to ensure call light buttons were accessible. Where necessary, the call light button was moved to ensure accessibility.

3. To prevent this from reoccurring the DON and/or delegate educated all staff on call light button placement with emphasis on ensuring that it is accessible by the resident.

4. To monitor and maintain ongoing compliance the DON and/or delegate will audit call light button placement 5 times daily for 1 month, and then 5 times weekly for 2 months. Results of audit will be presented to QAPI committee for further review and recommendation.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(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 facility policy, clinical record review and observation, it was determined that the facility failed to ensure that assessed safety interventions were in place in order to prevent accidents for one of three sampled residents who had smoking privileges. (Resident 37)

Findings include:

Review of the facility policy entitled, "Smoking Policy/Resident Safety", last reviewed January 24, 2019, revealed that if deemed per assessment to be able to smoke, a smoking apron was to be provided along with any other needed equipment to keep the resident safe.

Review of the facility smoke break schedule revealed that residents with smoking privileges were provided with assistance and supervision from staff to smoke four times a day at set smoking times that included 9:30 a.m., 1:30 p.m., 6:30 p.m., and 8:30 p.m.

Clinical record review revealed that Resident 37 had diagnoses that included dementia with behavior disturbance, anxiety, and schizoaffective disorder. The Minimum Data Set assessment dated February 22, 2019, indicated that the resident had some memory impairment and required assistance from staff for dressing. Observations during the survey revealed that the resident was an independent ambulator on the nursing units. Review of the quarterly assessment for smoking dated May 23, 2019, revealed that the resident chose to smoke, and was to be supervised by staff at all times when smoking and that the resident was not able to light a cigarette with a lighter and was not able to extinguish a cigarette safely and completely. Review of the current care plan identified the resident as a smoker and there was an intervention for staff to provide the resident with a smoking apron (protective clothing to prevent burns). Observation on June 4, 2019, at 1:30 p.m., revealed that Resident 37 was assisted by staff to light his cigarette; however, staff neglected to provide the resident with the smoking apron until the resident asked for the apron. Observation again on June 5, 2019, at 1:45 p.m., revealed that Resident 37 was again assisted by staff to light his cigarette. The resident proceeded to the outside court yard and was smoking the cigarette without the smoking apron in place.

28 Pa. Code 211.12 (d)(1)(5) Nursing services.







 Plan of Correction - To be completed: 07/02/2019

1. R37 is offered a smoking apron by staff when participating in smoking activity.

2. All residents who smoke and require an apron have the potential to be affected. The DON and/or delegate observed the scheduled smoking activity to ensure residents requiring aprons were offered, and were wearing them.

3. To prevent the potential for reoccurrence a smoking apron list was posted in the apron closet. The DON and/or delegate educated all staff on the need to check this list and provide aprons before handing out cigarettes or lighters.

4. To monitor and maintain ongoing compliance the DON and/or delegate will observe the smoking activity randomly 3 times weekly for 3 months. Results of audit will be presented to QAPI committee for further review and recommendation.

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 observation, it was determined that the facility failed to provide services and treatment to prevent further limitations in range of motion for two of 11 sampled residents who had limited range of motion. (Residents 30, 98)

Findings include:

Clinical record review revealed that Resident 30 had diagnoses that included muscle weakness and flaccid hemiplegia on the left side following a cerebral infarction. The Minimum Data Set (MDS) assessment dated February 8, 2019, indicated that the resident had no memory impairment, required extensive assistance from staff for dressing, and had limited range of motion on one side of her upper and lower extremities. Review of the current care plan identified that the resident had limited range of motion with potential for decreased range of motion in the hand, elbow and left wrist. There was an intervention for the resident to complete 30 repititions (reps) of passive range of motion and for staff to encourage the resident to participate in the restorative program. Review of an occupational therapy discharge summary dated May 16, 2019, indicated that the prognosis was excellent with participation in restorative nursing program with consistent staff follow through. Review of the restorative nursing documentation revealed that the passive range of motion for 30 reps for the hand, elbow and left wrist was blank for eight days in May 2019, and two days in June 2019.

Clinical record review revealed that Resident 98 had diagnoses that included cerebral infarction with hemiplegia, muscle weakness, partial brain craniotomy and contracture of the right hand. The MDS assessment dated May 2, 2019, indicated that the resident had memory impairment, needs some assistance with activities of daily living and had limited range of motion on one side of her upper and lower extremities. On March 14, 2019, a physician ordered a restorative passive range-of-motion nursing program for splinting. Review of the care plan identified that the resident had a splint to her right hand and an intervention was to complete a range of motion program before performing splint/brace program. Review of an occupational therapy discharge summary dated May 15, 2019, indicated that the resident was to participate in a restorative program for the use of a hand splint and to encourage the resident to wear the splint. Observation on June 4, 2019, at 12:40 p.m., revealed that the resident was dressed and in her wheelchair in her room without the splint in place on her right hand. Observation again on June 5, 2019, at 12:31 p.m., revealed that the resident was again dressed and in her wheelchair in her room without the splint in place on her right hand. The splint was located on her bed. The resident at this time attempted to put the splint on by herself but had a difficult time due to the contractures in her fingers on her right hand. Observation on June 6, 2019, at 12:59 p.m., again revealed the resident dressed and seated in her room in her wheelchair without the splint in place on her right hand. Review of the restorative nursing documentation revealed that assistance with the splint to her right hand was blank for nine days in May 2019, and four days in June 2019.

28 Pa. Code 211.12(d)(1)(5) Nursing services.






 Plan of Correction - To be completed: 07/02/2019

1. R30 encouraged to participate in ROM and R 98 maintain splint usage during prescribed time frame. R30 and R 98's Care Plan, Care Delivery Guide, and Behavior Flow Record were reviewed to ensure they capture resident's target behavior for splint removal and not participating in ROM exercise.

2. All residents requiring splints and ROM exercise have the potential to be affected. The DON and/or delegate reviewed the Care Plan, Care Delivery Guide, and Behavior Flow Record for all residents who are known to remove their splints and refuse ROM. Updates were made as needed to reflect this behavior.

3. To prevent this from reoccurring the DON and/or delegate educated all nursing staff on the procedure for identifying residents who remove their splints through their plan of care. Nursing staff was also educated on how to document refusals.

4. To monitor and maintain ongoing compliance the DON and/or delegate will audit resident splint removals records 5 times weekly for 1 month and the 1 time weekly for 2 months. Results of audit will be presented to QAPI committee for further review and recommendation.

483.25(b)(2)(i)(ii) REQUIREMENT Foot Care: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(b)(2) Foot care.
To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must:
(i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and
(ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments.
Observations:

Based on clinical record review and resident interview, it was determiend that the facility failed to provide adequate and timely podiatry care to one of 27 sampled residents. (Resident 42)

Findings include:

Clinical record review revealed that Resident 42 had diagnoses that included heart disease and difficulty walking. According to the Minimum Data Set (MDS) assessment dated March 5, 2019, the resident had no memory problems and required supervision or assistance from staff to walk. The ongoing care plan dated November 19, 2018, revealed that the resident had activities of daily living self-care deficits and staff would provide assistance to meet those needs. Review of a podiatry progress note dated February 15, 2019, revealed that resident had long toenails that were trimmed and a recommendation was made at that time for the resident to be seen again in nine weeks . There was no documentation to support that the resident was seen for podiatry care. In an interview with on June 4, 2019 at 10:30 a.m., Resident 42 stated, "I would like my toenails cut."

In an interview on January 7, 2019, at 12:10 p.m., the Assistant Director of Nursing confirmed the resident was not seen timely for podiatry care.

28 Pa. Code 211.12(d)(5) Nursing Services












 Plan of Correction - To be completed: 07/02/2019

1. R42 was seen by the Podiatrist on 6/6/2019.

2. All residents who have podiatry consults have the potential to be affected. The DON and/or delegate will audit all resident podiatry consults to ensure their next scheduled visit is consistent with the recommended time frame. Where necessary the facility worked to schedule consultation dates that align with the referenced time frame.

3. To prevent this from reoccurring the DON and/or delegate educated all nursing staff on documenting rationale when consultation follow ups do not match the requested time frame.


4. To monitor and maintain ongoing compliance the DON and/or delegate will audit podiatry consults 5 times weekly for 3 months to ensure scheduled follow ups match their recommended time frame.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on clinical record review and observation, it was determined that the facility failed to ensure that hygiene/grooming was provided to one of four sampled residents who were dependent on staff for hygiene/grooming. (Resident 39)

Findings include:

Clinical record review revealed that Resident 39 had diagnoses that included dementia and a depressed mood. The Minimum Data Set assessment dated March 8, 2019, indicated that the resident had some memory impairment and required assistance from staff to complete personal hygiene that included combing hair and shaving. Observation on June 4, 2019, at 12:35 p.m., and again on June 5, 2019, at 1:21 p.m., revealed that Resident 39 was dressed and in his wheelchair The resident's hair was uncombed and he was in need of a shave due to excessive facial hair.

28 Pa. Code 211.12(d)(5) Nursing services.







 Plan of Correction - To be completed: 07/02/2019

1. R39 was encouraged to comb his hair and shave his face. R39's Care Plan, Care Delivery Guide, and Behavior Flow Record were reviewed to ensure they capture resident's target behavior for refusal of care.

2. All residents who behaviorally refuse Activity of Daily Living (ADL) care; as it relates to grooming, have the potential to be affected. The DON and/or delegate reviewed the Care Plan, Care Delivery Guide, and Behavior Flow Record for all residents who are known to refuse ADL care. Updates were made as needed to reflect this behavior.

3. To prevent this from reoccurring the DON and/or delegate educated all nursing staff on the procedure for identifying residents who refuse ADLs through their plan of care. Nursing staff was also educated on how to document refusals.
4. To monitor and maintain ongoing compliance the DON and/or delegate will audit resident refusal records 5 times weekly for 1 month and the 1 time weekly for 2 months. Results of audit will be presented to QAPI committee for further review and recommendation.
483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities: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.
483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

483.24(b)(2) Mobility-transfer and ambulation, including walking,

483.24(b)(3) Elimination-toileting,

483.24(b)(4) Dining-eating, including meals and snacks,

483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
Observations:

Based on clinical record review, observation, and resident interview, it was determined that the facility failed to provide services to maintain personal hygiene (bathing,dressing) for one of four sampled residents. (Resident 42)

Findings include:

Clinical record review revealed that Resident 42 had diagnoses that included heart disease and difficulty walking. According to the Minimum Data Set (MDS) assessment dated March 5, 2019, the resident had no memory problems and required supervision, or assistance from staff for personal hygiene. The ongoing care plan dated November 19, 2018 revealed that the resident had activities of daily living self-care deficits and that staff would provide assistance to meet those needs.

Observations from June 4, 2019, at 10:30 a.m., and again on June 6, 2019, at 2:00 p.m., revealed Resident 42 was wearing the same soiled clothing. Review of the resident's bathing report from May 9, 2019 through June 6, 2019, and the activities of daily living task for dressing from June 4, 2019 to June 6, 2019, did not indicate the resident refused supervision or assistance from staff. In an interview on June 4, 2019 at 10:30 a.m., the resident stated staff assist her with bathing and dressing.

28 Pa. Code 211.12(d)(5) Nursing Services.













 Plan of Correction - To be completed: 07/02/2019

1. R42 was encouraged to change their clothing. R42's Care Plan, Care Delivery Guide, and Behavior Flow Record were reviewed to ensure they capture resident's target behavior for refusal of care.

2. All residents who behaviorally refuse Activity of Daily Living (ADL) care; as it relates to dressing, have the potential to be affected. The DON and/or delegate reviewed the Care Plan, Care Delivery Guide, and Behavior Flow Record for all residents who are known to refuse ADL care. Updates were made as needed to reflect this behavior.

3. To prevent this from reoccurring the DON and/or delegate educated all nursing staff on the procedure for identifying residents who refuse ADLs through their plan of care. Nursing staff was also educated on how to document refusals.

4. To monitor and maintain ongoing compliance the DON and/or delegate will audit resident refusal records 5 times weekly for 1 month and the 1 time weekly for 2 months. Results of audit will be presented to QAPI committee for further review and recommendation.


483.20(f)(1)-(4) REQUIREMENT Encoding/Transmitting Resident Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(f) Automated data processing requirement-
483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:
(i) Admission assessment.
(ii) Annual assessment updates.
(iii) Significant change in status assessments.
(iv) Quarterly review assessments.
(v) A subset of items upon a resident's transfer, reentry, discharge, and death.
(vi) Background (face-sheet) information, if there is no admission assessment.

483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.

483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:
(i)Admission assessment.
(ii) Annual assessment.
(iii) Significant change in status assessment.
(iv) Significant correction of prior full assessment.
(v) Significant correction of prior quarterly assessment.
(vi) Quarterly review.
(vii) A subset of items upon a resident's transfer, reentry, discharge, and death.
(viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment.

483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.
Observations:

Based on clinical record review, it was determined that the facility failed to encode and transmit a discharge Minimum Date Set (MDS) assessment for one of 27 sampled residents. (Resident 1)

Findings included:

Clinical record review revealed that Resident 1 had been discharged on January 29th, 2019. The resident's discharge Minimum Data Set (MDS) assessment was completed but not transmitted to the federal database within 14 days as required.

28 Pa. Code 211.12(d)(5) Nursing services.










 Plan of Correction - To be completed: 07/02/2019

1. R1's MDS was transmitted.

2. All residents requiring MDS completion have the potential to be affected. The NHA and/or delegate conducted an audit of all completed MDS assessments from date of survey exit through 6/24/19 to ensure successful transmission had occurred. Where necessary transmission was initiated and observed for acceptance.

3. To prevent this from reoccurring the NHA and/or delegate educated the MDS coordinator on the MDS transmission process.

4. To monitor and maintain ongoing compliance the NHA and/or delegate will audit MDS transmission 5 times a week for 3 months to ensure completion. Results of audit will be presented to QAPI committee for further review and recommendation.


483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is 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, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained on two of three nursing units. (First, Second Floor)

Findings include:

Observation on June 5th, 2019 at 1:30 p.m., of the first floor crest lounge revealed a stagnant odor of smoke throughout the room. There was a cart with an extinguisher attached to it that was soiled with cigarette residue and ashes. There was a cabinet that contained two smoking aprons and the aprons were soiled. The cabinet had the same stagnant odor of smoke. The crest lounge leads to an enclosed court yard that the residents utilize for their scheduled smoking privledges.

During a tour of the second floor nursing unit on June 4, 2019 at 10:20 a.m. and June 6, 2019 at 1:00 p.m., the following observations were made. In room 201 there was a hole on the bathroom door. Room 206, the walls were marred and scratched. The baseboard radiator in room 208 behind bed 1 was broken. The privacy curtains between bed 1, 2, and 3 were soiled in room 218. Three soiled chairs were observed in the front of the nursing station.

28Pa. code 207.2(a) Adminstrator responsibility







 Plan of Correction - To be completed: 07/02/2019

1. Crest lounge area the odor of smoke is controlled by closing the door tight. The smoking cart and extinguisher were cleaned. The smoking apron cabinet was wiped down. Soiled smoking aprons were discarded and replaced. The bathroom door in room 201 was repaired. Room 206 wall was painted. Room 208 base board was repaired. Privacy curtains in 218 were replaced with clean ones. Soiled chairs from second floor were discarded.

2. All residents have the potential to be affected. The NHA and/or delegate conducted an audit of all rooms to ensure that there were no other soiled privacy curtains, broken doors, or unpainted walls. The smoking area was also reviewed for additional cleaning opportunities. Where necessary repairs or housekeeping was conducted.

3. To prevent the potential for reoccurrence the NHA and/or delegate educated all employees on how to fill out a maintenance request slip.

4. To monitor and maintain ongoing compliance the NHA and/or delegate will observe the smoking area for housekeeping needs 3 times weekly for 3 months. An audit of all rooms to identify maintenance concerns will be conducted 1 time weekly for 3 months. Results of audit will be presented to QAPI committee for further review and recommendation.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.15(d) Notice of bed-hold policy and return-

483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed hold policy (an agreement for the facility to hold a bed for an agreed rate during a hospitalization) to the resident, family member or legal representative at the time of transfer out of the facility for one of four sampled residents transferred to the hospital. (Resident 65)

Findings include:

Review of the facility policy entitled "Bed-Hold Letter Policy", last updated January 24, 2019, revealed that the facility was to track Medicaid bed hold days and notify the appropriate parties via a Medicaid bed hold letter. The business office or designee was to complete the bed hold letter and send to the appropriate parties.

Clinical record review revealed that Resident 56 was transferred and admitted to the hospital on April 9, 2019, due to a change in condition. There was no documented evidence that the resident or legal representative was provided written information about the facility's bed hold policy at the time of transfer.

In an interview on June 7, 2019, at 11:00 a.m., the Administrator confirmed that the bed hold letter had not been provided to the resident or legal representative as per facility policy.







 Plan of Correction - To be completed: 07/02/2019

I hereby acknowledge the CMS 2567-A, issued to ELKINS CREST HEALTH & REHABILITATION CENTER for the survey ending 06/07/2019, AND attest that all deficiencies listed on the form will be corrected in a timely manner.

1. R65 no longer resides at Elkins Crest. A copy of the bed hold letter and policy was mailed to their last known residence.

2. All residents being transferred from the care facility to a different center have the potential to be affected. The Nursing Home Administrator (NHA) and/or delegate audited resident transfers from date of survey exit through 6/21/19 to ensure bed hold notification was delivered. Where necessary, a letter was generated and submitted to the resident for their records.

3. To prevent this from reoccurring the NHA educated the Business Office Manager (BOM) on the bed hold notification policy.

4. To monitor and maintain ongoing compliance the NHA and/or delegate will audit transferred residents for evidence that bed hold notification was provided 5 times weekly for 3 months. Results of audit will be presented to QAPI committee for further review and recommendation.


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