Nursing Investigation Results -

Pennsylvania Department of Health
CUMBERLAND CROSSINGS RETIREMENT COMMUNITY
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
CUMBERLAND CROSSINGS RETIREMENT COMMUNITY
Inspection Results For:

There are  71 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.
CUMBERLAND CROSSINGS RETIREMENT COMMUNITY - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid, State Licensure and Civil Rights survey as well as an Abbreviated survey in response to two complaints that was completed on November 14, 2019, it was determined that Cumberland Crossings Retirement Community was not in compliance with the following requirements of 42 CFR Part 483 Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.60(g) REQUIREMENT Assistive Devices - Eating Equipment/Utensils: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(g) Assistive devices
The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.
Observations:


Based on observation, review of select facility documents and resident and staff interviews, it was determined that the facility failed to provide assistive feeding devices for three of three residents observed (Residents 10, 23, and 40).

Findings include:

Review of Resident 10's clinical record revealed diagnoses that included Nutritional Deficiency (an inadequate supply of essential nutrients [as vitamins and minerals] in the diet resulting in malnutrition or disease), Abnormal Posture, Lack of Co-ordination, Dysphagia (difficulty swallowing) and Cerebral Palsy (a condition marked by impaired muscle coordination [spastic paralysis] and/or other disabilities, typically caused by damage to the brain before or at birth).

Review of Resident 10's current active physician orders revealed order ""Fluids to be in Kennedy cups (a lightweight spillproof drinking cup that is used with a straw" with an indicated initiation date of October 24, 2018.

Review of Resident 10's current interdisciplinary care plan revealed the care focus area of "...at risk for nutrition/hydration r/t (due to) cognitive deficits, distractibility, dysphagia, self feeding deficit, ....weight loss" with associated interventions including "lip plate and kennedy cup with straw."

Review of Resident 23's clinical record revealed diagnoses that included Vitamin Deficiency, Dysphagia (difficulty swallowing) and Lack of Co-ordination.

Review of Resident 23's current active physician orders revealed order "Diet: Adaptive Equipment Notes: thin liquids in kennedy cup with straw at all times" with an initiation date of October 24, 2018.


Review of Resident 23's current interdisciplinary care plan revealed the care focus area of "...at nutrition /hydration risk RT (due to) anxiety, Parkinson's,...weight fluctuations, dentures, ...significant weight changes" with associated care interventions including "kennedy cup with straw at all times."

Review of Resident 40's clinical record revealed diagnoses that included Vitamin Deficiency, Abnormal Posture and Lack of Co-ordination.

Review of Resident 40's current active physician orders revealed order "Resident to use kennedy cups for all drinks" with an initiation date of September 13, 2019.

Review of Resident 40's current interdisciplinary care plan revealed the care focus area of "...at nutrition risk related to pain...vitamin deficiency...pressure wound" with care associated interventions including "Adaptive equipment: Kennedy cup at all meals."

Observation was made in Resident 40's room on November 13, 2019, at approximately 1:10 PM that there were two drinks on her bedside table. One was observed to be a clear liquid in a kennedy cup with a straw (resembling a kennedy cup with water previously observed on her lunch meal tray earlier this date) and also observed was a styrofoam cup with a straw.

During an interview with Nursing Aide (NA) 2 at 1:15 PM regarding the process for providing beverages to residents, NA 2 stated that the process for passing water is that a resident's assigned Nursing Aide goes to nourishment pantry and gets cart/water/ice/cups/straws (styrofoam cups per her). When asked how Nursing Aides would know if a resident needed an adaptive cup, NA 2 stated that they would look at the list in nourishment pantry and the kennedy cups were in there.

Observation was made in the nourishment pantry on November 11, 2019, at 1:29 PM, immediately following interview with NA 2, that a diet list including names of all residents was laying flat on top of microwave oven underneath a small bunch of bananas. Review of the List of Residents and Diets for Crosscheck papers revealed that Residents 40, 23 and 10 were indicated to require kennedy cups with straws for their liquids. Observation in this pantry at this date/time failed to reveal the presence of kennedy cups.

Observations made in residents' hallway, immediately following review of diet list in pantry, revealed that in addition to the presence of a styrofoam cup in Resident 40's room, observation in Residents 10 and 23's room also revealed that they had been provided beverages in only styrofoam cups with straws on their bedside tables.

Immediately following the above hallway observations, an interview was conducted with Registered Dietitian (RD) 1, at which time RD 1 revealed that the kennedy cups are stored in a small pantry area between the dining room and the kitchen. Immediately following this interview, a tour was conducted in residents' hallway with RD 1 and Director of Dining Services (DOD) 1 for their observation of the styrofoam cups. DOD 1 confirmed that the kennedy cups are kept in the pantry behind dining room.

Review of facility policy, "Serving Drinking Water," failed to reveal any acknowledgement of the presence of a diet list, availability or location of adaptive equipment for serving beverages or updating of the diet list.

An interview with Director of Nursing and Nursing Home Administrator on November 14, 2019, at approximately 12:10 PM, revealed the expectation that the residents should have received the ordered adaptive equipment.

28 Pa Code 211.12(d)(2)(3)(5) Nursing services.































 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

1. Residents 10, 23, and 40 have had no negative outcomes due to Kennedy cups not in use.

2. No additional residents identified to not have Kennedy cups in place.

3. Education will be provided to the nursing staff by the Director of nursing or designee regarding the need to provide assistive feeding devices/Kennedy cups when ordered by physician.

4. Audits for assistive feeding devices/Kennedy cups will be completed daily for 4 weeks, then weekly for 5 weeks. The results will be reported to the Quality Assurance Process Improvement committee for review and recommendation.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.15(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 clinical record review and staff interviews it was determined that the facility failed to provide written information pertaining to bed hold policy to the Resident or Resident representative upon transfer from the facility to the hospital for one out of three resident records reviewed for hospital transfers (Resident 39).

Findings include:

Review of Resident 39's clinical record revealed diagnoses that included Atrial Fibrillation (irregular heartbeat) and Heart Failure (severe failure of the heart to function properly).

Further review of Resident 39's clinical record revealed that on September 16, 2019, he was transferred out of the facility to the hospital and returned on September 20, 2019, with a diagnoses of Congestive Heart Failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues) and Bilateral Effusion (an unusual amount of fluid around both lungs).

Additional review of Resident 39' clinical record failed to reveal that a notice of the bed hold policy was provided to the resident or his representative at the time of transfer.

During an interview with the Nursing Home Administrator (NHA) on November 13, 2019, at 2:48 PM, the NHA confirmed that notice of the bed hold policy had not been provided to the resident or his representative at the time of transfer due to transition in facility management.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 12/06/2018






































 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

1. Resident 39 had no negative outcomes due to the facilities failure to notify the resident/representative of facility's bed hold policy in writing at the time of transfer.

2. No additional residents have had negative outcomes to the facilities failure to notify the resident/representative of facility's bed hold policy in writing at the time of transfer.

3. Education will be provided to the IDT and licensed staff by the Director of Nursing or designee to assure bed hold policy is provided at time of transfer to resident/representative.

4. Fifty percent of resident transfers will be audited by the Social Services Director or designee weekly for 1 month and monthly thereafter for 3 months. Findings will be reported to the QAPI committee during monthly meeting for review and recommendation.

483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides: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.
483.95(g) Required in-service training for nurse aides.
In-service training must-

483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

483.95(g)(2) Include dementia management training and resident abuse prevention training.

483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at 483.70(e) and may address the special needs of residents as determined by the facility staff.

483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
Observations:


Based on personnel file review and staff interview it was determined that the facility failed to ensure each nurse aide was provided required in-service training consisting of no less than twelve hours per year which included dementia management and resident abuse prevention for one of 5 nurse aide employee records reviewed (Nurse Aide 1).

Findings Include:

Review of Nurse Aide 1's (NA 1) personnel information revealed a hire date of November 5, 2013.

During an interview with the Nursing Home Administrator on November 14, 2019, at 1:57 PM he confirmed that NA 1 did not have any recorded inservice training between the dates of November 1, 2018, and November 14, 2019. He also revealed that this concern would be corrected.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 201.20(a)(c) Staff development

28 Pa. Code 201.29 (d) Resident rights








 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

1. There were no residents effected due to the facility's failure to ensure each nurse aide was provided in-service training.

2. Identified C.N.A. will complete dementia and abuse/neglect training.

3. All C.N.A. staff will be educated by the Director of Nursing or designee to ensure understanding of facility to provide training consisting of no less than 12 hours per year.

4. The NHA or designee will audit 5 random C.N.A. on line education monthly to ensure compliance with training consisting of no less than 12 hours per year. Findings will be reported to the QAPI committee during monthly meeting for review and recommendation.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on observation, clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's care plan was reviewed and revised to reflect the resident's status for one of 20 residents reviewed (Resident 13).

Findings include:

Review of Resident 13's clinical record revealed diagnoses that included Alzheimer's disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and unsteadiness on feet.

Surveyor observation on November 12, 2019, at 10:13 AM revealed Resident 13 laying in bed. A fall mat was present on the floor to the resident's left.

Review of Resident 13's current care plan revealed a problem area of risk for falls related to weakness with an intervention of bilateral floor mats when resident is in bed.

During an interview with the Director of Nursing on November 12, 2019, at 11:32 AM, she confirmed that bilateral fall mats were no longer an active intervention and that the care plan hadn't been updated with this information.

28 Pa. Code 211.5(f) Clinical records.

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












 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

1. Resident 13 has had no negative outcomes due to the facility's failure to ensure resident's care plan was reviewed and revised to reflect resident status.

2. Current residents with fall mats at bedside will be audited to ensure care plan is reflective of current status.

3. Education will be provided to the IDT byb the Director of nursing or designee to ensure resident's care plans are reviewed and revised to reflect resident status.

4. The Director of Nursing or designee will audit 5 care plans per week for 4 weeks, then monthly thereafter to ensure care plan is reflective of current status. Findings will be reported to the QAPI committee during monthly meeting for review and recommendation.

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 clinical record review and staff interviews it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for one of 16 residents reviewed (Resident 34).

Findings Include:

Review of Resident 34's clinical record revealed diagnoses that included Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest; it affects how you feel, think and behave and can lead to a variety of emotional and physical problems; a person may have trouble doing normal day-to-day activities, and sometimes may feel as if life isn't worth living).

Review of Pharmacist Consultation Report dated for September 30, 2019, revealed statement indicating that Resident 34 "has received antidepressant, Fluoxetine 40 mg daily for management of depressive symptoms since 4/10/19."

Review of Resident 34's "November 2019 Physician Order Sheet" revealed order "Fluoxetine (also known as Prozac; is an antidepressant; is mainly used to treat major depression, obsessive-compulsive disorder, and panic disorder) 10 mg (milligrams) capsule (3) capsule oral Notes: give 3 caplets to = 30 mg" with an associated diagnosis of Major Depressive Disorder with a noted start date of October 2, 2019.

Review of Resident 34's Admission Minimum Data Set (MDS-a tool used to assess all care areas specific to the resident), dated March 10, 2019, revealed Resident 39 triggered in the Care Area Assessment (CAA- provides guidance on how to focus on key issues identified during a comprehensive MDS assessment) for Psychotropic Drug Use.

Review of the CAA Summary revealed a staff decision to proceed to the plan of care and develop a care plan to address Resident 39's use of Psychotropic Medications.

Review of Resident 34's interdisciplinary plan of care failed to reveal that a care plan was developed to address Resident 34's Depression/Use of Psychotropic Medications.

During an interview with Nursing Home Administrator (NHA) and Director of Nursing (DON) on November 14, 2019, at 12:10 PM, NHA revealed that a Psychotropic Medication/Depression care plan had not been developed prior to November 14, 2019, (due to alert by survey team member) and DON revealed the expectation that there should have been one in place.

28 Pa. Code 211.11(d) Resident care plan

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





























 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

1. Resident 34 has had no negative outcomes due to the facility's failure to develop and implement a comprehensive person-centered care plan.

2. Current residents with an active anti-depressant medication order will be audited for current month to ensure the facility has developed and implemented a comprehensive person-centered care plan.

3. Education will be provided to the IDT by the Director of Nursing or designee to ensure the facility has developed and implemented a comprehensive person-centered care plan.

4. The MDS coordinator or designee will audit any resident with new anti-depressant orders weekly for 4 weeks and monthly thereafter for 3 months to ensure the facility has developed and implemented a comprehensive person-centered care plan. Findings will be reported to the QAPI committee during monthly meeting for review and recommendation.

483.20(g) REQUIREMENT Accuracy of 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(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on observation, clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 20 residents reviewed (Resident 30).

Findings include:
Review of Resident 30's clinical record revealed diagnoses that included retention of urine (inability to completely empty the bladder) and obstructive and reflux uropathy (condition in which the flow of urine is blocked which causes the urine to back up and injure one or both kidneys).

Surveyor observation on November 12, 2019, at 10:16 AM revealed Resident 30 had a catheter (small, flexible tube that can be inserted through the urethra and into the bladder, allowing urine to drain).

Review of Resident 30's physician order summary revealed an order, dated September 12, 2019, for catheter care each shift.

Review of Resident 30's September 16, 2019, comprehensive admission MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed that the assessment was not coded to indicate that the resident had a catheter during the lookback period (seven day period prior to the assessment date).

During an interview with the Director of Nursing on November 14, 2019, at 12:09 PM she confirmed that the MDS was coded in error.

28 Pa. Code 211.5(f) Clinical records.

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










 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

1. Resident 30 has had no negative outcome due to the facility's failure to ensure resident assessment accurately reflected resident status.

2. Facility will audit all residents with active foley catheter to ensure resident assessment accurately reflects resident status.

3. Education will be provided to MDS coordinator to ensure resident assessment accurately reflects resident status.

4. MDS coordinator or designee will audit fifty percent of comprehensive assessments weekly for 4 weeks and monthly thereafter to ensure resident assessment accurately reflects resident status. Findings will be reported to the QAPI committee during monthly meeting for review and recommendation.

483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months: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(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.
Observations:


Based on review of the Resident Assessment Instrument User's Manual, clinical record review and staff interview, it was determined that the facility failed to complete a quarterly assessment at least every three months for two of 2 residents reviewed for resident assessments (Resident 2 and 3).

Findings Include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (federally-mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and was to be completed no later than the ARD plus 14 calendar days.

Review of Resident 2's clinical record revealed a quarterly MDS assessment with an ARD of September 24, 2019. Further review of the assessment revealed that the Registered Nurse Assessment Coordinator (RNAC) signed the assessment as complete on October 27, 2019 (33 days after the ARD).

Review of Resident 3's clinical record revealed a quarterly MDS assessment with an ARD of September 24, 2019. Further review of the assessment revealed that the RNAC signed the assessment as complete on October 31, 2019 (37 days after the ARD).

During an interview with the RNAC on November 14, 2019, at 2:20 PM she confirmed that the assessments were completed late.

On November 14, 2019, at approximately 2:45 PM, the Nursing Home Administrator and Director of Nursing were made aware of the Resident assessments not being completed timely.

28 Pa. Code 211.5(f) Clinical records.



















 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

1. Residents 2 and 3 had no negative outcomes due to the facility's failure to complete a quarterly assessment.
2. Facility will audit last 3 months of quarterly assessments to ensure assessments have been completed in the appropriate time period.

3. Education will be provided to all IDT members with a part in MDS completion by the Director of Nursing or designee to ensure quarterly assessments are completed at least every 3 months.

4. MDS coordinator or designee will audit all quarterly assessments weekly for 4 weeks, the monthly thereafter for 3 months to ensure quarterly assessments are completed at least every 3 months. Findings will be reported to the QAPI committee during monthly meeting for review and recommendation.

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

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

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

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

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


Based on clinical record review and staff interviews it was determined that the facility failed to notify the resident/resident representative and the representative of the Office of the State Long-Term Care Ombudsman of resident transfers in writing and with required transfer information for one of three resident records reviewed (Resident 39).

Findings include:

Review of Resident 39's clinical record revealed diagnoses that included Atrial Fibrillation (irregular heartbeat) and Heart Failure (severe failure of the heart to function properly).

Further review of Resident 39's clinical record revealed that on September 16, 2019, he was transferred out of the facility to the hospital and returned on September 20, 2019, with a diagnoses of Congestive Heart Failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues) and Bilateral Effusion (an unusual amount of fluid around both lungs).

Review of Resident 39's clinical record revealed no letter was provided to the Resident 39 or Resident 39's representative regarding the transfer and including the required contents; reason for the transfer, effective date of the transfer, location to which the resident was transferred to, contact and address information for the Office of the State Long-Term Care Ombudsman, information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. Further review of Resident 39's clinical record failed to reveal that a transfer notice was provided to the State Long-Term Care Ombudsman.

During an interview with the Nursing Home Administrator (NHA) on November 13, 2019, at 2:48 PM, the NHA confirmed that neither of the above referenced notices had been provided to the appropriate parties due to transition in facility management.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 12/06/2018














 Plan of Correction - To be completed: 01/07/2020

I hereby acknowledge the CMS 2567-A, issued to CUMBERLAND CROSSINGS RETIREMENT COMMUNITY for the survey ending 11/14/2019, AND attest that all deficiencies listed on the form will be corrected in a timely manner.

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

1. Resident 39 had no negative outcomes due to the facilities failure to notify the resident/representative of resident's transfer in writing.

2. No additional residents have had negative outcomes to the facilities failure to notify the resident/representative of resident's transfer in writing.

3. Education will be provided to the IDT and licensed staff by the Director of Nursing or designee to assure written notifications are provided at time of transfer to resident/representative.

4. Fifty percent of resident transfers and discharges will be audited by the Social Services Director or designee weekly for 1 month and monthly thereafter for 3 months. Findings will be reported to the QAPI committee during monthly meeting for review and recommendation.


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