Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

There are  208 surveys for this facility. Please select a date to view the survey results.

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Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to one complaint completed April 18, 2024, it was determined that Cheltenham Nursing and Rehab 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 related to the health portion of the survey process.

 Plan of Correction:

483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions: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(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

Based on review of facility documentation, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that a resident was informed of and allowed to participate in decisions regarding the resident's care and treatment for one of five residents reviewed (Resident R1).

Findings Include:

Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 29, 2924, revealed the resident was cognitively intact and had diagnoses of anxiety and depression.

Interview on April 18, 2024, at 12:27 p.m. with Resident R1 revealed the resident recently missed doses of Trazodone, a medication used to help the resident sleep. Resident R1 reported that nursing staff told him the medication was discontinued by the physician but was unable to explain why. Further interview with Resident R1 revealed poor sleep during the days Trazodone was not provided.

Continued interview on April 18, 2024, at 12:27 p.m. with Resident R1 revealed the physician did not inform the resident of the medication changes or review alternative treatment options to help him sleep.

Review of Resident R1's physician orders revealed the resident was prescribed Trazodone 150 milligrams (mg) at bedtime for insomnia (the inability to sleep adequately) started 2/20/2024 and discontinued 04/08/2024. Review of the discontinued ordered revealed it was marked as "completed" by the physician. There was no documented evidence by the physician why the medication was "completed".

Review of Resident R1's medication administration record confirmed the resident did not receive Trazodone on April 8, April 9, and April 10, 2024.

Continued review of Resident R1's physician orders revealed the Trazodone 150mg every night was re-started for insomnia on April 11, 2024.

Review of Resident R1's entire clinical record revealed no documented evidence that Resident R1 was informed by the physician of the medication change, was allowed to participate in decisions regarding his care and treatment, or that the physician reviewed alternative treatment options to help him sleep.

28 Pa Code 201.18(b)(2) Management

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

 Plan of Correction - To be completed: 05/10/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by this provider of the facts alleged, or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and/or state law. The plan of correction constitutes our credible allegation of compliance.

F552 Planning and implementing care.

1. On 4/10/2024 Resident R1 was evaluated by the psychiatrist. Resident R1's Trazadone order was restarted on 4/11/2024, and he continues to receive Trazadone per the physician order.
2. On 4/19/2024 the DON and/or designee reviewed the electronic medical record of all residents. The DON and/or designee verified that documentation of physician, practitioner, or professional was present for all residents with medication changes.
3. The IDT team will review medication changes during the morning clinical meeting and verify that the resident or responsible party are informed of any medication changes or alternative treatment options, reviewed with the resident, and documented in the clinical record.
4. The DON and/or designee will educate the licensed nursing staff before 5/10/2024 on the resident's right to be informed and participate in decisions regarding care and treatment.
5. The DON and/or designee will conduct random audits of resident charts who have had medication changes weekly for 4 weeks. Results of the audits will be reviewed at the monthly QAPI meeting by the QA committee.

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