Pennsylvania Department of Health
BELVEDERE CENTER, GENESIS HEALTHCARE, THE
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BELVEDERE CENTER, GENESIS HEALTHCARE, THE
Inspection Results For:

There are 140 surveys for this facility. Please select a date to view the survey results.

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BELVEDERE CENTER, GENESIS HEALTHCARE, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance survey completed on July 18, 2024 it was determined that The Belvedere Cente was not in compliance with the following requirements of 42 CFR 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as it relates 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 observation and staff interview, it was determined the facility failed to maintain resident dignity for one of one residents (Resident 80).

Findings include:

Review of Resident 80's Minimum Data Set (MDS, Standardized assessment used to collect information about a resident for quality measure) with a date of completion of May 9, 2024, revealed Resident 80 possesses a BIMS (Brief Interview for Mental Status) of 8 (indicating moderate cognitive impairment).

Additional review of Resident 80's MDS revealed under section 8 (Hearing, Speech, and Vision) that Resident 80 has difficulty understanding others and difficulty communicating with others.

Review of Resident 80's medical diagnosis revealed an active diagnosis of Other Nontraumatic Intracerebral Hemorrhage (brain bleed caused from a stroke that caused memory loss, difficulty speaking and understanding ...).

Observations conducted on July 15, 2024, at 9:45 a.m. revealed a sign on Resident 80 boor indicating, "Resident 80 FALL RISK."

Observations conducted on July 16, 2024, at 10:13 a.m. revealed the sign remained on Resident 80's door.

Observations conducted on July 17, 2024, at 8:30 a.m. revealed the sign remained on Resident 80's door.

Interview conducted with Nursing Home Administrator (NHA) on July 18, 2024, at 12:15 p.m. reported the facility did not have the consent of Resident 80 or Resident 80's POA (Power of Attorney). The NHA confirmed the facility failed to respect Resident 80's dignity.

28 Pa. Code 201.29 (j) Resident Rights

Plan of Correction - To be completed: 09/10/2024

Resident R80 signs were removed from his door during the survey.

An initial audit will be completed by the Director of Nursing/Designee on all current resident room doors to ensure that no signs are posted on the doors that resident or family are not agreeable too.

All staff will be re-educated by the Director Of Nursing/Designee not to post any signs on resident doors that are not requested or agreed upon by family or resident.

The Director of Nursing/designee will conduct weekly random audits for the next 90 days to ensure that no signs are posted on the doors that residents or family are not agreeable too.
Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:

§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Observations:

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure the advanced directives were accurately reflected in residents' records for one of 30 residents reviewed (Resident 79).

Findings include:

Review of Resident 79's clinical records revealed that the resident was admitted to the facility on January 17, 2023, and review of clinical record revealed diagnoses including Chronic Kidney Disease, Malignant Neoplasm of Prostate (prostate cancer), Bradycardia (slow heart rate), Cardiac Arrhythmia (irregular heartbeat), Urethral Stricture (narrowing of the urethra), Obstructive and Reflex Uropathy (blockage in urinary tract), Urine Retention, Benign Prostatic Hyperplasia (enlarged prostate), Hypertension (high blood pressure) and Abnormalities of Gait and Mobility (changes in walking pattern).

Continued review of Resident 79's clinical record revealed the resident had a BIMS (Brief Interview for Mental Status) scored of five which indicating the resident was severely cognitively impaired.

Review of Resident 79's clinical records revealed a care plan dated January 24, 2023, documenting the resident has an established advanced directive of Full Code (life sustaining measures).

Further review of Resident 79's clinical records revealed a care plan dated April 12, 2024, documenting the resident was admitted into hospice care due to end stage diagnosis of Senile Degeneration of the Brain, with the goal being the resident will achieve the highest possible level of acceptance and readiness for death by the time of death.

Review of Resident 79's active physician orders, revealed an order, dated April 10, 2024, indicated the resident's advanced directive to be Do Not Resuscitate (DNR), Do Not Intubate (DNI), Do Not Hospitalize (DNH).

Review of progress notes from April 10, 2024, through July 18, 2024, for Resident 79 revealed no indication as to reason the physician's orders did not match the resident's care plan.

Interview conducted on July 18, 2024, at 1:55 p.m. with Director of Nursing confirmed the above information.

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

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

Plan of Correction - To be completed: 09/10/2024

Resident R79 plan of care has been updated to reflect the correct Advanced Directive

An initial audit will be completed by the Director of Nursing/Designee on all residents Advance Directives to ensure the Physician orders and the Plan of Care correctly reflect the residents' code status.

Licensed nursing staff were re-educated by the Director of Nursing/Designee to ensure that the Physician orders and the Plan of Care correctly reflect the residents' code status.

The Director of Nursing/designee will conduct random weekly audits for the next 90 days to ensure that residents' code status is documented correctly in the Physician Orders and Plan of Care. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on review of clinical records and staff interviews, it was determined the facility failed to ensure a baseline care plan was developed for one of the 30 residents reviewed (Resident 110).

Findings include:

Review of Resident 110's clinical record revealed the resident was readmitted to the facility on April 21, 2024, with a diagnosis of Acute Diastolic (Congestive) Heart Failure, Hypertension (high blood pressure), and Absence of Left Leg Above Knee.

Review of Resident 110's clinical records revealed physician orders dated July 3, 2024, documenting the following orders: "Pulse Oxygen every shift to keep oxygen sats greater than or equal to 90%. Clean external filter on oxygen concentrator. Oxygen tube change weekly, label each component with date and initials. Oxygen at 2L/min via Nasal Cannula, continuously."

Review of Resident 110's clinical records revealed a Minimum Data Set (MDS) Assessment dated July 10, 2024, documenting the resident required oxygen therapy on admission and while in the facility.

Review of Resident 110's care plan failed to reveal that a baseline care plan was developed for the resident receiving oxygen.

The facility failed to ensure Resident 110's baseline care plan for oxygen was developed.

Interview conducted with the Director of Nursing on July 18, 2024, at 1:55 p.m. when the above findings were reviewed.

28 Pa. Code 211.5(f) Clinical Records

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

28 Pa Code: 211.10(c) Resident care policies

Plan of Correction - To be completed: 09/10/2024

Resident R110 Plan of Care was updated to reflect the need for oxygen and the physician orders that pertain to oxygen administration

An initial audit will be completed by the Director of Nursing/Designee on current residents receiving oxygen to ensure that the Plan of Care reflects the physician orders that pertain to oxygen administration.

Licensed nursing staff were re-educated by the Director of Nursing/Designee on updating the plan of care to reflect the utilization of oxygen.

The Director of Nursing/designee will conduct random weekly audits for the next 90 days to ensure that residents receiving oxygen have a Plan of Care developed to meet the physician orders. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§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, it was determined that the facility failed to ensure residents had comprehensive care plans for one of 26 residents reviewed (Resident 113).

Findings include:

Review of Resident 113's admission elopement assessment dated April 3, 2024, revealed the resident scored a 6, indicating the resident was an elopement risk.

Review of Resident 113's elopement assessment dated June 19, 2024, revealed the resident scored a 1, indicating the resident was an elopement risk.

Review of Resident 113's care plan failed to reveal a plan of care addressing the resident's risk for elopement.

The above findings were discussed with and confirmed with the Director of Nursing on July 18, 2024, at 10:05 a.m.

28 Pa. Code 211.5(f) Clinical records

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

Plan of Correction - To be completed: 09/10/2024

Resident R113 has been discharged.

An initial audit will be completed by the Director of Nursing/Designee on current residents who are deemed at risk for elopement based elopement assessments and ensure that a Plan of Care has been developed addressing the resident's risk for elopement.

Licensed nursing staff were re-educated by the Director of Nursing/Designee on updating the plan of care to reflect the resident's risk for elopement.

The Director of Nursing/designee will conduct random weekly audits for the next 90 days to ensure that residents at risk for elopement have a Plan of Care developed addressing the resident's risk for elopement. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§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.

Plan of Correction - To be completed: 09/10/2024

Resident R113 has been discharged.

An initial audit will be completed by the Director of Nursing/Designee on current residents to determine if they need supervision for outside appointments due to being at risk for elopement.

Resident Representatives who agree to escort residents to outside appointments will be educated by the Director of Social Services/Designee on the need to meet the resident at The Belvedere Center when accompanying them to the outside appointment.

The Director of Nursing/designee will conduct random weekly audits for the next 90 days to ensure that residents whose Resident Representatives are supervising outside appointments are meeting the resident at the The Belvedere Center prior to the appointment. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on clinical record review and staff interview it was determined the facility failed to provide care and services related to catheter care for one of five residents reviewed. (Resident 90)

Findings Include:

Review of Resident 90's physician orders revealed an order dated January 16, 2024 to perform indwelling catheter care every day and night shift. The physician's order was discontinued on April 17, 2024.

Observation of Resident 90 on July 15, 2024 at 9:30 a.m. revealed Resident 90 had an indwelling catheter.

Review of resident 90's clinical record revealed there was no documented evidence Resident 90 had been receiving catheter care since April 17, 2024 when the order for care was discontinued.

Interview with the Director of Nursing on July 18, 2024 at 11:30 a.m. confirmed Resident 90 had an indwelling catheter and there was no documented evidence they had received care since April 17, 2024.

28 Pa. Code 211.5 (f) Clinical record

28 Pa. Code 211.10 (d) Resident care policies

28 Pa. Code 211.12 (c)(d)(1)(3) Nursing services

Plan of Correction - To be completed: 09/10/2024

Resident R90 had orders entered for catheter care.

An initial audit will be completed by the Director of Nursing/Designee on current residents with indwelling catheters to ensure there are physician orders for indwelling catheter care.

Licensed nursing staff were re-educated by the Director of Nursing/Designee on the need for indwelling catheter care orders for those residents' it applies to.

The Director of Nursing/designee will conduct random weekly audits for the next 90 days to ensure that residents with indwelling catheters have orders for catheter care. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:
Based on review of facility staffing data, it was determined that the facility failed to ensure a minimum of one certified nurse aide per 10 residents on day and shift for one out of three weeks of facility staffing reviewed (Week of July 11, 2024).

Findings include:

Review of the week of July 11, 2024, revealed the following dates the day shift did not meet the requirement of one certified nurse aide per 10 residents:

Review of the week of July 11, 2024, revealed that the facility failed to meet the requirement by -0.10 for July 14, 2024, and -1.16 for July 17, 2024.

During phone conversation with NHA on July 25, 2024, at 3:22 p.m., findings were confirmed of non-compliance for certified nurse aide ratios.

Plan of Correction - To be completed: 09/10/2024

There were zero adverse effects to the residents in The Belvedere Center as a result of the CNA ratio on the day shift of July 14th 2024 or July 17th 2024.

Facility management will continue to utilize all resources to advertise open positions and initiate new hire interviews. Staffing and labor meetings are held every weekday to review staffing ratios.

NHA, DON, ADON, and Scheduling Manager are to be educated on maintaining a ratio of 1-10 for CNAs on day shift.

The Administrator (or designee) will randomly audit schedules, to ensure ratio of 1 CNA to 10 residents on day shiftis met, weekly x4 and then monthly x3. Results are to be reviewed in QAPI.

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Observations:
Based on review of facility staffing data, it was determined that the facility failed to ensure a minimum of one licensed nurse per 25 residents on day and evening shift for one out of three weeks of facility staffing reviewed (Weeks of July 11, 2024).

Findings include:

Review of the week of July 11, 2024, revealed the following dates the evening shift did not meet the requirement of one licensed nurse per 25 residents:

Review of the week of July 11, 2024, revealed that the facility failed to meet the requirement by -1.9 on July 14, 2024, for the evening shift.

Review of the week of July 11, 2024, revealed the following dates the day shift did not meet the requirement of one licensed nurse per 25 residents

Review of the weeks of July 11, 2024, revealed the facility failed to meet the requirement by -.10 on July 14, 2024, for the day shift.

During phone conversation with NHA on July 25, 2024, at 3:22 p.m., findings were confirmed of non-compliance for licensed nurse ratios.

Plan of Correction - To be completed: 09/10/2024

There were zero adverse effects to the residents in The Belvedere Center as a result of the licensed nurse ratio on the day and evening shift of July 14th 2024.

The facility will continue to utilize all resources to advertise open positions and initiate new hire interviews. Staffing and labor meetings are held every weekday to review staffing ratios.

NHA, DON, ADON, and Scheduling Manager are to be educated on maintaining a ratio of 1-25 for licensed nurses on day and evening shift.

The Administrator (or designee) will randomly audit schedules, to ensure ratio of 1 licensed nurse to 25 residents on day and evening shift is met, weekly x4 and then monthly x3. Results are to be reviewed in QAPI.

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