Pennsylvania Department of Health
DEER MEADOWS REHABILITATION CENTER
Patient Care Inspection Results

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DEER MEADOWS REHABILITATION CENTER
Inspection Results For:

There are  150 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.
DEER MEADOWS REHABILITATION CENTER - 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 three complaints, completed on February 16, 2024 , it was determined that Deer Meadows Rehabilitation Center, 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:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on review of facility policy, review of clinical records, review of facility documents, staff and family interview, it was determined that the facility failed to uphold the dignity of two of eight residents (Resident R25 and Resident R85) and during dining service for one of eight nursing unit reviewed. (Bair 2 nursing unit)

Findings include:

Review of the facility document titled "Abuse Policy" last revised February 8, 2022, revealed verbal abuse is defined as oral, written, or gestured language, that willfully includes disparaging and derogatory terms, to the resident/patient or their families, or within their hearing distance, to describe resident, regardless of their age, ability to comprehend or disability. Continued review of this policy revealed the protocol for any abuse allegations including screening, training, prevention, identification, protection, investigation, employee suspension, reporting to the appropriate agency, and the facility is to ensure that the appropriate corrective, remedial or disciplinary action occurs in accordance with local, state, and federal law in response to findings resulting from investigations.

Review of facility's reported incident to the State survey agency dated June 16, 2023, revealed that the Resident R25's daughter reported an allegation of verbal abuse. Nurse aide, Employee E9 was recorded as she called Resident R25 "dead weight" and refusing to assist him to bed. The facility's investigation included statements from the employee accused, Resident R25, who was unable trecall the event, and interviews with five other residents.

Interview with Resident R25 at 9:40a.m. February 14, 2024, revealed that he did not remember the incident. He voiced no complaints or concerns of any staff providing him with care.

Interview with Resident R25's family, on February 16, 2023, at 11:15 a.m. revealed that Resident R25 is often confused, Resident R25 called her, which she did not answer, and he was prompted to leave a message. Resident R25 did not know that the phone was recording, he believed his daughter was on the phone with him. During this time, Employee E9 was providing care to Resident R25, he had requested assistance to get back in bed at which time Employee E25 said he was "dead weight" and his daughter can come put him back to bed." Resident R25's family member listened to the conversation of Resident R25 and Employee E9 and immediately presented the audio recording to facility administration.

Interview with Nursing Home Administrator E1 on February 15, 2023, at 2:35 revealed that the day of the incident the resident was assisted back to bed. The investigation was completed and found substantiated. Employee E9 was terminated from her position at the facility.

Observation of the lunch service on February 12, 2024, at 1:30 p.m., revealed that there were 5 residents sitting at a table and were eating lunch. One resident had her food in front her, but the resident was not eating the lunch. Employee E18, Nurse Aide was observed sitting at the same table with a computer and was observed documenting on the computer while residents were eating.

Further observation revealed that the computer was placed on an incontinence pad on the table one end of the pad was touching a resident's lunch tray.

Interview with Employee E19, Licensed Practical Nurse, on February 12, 2024, at 1:35 p.m., confirmed the above observation and stated staff should not document while residents eating and should provide necessary assistance to the resident. Employee E19 also confirmed that the staff should maintain resident dignity during meal services.

Observation of Bair 2 nuring unit on February 12, 2024 at 9:45 a.m. revealed that Resident R85 was sitting in the hallway in a wheelchair. Resident had a bedside table in front of him. Resident was wearing a t-shirt and an incontinence breif. There was no clothing or sheet to provide privacy for the resident.

Interview with Unit Manager, Employee E12, on February 12, 2024 at 10:45 a.m. confirmed that the resident was only wearing a t-shirt and a breif.

28 Pa. Code 201.14(a) Responsibility of Licensee

28. Pa. Code 201.20 (5)(6) Staff Development

28. Pa. Code 211.12 (d)(1) Nursing Services







 Plan of Correction - To be completed: 04/12/2024

The provider submits the following plan of correction in good faith and to comply with Federal regulation. This plan is not admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the statement deficiencies

Employee E9 was terminated
Employee E18 in-serviced about resident right, dignity, use of electronic device during resident meal and resident assistance during meals
Resident 85 was groomed and appropriately dressed same day
Staff development or designee will complete in-service about resident right, resident dignity, and resident assistance during meals.
Staff development or designee will in-service all staff about facility policy regarding use of electronic devices
All in-services will be completed by March 22, 2024
Social worker will complete resident abuse audit during resident weekly care conference weekly x 1 month, and monthly for 2 months.
Director of nursing or designee will complete Randon meal audits to ensure resident dignity (resident appropriately dressed, staff interacting/assisting residents and not using electronic devices) maintained during meals weekly x4 weeks, and then monthly x 2months.
Result of audits will be presented at monthly QAPI until substantial compliance is achieved.

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

Based on observations and interviews with resident and staff, it was determined that the facility failed to ensure a safe sanitary and functional environment for one resident and four resident rooms of two floors (Second floor dining room and First Floor Rehab).

Finding Include:

Interview with Resident R116 on February 12, 2024, at 10:27 a.m. stated his wheelchair leg rest was broke and part of the leg rest was missing foot pad. He stated it was like that for almost four months.

Observation of Resident R116's wheelchair revealed that the left side leg rest was missing foot pad which exposed sharp metal edges. Wheelchair also had white color substance underneath the seat on the metal frame appeared like dust and cobb webb.

Observation of resident rooms 208, 209 and 210 revealed that there was window air-condition unit on the windowsills. There was wash cloths and towels around the air conditioning unit.

Interview with Resident R116 on February 12, 2024, at 11:00 a.m., stated he was keeping the towel to prevent cold air from getting inside and if there was no towel his room could get cold especially at night.

During a tour with Unit Manager, Employee E12, on February 12, 2024, at 11:00 a.m., confirmed the above findings.

Observation of resident bathroom in room 212A had water in the floor with 4 wet towels on the floor next to the toilet. Interview with Employee E20, Nursing Assistant on February 12, 2024, at 10:15 a.m., stated the toilet was leaking and the water was from underneath the toilet through a leak.

28 Pa. Code 201.14 (a) Responsibility of licensee.

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




 Plan of Correction - To be completed: 04/12/2024

Resident 116-wheel chair leg rest was replaced
Resident rooms 208, 209, and 210 wash cloths, towels and air condition removed
Room 212 A Leaking toilet was repaired February 12, 2024
Wheel chair audit completed by maintenance, no new wheel chair found with sharp edges or missing leg rest pad
Room audit completed for window air condition, none found
Room audit for leaking toilet will be completed by March 15 for repairs, any room needing repair will be corrected
Maintenance will complete 25% of resident wheel chairs for repair, resident room toilet for leaks weekly x4, then monthly x2 months. Any wheel chair needing repair or leaking toilet found during the audit will be repaired at the time or removed with a replacement if not repairable
Result of audits will be presented at monthly QAPI until substantial compliance is achieved

483.80(d)(3)(i)-(vii) REQUIREMENT COVID-19 Immunization: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.
§483.80(d) (3) COVID-19 immunizations. The LTC facility must develop and implement policies and procedures to ensure all the following:
(i) When COVID-19 vaccine is available to the facility, each resident and staff member
is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized;
(ii) Before offering COVID-19 vaccine, all staff members are provided with education
regarding the benefits and risks and potential side effects associated with the vaccine;
(iii) Before offering COVID-19 vaccine, each resident or the resident representative
receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine;
(iv) In situations where COVID-19 vaccination requires multiple doses, the resident,
resident representative, or staff member is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses;
(v) The resident, resident representative, or staff member has the opportunity to accept or refuse a COVID-19 vaccine, and change their decision;
(vi) The resident's medical record includes documentation that indicates, at a minimum,
the following:
(A) That the resident or resident representative was provided education regarding the
benefits and potential risks associated with COVID-19 vaccine; and
(B) Each dose of COVID-19 vaccine administered to the resident; or
(C) If the resident did not receive the COVID-19 vaccine due to medical
contraindications or refusal; and
(vii) The facility maintains documentation related to staff COVID-19 vaccination that
includes at a minimum, the following:
(A) That staff were provided education regarding the benefits and potential risks
associated with COVID-19 vaccine;
(B) Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and
(C) The COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Observations:

Based on interviews with resident and staff, review of clinical records and facility policy, it was determined that the facility failed to ensure one resident who concent to received the Covid -19 vaccine was provided the vaccine in a timely manner for one of 35 resident records reviewed (Resident R166).

Findings include:

Review of the facility's policy for Covid-19 vaccines and booster vaccines revised in May 2023 stated all vaccines shall be offered to residents unless the vaccine is medically contraindicated, to encourage and promote the benefits associated with vaccinations against Covid-19 by minimizing the risk of acquiring, transmitting or experiencing complications from the Corona virus. The policy continues to state that residents who received the vaccine will have the vaccine administration documented in the resident's Vaccine Administration Record (VAR) .

Review of Resident R166's clinical record revealed the resident was admitted to the facility on June 21, 2023, diagnosed with high blood pressure and chronic peripheral venous insufficiency.

Interview with Resident R166's on February 14, 2024, at 11:30 a.m. stated, "I spoke to the physician numerous times because I want the Covid vaccine. I waited so long I got Covid instead."

Review of Resident R166's VAR revealed on December 28, 2023, a consent was obtained, and the Covid-19 vaccine was administered. Further review of Resident R166's clinical records revealed on January 19, 2024, the resident tested positive for Covid.

Interview with the Assistant Director of Nursing (ADON) on February 15, 2024, at 10:00 a.m. stated the documentation was incorrect and Resident R166 was not vaccinated on December 28, 2023. Vaccines expired and an order was placed with the pharmacy. During the three weeks Resident 166 waited for the vaccine the resident tested positive for Covid.

28 Pa Code 201.14(a) Responsibility of licensee

28 Pa Code 201.18(b)(1) Management

28 Pa Code 211.12(d)(2) Nursing services

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







 Plan of Correction - To be completed: 04/12/2024

Resident 166 received covid vaccination February 28, 2024
Audit completed for residents that gave consent for covid vaccination to ensure that they received covid vaccination
Director of nursing/designee will in-service Infection Control Preventionist about administering covid vaccine timely when requested by resident.
ICP will complete weekly audit of new admissions for consent and Covid vaccination administration weekly x4, then monthly x2 months
Result of audits will be presented at monthly QAPI meeting until substantial compliance is achieved

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
§483.60(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 review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure foods were stored in accordance with food safety standards for one of eight nursing unit pantry's (Bair 1).

Findings Include:

Review of facility policy "Pantry Refrigerator", revised September 2021, revealed pantry refrigerators will be monitored on a routine basis to ensure food safety. Refrigerator temperatures will be maintained at 32 to 41 degrees Fahrenheit and freezer temperatures will be maintained at 0 to less than or equal to -10 degrees Fahrenheit. Further review of facility policy revealed refrigerators will be checked on a routine basis for cleanliness and cleaned monthly or as needed.

Review of facility policy "Food from Home", revised July 2017, revealed it is the policy of the facility to provide safe and sanitary storage and handling of all food including food brought to residents by family and other visitors. Further review of facility policy revealed foods requiring refrigeration will be received by the facility designee for proper and immediately storage including labeling and dating.

Observations on February 12, 2024, at 12:40 p.m. revealed the pantry area on Bair 1 was equipped with a refrigerator/freezer and ice machine. Observations revealed a significant build-up of trash and debris surrounding the ice machine.

Observations inside the refrigerator revealed personal food items were stored for Resident R75 including an undated container with 1 muffin inside, and a small carton of milk with a sell by date of 2/9/2024.

Observations of the digital thermometer outside the refrigeration unit revealed the freezer was reading a temperature of 4 degrees Fqahrenheit. Observations inside the freezer revealed the bottom was soiled with dried up spillage and had a bag of take-out food that was not dated or labeled with who's it was or when it was received.

Observations of the Bair 1 pantry were confirmed on February 12, 2024, at 1:00 p.m. by the Regional Food Service Manager, Employee E14.







 Plan of Correction - To be completed: 04/12/2024

F812 Food Procurement, Store/Prepare/Serve-Sanitation
Build up of trash and debris around the freezer refrigerator and ice machine was cleaned February 12, 2024
Personal food items for R75, undated container with muffin and small carton of milk with a sell by date 2/9/2024 removed from the refrigerator February 12, 2024
Freezer temperature was rechecked and was 0-degree Fahrenheit by Director of food service
The bottom of the freezer was cleaned February 12, 2024
Other pantries were audited and no noncompliance observed
Staff educator will educate nursing staff about food procurement, store food, prepare and serve sanitation
Kitchen director will educate kitchen staff about food procurement, store food, prepare and serve sanitation
Dietary director will complete weekly audit of pantry refrigerator for cleanliness, dated food and refrigerator/freezer temperature weekly x 4, then monthly x2
Director of housekeeping will audit all pantry floors weekly x4 then monthly x 3 months
Results of audits will be presented at monthly QAPI until substantial compliance is achieved


483.60(d)(3) REQUIREMENT Food in Form to Meet Individual Needs: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.
§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(3) Food prepared in a form designed to meet individual needs.
Observations:

Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to provide appropriately textured foods to meet the needs of residents on a mechanically altered diet for one of 22 residents observed during dining (Resident R158).

Findings Include:

Review of the "clear liquid diet" guidelines from the facility's diet manual revealed the diet consists of foods that are clear and liquid, or that becomes liquids at room or body temperature. The diet contains no milk or milk products.

Review of Resident R158's physician order dated January 25, 2024, revealed the resident was ordered a clear liquid diet.

Continued review of Resident R158's physician orders revealed an order dated October 15, 2023, to provide a pureed snack at bedtime.

Review of Resident R158's administration record for November 2023 through February 2024 revealed the resident was routinely offered the nighttime pureed snack with 50-100% consumption.

Review of Resident R158's speech therapy discharge summary dated November 22, 2023, completed by the Speech Therapist, Employee E13, revealed the discharge status and recommendations were NPO (nothing by mouth) for solids, and thin liquids only with close supervision.

Interview on February 15, 2024, at 1:00 p.m. with Registered Nurse, Employee E12, confirmed that the nurse aide provides and assists Resident R158 with ice cream every night.

Interview on February 15, 2024, at 1:35 p.m. with Speech Therapist, Employee E13, confirmed ice cream is not part of a thin liquid or clear liquid diet. Continued interview with the Speech Therapist, Employee E13, confirmed a pureed snack is not appropriate to safely meet the resident's needs and according to the most recent speech assessment in November 2023.

28 Pa. Code 201.14(a) Responsibility of licensee

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





 Plan of Correction - To be completed: 04/12/2024

Resident 158 has a new physician order for NPO and speech evaluation and treatment on 2/16/2024
Audit completed of residents on clear liquids, no other resident is on clear liquid diet
Staff educator or designee will educate nursing staff about clear liquid diet
Director of nursing or designee will complete audit of resident on clear liquid diet to ensure that they are only fed clear liquid diet weekly x4 and monthly x 2
Results of audits will be presented at monthly QAPI until substantial compliance is achieved

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on observations, review of clinical records and facility policy, and interviews with staff, it was determined that the facility failed to administer oxygen as ordered by the physician for one of 21 residents reviewed. (Resident R104)

Finding Include:

Observation of Resident R104 on February 12, 2024, at 10:42 a.m, revealed that the resident was receiving oxygen via nasal cannula from a portable oxygen concentrator (machine). The oxygen was set at 4 liters per minute. This was verified by Employee E2, Registered Nurse Unit Manager.

Review of physician orders for Resident R104 on April 16, 2023, revealed an order to administer oxygen at 2 liters per minute via nasal cannula continuously."

Interview with Employee E12, on February 12, 2024, at 10:42 a.m. confirmed that the resident was receiving oxygen at 4 liters per minute and the resident should be receiving oxygen at 2 liters per minute.

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

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






 Plan of Correction - To be completed: 04/12/2024

Resident 104 oxygen adjusted to 2L according to physician order on February 12, 2023
Audit of residents on oxygen completed, all resident receiving oxygen as ordered
Staff educator will educate nursing staff about administering oxygen according to physician order
Random audit of 5 residents on oxygen will be completed weekly x4, and monthly x 2
Results of audits will be presented at monthly QAPI until substantial compliance is achieved

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 observation, review of resident's clinical record, and interview with staff, it was determined that the facility failed to ensure the appropriate supervision related to risk of aspiration for one of eight residents reviewed. (Resident R 381)

Findings include:

Review of Resident R38'1s clinical record reveal that Resident R381 was admitted in the facility on February 6, 2023, with diagnoses of pneumonia (an infection that inflames the air sacs of one or both lung) COPD (Chronic Obstructive Pulmonary Disease, is an inflammatory lung disease that cause obstructive airflow from the lungs) and dysphagia (a medical term meaning difficulty swallowing which is a symptom of many different medical conditions).

Continued review of Resident R 381's clinical record revealed a dietary initial assessment which indicated that there resident was to have a mechanically altered diet consisting of pureed textured foods and thin liquids. Further review of this assessment stated that Resident R381 needed supervision while eating meals.

Continued review of Resident R 381's clinical record revealed a physician's order dated February 9, 2023, which stated that Resident R381 was an aspiration risk and ordered Resident R381 to be supervised during meals. Further review of Resident R381's clinical record revealed documentation of Resident R381's eating performance. The resident was documented as having independent dining (no help of staff oversight at any time), or supervised dining (a staff member supervising the resident dining). The document revealed inconsistency with the ordered supervision of dining. The task document revealed that on February 6, 2023, Resident R381 had supervision during lunch and dined independently during dinner. This document revealed that on February 7, 2023, the resident dined independently for all meals. On February 8, 2023, that Resident R381 had independent dining for breakfast and lunch and had supervision for dinner. Continued review of the dining task document revealed on February 9, 2023, revealed Resident R 381 had no supervised meals. On February 10, 2023, the only meal Resident R381 was supervised was for lunch. February 11, 2023 Resident R381 was supervised for breakfast and lunch and independent for dinner. February 12, 2023, the document revealed that Resident R381 was not supervise for any meal that day.

Observation February 14, 2023, 12:00 p.m. on the first-floor nursing unit revealed Employee E17, administering medication to Resident R381. This surveyor accompanied Employee E 17 into Resident R381's room, there was no one else in the room and observed medication administration. After Resident R381 received and consumed her medication, Employee E17, then left the room, leaving Resident R381 alone to finish her lunch.

Interview with Employee E17 at time of observation on February 14, 2023, at 12:00 p.m. revealed that
Employee E17 was unaware of Resident R381's aspiration risk and had orders to be supervised at all meals. Employee E17 then checked the residents orders and confirmed that Resident R381 required supervision during meals.

Interview with Speech therapist Employee E13 at 11:25a.m. on February 15, 2023, revealed that he observed Resident R381 that morning dining on her breakfast. Employee E13 stated that she was not being supervised. He was not aware that Resident R321 had an order to be supervised during meals. Employee E13 stated that he assessed Resident 381 for swallowing and did not order for supervised meals. Employee E13 stated that he attended staff meeting weekly.

Interview on February 15, 2024, at 12:10 p.m. with Occupational therapist, Employee E 16 revealed that Employee E16 was aware that Resident R381 was an aspiration risk and had knowledge of the resident's orders for supervision. Employee E16 produced a plan of care consisting for occupational therapy including aspiration risks. Employee E16 states the aspiration risk was present at time of resident entering the facility.

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

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








 Plan of Correction - To be completed: 04/12/2024

Resident 381 discharged from the facility
Director of nursing completed audit to identify resident that need supervision for meals.
Staff educator will complete staff re-education about providing supervision for residents that requires supervision and completing documentation in resident tasks that supervision was provided for all meals
Director of nursing or designee will complete weekly audit of residents that require supervision that supervision was provided and documented weekly x4 then monthly x 2
Result of audits will be presented at monthly QAPI until substantial compliance is achieved

483.25 REQUIREMENT Quality of 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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of clinical record, review of facility documents and interview with staff, it was determined that the facility failed to ensure that a physician's orders were followed for two of 35 records reviewed. (Resident R4 and Resident R116)

Findings include:

Review of the clinical record revealed that Resident R4 was admitted to the facility on December 6, 2022, with a bilateral primary osteoarthritis of knee (degenerative joint disease affecting both knees due to natural wear and tear), disorder of muscle, unspecified atrial fibrillation (irregular heart beat), and congenital deformity of the spine (refers to an abnormality present at birth that affects the structure or alignment of the spine).

Review of Resident R4's February 2024 physician orders revealed an order dated February 1, 2024 "cleanse RLE (right leg) w (with)/NSS (normal saline solution), pat dry, apply silvedene and calcium alginate, wrap w/kerlex and cover Tubi grip BID (twice a day) and PRN (as needed)".

On February 12, 2024, at 2:07 p.m. an interview was conducted with Resident R4 and observation with License nurse, Employee E6 revealed Resident R4 was sitting in her bedside chair. The resident's right foot had a dressing on the foot, there were open wound with blood on the upper and lower part of the dressing. There were no tubigrip applied to the foot. Left foot had a dressing with ACE wraps applied on top of the foot.

On February 12, 2024, at 2:17 p.m. an interview with Licensed nurse, unit manager, Employee E4 revealed that there was no tupigrip on the unit available. Employee E4 was able to locate the tupigrip off the unit in the storage room.

On February 14, 2024 License Wound Nurse, Employee E15 confirmed that Resident R4 had no physician order for left foot dressing and ACE warp on February 12, 2024.

Review of physician order for Resident R116 dated January 31, 2023, revealed an order for Amlodipine 5 milligrams table two times a day for hypertension, hold systolic blood pressure below 100.

Review of Resident R116's Medication Administration Record (MAR) for February 2024, revealed that the medication Amlodipine was held for February 4, 8, 9 and 11 when Resident R116's systolic blood pressure was documented above 100.

Interview with Director of Nursing, Employee E2, on February 14, 2024, at 2:30 p.m. confirmed that the medication, Amlodipine, was documented as not administered when Resident R116's systolic blood pressure was above 100.

28 Pa. Code 201.29 (d) Resident's rights

28 Pa. Code 211.12 (c) Nursing services




 Plan of Correction - To be completed: 04/12/2024

Resident R4 wound order changed on February 17, 2024, for weekly wound care at Nazareth wound clinic
Skin checks will be completed for all residents by March 15, 2024, to identify resident with new wound or wound dressing without doctor's order
Audit of residents with order for tubigrip completed to ensure that tubigrip is available
Resident R116 parameter to hold medication clarified by physician on February 17, 2024
Audits of residents that require parameter for blood pressure completed to ensure that parameter is appropriate and followed
Staff educator will in-service nurses about getting order from physician for new wound and following physician order for wound treatment.
Staff development will in-service nurses about following physician parameter order for blood pressure medication and documentation
Director of nursing or designee will complete weekly audit of wound treatment of residents that has physician order for tubigrip weekly x4 and monthly x 2
Wound nurse or designee will complete random audit of 5 residents per week to ensure that all wounds are recorded with treatment orders weekly x4, then monthly x2
Director of nursing will or designee will complete 25% of residents with blood pressure medication parameter weekly x4, then monthly x2
Result of audits will be presented at monthly QAPI meeting until substantial compliance is achieved

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 clinical record review and interviews with resident and staff, it was determined that the facility failed to revise the care plan for participation in restorative therapy for one of 35 residents reviewed (Resident R166).

Findings include:

Review of Resident R166's care plan revealed the resident was admitted to the facility on June 21, 2023, with the diagnoses of high blood pressure and chronic peripheral venous insufficiency (poor circulation of the extremities). Further review of the resident's care plan revealed the resident was on the restorative program to prevent functional decline dated August 31, 2023. Interventions included transferring out of bed to the wheelchair with one person assisting the resident.

Interview with Resident R162 on February 14, 2024, at 11:30 a.m. stated she no longer participates in restorative therapy.

Interview with the Nursing Home Administrator on February 14, 2024. at 3:30 p.m. confirmed the facility failed to revise and update Resident R166's care plan when the resident no longer participated in restorative therapy.

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





 Plan of Correction - To be completed: 04/12/2024

Resident 166 care plan revised and restorative nursing removed from her care plan
Audit of residents on restorative nursing program will be completed, resident that refused to participate in restorative program care plan will be updated by March 15, 2024
Nursing staff will be educated by staff educator or designee about communicating resident refusals to charge nurses so that resident care plan can be revised.
Director of nursing or designee will complete audit of residents on restorative program for refusals and care plan revision weekly x4, then monthly x 2
Result of audits will be presented at monthly QAPI until substantial compliance is achieved

483.21(b)(1)(3) 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.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:


Based on, review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to develop comprehensive person-centered care plans related to supervision needs for one out of eight residents reviewed. (Resident R381)

Findings include:

Review of facility's policy titled "Care Planning Process and Care Conference" last revised July 3, 2023, revealed facility will develop a comprehensive resident centered care plan for each resident. Care plan development, renewal and revision will be based upon the results of the resident's assessment. The care plan is a working tool that provides a profile of the needs of the individual resident. The care plan will include the initial needs such as adls (activities of daily living), falls, skin tears, nutritional status, behaviors, anticoagulants, psychotropic medication , related to the resident primary diagnosis . The care plan is a working tool that provides a profile of the needs of the individual resident. Further review of this policy revealed that all resident care and interventions must be carried out per the care plan.

Review of Resident R381's clinical record revealed that Resident R381 was admitted in the facility on February 6, 2023, with diagnosis' including pneumonia (an infection that inflames the air sacs of one or both lung, COPD (Chronic Obstructive Pulmonary Disease, is an inflammatory lung disease that cause obstructive airflow from the lungs) and dysphagia (a medical term meaning difficulty swallowing which is a symptom of many different medical conditions).

Continued review of resident R381' s clinical record revealed a dietary initial comprehensive assessment which indicated that the resident was to have a mechanically altered diet consisting of pureed textured foods and thin liquids. Further review of this assessment stated that Resident R381 needed supervision while eating meals.

Continued review of Resident R381's clinical record revealed a physician's order dated February 9, 2023, which noted that Resident R381 was an aspiration risk and ordered Resident 381 to be supervised during meals.

Observation of Resident R381 on February 14 at noon, lunchtime, during med pass with Employee 17, revealed that Resident R381 was observed dining alone in her room.

Interview with Licensed nurse Employee E17 on February 14, 2023, at 12:05 p.m. revealed that Employee E17 was unaware that Resident R381 required supervision. Employee E17 confirmed Resident R381's physician order for supervision at meals.

Review of Resident R 381's care plan dated February 6, 2023, with a dietary focus of risk of alteration of nutrition related to need of mechanically altered diet. The goal of this plan was for Resident R 381 to remain free from signs and symptoms of aspiration. Further review of care plan's intervention did not contain any implementation of supervised meals.

28 Pa. Code 211.10(a)(c) Resident Care policies

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







 Plan of Correction - To be completed: 04/12/2024

Resident 381 discharged home February 23, 2024
Residents that have order for supervision for meals care plan will be audited to ensure that resident care plan includes supervision for meals
Staff educator will complete staff re-education about completing care plan for any resident that has an order for supervised meals
Director of nursing or designee will complete weekly audit of care plan of residents that require supervision to ensure that care plan is in place for supervised meals weekly x4 then monthly x 3
Result of audits will be presented at monthly QAPI until substantial compliance is achieved

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 observations, resident and staff interview, it was determined that the facility failed accommodate the residents' needs related to having a bariatric bed and beside chair for 1 out of 35 residents observed. (Resident R41)

Findings include:

Review of the clinical record revealed that Resident R41 was admitted to the facility on June 27 , 2023, with diagnosis of Type 2 diabetes (failure of the body to produce insulin), chronic obstructive pulmonary disease (disease process that causes decreased ability of the lungs to perform), end stage renal disease.

Review of the Resident R41's Minimum Data Set (MDS- assessment of care needs) dated January 23, 2024, revealed that a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact.

Review of Resident R41's weight record revealed that the resident weighed on 290.1 pounds on February 10, 2024.

On February 12, 2024, at 2:07 p.m. an interview was conducted with Resident R41 who reported that he desires a bigger bed and a larger bedside chair. Observation of Resident R41's room revealed that the resident had a regular size bed, and bariatric wheelchair and bariatric commode by bedside.

On February 12, 2024, at 2:07 p.m. an interview was conducted with License unit manager, Employee E4 who confirmed Resident R41's chair by bedside is a regular chair doesn't adequately fit the resident. Resident R4 reported referring to the chair "I can't get myself into that chair I have to shrink" the

On February 15, 2024, at 9:03 a. m. an interview was held with Rehabilitation Director, Employee E7 who reported that nursing staff are responsible to ensure resident has adequate bedside chair and bed.

On February 15, 2024, at 11:43 a.m. an interview was held with Nursing Home Administrator, Employee E1 who reported that Resident R41 requires a longer mattress due to his high.


28 Pa. Code: 201.29(j) Resident rights.

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

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





 Plan of Correction - To be completed: 04/12/2024


Administrator met with resident 58; he prefers to be in the same bed but asked for the length of his bed to be extended which was completed on February 12, 2024
Administrator met with resident 58 on February 12 and February 28, 2024 and refused to have a wider bariatric chair in the room.

Facility will audit all residents to ensure that they have appropriate bed, chair and devices
Admission director will screen all bariatric referrals for admissions to ensure that facility has appropriate bariatric equipment for resident.
All new bariatric residents will be audited for appropriate devices weekly x 4 and then monthly x2 months
Result of audit will be presented at monthly QAPI until substantial compliance is achieved.




483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observation and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for residents on one of eight nursing units. (Bair 2 Nursing Unit)

Findings include:

During the initial tour of the Bair 2 nursing unit on February 12, 2024, at 11:00 a.m., the following observations were made,

-Next to the nurse's station (lower number resident rooms), there was coffee cups, a cup of water and a clear cup on the on the handrail.

- There was used socks, trash and food like substance throughout the hallway.

-Next to the dining room closet there was trash on the floor appeared like used napkins, sugar packets and food particles on the floor.

-Resident Room 209A had a bed side table next to the bed which had a black substance on the table which appeared like dried food or drink.

-Next to the nurse's station with higher number resident rooms, there was white powder like substance on the floor,

- Resident bathroom in room 212A had water in the floor with 4 wet towels on the floor next to the toilet.

-In Bair 2 nursing unit dining room, there were breakfast trays from the morning,

-Inside the Bair -2 elevator there was trash on the elevator floor.

During a tour with Unit Manager, Employee E12, on February 12, 2024, at 11:00 a.m., confirmed the above findings.

28 Pa. Code: 201.14(a) Responsibility of licensee.






 Plan of Correction - To be completed: 04/12/2024

Coffee cups, cup of water and clear cup removed from the handrail on February 12, 2024 by housekeeping
Trash on the floor; napkins, sugar packets and food particles were cleaned from the floor on February 12, 2024 by housekeeping
Next to the nurse's station with higher number resident rooms with white like substance on the floor were cleaned on February 12, 2024 by housekeeping.
Room 209 bedside table cleaned on February 12, 2024
Leaking toilet in Room 212 was repaired by Maintenance on February 12, 2024 and towels removed from the floor
Left over meal trays removed by Dietary February 12, 2024
Bair 2 elevator trash was cleaned by housekeeper on February 12, 2024
Resident rooms, hallways, dining rooms, elevators audited for cleanliness and leaking toilet on February 19, 2024
Staff development or designee will complete in-service to nursing staff about completing work order for repair, ensuring cleanliness of resident rooms and hallways in order to ensure homelike environment.
Housekeeping Director will in-service housekeeping staff about proper cleaning of resident rooms, hallways, kitchen during their shift
Housekeeping director will complete hallways and rooms audit of 2 units weekly x4, and monthly x 3 months
Dietary Director will complete weekly audits for late trays weekly x4 and monthly x3 months
Maintenance director will complete 25% audit of room toilets for leaks and complete repair weekly x4, them monthly x3 months
Administrator or designee will complete weekly audit with housekeeping director, maintenance director of 2 units per week x4 weeks and monthly x 3months
Result of audits will be presented at monthly QAPI until substantial compliance is achieved

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

Based on review of the Resident Assessment Instrument (RAI) Manual, review of clinical records, and staff interviews, it was determined that the facility failed to ensure that the Minimum Data Set Assessments accurately reflected residents' cognitive status for 3 of 35 residents reviewed (Residents R158, R64, and R66).

Findings Include:

Review of the Centers for Medicare and Medicaid Services (CMS) Long Term Care RAI Manual dated October 2019 revealed the resident Minimum Data Set (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) included "Section C: Cognitive Status" which is used to determine the resident's attention, orientation, and ability to registry and recall information.

Review of Resident R158's clinical record revealed a Quarterly MDS dated January 12, 2024.

Review of Resident R64's clinical record revealed an Annual MDS dated February 1, 2024.

Review of Resident R66's clinical record revealed a Quarterly MDs dated February 4, 2024.

Review of "Section C: Cognitive Pattern" for each above mentioned resident's MDS, revealed section C0100 "should brief interview for mental status (C0200-C0500) be conducted" was coded as "yes".

Continued review of Residents R158, R64, and R66s' MDS revealed the Brief Interview for Mental Status (BIMS), section C0200-C0500, was coded as no-information (-).

Interview on February 16, 2024, at 9:50 a.m. with Registered Nurse Assessment Coordinator (RNAC), Employee E10, revealed the BIMS assessment should have been conducted, however, were not completed timely and therefore needed to be coded as not assessed. Further interview confirmed the MDS assessments did not accurately reflect the residents cognitive status.

28 PA Code 211.5(f)(ix) Medical records










 Plan of Correction - To be completed: 04/12/2024


F641 Accuracy of assessments
Resident 158 Bim assessment completed
Resident 64 Bim was completed during the time frame, MDS revised.
Resident 66 Bim completed
RNAC audited MDS for the quarter to ensure no other resident BIM was missed
Social service staff re-educated about BIM assessment and timely completion
Social service director will complete weekly audit of scheduled BIM assessment weekly x4 weeks, and then quarterly for 3 months
Result of audits will be presented at monthly QAPI until substantial compliance is achieved


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