Pennsylvania Department of Health
 BROOKMONT HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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BROOKMONT HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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BROOKMONT HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a revisit and abbreviated complaint survey completed on May 23, 2024, it was determined that Brookmont Healthcare and Rehabilitation Center failed to correct federal deficiencies cited during the survey of April 5, 2024, and continued to be out of 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:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(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 observations, clinical record review and staff and resident interviews it was determined that the facility failed to provide care in a manner that maintains the personal dignity, respect, and quality of life of seven residents out of 17 sampled (Resident 3, 4, 7, 9, 11,12, 16).

Findings include:

A review of Resident 11's clinical record revealed the resident was admitted to the facility April 11, 2024, with diagnoses which included type 2 diabetes and muscle weakness.

An interview with Resident 11 on May 23, 2024, at 9:10 AM revealed that the resident stated that staff do not answer call bells timely. The resident stated that "on a good day the staff will answer the call bells in 30 minutes." The resident stated that "it can take up to two hours" for staff to answer his call bell. The resident further explained that he was in the bathroom recently and rang for staff because there was no toilet paper left in the bathroom. The resident stated it took 25 minutes for a staff member to come in and ask what he needed. The staff member stated she would be right back with toilet paper and then the resident waited another 26 minutes on the toilet until the staff member came back. Resident 11 stated he waited 51 minutes in total in the bathroom waiting for staff assistance. Further the resident stated that staff are "very rude and talk down" to him. He stated he does not feel respected and when he has brought his concerns to the director of nursing attention, she "gaslights" him and tells him what he is saying is not true. The resident stated that there are many staff that will yell and talk down to the residents on all shifts.

A review of Resident 16's clinical record revealed that the resident was admitted to the facility on January 24, 2024, with diagnoses which included muscle wasting and cirrhosis of the liver.

An interview with Resident 16 at 9:50 AM on May 23, 2024, revealed that the resident stated that staff take at least 30 minutes to answer his call bell when he rings for help. The resident stated this happens on all shifts.

A review of Resident 7's clinical record revealed the resident was admitted to the facility on March 10, 2021, with diagnoses which included type 2 diabetes and stage 3 kidney disease.

An observation on May 23, 2024, at approximately 10:00 AM revealed Employee 3 NA (nurse aide) interacting with Resident 7 trying to get her dressed. The employee was heard yelling at Resident 7 telling her she needed to "put these pants on." The employee was heard telling the resident resident your son called and said you need to do this. The resident replied to the employee, by stating "Bullsh*t." The employee was heard yelling at Resident 7, "Bullsh*t, Bullsh*t, call him you will see!" The resident told Employee 3 to leave her alone, that she is not getting those pants on. The resident then yelled out "ouch" and stated, "Don't fight with me." The employee got loud with the resident and stated, "You don't fight with me!" Resident 7 told the employee that she was not going to do what the employee was telling her to do. The resident stated she was not putting on those pants that the employee was trying to put on her. The employee said "oh, why is this not your shirt or pants or walker here." The employee continued to try to force the resident to put the pants on. The resident continued to tell the employee that she doesn't feel good and to leave her alone. Employee 3 got loud and yelled, "Whatever!" at the resident and exited the resident's room.

An interview with Resident 7 On May 23, 2024, at 10:07 AM, revealed that the resident was upset. The resident stated she was not doing well. The resident stated that Employee 3 tried to put a pair of pants on her she did not want on. The resident stated the employee was "rude and fighting" with her and "went to go tell"on her for not getting dressed. The resident stated she just wanted to be left alone but the employee kept fighting with her. The resident stated the employee just left her in a brief uncovered and pointed down. Observation at that time revealed the resident lying with no pants on just a brief in bed exposed. The resident stated staff are always rude and disrespectful to her. She stated that the "call bell wait times are terrible." She stated that she has to wait an hour at times for staff to meet her needs. She stated she will be waiting for help while staff are "yapping" with each other in the halls.

A review of Resident 9's clinical record revealed the resident was admitted to the facility on April 5, 2024, with diagnoses which included muscle weakness, and osteoarthritis.

An interview with Resident 9 on May 23, 2024, at approximately 10:15 AM revealed that the resident stated that staff do not answer call bells timely. The resident stated that he has waited up to two hours for staff to answer his bell and assist him. The resident stated normal wait time is over 30 minutes and it happens on all shifts.

A clinical record review revealed that Resident 3 was admitted to the facility on June 9, 2021, with diagnoses that include neurogenic bladder and the need for assistance with personal care.

Interview with Resident 3 on May 23, 2024, at approximately 10:16 AM, the resident stated that staff do not answer call bells timely and has experienced very long waits for staff to answer the call bells and this happens on a regular basis. " It just happened this morning, waited over 30 minutes." Some waits are up to two hours. The resident states "what if it was a true emergency, I would be dead." The resident mentioned complaining to staff and the administration is aware but the more they complain the "more rude staff" becomes when they finally come in to assist. The resident stated waits results in sitting in their own urine and feces while waiting for someone to come help them.

A clinical record review revealed that Resident 4 was admitted to the facility on March 5, 2024, with diagnoses that include lack of coordination, muscle weakness, gait and mobility abnormalities and repeated falls.

Interview with Resident 4 on May 23, 2024, at approximately 10:23 AM, revealed that she often waits up to an hour for staff to assist after ringing the call bell. The resident stated that she suffers from constipation and if she feel like having to hold a bowel movement ends up making this worse and becomes embarrassed when she becomes incontinent and requires total assistance to get cleaned up.

An interview with Resident 12 (who wishes to remain anonymous in fear of retaliation) on May 23, 2024, at approximately 10:45 AM revealed the resident has to wait 30 minutes for the call bell to be answered. The resident stated it happens on all shifts. The resident further indicated that "staff are rude and have bad attitudes." The resident stated some staff are disrespectful to the residents. The resident stated some employees speak very nasty to this resident and to other residents and tell them "this is the way it is." The resident stated it is sometimes just the employee's demeanor and presence alone that make the resident uncomfortable. The resident stated employees are fighting with each other in that halls and residents can hear them. The resident reiterated "please not to identify me" for feat the staff will retaliate against the resident.

During an interview on May 23, 2024, at approximately 1:15 PM with the Nursing Home Administrator (NHA) verified that it is the facility's expectation that all residents be treated with dignity and respect. The NHA was unable to explain why multiple residents are reporting untimely staff response times, resulting in the residents' feelings that the facility is not adequately staffed, which was negatively affecting the residents' quality of life in the facility.



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

28 Pa. Code 201.29 (a) Resident rights

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



 Plan of Correction - To be completed: 06/19/2024
Please note that the filing of this plan of correction does not constitute any admission to the alleged violations set for in the statement of deficiencies. This plan of correction is being filed as evidence of the facility continues compliance with all applicable laws.

- Resident R16, R3, R4s call bell is being answered in a timely manner and needs are addressed (R11 & R9 no longer reside in the facility). Other residents, including R12, call bells are being answered in a timely manner. Resident 7 care is being provided care with respectful interactions and dignity maintained. Corrective action occurred with agency Employee 3.
- Audit residents to ensure that their call bells are answered timely and needs met. interview/observations with residents to ensure monitoring employee conduct and behavior, and resident satisfaction with employees meeting customer service standards.
- Educate staff on customer service, resident and peer interactions and answering call bells timely and being sure to meet the residents needs
- Monthly audits X3
- Results will be brought to QAPI

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, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment.


Findings include:

An observation on May 23, 2024, at approximately 9:00 AM revealed a strong urine smell when entering the facility.

An observation on May 23, 2024, at 9:10 AM revealed a strong urine smell emanated from resident room 4. There were gouges in the paint on the wall behind the residents' beds. Paper and debris was observed on the floor. A used glucose monitoring strip was observed lying on the baseboard heater. The light at the first bed did not turn off. The light switch was broken and does not turn the light off. The handle was broken off the nightstand.

An observation on May 23, 2024, at 9:26 AM, in the "Nourishment Room" in the Center Hallway revealed the hinges broken off the cabinet door.

An observation on May 23, 2024, at approximately 10:00 AM revealed resident Room 46's door was cracked and chipped. Dirt, debris, and food crumbs were observed on the floor and fall mats.

In Resident Room 44 dirt and debris was observed on the floor. The room had a strong odor of feces. The bedroom door was cracked and chipping. Brown spots were observed splattered on the privacy curtains.

An observation on May 23, 2024, at 10:03 AM, in resident room 59 revealed a dark brown water stain in the bowl of bathroom toilet. The surface of the wall to the right upon entering the room was cracked, crumbling and flaking.

An observation on May 23, 2024, at 10:43 AM, in resident room 24 revealed a used wet washcloth in shared resident bathroom hanging on the top of the toilet seat. Upon entering the to right of the room, several black marks were observed on the wall.

Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on May 23, 2024, at approximately 1:00 PM confirmed that the facility is to be maintained daily to provide a clean and sanitary environment for the residents.



28 Pa. Code 201.18 (e)(2.1) Management




 Plan of Correction - To be completed: 06/19/2024

- There is no urine smell upon entering the facility or in Room 4. Gouges behind the residents bed in room 4 were repaired and paper and debris was swept from the floor and floor cleaned. The blood glucose monitoring strip from baseboard was disposed of. The light/ light switch in room 4 bed 1 has been repaired. The handle of nightstand was repaired. The Nourishment Room broken hinges were repaired. Resident 46 door was repaired and dirt and debris disposed of and floor and floor mat cleaned. Room 44 dirt and debris was disposed of and floor cleaned. Room 44 odor resolved. Room 44 door repaired and the privacy curtain replaced. Room 59 stain in toilet cleaned and wall was repaired. Room 24 wet washcloth was removed and black marks upon wall addressed.
- Audit rooms to ensure homelike environment including, checking for dirt, debris, gouges in wall, toilet cleaned, no foul smell, clean privacy curtains, no wet linen in bathrooms, night stand handles in good repair, bedroom door and light in good repair. Cleaning and preventive maintenance program were reviewed.
- Educate housekeeping and maintenance staff on providing housekeeping and maintenance services to maintain a clean and safe resident environment
- Monthly auditsX3 Director of Maintenance and Director of housekeeping/designee will conduct the audits to ensure that the cleaning schedules and preventive maintenance are effective
- Results will be brought to QAPI

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 clinical record review and staff interviews, it was determined that the facility failed to develop person-centered care plans that addressed a resident's medical needs and prescribed medication therapy for one resident out of 17 sampled residents (Resident 13).

Findings include:

A review of the clinical record revealed Resident 13 was admitted to the facility April 29, 2024, with diagnoses of type two diabetes (a condition from insufficient production of insulin causing high blood sugar), sarcoidosis (a condition where there is an abnormal collection of inflammatory cells that form clumps in the skin or lymph nodes that result in dry cough and shortness of breath), and long-term use of anticoagulants (blood thinning medication) and insulin (injectable medication to treat diabetes).


A review of a physician order initially dated April 29, 2024, revealed that the resident was receiving Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/milliliter (ml) inject 17 unit subcutaneously in the afternoon for diabetes and Apixaban (Eliquis) Oral Tablet 5 milligrams (mg) give every morning and at bedtime to prevent blood clots related to Atrial Fibrillation.

A review of Resident 13's care plan, conducted during the survey ending May 23, 2024, revealed that the resident's comprehensive care plan did not include the resident's medical condition, type two diabetes and sarcoidosis, and the necessary care and services needed to manage those conditions and failed to identify the resident's daily insulin use for diabetes and interventions to monitor for signs and symptoms of hypo or hyperglycemia. The resident's plan of care failed to identify the resident's anticoagulant therapy and interventions to monitor for bleeding and related side effects.


During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on May 23, 2024, at approximately 1:15 PM confirmed the absence of Resident 13's medical conditions and failed to ensure that comprehensive care plans were developed in manner to meet the resident's medical and treatment needs.


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



 Plan of Correction - To be completed: 06/19/2024

- Resident R13 has a person-centered care plan including the resident's sarcoidosis, diabetic conditioning including monitoring for hyper/ hypoglycemia, anticoagulant therapy, and interventions to monitor for bleeding and related side effects.
- Audit residents with type 2 diabetes to ensure that their care plan includes the resident's risk for hyper/ hypoglycemia. Audit resident on anticoagulant therapy and ensure interventions to monitor for bleeding and related side effects. Audit residents with diagnosis of sarcoidosis and care plan appropriately.
- Educate nursing admin on ensuring that the resident's anticoagulant therapy and interventions to monitor for bleeding and related side effects are in place for residents with type 2 diabetes
- Monthly auditsX3
- Results will be brought to QAPI

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

§483.45(h) Storage of Drugs and Biologicals

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

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


Based on select facility policy, observation, and staff interview, it was determined that the facility failed to ensure adherence to medication expiration/use by dates for one of 15 residents (Resident 15) and failed to properly label medication in one of five medication carts (Center Cart).



Findings include:

A review of facility policy entitled "Storage of Medications" indicated that the pharmacy dispenses medications in containers that meet legal requirements including standards established, medications are maintained in the dispensed packaging. Medications outdated are disposed of according to disposal guidelines.

A review of facility policy entitled "Medication Administration" indicated that the individual administering medications must verify the resident's identity before giving the medication verifying the name and date of birth, checking identification band, checking photograph and medical record. The manufacturer's expiration/beyond use date on the medication label must be checked prior to administering.

An Observation on May 23, 2024, at 9:41 AM, of the Center Hall medication cart in the presence of Employee 1 Licensed Practical Nurse (LPN), revealed an opened Hemorrhoid (Phenylephrine-Mineral Oil) 0.25-14-74.9 % Ointment (hemorrhoid pain and discomfort relief ointment used rectally) and X-Treme Freeze (pain relieving cold therapy gel) 16-ounce bottle without a label identifying the resident or instructions of use.

A clinical record review revealed that Resident 15 was admitted to the facility on February 25, 2021, with diagnoses that include glaucoma (a condition where the eye's optic nerve is damaged with or without raised intraocular pressure and could cause gradual vision loss if untreated).
A review of Medication Administration Record (MAR) for the month of May, revealed that Resident 15 was ordered Xalatan Solution (Latanoprost) with instructions to instill one drop in both eyes at bedtime for glaucoma with a start date of April 26, 2024, and to be discontinued on May 17, 2024.

An observation on May 23, 2024, at 10:17 AM of the East Hall medication cart in the presence of Employee 2, LPN revealed an opened Latanoprost Ophthalmic (eye) drop medication with an open date of April 7, 2024, and without an expiration date noted on the bottle.

According to the product manufacturer storage instructions Latanoprost eye drops are to be thrown away and not used after six weeks of opening.

The Latanoprost eye drops were opened on April 7, 2024, and would have expired on May 19, 2024 (six weeks after opening).


During an interview with Director of Nursing (DON) and Nursing Home Administrator (NHA) on May 23, 2024, at 1:00 PM it was confirmed that the eye drops should be dated when opened and discarded six weeks after the initial date opened and medications in use should have a proper label present prior to administering.



28 Pa. Code 211.9 (a)(1)(k)(1) Pharmacy Services

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




 Plan of Correction - To be completed: 06/19/2024

- Hemorrhoid ointment, xtreme freeze, Xalatan, and latanoprost that was not labeled and dated properly were disposed of
- Audit nursing carts to ensure that there is no undated Hemorrhoid ointment, extreme freeze, Xalatan, and latanoprost
- Educate licensed nurses on properly labeling medications
- DON/designee will conduct Monthly auditsX3 on the nursing carts to ensure that that there are no undated/expired meds and remove as appropriate
- Results will be brought to QAPI


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