Nursing Investigation Results -

Pennsylvania Department of Health
EDISON MANOR NURSING & REHAB CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
EDISON MANOR NURSING & REHAB CENTER
Inspection Results For:

There are  126 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.
EDISON MANOR NURSING & REHAB CENTER - 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, and an Abbreviated survey in response to a complaint, completed on September 13, 2019, it was determined that Edison Manor Nursing and Rehab 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.




 Plan of Correction:


483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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.
483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on observation and resident interviews, it was determined that the facility failed to ensure medications were consumed for one of 25 residents reviewed (Resident R231).

Findings include:

Observation on 9/10/19, at 9:56 a.m. revealed Resident R231 sitting in bed with three medication cups on the overbed stand, one med cup had amber liquid in it. Resident R231 stated that "staff doesn't wait for me to take that because I don't like it and it takes a while for me to get it down. Nurses don't always watch you take your pills."

During interviews on on 9/10/19, at 10:00 a.m. with Resident R24 and on 9/11/19, at 1:08 p.m. Residents R47, R75, R46, R65, R72, R48, and R74 also indicated that nurses don't watch residents take their pills. They just set them down and walk away.

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

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




 Plan of Correction - To be completed: 10/15/2019

R231 had no adverse reaction to medication not observed taken.

Residents receiving medication have the potential to be affected. A screen of ten resident's medication administration was completed with no deficient practice identified.

RN's and LPN's will be re-educated on the five rights of medication administration to included observation of resident consumption of medication and not leaving medication cups at bedside.

The DON or designee will be responsible for ongoing compliance monitoring. Random audits of ten resident medication observations of LPN's will be conducted weekly for two weeks, and monthly for two months. Results of the audits will be reported to the Quality Assurance Performance Improvement committee monthly for two months then as directed by the QAPI committee.

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(f) Frequency of Meals
483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.
Observations:


Based on review of facility documentation and staff and resident interviews, it was determined the facility failed to ensure the provision of a substantial evening snack when more than 14 hours elapsed from the evening meal to breakfast the following day.

Findings include:

A review of the facility's scheduled meal times revealed greater than 14 hours between dinner and breakfast.

Interviews conducted with several residents throughout the days of survey from 9/10/19 through 9/13/19, at various times, revealed that residents are not served a nourishing evening snack but can obtain a snack only upon request.

The facility was unable to provide evidence of nourishing snacks served each evening for all residents.

During an interview on 9/12/19, 9:00 a.m. the Dietary Manager confirmed the meal times that showed an elapsed time of greater than 14 hours between the evening and breakfast meals and that not all the residents were routinely served a nourishing evening snack.

28 Pa. Code 211.6(a)(b) Dietary services
Previously cited 10/15/18




 Plan of Correction - To be completed: 10/15/2019

Residents affected by lack of substantial snack for greater than 14 hours were reviewed. Residents going greater than 14 hours between meals have the potential to be affected by lack of substantial snacks. For all residents the meal times have been changed so that evening meal and breakfast the following day will not exceed the 14 hour mark.

Meal times were adjusted by 15 minutes to maintain regulatory compliance of 14 hours or less between meals. A screen of meal times was completed for frequency of meals.

The DON or designee will be responsible for ongoing compliance monitoring. Audits of meal times will be conducted weekly for two weeks, and monthly for two months. Results of the audits will be reported to the Quality Assurance Performance Improvement committee monthly for two months then as directed by the QAPI committee.


483.60(d)(6) REQUIREMENT Drinks Avail to Meet Needs/Prefs/Hydration:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(6) Drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration.
Observations:


Based on observations and resident and staff interviews, it was determined that the facility failed to consistently ensure fresh water was readily accessible to residents to promote adequate hydration and comfort for 14 of 27 residents reviewed (Residents R7, R64, R72, R74, R65, R48, R17, R43, R78, R37, R46, R47, R18 and R49).

Findings include:

During an interview on 9/10/19, at 9:40 a.m. Resident R18 reported that he/she does not receive fresh ice water unless he/she asked for it.

During an interview on 9/11/19, at 1:08 p.m. Residents R64, R72, R74, R65, R48, R17, R43, R78, R37, R46, and R47 reported that the facility does not provide fresh ice water unless residents specifically ask for it.

Observations conducted throughout the facility from 9/10/19 through 9/12/13, revealed that the residents did not have any hydrating drink in their rooms or at the bedside.

During interviews conducted with several residents throughout the days of survey from September 10th through the 12th, at various times, the residents disclosed that they are not served water and that they must ask the staff to bring them something to drink which is provided in small plastic cups that are used during medication administration.

Observations of the residents from 9/10/19 through 9/13/19, revealed multiple residents without fresh ice water at the bedside.

On 9/12/19, at 1:15 p.m. Licensed Practical Nurse Employee E4 confirmed that the residents are not provided water unless they specifically so request.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 10/15/18









 Plan of Correction - To be completed: 10/15/2019

The facility cannot determine the identity of R7, R49, R64, R72, R65, R48, R17, R43, R78, R37, R46, R47, and R18. R74 is care planned for and has a history of making false allegations, hydration was offered.

All residents who are able to consume liquids have the potential to be affected. A screen of hydration (ice water at bedside) was completed ensuring all residents had hydration following their care plan.

Nursing staff will be educated on hydration and the need to pass ice water each shift.

The DON or designee will be responsible for ongoing compliance monitoring. Random audits ensuring hydration of 10 residents will be conducted five times per week for two weeks, weekly for two weeks, and monthly for two months. Results of the audits will be reported to the Quality Assurance Performance Improvement committee monthly for two months then as directed by the QAPI committee.

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 observations and resident interviews it was determined that the facility failed to maintain a dignified personal appearance for three of 21 residents. (Residents R11, R72, R56)

Findings include:

Observation on 9/10/19, at 11:20 a.m. revealed resident R11 unshaven and in a hospital gown. During interview at this time, the resident expressed the desire to be dressed and shaven.

Observation on 9/10/19, at 2:20 p.m. revealed resident R72 unshaven and in a hospital gown. During interview at this time, the resident's responsible party expressed anger and frustration that the resident remained in a gown and was not appropriately groomed at this time of day.

Observation on 9/10/19, at 1:51 p.m. revealed Resident R56 seated in the common lounge area with several other residents and families present wearing a hospital gown with a blanket on his/her lap which had become displaced and was exposing his/her adult incontinence brief.

28 Pa Code 201.29(a)(j) Resident rights
Previously cited 10/15/18


 Plan of Correction - To be completed: 10/15/2019

This plan of correction is prepared because it is required by State and Federal law and not because Edison Manor Nursing and Rehabilitation Center agrees with the allegations and citations listed on pages 1-57 of this statement of deficiencies (SOD). Edison Manor Nursing and Rehabilitation Center does not admit any deficiency is present. Edison Manor Nursing and Rehabilitation Center is constantly reviewing and revising its policies, procedures, and methods of health care service delivery. There are no subsequent remedial measures undertaken in response to the SOD and no admission can be inferred from Edison Manor Nursing and Rehabilitation Center continuing the process of enhancing the facility's practices. This plan of correction shall operate as Edison Manor Nursing and Rehabilitation Center's written credible allegation of compliance effective October 15, 2019.

The facility cannot determine the identity of R11 and R72. A screen of all residents was completed to correct the deficient practice. R56 was offered to be dressed. R56 was care planned that he resist care, this will revised to specify dressing and grooming.

Residents who need assistance with ADL's and are resistant to care have the potential to be affected. A screen has been completed for all residents requiring assistance with ADL's. No other residents were affected.

Clinical staff will be re-educated on AM care and the need ensure the dignity of the residents personal appearance is carried out. RN's/LPN's/CNA's will be educated on resident rights of personal appearance.

The DON or designee will be responsible for ongoing compliance monitoring of resident's care planned for non-compliance. Dignified personal appearance audits ensuring residents are shaved and dressed appropriately will be conducted daily for two weeks, weekly for two weeks, and monthly for two months. Ten resident's per audit will be completed. Results of the audits will be reported to the Quality Assurance Performance Improvement for two months then as directed by the Quality Assurance Performance Improvement.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:


Based on observations, review of clinical records and facility policies and staff interview, it was determined that the facility failed to prevent the potential for cross contamination during a dressing change for one of 21 residents (Resident R18).

Findings include:

Resident R18's admission record revealed a date of 9/08/17, with diagnoses that included high blood pressure, diabetes, coronary artery disease, chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed airflow from the lungs), and adult failure to thrive (weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction, and low cholesterol).

A facility policy entitled "Hand Washing- Infection Control" dated 9/11/18, indicated that the use of gloves does not replace the need for hand cleaning, and that hand hygiene should be performed after removing gloves, before handling an invasive device regardless of whether or not gloves are used, after contact with body fluids or excretions, non-intact skin and/or wound dressings.

Observation on 9/10/19, at 10:13 a.m. revealed that the wound Certified Registered Nurse Practitioner (CRNP) washed his/her hands, applied gloves and cleansed a wound on Resident R18's right great toe, after which he/she applied skin prep wipes to the wound on the right great toe. The CRNP changed his/her gloves without washing his/her hands and began to clean the wound on Resident R18's coccyx/sacral area with normal saline solution and measure the wound while touching the wound and surrounding tissues. The CRNP began to pack the wound with a clean dressing (gauze roll soaked with normal saline) without changing his/her contaminated gloves and/or washing his/her hands. He/she applied skin prep wipes around the wound and placed a foam dressing over the saline soaked gauze inside the wound using the same contaminated gloves.

28 Pa. Code 211.10(c)(d) Resident Care Policies

28 Pa. Code 211.12 (d)(2) Nursing Services

28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 10/15/18











 Plan of Correction - To be completed: 10/15/2019

Resident 18 had no adverse effects from the dressing change.

Residents that have wounds that require dressing changes have the potential to be affected. Initial observation of dressing change was completed.

Practitioners who perform dressing changes will be re-educated on proper procedure to prevent infection and cross contamination. A screen of dressing changes was completed to determine residents with dressing ordered.

The DON or designee will be responsible for ongoing compliance monitoring. Audits of two dressing changes (infection control) will be conducted five times per week for two weeks, weekly for two weeks, and monthly for two months. Results of the audits will be reported to the Quality Assurance Performance Improvement committee monthly for two months then as directed by the QAPI committee.

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 observation and staff interviews, it was determined that the facility failed to ensure that all medications were disposed of properly before expiration dates for one of two medication rooms observed, and that the facility failed to safely secure medications all medications for one of 21 residents (Resident R14).

Findings Include:

Observation on 9/10/19, at 10:13 a.m. with Registered Nurse (RN) Employee E2 in the second floor medication room revealed the following:

Four bottles of Vitamin D with expiration dates of 1/2019
One bottle of oyster shell calcium 500 milligram (mg) with an expiration date of 3/2018
One bottle of Lansoprazole (a medication used to treat stomach ulcers) 15 mg with an expiration date of 4/2019
One bottle of Vitamin A 10,000 International Units with an expiration date of 10/2018

During an interview at the time of the observation RN Employee E2 verified the expired medications and stated "Those should not be in the cupboard, they are expired" and proceeded to dispose them in the garbage can.

Resident R14's clinical record revealed an admission date of 5/18/18, with diagnoses including acute (sudden) kidney failure, diabetes, chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed airflow from the lungs), myoclonus (twitches or jerks usually are caused by sudden muscle contractions), peripheral vascular disease (blood vessels outside of your heart and brain to narrow, block, or spasm), and heart disease.

A physician's order dated 9/04/19, indicated that Resident R14 was to take one Midodrine hydrochloride (narrows the blood vessels to increase blood pressure) 2.5 mg tablet three times a day, and four Midodrine hydrochloride 2.5 mg tablets (10 mg) on Mondays, Wednesdays, and Fridays.

Observation on 9/11/19, at 3:09 p.m. revealed Resident R14's open top dialysis bag hanging on the back of his/her wheelchair with one multi-punch bubble medication card containing 22 tablets of Midodrine hydrochloride 2.5 mg and one pharmacy bottle labeled by CVS Pharmacy with nine tablets of Midodrine hydrochloride 10 mg.

Interview on 9/11/19, at 3:09 p.m. with Resident R14 confirmed that the pills are kept in his/her bag to go to dialysis with him/her. Resident R14 stated that there are two female residents on his/her hall who wander into his/her room and rummage through his/her personal items.

483.45 Previously cited 10/15/18

28 Pa. Code 201.14 (a) Responsibility of Licensee

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

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services
Previously cited 10/15/18




















 Plan of Correction - To be completed: 10/15/2019

The facility cannot determine the identity of R14. A screen of all dialysis residents was completed to correct the deficient practice.

Residents with medications/treatments stored in the second floor medication room and the residents on the third floor with access to R14's room have the potential to be affected. A screen of medications in the facility was completed and any expired medications were disposed of. A screen of dialysis residents was completed and residents receiving medications at dialysis will be stored and administered by the dialysis clinic, eliminating the need for the resident to transport.

Licensed staff will be educated on the labelling, dating, storage, and disposal of medication/treatments and also secure medication immediately upon return to facility from dialysis.

The DON or designee will be responsible for ongoing compliance monitoring. Audits of med room medications and unsecured medications for dialysis will be conducted five times per week for two weeks, weekly for two weeks, and monthly for two months. Results of the audits will be reported to the Quality Assurance Performance Improvement committee monthly for two months then as directed by the QAPI committee.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

483.45(c)(2) This review must include a review of the resident's medical chart.

483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:


Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that monthly pharmacy medication reviews were completed for one of six residents reviewed (Resident R66).

Findings include:

Resident R66's clinical record revealed an admission date of 4/23/19, with diagnoses that included generalized muscle weakness, fracture of right lower leg, history of falling, type 2 diabetes, anxiety disorder, and obesity.

Physician orders included Oxycodone 5-325 milligram (mg) one tablet by mouth every 6 hours as needed for pain, Buspirone HCL (Buspar), 1 mg tablet by mouth daily for anxiety, Venlafaxine HCL ER (Effexor XR) 150 mg 1 capsule by mouth daily for anxiety/depression, Ativan 1 mg 0.5 tablets by mouth daily as needed for anxiety, and Eliquis 5 mg by mouth two times per day to prevent blood clots.

There was no documented evidence that pharmacy completed a monthly drug regimen review for Resident R66 for August 2019.

During an interview on 9/13/19, at 10:25 a.m. Registered Nurse Employye E2 confirmed that there were no pharmacy reviews for Resident R66 for August 2019.

28 Pa. Code 201.14(a) Responsibility of licensee






 Plan of Correction - To be completed: 10/15/2019

Resident 66 was not affected by the deficient practice. R66 was hospitalized during consultant pharmacist monthly review. R66 was reviewed at the pharmacy at the time of readmission.

Residents are out of the facility for the consultant pharmacist monthly review have the potential to be affected.
Residents who are hospitalized during consultant pharmacist monthly review are reviewed at the pharmacy upon readmission. A screen of all residents was completed and monthly pharmacy reviews were verified.

Pharmacist will be re-educated on regulatory guidelines for drug regimen review requirements.

The DON or designee will be responsible for ongoing compliance monitoring. Audits will be completed for two months that consultant pharmacist reviews were completed. Results of the audits will be reported to the Quality Assurance Performance Improvement committee monthly for two months then as directed by the QAPI committee.

483.30(c)(1)-(4) REQUIREMENT Physician Visits-Frequency/Timeliness/Alt NPP: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.
483.30(c) Frequency of physician visits
483.30(c)(1) The residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter.

483.30(c)(2) A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required.

483.30(c)(3) Except as provided in paragraphs (c)(4) and (f) of this section, all required physician visits must be made by the physician personally.

483.30(c)(4) At the option of the physician, required visits in SNFs, after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist in accordance with paragraph (e) of this section.
Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to make certain that residents receive a physician visit at least every 60 days for one of 21 residents (Resident R77).

Findings include:

Resident R77's clinical record revealed an admission date of 9/19/17, with diagnoses that included paralytic gait (abnormal walking due to weakness in the leg), cerebral infraction (stroke), high blood pressure, diabetes, chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed airflow from the lungs), and contractures of both hips and knees.

Resident R77's clinical record contained a physician's progress note dated 1/18/19, with the next physician's progress note dated 4/15/19 (total of 87 days later).

During an interview on 9/12/19, at 9:40 a.m. the Registered Nurse Assessment Coordinator confirmed that Resident R77 was not visited by the physician every 60 days.

28 Pa Code 211.2(a) Physicians services

28 Pa Code 211.5(f) Clinical records

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







 Plan of Correction - To be completed: 10/15/2019

Resident 77 was not affected by the deficient practice. The physician for R77 conducted a visit.

Resident with non-compliant physicians have the potential to be affected. A screen of physician visits was conducted on all residents and physicians were notified of required visits as needed.

Physicians with deficient practice will be re-educated on regulatory guidelines for physician visits at least every 60 days.

The DON or designee will be responsible for ongoing compliance monitoring. Audits of ten residents for physician visits will be conducted, weekly for two weeks, and monthly for two months. Results of the audits will be reported to the Quality Assurance Performance Improvement committee monthly for two months then as directed by the QAPI committee.

483.30(b)(1)-(3) REQUIREMENT Physician Visits - Review Care/Notes/Order: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.
483.30(b) Physician Visits
The physician must-

483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section;

483.30(b)(2) Write, sign, and date progress notes at each visit; and

483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.
Observations:

Based on observation, review of clinical records and staff interview, it was determined that the facility failed to ensure that residents' physician signed and dated the physician orders during visits to the facility for one of 21 residents (Residents R77).

Findings include:

Resident R77's clinical record revealed an admission date of 9/19/17, with diagnoses that included paralytic gait (abnormal walking due to weakness in the leg), cerebral infraction (stroke), high blood pressure, diabetes, chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed airflow from the lungs), and contractures of both hips and knees.

Resident R77's physician had visited the facility and written progress notes dated 9/07/18, 10/16/18, 11/06/18, 12/11/18, 1/13/19, 1/18/19, 4/15/19, 5/13/19, and 6/03/19.

Physician's orders for Resident R77 from September 2018 to June 2019, (total 302 days) were not signed by the physician.

During an interview on 9/10/19, at 2:20 p.m. the Assistant Director of Nursing confirmed that the physician's orders from September 2018 to June 2019, were not signed for Resident R77.


28 Pa Code 201.14(a) Responsibility of Licensee

28 Pa. Code 211.2(a) Physician services

28 Pa Code 211.5(f)(h) Clinical records









 Plan of Correction - To be completed: 10/15/2019

Resident 77 was not affected by the deficient practice. The physician for R77 came into the facility and reviewed the record and signed the orders.

Resident with physician orders that have not been signed have the potential to be affected. A screen of all resident orders was completed and physicians were notified as needed to sign orders.

Physicians with deficient practice will be re-educated on regulatory guidelines for signing physician orders.

The DON or designee will be responsible for ongoing compliance monitoring. Audits of ten resident's monthly orders will be conducted five times per week for two weeks, weekly for two weeks, and monthly for two months to ensure physician signature. Results of the audits will be reported to the Quality Assurance Performance Improvement committee monthly for two months then as directed by the QAPI committee.


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 facility policy, observations, review of clinical records and staff interview, it was determined that the facility failed to promote cleanliness and prevent the spread of infection regarding respiratory care equipment according to physician orders for three of 21 residents (Residents R14, R24, and R42).

Findings include:

A facility policy entitled "Respiratory Schedules for Cleaning and Replacing Equipment" dated 9/11/18, indicated that staff are to change the oxygen tubing every week.

Resident R14's clinical record revealed an admission date of 5/18/18, with diagnoses that included acute (sudden) kidney failure, diabetes, chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed airflow from the lungs), myoclonus (twitches or jerks usually are caused by sudden muscle contractions), peripheral vascular disease (blood vessels outside of your heart and brain to narrow, block, or spasm), and heart disease.

Observation on 9/10/19, at 10:40 a.m. revealed Resident R14's nasal cannula prongs (lightweight tube which on one end splits into two prongs which are placed in the nostrils to delivery supplemental oxygen) noted to have a brown tinged moist substance in the prongs. Also observed at the same time was a piece of tape wrapped around the oxygen tubing dated 5/21/19, or 112 days ago.

Further observations of Resident R14's oxygen tubing on 9/11/19, at 3:09 p.m., 9/12/19, at 2:25 p.m., and on 9/13/19, at 9:20 a.m. revealed the same brown moist substance in the prongs and the same piece of tape dated 5/21/19.

Resident R14's clinical record revealed a physician's order dated 9/04/19, to change the oxygen tubing every Sunday on the 11-7 shift.

Resident R14's Treatment Record for August 2019 lacked evidence that the oxygen tubing was changed as ordered.


Resident R24's clinical record revealed an admission date of 11/06/17, with diagnoses that included heart failure, Alzheimer's Disease, diabetes, chronic bronchitis (inflammation or irritation of the lungs' airways that causes a cough), and sleep apnea (sleep disorder in which breathing repeatedly stops and starts).

Observation on 9/10/19, at 10:02 a.m. revealed Resident R24's oxygen tubing was not dated and connected to the oxygen concentrator (device that provides oxygen therapy to patients at substantially higher concentrations than room air).

Additional observations of Resident R24's oxygen tubing on 9/11/19, at 12:03 p.m., 9/12/19, at 1:07 p.m., and 9/13/19, at 9:08 a.m. revealed the oxygen tubing without a date still connected to the concentrator and the bag for the oxygen tubing was dated for 5/21/19.


Resident R42's clinical record revealed an admission date of 1/15/18, with diagnoses that included end stage kidney failure, diabetes, heart failure, chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed airflow from the lungs), and peripheral vascular disease (blood vessels outside of your heart and brain to narrow, block, or spasm).

Resident R42's clinical record revealed a physician's order dated 9/02/19, to administer oxygen at three liters (about equal to three quarts) per minute through a nasal cannula.

Observation on 9/10/19, at 12:14 p.m. revealed Resident R42's oxygen tubing being used lacked a date when it was changed and the bag for the oxygen tubing was dated for 5/21/19. Further observations on 9/11/19, at 11:06 p.m., 9/12/19, at 1:57 p.m., 9/13/19, at 9:11 a.m. revealed that the tubing remained undated and the bag remained dated for 5/21/19.

During an interview on 9/13/19, at 10:33 a.m. the Registered Nurse Assessment Coordinator confirmed that the oxygen tubing is to be changed weekly and dated when it is changed.

During an interview on 9/13/19, at 11:15 a.m. the Director of Nursing confirmed the oxygen tubing for Residents R24 and R42 was not dated and the oxygen bags were dated for 5/21/19.

28 Pa. Code 211.5(f)(h) Clinical records

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 10/15/18












 Plan of Correction - To be completed: 10/15/2019

The facility cannot determine the identity of R14. A screen of all residents requiring oxygen was completed to correct the deficient practice. R24 and R42 had their oxygen tubing and supplies changed out and dated.

Residents requiring oxygen have the potential to be affected. A screen of residents utilizing oxygen was completed and oxygen tubing and supplies were changed out as needed.

RNs and LPNs will be re-educated on oxygen administration procedure to include dating and changing out of tubing as well as monitoring for outdated tubing.

The DON or designee will be responsible for ongoing compliance monitoring. Audits of ten residents requiring oxygen will be conducted five times per week for two weeks, weekly for two weeks, and monthly for two months to ensure changing and dating of tubing. Results of the audits will be reported to the Quality Assurance Performance Improvement committee monthly for two months then as directed by the QAPI committee.

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 observations, review of clinical records and staff interviews, it was determined that the facility failed to follow physician ordered fall precautions for one of 21 residents (Resident R56).

Findings include:

Resident R56's clinical record revealed an admission date of 8/02/19, with diagnoses that included stroke, difficulty in walking, dysphagia (difficulty swallowing), aphasia (difficulty talking), encephalopathy (brain disease, damage, or malfunction), and general muscle weakness.

Resident R56's Minimum Data Set (MDS-periodic assessment of resident care needs) dated 8/09/19, indicated that Resident R56 required extensive assistance of two staff members to transfer from one surface to another. A care plan for risk for falls initiated on 8/06/19, contained interventions to maintain call light within reach and implement preventative fall interventions/devices.

Observation on on 9/13/19, at 8:59 a.m. revealed Resident R56 sitting in bed with head of bed elevated. No staff members were present. His/her call bell was laying on the floor between the two beds. A fall mat present in the room was not in place between the two beds.

During an interview on 9/13/19, at 9:00 a.m. Licensed Practical Nurse Employee E5 confirmed that Resident R56's call bell was out of reach on the floor and that the fall mat was not in place to prevent injury should Resident R56 fall out of bed.

28 Pa. Code 211.12 (d)(1)(5) Nursing Services
Previously cited 10/15/18











 Plan of Correction - To be completed: 10/15/2019

R56 had tray table at side of bed which prevented the mat to be put back down. R56 pushes bed side table, call bell, and linens from bed. R56 care plan will be updated. The tray table was removed and the call bell and mat were in place.

Residents with fall mats have the potential to be affected. A screen of all residents with fall mats was completed and all fall mat interventions were in place. Resident's identified to remove their call lights will be care planned.

Staff will be re-educated on procedure for placement of fall matts behind the tray table while tray table is in use. Staff will be re-educated on ensuring placement of call bells and re-educated on safety devices.

The DON or designee will be responsible for ongoing compliance monitoring. Audits of ten resident fall mats and call bell placement will be conducted weekly for two weeks, and monthly for two months. Results of the audits will be reported to the Quality Assurance Performance Improvement committee monthly for two months then as directed by the QAPI committee.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:


Based on observations, review of clinical records and facility documentation, and resident and staff interviews, it was determined that the facility failed to provide assistance with dining, grooming and personal hygiene for four of 21 residents (Residents R14, R56, R43, R48).

Findings include:

Resident R14's Minimum Data Set (MDS-periodic assessment of resident care needs) dated 6/14/19, indicated that Resident R14 required physical help in part by staff for bathing.

During an interview on 9/10/19, at 10:45 a.m. Resident R14 stated that he/she is not getting bathed and hasn't had a shower in two weeks.

The Third Floor bathing schedule revised 3/29/18, revealed that Resident R14 was scheduled to receive a shower/bath on Mondays 7-3 Shift and Thursdays 7-3 Shift.

Shower/bath sheets for August and September 2019, revealed that Resident R14 only received four showers/baths out of 12 scheduled days.

During an interview on 9/13/19, at 12:10 p.m. the ADON confirmed that there was no evidence to determine that Resident R14 was bathed more than four of 12 scheduled bath days.


During an interview on 9/11/19, at 1:08 p.m. Resident R43 reported that he/she does not get showered/ bathed routinely and that he/she has not received a shower/bath in two months.

Resident R43's most recent quarterly MDS dated 8/07/19, indicated that he/she required extensive assistance from staff for bathing. Shower/bath sheets revealed that Resident R43 received a shower/bath on 5/10/19, 5/23/19, 5/30/19, 6/7/19, 7/04/19, and 7/20/19, or six times in 82 days.

Resident R48's most recent quarterly MDS dated 8/07/19, indicated that he/she required extensive assistance from staff for bathing. Upon request for Shower/Bath Sheets from May, June, July and August 2019, revealed that Resident R48 received a shower/bath on 5/22/19.

During an interview on 9/13/19, at 12:10 p.m. the ADON confirmed that only six Shower/Bath sheets were completed for May, June, July, and August for Resident R43 and that Resident R48 only had one Shower/bath sheet dated for 5/22/19.


Resident R56's MDS dated 8/09/19, indicated that Resident R56 required limited assistance of staff to eat. A care plan related to nutrition/hydration risk indicated that staff are to provide assistance with meals as needed to encourage intake.

Observation on 9/13/19, at 8:59 a.m. revealed Resident R56 sitting in bed with the head of bed elevated. No staff members were present. The breakfast tray was sitting on the over-the-bed stand with three individual red bowls containing oatmeal, toast, and scrambled eggs; the milk, juice, and peanut butter were not open, and the stand was out of the resident's reach.

During an interview on 9/13/19, at 9:00 a.m. Licensed Practical Nurse (LPN) Employee E5 confirmed that Resident R56 requires help opening and arranging the items on his/her food tray and that he/she requires assistance to start eating. LPN Employee E5 also confirmed that the breakfast trays were delivered to the resident rooms at approximately 7:30 a.m. and that Resident R56's tray of food had been sitting on the table for approximately one and half hours.

Observation on 9/13/19, at 9:27 a.m. revealed that Resident R56's tray of uneaten food was taken to the kitchen by staff.

28 Pa. Code 211.12 (d)(1)(5) Nursing Services
Previously cited 10/15/18














 Plan of Correction - To be completed: 10/15/2019

The facility cannot determine the identity of R14, R43 and R48. A screen of all residents was completed to correct the deficient practice. R56 is care planned to resist care, this will revised to specify dressing, grooming, hygiene, and dining.

Residents choosing to receive showers have the potential to be affected. Residents requiring assistance with meals have the potential to be affected. A screen of all residents was completed. Residents choosing to receive a shower were provided one. Those residents that choose not to be showered had their care plans reviewed and updated as needed. Residents requiring assistance with dining were screened to ensure assistance provided and if resistant to assistance care plans adjusted to reflect.

Staff will be re-educated on shower schedules, shower sheets, documentation of refusal, notification of nurse, and providing assistance with meals.

The DON or designee will be responsible for ongoing compliance monitoring. Audits of five showers and dining assistance will be conducted five times per week for two weeks, weekly for two weeks, and monthly for two months. Results of the audits will be reported to the Quality Assurance Performance Improvement committee monthly for two months then as directed by the QAPI committee.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:

Based on review of clinical records and staff interviews, it was determined that the facility failed to notify a resident's responsible party of a change in condition for one of 21 residents reviewed (Resident R62).

Findings include:

Resident R62's clinical record revealed an admission date of 1/20/14, with diagnoses that included dementia (a loss of mental ability), muscle weakness, heart failure, high blood pressure and diabetes.

An 8/7/19, progress note revealed that Resident R62 was identified to have a change in condition: shortness of breath, starting on the morning of 8/7/19. The note also documented the resident's Oxygen level as 55%, (normal levels are above 93%), and indicated that the physician was notified of these changes at 11:00 a.m. There was no documented evidence to indicate that Resident R62's responsible party was notified of the change in condition.

During an interview on 9/12/19, 11:15 a.m. the Assistant Director of Nursing confirmed that there was no documentation to indicate that Resident R62's responsible party was notified.


28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 10/15/18

28 Pa. Code 211.5(f) Clinical records








 Plan of Correction - To be completed: 10/15/2019

R62 was not affected by the lack of documentation of notification of family of change in condition. Family was present at facility at the time of the change in condition and confirmed with the ADON that she was notified.

Any resident with change in condition has the potential to be affected. A screen was completed of change in condition from 8/26/19 to 9/26/19 no other resident was affected.

RN's and LPN's will be re-educated on change in condition policy and the completion of the SBAR to include notification of family/responsible party.

The DON or designee will be responsible for ongoing compliance monitoring. Audits will be conducted five times per week for two weeks, weekly for two weeks, and monthly for two months. Each change in condition during audit period will be monitored for notification of responsible party. Results of the audits will be reported to the Quality Assurance Performance Improvement committee monthly for two months then as directed by the QAPI committee.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
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 81F; and

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

Based on observations, review of facility policy and staff and resident interviews, it was determined that the facility failed to provide adequate housekeeping services to maintain a clean and sanitary environment for six resident rooms (Rooms 316, 318, 322, 323, 325, and 327) and failed to maintain entertainment equipment in good working order in the common dining area.

Findings include:

A facility policy entitled "Daily Patient Room Cleaning" dated 9/11/18, indicated that staff are to empty trash, dust, mop, or vacuum.

Observations throughout the survey from 9/10/19 at 10:34 a.m. through 9/12/19 2:40 p.m. revealed the following that all remained throughout the survey as first observed:

Room 316 --food crumbs on the floor

Room 318--food crumbs on the floor and under both beds

Room 323 - tissues on the floor between the beds, tissue on floor between bed side stand and bed, cards and napkins between resident night stands

Room 327 --gown in corner on floor, medicine cup under "D" bed, sticky substance on floor under wheel of the bed, brown debris on tub floor and shower chair in the tub, brown stains on toilet seat, unmarked bottle of lime colored liquid on shelf above sink, a floor tile with a golf ball sized hole

Room 322-- "D" bed had a pop-tart box under it. In the bathroom there were two small cups and a toothbrush on the floor, the toilet had brown debris on the rim and on floor in front of toilet

Room 325- pieces of paper, crumbs under the bed, in the bathroom was a raised toilet seat with splattered dark brown substance on inside rim

On 9/11/19, at 1:08 p.m. Residents R64, R72, R74, R65, R48, R17, R43, R78, R37, R46, and R47 reported that their garbage isn't emptied, and rooms aren't cleaned every day. Residents living on the Third Floor reported that their beds aren't made routinely.

During an interview on 9/13/19, at 11:10 a.m. the Director of Nursing confirmed the condition of the resident rooms.

Observation on 9/12/19, at 12:00 p.m. in the common dining area revealed a large screen television that was in use for the resident's viewing entertainment, during pre-meal service and dining that was not functioning in a viewable manner for the residents. During an interview at this time, Resident R65 indicated it was common for the television not to be functioning properly and often the remote control was unable to be located.


Observation on 9/10/19, at 9:59 a.m. in Room 205 revealed clear wrappers under the bed by the door and crumbs of dirt on the floor. Additional observation on 9/11/19 of Room 205 at 12:23 p.m. revealed the clear wrappers remained under the bed and also straw wrappers were present.

Observation on 9/10/19, in Room 214 at 10:07 a.m. revealed the housekeeper mopping Room 214 without sweeping the floor first. Clear wrappers were present under the bed near the door. A white spoon was under the bed by the window. Additional observation on 9/11/19, at 12:20 p.m. revealed the clear wrappers and the white spoon remained. Observation on 9/12/19, at 12:45 p.m. in Room 214 revealed the white spoon and the clear wrappers remained on the floor.

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

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

28 Pa. Code 201.29(j) Resident Rights
Previously cited 10/15/18

28 Pa. Code 201.14(a) Responsibility of licensee













 Plan of Correction - To be completed: 10/15/2019

Resident rooms identified have been cleaned. Common dining room television not functioning properly due to static has been corrected with a new cable line. The dining room television remote has been attached to the wall.

Residents who watch the TV in the main dining room have the ability to be affected. Resident rooms have the ability to be affected by housekeeping. A screen of was completed of all resident rooms for adequate housekeeping. Rooms identified as inadequate at the time of the screen have been cleaned.

Maintenance Director will be educated to ensure channels are functioning in a visible manner. Maintenance Director and Housekeeping staff will be educated on daily patient room cleaning.

The NHA or designee will be responsible for ongoing compliance monitoring. Audits of ten resident rooms and the dining room television will be conducted five times per week for two weeks, weekly for two weeks, and monthly for two months to ensure the dining room television channels are visible and resident rooms are cleaned according to policy. Results of the audits will be reported to the Quality Assurance Performance Improvement committee monthly for two months then as directed by the QAPI committee.

483.10(f)(10)(iv)(v) REQUIREMENT Notice and Conveyance of Personal Funds:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.10(f)(10)(iv) Notice of certain balances.
The facility must notify each resident that receives Medicaid benefits-
(A) When the amount in the resident's account reaches $200 less than the SSI resource limit for one person, specified in section 1611(a)(3)(B) of the Act; and
(B) That, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI.

483.10(f)(10)(v) Conveyance upon discharge, eviction, or death.
Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility must convey within 30 days the resident's funds, and a final accounting of those funds, to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law.
Observations:

Based on review of clinical records and resident fund accounts and staff interview, it was determined that the facility failed to provide a final accounting of funds within 30 days of death to the individual/probate jurisdiction for the resident's estate for one resident (Resident R82).

Findings include:

Resident R82's clinical record that he/she expired at the facility on 7/12/19. Resident R82's account managed by the facility revealed that there was no evidence that the facility provided a final accounting to the individual/probate jurisdiction for the resident's estate within 30 days of the resident's death.

During an interview on 9/13/19, at 11:17 a.m. the Medical Records Employee confirmed that there was no evidence the facility provided a final accounting to the individual/probate jurisdiction for Resident R82's estate.


28 Pa. Code 201.18 (b)(2)(3)(e)(1) Management

28 Pa. Code 201.29 (a) Resident rights





 Plan of Correction - To be completed: 10/15/2019

I hereby acknowledge the CMS 2567-A, issued to EDISON MANOR NURSING & REHAB CENTER for the survey ending 09/13/2019, AND attest that all deficiencies listed on the form will be corrected in a timely manner.


35 P. S. 448.809b LICENSURE Photo Id Reg:State only Deficiency.
(1) The photo identification tag shall include a recent photograph of the employee, the employee's name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.


Observations:


Based on observations and staff interview, it was determined that the facility failed to ensure that all employees were wearing photo identification tags that included all the required information for four employees (Licensed Practical Nurse (LPN) Employee E1, RN Employee E2, Dietary Employee E7, and Nurse Aide (NA) Employee E3.

Findings include:

Observations on 9/10/19, at 10:25 a.m. revealed the lack of any photo or other visual identification for LPN Employee E1 for residents and visitors to know what position he/she was in the facility. During an interview with LPN Employee E1, he/she stated that identification was in his/her car and not currently on their uniform.

Additional observations during the first shift on 9/10/19, of nursing staff revealed RN Employee E2 and NA Employee E3 without any photo identification.

Observation on 9/11/19, at 12:29 p.m. revealed that Dietary Employee E7 did not have his/her photo identification employee tag displayed for staff, residents, and visitors to see. At that time Dietary Employee E7 shared that his/her "name tag" was in his/her vehicle.







 Plan of Correction - To be completed: 10/15/2019



There were no adverse effects from staff not maintaining photo id badges.

Human Resources will be re-educated on the monitoring of photo id badges. Human Resources will complete a screen of name badges to ensure employees are wearing them. Staff will be educated on wearing name badges.

Human Resources or designee will complete five audits of random staff to verify photo ID will be conducted five times per week for two weeks, weekly for two weeks, and monthly for two months. Results of the audits will be reported to the Quality Assurance Performance Improvement committee monthly for two months then as directed by the QAPI committee.


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