Nursing Investigation Results -

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

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BIRCHWOOD HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  106 surveys for this facility. Please select a date to view the survey results.

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


Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and Abbreviated Complaint Survey completed on June 10, 2022, it was determined that Birchwood Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.80(g)(3)(i)-(iii) REQUIREMENT Reporting-Residents,Representatives&Families:This is a less serious (but not lowest level) 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 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(g) COVID-19 reporting. The facility must—

§483.80(g)(3) Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. This information must—

(i) Not include personally identifiable information;
(ii) Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered; and
(iii) Include any cumulative updates for residents, their representatives, and families at least weekly or by 5 p.m. the next calendar day following the subsequent occurrence of either: each time a confirmed infection of COVID-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other.
Observations:


Based on review of the information provided by the facility and family and staff interview, it was determined that the facility failed to ensure that residents representatives and families were timely informed of cumulative, confirmed and suspected COVID-19 infections in the facility.


Findings include:

Interview with the Director of Nursing, on June 7, 2022, at 10:32 AM revealed that the facility notifies residents representatives and families of confirmed of suspected COVID-19 within the facility by means of a telephone call made by the nurses on the units, which will be documented in the residents' clinical records that the residents and families are made aware.

Review of facility line listing revealed a resident tested positive for COVID-19 on April 25, 2022, and facility wide testing was initiated.

Further review of the facility line listing revealed staff and/or residents tested positive or were symptomatic for COVID-19 on May 15, 2022, May 16, 2022, May 19, 2022, May 23, 2022, May 25, 2022, May 26, 2022, and May 30, 2022.

Additionally, the facility provided a list of residents that were admitted to the facility with active COVID-19 infections on May 12, 2022, May 17, 2022, May 18, 2022, May 23, 2022, May 24, 2022, and May 26, 2022.

Interview with the Nursing Home Administrator (NHA) on June 8, 2022, at approximately 10:00 AM when it was brought to their attention that upon clinical record reviews there was no documented evidence that families and residents were timely informed of cumulative, confirmed or suspected COVID-19 infections in the facility, the NHA stated that residents' families or responsible parties are provided a memorandum on admission, which was dated May 28, 2020, entitled "Assessing Guardian's COVID-19 Case Updates" with directions and an internet link. However, upon trying to utilize the link provided an error message populated and the link was no longer active.

An interview with a resident's family member conducted on June 10, 2022, revealed that this resident's interested family is aware that the facility was currently experiencing a COVID-19 outbreak which began on April 25, 2022 because she visits the facility, however was not notified by 5:00 PM after each confirmed or suspected case of COVID-19.

Interview with the Director of Nursing on June 10, 2022, at approximately 2:00 PM confirmed that the facility could not provide documented evidence that the facility timely informed and updated residents, representatives and families of confirmed or suspected COVID-19 activity in the facility.



28 Pa. Code 201.14(a) Responsibility of Licensee

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










 Plan of Correction - To be completed: 08/01/2022

F 885 Covid Reporting
The preparation, submission and implementation of this Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on this survey report. The Plan of correction is prepared and executed to continuously improve the quality of care and to comply with all applicable federal and state regulatory requirements.
1. The facility cannot retroactively correct resident/RP notifications for active covid cases in May.
The facility has updated the memorandum "Assessing Guardian's COVID-19 Case Updates" with the revised facility website address.

2. An audit of resident/ RP notifications of any active or suspected COVID infections will be completed within the last 2 weeks to ensure compliance with timely notifications.

3. Education provided to ICN, IDT members and licensed staff on importance of ensuring the timely notification of positive or suspected COVID infection.

4. An audit will be completed by the NHA/Designee to ensure that residents /RP's have been notified by 5pm the following day of any active or confirmed COVID cases. The results of the audits will be reviewed at QAPI to ensure compliance and the need for further education.


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

The initial tour of the kitchen was conducted with the facility's Registered Dietitian (RD), on June 7, 2022, at 8:47 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, was identified:

When entering the kitchen it was observed that the paper towel dispenser was not working. The RD reported that the batteries were probably dead and needed to be replaced.

Inside the walk-in cooler there was a yellow "wet floor" sign and a large puddle of water pooling in front of the entrance to the walk-in freezer. The RD reported that the floor was just mopped. Upon entering the walk-in freezer accumulations of ice and clumps of ice were observed on the floor and build up around the door.

Inside the dry storage area that there was a wire rack used to store event equipment that had an accumulation of dust and cobwebs on the bottom shelf and kitchen equipment was stored on that shelf.

The wall behind the cook's reach-in cooler was damaged. There were several wall tiles that were pulling away from the wall and left an opening.

Interview with the Nursing Home Administrator (NHA) May 9, 2022, 9:36 AM, confirmed that the facility could not provide documented evidence that the maintenance department was aware of ice build-up in the freezer and confirmed that the dietary department was to be maintained in sanitary manner to ensure food safety.




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

28 Pa Code 211.6(c) Dietary services



 Plan of Correction - To be completed: 08/01/2022

F 812 Food Procurement/Storage/Prepare/Serve-Sanitary
The preparation, submission and implementation of this Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on this survey report. The Plan of correction is prepared and executed to continuously improve the quality of care and to comply with all applicable federal and state regulatory requirements.
1. The following areas have been addressed: the paper towel dispenser's battery was changed; the wall tiles were fixed; the accumulation of dust and cobwebs in dry storage area have been cleaned; the floor in the walk in has been appraised for repair and quote submitted.


2. An audit of the kitchen has been completed, to ensure and maintain acceptable practices for the storage and service of food.
3. Education to dietary staff on the importance of maintaining acceptable practices for the storage and service of food.
4. An audit of the kitchen will be done weekly x 4 then monthly x 2 to ensure and maintain acceptable practices for the storage and service of food.

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 a review of clinical records and grievances lodged with the facility and interviews with staff and resident family members it was determined that the facility failed to provide care in a manner and environment that promotes each resident's dignity and personal comfort for one resident out of 22 sampled (Resident 84).

Findings included:

Review of Resident 84's clinical record revealed that the resident was admitted to the facility on May 12, 2022, with diagnoses to have included traumatic subdural hemorrhage (brain bleed), fracture to the neck, malignant neoplasm of the pancreases, and difficulty walking.

Review of Resident 84's Admission /Medicare - 5 Day Minimum Date Set [(MDS - is part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes that is conducted periodically to plan resident care] assessment dated May 18, 2022, revealed that the was cognitively intact, required extensive assistance for ADLs (activities of daily living), was occasionally incontinent of urine, and was always continent of bowel. The MDS noted that the resident was not on a toileting program.

Review of Resident 84's person-centered care plan that was initiated on May 12, 2022, identified that the resident was at risk for urinary incontinence related to decreased mobility with a resident goal to be maintained in as clean and dry and dignified state as possible. Planned interventions included to provide assistance with toileting or provide incontinent care as needed, place urinal/bedpan within the patient's reach, and a scheduled toileting at 3 AM and 2 PM to decrease episodes of incontinence.

Review of a facility "Resident/Family Grievance Form" dated May 20, 2022, that was filed by the Director of Nursing (DON), on behalf of Resident 84's wife, revealed that the resident's wife reported to staff that the resident was laying in urine and BM that morning. Resident 84's wife reported that the resident told her that staff told him that there were no bedpans or urinals.

Review of Resident 84's clinical record "eMar - Orders Administration Note" dated May 20, 2022, at 8:46 PM, revealed that the resident discharged home.

Further review of the clinical record revealed several late entry nursing notes that were created on May 24, 2022 (four days after the resident discharged home), at 7:27 PM, at 8:19 PM, and at 9:14 PM, noting events surrounding Resident 84's discharge to home with his wife and daughter.

Interview with Employee 3, an RN/Nurse Supervisor, reported that the facility had a full stock of bedpans and urinals and that the facility was never without a supply. Employee 3 stated that possibly an agency nursing staff member may have told Resident 84 that there were no bedpans or urinals available due to not knowing where supplies were kept.

Interview with a resident's family member that was conducted on June 10, 2022, revealed that they stated that during the resident's stay at the facility the resident became more incontinent of urine and bowel. The resident's family stated that when they had visited the resident they noted a strong smell of urine and often her brief was wet.



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

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






 Plan of Correction - To be completed: 08/01/2022

F 550 Resident Rights
The preparation, submission and implementation of this Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on this survey report. The Plan of correction is prepared and executed to continuously improve the quality of care and to comply with all applicable federal and state regulatory requirements
1. Resident 84 has been discharged from facility.

2. An audit of current residents on a scheduled toileting program will be completed to ensure the program meets the needs of the resident.
3. Education will be provided to licensed and non-licensed staff on importance of following and revising scheduled toileting programs to meet the needs of the resident that allows for the comfort and dignity of the resident.

4. Weekly audits of toileting schedules will be completed by the UM/ Designee weekly x 4 then monthly x 2, to ensure toileting programs are followed and/or revised as needed to provide comfort and dignity of the resident. Result of the audits will be reviewed at QAPI to ensure compliance and the need for further education.

483.95(c)(1)-(3) REQUIREMENT Abuse, Neglect, and Exploitation Training:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.95(c) Abuse, neglect, and exploitation.
In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on-

§483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12.

§483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property

§483.95(c)(3) Dementia management and resident abuse prevention.
Observations:

Based on review of employee personnel files and staff interviews, it was determined that the facility failed to timely train two employees out of five reviewed on the facility's abuse prohibition policy and procedures.

Findings include:

A review of the personnel files of new employees, including contracted employees, recently hired, revealed that Employee 6 activities aide was hired on April 11, 2022. Further review revealed the employee never signed or dated that facility specific abuse training was completed prior to working with residents in the facility.

Employee 7 LPN (license practical nurse) was hired on April 4, 2022. Employee 7's file revealed no date indicated that abuse training was completed prior to the employee working on the nursing unit with residents.

An interview with the Human Resources Director on June 10, 2022, at 9:50 AM confirmed there was no documentation that Employees 6 and 7 were trained on the facility's abuse prohibition policy and procedures prior to assuming their job duties.


28 Pa. Code 201.20(b) Staff development

28 Pa Code 201.18 (e)(1) Management

28 Pa. Code 201.29(a)(c) Resident rights



 Plan of Correction - To be completed: 08/01/2022

F 943 Abuse, Neglect, Exploitation Training
1. Employee 6 and Employee 7 have received, signed and dated the abuse education.

2. An audit of new hires in the past 30 days has been reviewed to ensure that all new hires have received, signed and dated the abuse education.

3. Education has been completed with HR on importance of ensuring new hires complete, sign and date abuse education on orientation.

4. An audit of new hire abuse training paperwork will be completed monthly x 3 to ensure compliance with a signature and date. The results of the audit will be reviewed at QAPI to ensure compliance.


483.80(i)(1)-(3)(i)-(x) REQUIREMENT COVID-19 Vaccination of Facility Staff: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(i)
COVID-19 Vaccination of facility staff. The facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine.

§483.80(i)(1) Regardless of clinical responsibility or resident contact, the policies and procedures must apply to the following facility staff, who provide any care, treatment, or other services for the facility and/or its residents:
(i) Facility employees;
(ii) Licensed practitioners;
(iii) Students, trainees, and volunteers; and
(iv) Individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement.

§483.80(i)(2) The policies and procedures of this section do not apply to the following facility staff:
(i) Staff who exclusively provide telehealth or telemedicine services outside of the facility setting and who do not have any direct contact with residents and other staff specified in paragraph (i)(1) of this section; and
(ii) Staff who provide support services for the facility that are performed exclusively outside of the facility setting and who do not have any direct contact with residents and other staff specified in paragraph (i)(1) of this section.

§483.80(i)(3) The policies and procedures must include, at a minimum, the following components:
(i) A process for ensuring all staff specified in paragraph (i)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its residents;
(iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19;
(iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (i)(1) of this section;
(v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC;
(vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law;
(vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the facility has granted, an exemption from the staff COVID-19 vaccination requirements;
(viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains:
(A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and
(B) A statement by the authenticating practitioner recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications;
(ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and
(x) Contingency plans for staff who are not fully vaccinated for COVID-19.

Effective 60 Days After Publication:
§483.80(i)(3)(ii) A process for ensuring that all staff specified in paragraph (i)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations;
Observations:


Based on a review of select facility policy, the Centers for Medicare and Medicaid directives, employee vaccine data, and staff interviews, it was determined that the facility failed to fully develop implement policies and procedures to ensure that all staff were vaccinated for COVID-19. The facility's staff vaccination rate was 97.8% at the time of the survey on June 10, 2022.

Findings include:

A review of a DEPARTMENT OF HEALTH & HUMAN SERVICES, Center for Clinical Standards and Quality/Quality, Safety & Oversight Group dated December 28, 2021, QSO 22-07-ALL memo stated that within 60 days after the issuance of this memorandum the facility demonstrates that policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or patient or resident contact are vaccinated for COVID-19; and 100% of staff have received the necessary doses to complete the vaccine series (i.e., one dose of a single-dose vaccine or all doses of a multiple-dose vaccine series), or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is compliant under the rule; or Less than 100% of all staff have received at least one dose of a single-dose vaccine, or all doses of a multiple-dose vaccine series, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is noncompliant.

A review of a facility policy for "Covid -19 Vaccine Policy for Healthcare Personnel", revised January 21, 2022 and last reviewed June 1, 2022, revealed that the facility's policy would comply with the Federal mandate that all staff are vaccinated against COVID-19 unless they have a medical or religious exemption to help reduce the risk residents and staff have of contracting and spreading COVID-19.

According to the facility policy staff refers to any individuals that work or volunteer in the facility, regardless of clinical responsibility or resident contact. This includes individuals who may not be physically in the LTC (long term care) facility for a period (e.g., illness, disability, or scheduled time of), but are expected to return to work.

The policy indicated that all facility staff are required to have received at least one dose of an FDA-authorized COVID-19 vaccine by January 27, 2022, and the final dose of a primary vaccination series by February 28, 2022. New hires will be subject to the same requirements as current staff and must have received, at a minimum, the first dose of a two-dose COVID-19 vaccine or a one-dose COVID-19 vaccine by the regulatory deadline or prior to providing any care, treatment, or other services for the facility and/or its patients.

When reviewed during the survey of June 10, 2022, the facility's policy failed to identify timeframes for partially vaccinated staff (deadlines for partially vaccinated newly hired staff) and/or further steps that will be taken should a staff member fail to become fully vaccinated.

A review of the facility staff vaccination data revealed that Employee 1, a nurse aide, was only partially vaccinated at the time of the survey of June 10, 2022. Further review of the employee's vaccination status revealed that Employee 1 received her first dose of a two dose series of the COVID-19 vaccine on April 27, 2022. However, as of the time of the survey ending June 10, 2022, Employee 1 had not received her second dose of the 2-dose COVID-19 vaccination series. As a result, the facility's staff vaccination rate was 97.8%.

A review of the facility staff vaccination data revealed that Employee 2, a temporary nurse aide, was only partially vaccinated at the time of the survey of June 10, 2022. Further review of the employee's vaccination status revealed that Employee 2 received her first dose of a two dose series of the COVID-19 vaccine on April 27, 2022. However, as of the time of the survey ending June 10, 2022, Employee 1 had not received her second dose of the 2-dose COVID-19 vaccination series. As a result, the facility's staff vaccination rate was 97.8%.

A review of NHSN reported data dated May 29, 2022, revealed that the facility COVID-19 staff vaccination percentage rate was 91.5 %.

At the time of the end of survey on June 10, 2022, the facility policy and procedures for staff COVID-19 vaccinations had not been fully developed or implemented.

Interview with the Director of Nursing on June 10, 2022, at 2:00 PM confirmed that the facility did not fully develop and implement a COVID-19 vaccination policy to include timeframes for newly hired partially vaccinated staff to receive all doses of their vaccination series. The facility confirmed that the current staff vaccination rate was less than 100%.


28 Pa. Code 201.14 (a) Responsibility of Licensee

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

28 Pa. Code 211.12 (c) Nursing Services






 Plan of Correction - To be completed: 08/01/2022

F888 COVID 19 Vaccination of Facility Staff
The preparation, submission and implementation of this Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on this survey report. The Plan of correction is prepared and executed to continuously improve the quality of care and to comply with all applicable federal and state regulatory requirements.
1. Employee 1 and Employee 2 have received their second dose at local pharmacies.

2. An audit of new hires in the last 30 days will be completed by HR/ designee to ensure the new employee has received the first dose of the covid vaccine or has completed and acceptable exemption.

3. Education to HR and staffing director on the COVID vaccine policy.

4. An audit of new hires will be completed by HR/designee to ensure compliance with the covid 19 policy monthly x 3. Results of the audit will be reviewed at QAPI to ensure compliance.


483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on a review of clinical records and staff interview, it was determined that the facility failed to ensure adequate indication for use of an antipsychotic drug for one resident (Resident 24) out of 5 residents reviewed.

Findings include:

A review of Resident 24's clinical record revealed that the resident was admitted to the facility on June 11, 2020, with diagnoses of vascular dementia, heart failure, and chronic kidney disease.

A review of Resident 24's current plan of care with a revision date of December 21, 2021 revealed that the facility noted that Resident 24 becomes verbally/physically aggressive towards staff at times.

A review of Resident 24's clinical record revealed a physician order dated December 22, 2021, for Seroquel 25 mg ( an antipsychotic), give 1 tablet daily for vascular dementia with behavioral disturbances.

On February 3, 2022, the resident's dose of Seroquel was increased to Seroquel 25 mg daily, give 1 tablet two times a day for vascular dementia with behavioral disturbances.

A pharmacist recommendation to the physician dated as printed January 18, 2022, revealed that the pharmacist noted there is a Black Box Warning for this medication (anti-Psychotic) to be given to dementia residents and increased mortality in elderly patients with dementia-related psychosis. The pharmacist noted, "Please assess the use of an Antipsychotic medication with a Dementia resident and document Risk vs Benefit below" and "Please also be sure the proper documentation for behaviors are in place in PCC (Point Click Care) and Care Plans". Additionally, the pharmacist noted, "Anti-psychotics should not be given unless there is harm to oneself or others or a psychotic behavior is present.

The physician's response, dated February 8, 2022, indicated that the physician noted "agree" but documented "no change." The physician did not include resident specific details regarding the risk vs. benefit analysis and how the medication, and its current dose, improved the resident's level of functioning and psychosocial well being.

A review of Resident 24's behavior tracking revealed that the facility identified verbally/physically aggressive behavior towards staff together as the targeted behaviors on the medication administration record from December 2021 until May 2, 2022. The two behaviors were then separated for tracking purposes during May 2022. The facility failed to document in progress notes if the resident was verbally or physically aggressive towards staff when it was noted the resident had displayed behaviors.

Review of Resident 24's medication administration record for treatment of behaviors from May 2, 2022 to the time of the survey ending June 10, 2022, failed to reveal documented evidence of physically aggressive behaviors displayed by the resident towards others.

Review of Resident 24's clinical record from January 2022 to the time of the survey ending on June 10, 2022 failed to reveal documented evidence of harm to oneself or others or the presence of psychotic behavior to support the resident's continued need for the antipsychotic drug.

Review of Resident 24's Physician Progress notes dated January 28, 2022, March 29, 2022, April 26, 2022, and May 31, 2022 failed to address the resident's use and continued need for the antipsychotic medication Seroquel or the current indications for its use and dosage

Interview with the Director of Nursing on June 10, 2022, at 2:00 PM failed to provide any physician supporting documentation to justify the use and dose of the antipsychotic medication.


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

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

28 Pa. Code 211.2(a) Physician services

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



 Plan of Correction - To be completed: 08/01/2022

F 758 Free of Uncess Psychotropics
The preparation, submission and implementation of this Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on this survey report. The Plan of correction is prepared and executed to continuously improve the quality of care and to comply with all applicable federal and state regulatory requirements.
1. Resident 24's medications have been reviewed with the physician and a
GDR completed for the Seroquel.
2. An audit of current residents on an antipsychotic will have their medications reviewed to ensure an adequate indication for use.
3. Education to licensed staff on the importance of supporting documentation and an adequate indication of the antipsychotic medication.
4. An audit of current residents on an antipsychotics to ensure adequate indication of use will be completed weekly x 4 then monthly x 2 to ensure compliance and the need for further education.

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 a review of clinical records and staff interview, it was determined that the facility's consultant pharmacist failed to identify irregularities in the medication regimen of one of five residents sampled (Resident 79).

Findings include:

A review of the clinical record revealed that Resident 79 was admitted to the facility on November 18, 2019, and had diagnoses that included anxiety.

Review of physician's orders revealed that Resident 79 had been receiving Paxil (used to treat the symptoms of depression, obsessive-compulsive disorder (OCD), panic disorder, social phobia, generalized anxiety disorder) 10 mg daily since November 18, 2019.

A review of the "Drug Regimen Reviews" conducted by the facility's consultant pharmacist from June 2021, through June 2022, revealed no indication that the pharmacist identified the lack of a gradual dose reduction of the resident's Paxil within the last year.

An interview with the Director of Nursing (DON) on June 10, 2022, at 10:24 AM, confirmed that there was no documentation that the pharmacist recommended that the physician consider a gradual dose reduction of the residents' psychoactive medication.



28 Pa. Code 211.9 (k) Pharmacy services







 Plan of Correction - To be completed: 08/01/2022

F 756 Drug Regimen Review
The preparation, submission and implementation of this Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on this survey report. The Plan of correction is prepared and executed to continuously improve the quality of care and to comply with all applicable federal and state regulatory requirements
1. Resident 79 has had a GDR completed for her Paxil.

2. An audit of the current months' pharmacy recommendations will be completed to ensure that the pharmacy consultant has reviewed and recommended a GDR for psychotropics per the regulation.

3. Education will be completed to the pharmacy consultant to ensure monthly pharmacy recommendations for psychotropics are reviewed and GDR's are recommended to the physician per regulation.
4 Audits will be completed monthly x 2 on the monthly pharmacy psychotropic reviews to ensure the pharmacy consultant has reviewed and recommended GDR's as per regulation. Results of the audits will be reviewed at QAPI for compliance.


483.40 REQUIREMENT Behavioral Health Services: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.
§483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations:

Based on review of clinical records and staff interview it was determined that the facility failed to provide necessary behavioral health care to promote the highest practicable physical and psychosocial well being of one resident out of 22 sampled (Resident 75).


Findings included:

Review of Resident 75's pre-admission data dated May 3, 2022, provided to the facility by the hospital, revealed that during the resident's hospital stay that the resident was "very agitated, throwing objects at nursing, and would not cooperate and demanded to go home" and wrist restraints were applied. Hospital records noted that the capacity determination deemed that the resident did not have the capacity to make healthcare decision making.

Review of Resident 75's clinical record revealed that the resident was admitted to the facility on May 5, 2022, at 4:42 PM, with diagnoses to have included psychoactive substance abuse [refers to illegal substances that people most commonly use to alter their mental state] major depressive disorder [a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies], and bipolar disorder [is a serious mental illness characterized by extreme mood swings].

A 5-Day/Admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated May 11, 2022, indicated that Resident 75 had a BIMS (brief screener that aids in detecting cognitive impairment) score of 13 indicating cognitively intact.

Review of Resident 75's care plan that was initiated on May 5, 2022, indicated that the resident was at risk for changes in mood related to history of drug abuse with interventions noted to assess for physical/environmental changes that may precipitate change in mood.

The problem of elopement was noted on the resident's care plan dated May 5, 2022, indicated that the resident was an elopement risk related to new admission/change of environment and that the resident would not leave the facility unattended. Interventions were to allow the resident to vent feelings and/or frustration as needed and when the resident has increased agitation with 1:1 and begins throwing objects, swearing at staff, punching walls/doors, etc. staff to provide distant supervision.

Review of the facility's incident report dated May 5, 2022, at 6:14 PM, that was completed by Employee 8, a RN, indicated that the first-floor fire exit was alarming, and an LPN and nurse aide (NA) went to check and found Resident 75 standing outside with juice in his hand. The resident was previously observed by staff sitting in his room eating supper. Resident 75 stated "I was going home" and staff assisted him back into the building.

The immediate action taken was to initiate 1:1 supervision, and the certified registered nurse practitioner (CRNP) ordered a wanderguard that was applied to the resident's left wrist.

Review of a nursing progress note completed by Employee 8, a RN, noted a "Late Entry" noted with an effective date of May 5, 2022, at 5:30 PM, and was created on May 24, 2022, at 9:26 PM, revealed that while on second floor obtaining supplies, heard door alarm panel sound. Upon arriving to first floor, noted staff walking with the resident from behind an isolation barrier. The first-floor east wing fire door alarm was reset. Resident 75 had exited his room and proceeded through barriers and was able to undo the zippers. He had found the fire exit door and attempted to leave the building, holding a cup of juice and dinner roll. When asked where he was going, he responded "I was going home." Staff redirected resident back onto the unit and secured locks and barriers again. 1:1 safety watch initiated at this time. MD and RP notified of incident and in agreement with plan of care.


Review of an incident statement dated May 6, 2022, at 1:19 PM, completed by Employee 9, a NA, revealed that on May 5, 2022, after dinner trays were served, Resident 75 was in bed eating dinner. Employee 9 heard the fire door alarm sounding and ran toward the door and found that Resident 75 had walked out the fire door exit and was standing leaning up against the sidewalk light with his juice and roll in his hand. The resident was directed back into the building and placed him in a wheelchair and brought him up to the front desk with his dinner.

Review of a social services progress note dated May 6, 2022, at 11:55 AM, revealed that when speaking with resident this date; Resident 75 voiced "I'm getting out of here today, I've been waiting to leave, I miss my wife, Norma." I'm originally from West Virginia but I'm only here because that is where my wife is from." Nursing made aware.

Review of nursing progress notes dated May 9, 2022, at 5:00 PM, revealed that Resident 75 was observed walking down the hallway with personal belongings in hand, made a left at the nurse's station and when staff asked where he was going, he stated "home, my wife is in the parking lot to pick me up." Staff member tried to redirect resident, he became hostile and combative with staff. Resident sat down on the floor back supported by the wall near fire door and refused to move, resident had self-harm behaviors. The RN supervisor was alerted to the situation and a skin tear was noted where a scab fell off from the left forearm treat as ordered. No other signs of injury noted at this time will continue to monitor.

Further review of nursing progress notes dated May 9, 2022, at 5:30 PM, revealed that the resident had increased behaviors, noted picking at scab on left forearm causing 1 cm 1 cm x <0.1 cm skin tear.

Review of the resident's task list and facility logs revealed that 1:1 was initiated immediately after the resident's elopement until May 10, 2022. 1:1 was re-initiated on May 14, 2022, due to behaviors and increased agitation expressed with current situation.

Further review of Resident 75's clinical record revealed a nursing progress note dated May 21, 2022, at 4:40 PM, revealed that the resident had aggressive behaviors and was found by staff trying to open the window to get out. Resident 75 stated, "I have to go home, I have to leave this place." Staff were unable to calm the resident down and the resident was verbally abusive and screaming and throwing items at staff. The MD made aware with new orders to send the resident to the emergency room. Responsible party made aware.

Resident 75 was noted to have returned from the hospital on May 22, 2022 at 3:08 PM, and one to one supervision was to continue.

Review of a "Psychological Evaluation and Consultation" dated May 25, 2022, indicated that Resident 75 was unhappy about placement in facility and that he would like to return home with his wife. He reported that his mood was "frustrated and down" and reported hopelessness and stated, "If I'm stuck here, I may as well get divorced." The resident verified that that he tried to elope on several occasions and stated that he "just wants to go home". Continued intermittent restlessness and anxiety. The consultation noted that the resident would benefit from psychotherapy in addition to current medication regimen.

Further review of the psychological evaluation and consultation indicated that supportive interventions, frequent redirection, activity participation and socialization beneficial with psychotherapy were indicated. Reviewed current stressors and discussed coping mechanisms to combat stressors. Discussed various techniques to de-escalate behavioral situations, reduce anxiety and improve depression including breathing exercises, meditation, and imagery.

There was no documented evidence that the facility had developed and implemented these recommended supportive interventions and techniques into the resident's person-centered care plan to support the behavioral health care needs of Resident 75 as identified in the psychological evaluation to manage the resident's major depression and displayed agitation, aggression, and exit seeking behaviors.

Interview with the Nursing Home Administrator on June 10, 2022, at approximately 11:30 AM, revealed that the facility was unable to provide evidence that Resident 75 that the facility had provided the necessary care and services to address the resident's behavioral health needs.


28 Pa Code 211.12 (d)(1)(3)(5) Nursing Services

28 Pa. Code 211.16 (a) Social Services

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





 Plan of Correction - To be completed: 08/01/2022

F 740 Behavioral Health Services
The preparation, submission and implementation of this Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on this survey report. The Plan of correction is prepared and executed to continuously improve the quality of care and to comply with all applicable federal and state regulatory requirements.
1 Resident 75 has been discharged to his home.
2. An audit of residents that have triggered on the most recent MDS for behaviors in the past 30 days will be completed by social services to ensure the resident is receiving behavioral health support to better meet their needs.
3. Education will be provided to social services on the importance of setting up behavioral health support / interventions for those residents that are in need based on their assessment.
4. An audit will be completed by SSD/ designee, weekly x 4 then monthly x 2, on residents that trigger on their assessment for behaviors to ensure that behavioral support and interventions are completed to meet the needs of the resident. Results of the audit will be reviewed at QAPI for compliance.

483.25(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on clinical records and staff interviews it was determined the facility failed to follow physician orders for administration of pain medication to manage pain for one of five residents reviewed for pain management (Resident 86).

Findings include:

Review of Resident 86's clinical record revealed that the resident was admitted to the facility on July 16, 2022, with diagnosis to include Periperal Vascular disease and Major Depressive disorder.

Review of Resident 86's Medication Administration Record (MAR) dated April 2022, revealed orders dated December 15, 2021, for Acetaminophen 325 mg give two tablets every 4 hours as needed for mild pain (level 1-3) and Febraury 1, 2022, an order for Ultram 50 mg every 8 hours as needed for moderate pain 3-6.

According to interview with the Director of Nursing (DON) on June 9, 2022, the facility's procedure for pain administration is for mild pain 1 to 3, moderate pain 4 to 6 and severe pin 7 to 10. Resident 86's scale should have read moderate pain level 4-6.

April 2022 MAR's revealed that on April 13, 2022, Acetaminophen 325 mg was administered for a pain level of 4 (moderate pain).

On April 4, 2022, and April 16, 2022, Ultram was administered for pain levels of 7 (severe pain) according to facility's pain scale.

Review of Resident 86's MAR dated May 2022, revealed that on May 23, 2022, Acetaminophen 325 mg was administered for a pain level of 4 (moderate pain).

On May 4, 2022, May 16, 2022, May 13, 2022, Acetaminophen 325 was administered for a pain level of 7 and May 29, 2022, for a pain level of 8 (all for severe pain).

Review of Resident 86's MAR, dated June 2022, revealed that on June 3, 2022, Acetaminophen 325 mg was administered for a pain level of 4 (moderate pain).

During an interview with the Director of Nursing on June 9, 2022, at 11:23 AM, it was confirmed that nursing staff failed to follow physician orders and the facility's procedures for administration of pain medications based on assessed levels of pain severity.


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

28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services









 Plan of Correction - To be completed: 08/01/2022

F 697 Pain Management
The preparation, submission and implementation of this Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on this survey report. The Plan of correction is prepared and executed to continuously improve the quality of care and to comply with all applicable federal and state regulatory requirements
1. Resident 33's prn pain medication orders have been reviewed with the physician and revised.

2. An audit of current residents receiving prn pain medications in past 2 weeks to ensure compliance with documentation of pain scales per the physician orders.

3. Education will be provided to licensed staff on the pain management policy and following the physician orders related to the pain scale.

4. An audit of prn pain medication usage will be completed weekly x 4 then monthly x 2 to ensure compliance with accurate documentation of pain scales per the physician orders. Results of the audit will be reviewed at QAPI for compliance and the need for further education.


483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on observation, a review of clinical records, facility incident reports, and select facility policy, and staff interview it was determined that the facility failed to provide timely and necessary care and services to prevent the development of pressure sores for one out of 22 residents sampled. (Resident 33).


Findings include:


According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk.

ACP (The American College of Physicians is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair.

A review of the clinical record revealed that Resident 33 was admitted to the facility on March 24, 2022, with diagnoses to include Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors).

A review of an Admission Minimum Data Set assessment dated March 30, 2022, (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed that the resident was moderately cognitively impaired, required extensive assistance with the assistance of two people activities of daily living, and at risk for developing pressure sores.

A review of an admission assessment dated March 24, 2022, indicated that the resident did not have any skin breakdown.

A review of a Braden scale for predicting pressure sore assessment dated May 9, 2022, revealed that the resident was at moderate risk for developing a pressure sore.

A review of Resident 33's plan of care, initially dated March 24, 2022, revealed that the resident was at risk for urinary and bowel incontinence with a goal for the resident to remain free of breakdown. Interventions planned were to identify voiding patterns and establish toileting needs and provide incontinence care.

Further review of the resident's plan of care initially dated March 24, 2022, revealed that the resident was at risk for alteration in skin integrity with a goal for the resident to remain free of breakdown. Interventions planned were to administer preventative skin treatment, apply barrier cream with incontinent episodes, and assist with repositioning.

A review of nursing tasks completed for Resident 33 dated June 2022, at the time of the survey ending on June 10, 2022, revealed that the resident's preventative skin care was not provided three times from June 1, 2022, through June 10, 2022 and turning and repositioning was not completed on three occassions during this time frame. Nursing staff documented the provision of turning and repositioning on 16 occassions prior to completing the task at the end of the shift. Barrier cream for incontinent episodes was not provided on June 9, 2022.


Further review of June 2022 tasks indicated the resident was on a toileting program to decrease incontinence. The resident's scheduled toileting was to be completed at 12:00 AM, 6:00AM, 9:00 AM, 1:00 PM, 5:00PM, and 9:00 PM. On June 2, 2022, the resident was not toileted on the night shift at 12:00 AM and 6:00 AM; on June 3, 2022, the resident was not toileted on dayshift at 9:00 AM and 1:00 PM; on June 4, 2022, the resident was not toileted on the night shift at 12:00 AM and 6:00 AM. No documentation was found the resident was being toileted at 5:00 PM and 9:00 PM from June 1, 2022, and June 9, 2022.

A review of a wound consult report dated June 7, 2022, revealed the resident had a developed a new unstageable pressure ulcer (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic \ tissue or slough \ on his coccyx (bony area at the base of the spine) measuring 6 cm x 2cm x 0.2 cm. The wound contained 50 percent slough. This was a new area of skin breakdown due to complications of poor mobility and incontinence.

A review of the resident's care plan for actual skin breakdown revised on June 9, 2022, indicated a new intervention for the resident to be turned and repositioned every hour.
A review of June 2022 tasks revealed that staff were recording the completion of this task on paper at the nursing station and not part of the electronic documentation in the resident's record.

A review of every hour turning and repositioning for June 10, 2022, at 12:00 PM revealed the resident was not repositioned at 8:00 AM, 9:00 AM, 10:00 AM, 11:00 AM, or 12:00 PM on June 10, 2022, as indicated in his plan of care.

An observation on of the resident's wound on June 10, 2022, revealed an opened area on the resident's coccyx. The wound appeared black in the middle sounded by yellow slough. Below the coccyx wound appeared another smaller wound that appeared black in color. Multiple red superficial open areas were noted around the wound.

Interview with the Director of Nursing on June 9, 2022, at approximately 1:00 PM confirmed that the facility failed to demonstrate the consistent implementation of measures planned to prevent pressure ulcers for residents at risk for skin breakdown.




28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services

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



 Plan of Correction - To be completed: 08/01/2022

F 686 Treatment/ Services to Prevent/ Heal Pressure Ulcers
The preparation, submission and implementation of this Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on this survey report. The Plan of correction is prepared and executed to continuously improve the quality of care and to comply with all applicable federal and state regulatory requirements
1. The facility is unable to retroactively correct incomplete documentation for Resident 33.

2. An audit of current residents with pressure ulcers and those that trigger for moderate to high risk for pressure ulcers per their most recent Braden Scale will be completed to ensure that the documentation for the toileting and turn and repo tasks is completed.

3. Education will be completed to licensed and non-licensed staff on importance of ensuring that pressure ulcer interventions such as toileting programs and turn and repo programs are completed and documented on to assist in the prevention / treatment of pressure ulcers.

4. An audit will be completed weekly x 4 then monthly x 2, by the ADON/designee on completion of pressure ulcer interventions such as toileting programs and turn and repo programs. Results of the audits will be reviewed at QAPI to ensure compliance.

483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary: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(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide a discharge summary of the resident's stay for one of three discharged residents reviewed (Resident 87).

Findings include:

A review of the clinical record for Resident 87 revealed the resident was admitted to the facility March 29, 2022, and discharged to home on April 30, 2022.

There was no completed discharge summary present in the resident's closed clinical record at the time of the survey ending June 10, 2022.

During an interview on June 10, 2022, at 9:13 AM, with the Director of Nursing, confirmed the facility failed to provide a discharge summary for Resident 87.




28 Pa Code: 211.5(d)(f) Clinical records





 Plan of Correction - To be completed: 08/01/2022

F 661 Discharge Summary
The preparation, submission and implementation of this Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on this survey report. The Plan of correction is prepared and executed to continuously improve the quality of care and to comply with all applicable federal and state regulatory requirements
1. The Discharge Summary for Resident 87 has been completed by the physician.

2. An audit of discharges in the last 2 weeks will be completed by medical records for compliance with a written recapitulation of care on a discharge summary.

3. Education was provided to the medical records employee by the consultant on importance of ensuring the discharge summary is completed by the physician.

4. An audit will be completed weekly x 4 then monthly x 2, to ensure that a written recapitulation of the residents' stay is documented on a discharge summary by medical records. Audit results will be reviewed at QAPI to ensure compliance and the need the further education.


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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(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 select facility policy and staff interview, it was determined that the facility failed to timely consult with the physician and notify the resident's representative of a significant change in condition displayed by one resident out of 22 sampled (Resident 33).

Findings include:

A review of facility policy entitled "Change in a Resident's Condition or Status" last reviewed June 1, 2022, revealed the facility shall promptly notify the attending physician and resident representative of changes in the resident's medical condition or status. Further the policy indicated except for medical emergencies, notifications will be made within 24 hours of a change occurring.

A review of the clinical record revealed that Resident 33 was admitted into the facility on March 24, 2022, with diagnoses, which included Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors).

A review of a wound consult report dated June 7, 2022, revealed that the resident had developed a new unstageable pressure ulcer (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic \ tissue or slough \ on his coccyx (bony area at the base of the spine).

A review of the resident's clinical record revealed no documented evidence the resident's attending physician and the resident's interested representative were notified of the resident's change in condition, the development of an unstageable pressure sore.

An interview with the Director of Nursing on June 9, 2022, at approximately 1:00 PM confirmed that the facility failed to notify the physician and resident's representative of the resident's new unstageable pressure ulcer.

28 Pa. Code 211.10(a) Resident care policies

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

28 Pa. Code 201.29 (l)(1) Resident rights






 Plan of Correction - To be completed: 08/01/2022


F 580 Notification of Changes
The preparation, submission and implementation of this Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on this survey report. The Plan of correction is prepared and executed to continuously improve the quality of care and to comply with all applicable federal and state regulatory requirements
1 Resident 33's RP and CRNP have been notified of open area.
2. An audit of residents with new onset of skin impairment in the last 2 weeks to ensure both physician and resident's representative was made aware.
3. Education will be provided to licensed staff on Notification of RP and Physician Policy.
4. An audit of residents with new onset of pressure injuries will be completed weekly x 4 then monthly x 2 for compliance with notification of RP and MD's. Results of the audits will be reviewed at QAPI to ensure compliance and the need for further education.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

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

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

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

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a written notice of transfer to the hospital was provided to the resident and the residents' representative in a language and manner that could be easily understood for three out of 22 residents reviewed (Residents 64 and 65).

Findings include:

Review of Resident 64's clinical record revealed that the resident admitted to the hospital on April 29, 2022, and returned to the facility on May 3, 2022.

Review of the facility provided "Notice of Transfer or Discharge" form that was dated May 2, 2022, revealed that the resident was transferred /discharged to an acute care facility on April 29, 2022, for the reason of "change in condition."

Interview with the Director of Nursing (DON) on June 8, 2022, at 1:55 PM, confirmed that the written notices provided to Resident 64 and the resident's representative did not include a reason for the facility-initiated transfer in a language and manner that could be easily understood.

Resident 65 was admitted to the hospital on April 17, 2022, and returned to the facility on April 23, 2022. The notice of transfer or discharge form indicated the resident was transferred to the hospital due to a change in condition.

Resident 65 was admitted to the hospital on April 27, 2022, and returned to the facility on May 1, 2022. The notice of transfer or discharge form indicated the resident was transferred to the hospital due to a change in condition.

Resident 65 was admitted to the hospital on June 2, 2022, and returned to the facility on June 4, 2022. The notice of transfer or discharge form indicated the resident was transferred to the hospital due to a change in condition.

There was no documented evidence that a notice was sent to the resident's representative to inform them of the resident's hospitalizations.

During an interview with the facility Social Service Director on June 9, 2022, at 2:14 PM, he confirmed that the letters of Resident 65's hospitalizations were not sent to the resident representative.

During an interview with the DON, on June 9, 2022, at 12:21 PM, it was confirmed that the letters for the discharges did not include a reason for the hospitalizations in a language and manner that could be easily understood.


28 Pa. Code 201.29 (g) Resident rights







 Plan of Correction - To be completed: 08/01/2022


F 623 Notice Requirements Before Transfer/ Discharge
The preparation, submission and implementation of this Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on this survey report. The Plan of correction is prepared and executed to continuously improve the quality of care and to comply with all applicable federal and state regulatory requirements

1. The facility is unable to retroactively correct the transfer/ discharge notification forms for Resident 64 and Resident 65.

2. An audit of transfers/discharges in past 2 weeks will be completed by SS/designee to ensure the transfer/ discharge notifications are written in layman's terms as well as the mailing the notification to the residents RP's is completed.

3. Education to licensed staff and social services on the Transfer/ Discharge Notification Policy.

4. SSD/Designee will audit all Transfer/Discharge Notification forms are completed in layman's terms and that the mailing of Notification of Transfer/ Discharge to the residents RP's has been completed, weekly x 4 weeks, then monthly x 2. Results of the audit will be reviewed at QAPI to ensure compliance and the need for further education.

§ 211.5(f) LICENSURE Clinical records.:State only Deficiency.
(f) At a minimum, the resident's clinical record shall include physicians' orders, observation and progress notes, nurses' notes, medical and nursing history and physical examination reports; identification information, admission data, documented evidence of assessment of a resident's needs,
establishment of an appropriate treatment plan and plans of care and services provided; hospital diagnosis authentication--discharge summary, report from attending physician or transfer form--diagnostic and therapeutic orders, reports of treatments, clinical findings, medication records and discharge summary including final diagnosis and prognosis or cause of death. The information contained in the record shall be sufficient to justify the diagnosis and treatment, identify the resident and
show accurately documented information.
Observations:

Based on a review of closed clinical records and interview with facility staff, it was determined that the facility failed to ensure that a discharge summary was completed by the physician for one out of three residents reviewed (Resident 88)

Findings include:

A review of Resident 88's closed clinical record revealed that the resident was admitted to the facility on February 1, 2022. The resident expired and was discharged from the facility on April 16, 2022.

A review of the resident's closed clinical record on June 10, 2022, revealed the resident's record did not contain a physician's discharge summary.

An interview with the Director of Nursing on June 10, 2022, at 10:20 AM confirmed the facility could not provide documentation a discharge summary was written by the physician upon the resident's discharge.




 Plan of Correction - To be completed: 08/01/2022

P1720 Clinical Records
1. Resident 88 has a completed discharge summary in the closed record.

2. An audit of closed records will be completed in the past 2 weeks to ensure the closed record contains the discharge summary.

3. Education to the medical records employee has been completed on the importance of ensuring the closed chart contains a discharge summary.

4. An audit of closed records weekly x 4 then monthly x 2 will be completed to ensure that the closed records contain the discharge summary. The results of the audit will be reviewed at QAPI to ensure compliance.

§ 211.9(j) LICENSURE Pharmacy services.:State only Deficiency.
(j) Disposition of discontinued and unused medications and medications of discharged or deceased residents shall be handled by facility policy which shall be developed in cooperation with the consultant pharmacist. The method of disposition and quantity of the drugs shall be documented on the respective resident's chart. The disposition procedures shall be done at least quarterly under Commonwealth and Federal statutes.
Observations:

Based on review of three closed records and staff interviews, it was determined that the facility failed to account for medications upon discharge of one resident (Resident 89) out of three discharged residents sampled.

Findings include:

A review of Resident 89's clinical record revealed that she was admitted to the facility on April 14, 2022 and discharged to home on May 7, 2022.

Further review of the resident's clinical record indicated there was no documentation of the disposition of the resident's remaining medications upon her discharge from the facility.

During an interview with the Director of Nursing (DON) on June 10, 202, at 1:03 PM, the DON acknowledged there was no documentation of the disposition residents medications in the resident's clinical record upon discharge from the facility.



 Plan of Correction - To be completed: 08/01/2022

P 1895 Pharmacy Services

1. Resident 89's disposition of medications has been included into the closed record.

2 An audit of closed records within the last 2 weeks has been completed to ensure the disposition of medications upon discharge is included into the closed chart.

3 Education was provided to the medical records employee on the importance of ensuring the medication disposition sheets completed are included in the closed record.

4 An audit of closed records will be completed weekly x 4 then monthly x 2 to ensure the medication disposition is included in the closed chart. The results of the audits will be reviewed at QAPI to ensure compliance.


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