Pennsylvania Department of Health
BRINTON MANOR NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BRINTON MANOR NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 110 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


BRINTON MANOR NURSING 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 Survey and an Abbreviated Complaint Survey, completed on May 09, 2024, it was determined that Brinton Manor Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.

Plan of Correction:

483.12(a)(3)(4) REQUIREMENT Not Employ/Engage Staff w/ Adverse Actions:

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.

§483.12(a) The facility must-

§483.12(a)(3) Not employ or otherwise engage individuals who-
(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;
(ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or
(iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.

§483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff.

Observations:
Based on review of facility policy and personnel records, it was determined that the facility failed to complete a criminal background check upon hire for one of five employee personnel records reviewed (Employee E4).

Findings include:

Review of facility policy, "Background Screening Investigations," last revised March 2019, revealed: "The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment."

Review of nurse aide Employee E4's personnel record revealed a hire date of February 23, 2024, with a criminal background check obtained May 8, 2024.

Interview with the Nursing Home Administrator on May 9, 2024, at 1:30 p.m. confirmed nurse aide Employee E4 did not have a criminal background check upon hire.

28 Pa. Code 201.14(a) Responsibility of Licensee

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

28 Pa. Code 201.29(a)(d) Resident Rights

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

1. Employee 4 had a background check run and the employee file has been updated to be in compliant with hiring standards
2. Audit of current staff hired in the last 6 months to ensure each has a background screen in their employee file
3. Reeducation by NHA/Designee to Director of Human Resources on background checks being initiated prior to first day of employment.
4. Audits will be conducted on all new hires by the NHA/Designee weekly x4 weeks. Audits will be reported to QAPI for review and further recommendation as needed.

483.25(k) REQUIREMENT Pain Management:

§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 record review, resident and staff interview, it was determined that the facility failed to ensure the highest practicable pain management for one of one resident reviewed (Resident 20).

Findings include:

Review of Resident 20's Minimum Data Set (MDS, periodic assessment of resident needs) dated April 19, 2024, reviled in Section J (Health Conditions) that Resident 20 receives a scheduled pain medication regimen.

Review of Resident's 20 clinical record revealed an active order for Oxycodone (semi-synthetic opioid used medically for treatment of moderate to severe pain) HCL 10 MG (milligrams) with a start date of April 11, 2023, Further review of the order revealed the following, "Give 1 tablet by mouth three times a day for severe pain 8-10".

Review of Resident 20's electronic medication administration record (eMAR) for the month of April 2024, revealed Resident 20 was administered oxycodone 10 mg a total of 58 times to treat a reported pain of 0 out of 10 (0 being no pain and 10 indicating severe pain).

An interview conducted with Registered Nurse (Employee E1) on May 9, 2024, at 12:34 p.m. reported "we just write down 0, Resident 20 always has pain, or so she says".

An interview conducted with the Nursing Home Administration (NHA) on May 9, 2024, at 1:50 p.m. confirmed Registered Nurse (Employee E1) should have been accurately recording Resident 20's pain severity in the eMAR prior to administering Resident 20's scheduled pain medication.

28 Pa Code 211.10 (c) Resident Care Policy

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

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

1. Resident 20's order was adjusted to remove the pain scale from the standing order.
2. Whole house audit of all pain medication on standing order. Any resident identified had the pain scale removed from the standing order.
3. DON/Designee will reeducate licensed nursing staff on proper input of standing order pain medication and that no pain scale should be added in order to receive.
4. Audits will be conducted by the DON/Designee on all residents with pain medication on standing order to ensure no pain scales have been added. Audits will be conducted weekly x4 weeks. Audits will be reported to QAPI for review and further recommendations as needed.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Observations:

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to monitor weight changes in a timely manner for one of seven residents reviewed for nutrition (Resident 62).

Findings include:

Review of facility policy, "Weight Assessment and Intervention," last revised March 2022, revealed: "Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation."

Review of Resident 62's weights revealed that on November 25, 2023, the resident was recorded as weighing 180 pounds (lbs.) On December 5, 2023, the resident was recorded as weighing 199.3 lbs., a 19.3 lb. gain or 10.72% weight change in 10 days.

Review of Resident 62's progress notes revealed a Weight Change note from the dietitian on December 6, 2023, which stated: "Reweight requested for 19 [pound] gain x 2 weeks. No noted fluid retention. Reviewed provider notes 12/5, [abdomen] pain noted. Intake trending >75%. Will follow."

Review of Resident 62's weights revealed the next weight obtained was on December 18, 2023, 13 days past the initial weight change recording and 12 days following the dietitian's request for a reweight.

Interview with the dietitian, Employee E3, on May 9, 2024, at 12:10 p.m. confirmed the facility failed to obtain a reweight for Resident 62 in a timely manner.

28 Pa. Code 211.5(f) Clinical Records

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

28 Pa Code: 211.10(c) Resident care policies

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

1. Resident 62 was reweighed to ensure no significant weight loss/gain from prior weight
2. A house wide audit completed by Dietitian/Designee to ensure proper nutritional status amongst all residents and if any reweights need to be ordered. Any residents identified with significant change will be ordered a reweight
3. DON/Designee will reeducate all nursing staff on obtaining weights as ordered.
4. Audits will be conducted by the DON/Designee on all reweight orders to ensure compliance weekly x4 weeks. Audits will be reported to QAPI for review and further recommendation as needed.

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

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

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

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

Observations:
Based on clinical record review, it was determined that the facility failed to provide treatment and services to maintain/restore bladder continence for one of two residents reviewed for bowel and bladder (Resident 31).

Findings include:

Review of Resident 31's Quarterly MDS (Minimum Data Set - periodic assessment of resident care needs) dated January 9, 2024, revealed under Section H - Bladder and Bowel, that the resident was coded as being always continent of bladder. Review of Resident 31's Quarterly MDS dated March 26, 2024, revealed under Section H - Bladder and Bowel, that the resident was coded as being occasionally incontinent of bladder.

Review of Resident 31's Bowel and Bladder Program Screener dated March 25, 2024, revealed the resident voided appropriately without incontinence at least daily, was independently but slowly able to get to the bathroom/toilet/commode/adjust clothing/and wipe self, was forgetful but able to follow commands, and was usually mentally aware of the need to toilet. The evaluation concluded that Resident 31 was a candidate for scheduled toileting/timed voiding.

Review of Resident 31's clinical record failed to reveal a plan of care in place addressing the resident's incontinence and failed to reveal evidence that the resident was ever offered scheduled toileting/timed voiding.

The abovementioned findings were presented to the Nursing Home Administrator and Director of Nursing on May 9, 2024, at approximately 2:00 p.m.

28 Pa. Code 211.5(f) Clinical records

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

28 Pa. Code 211.10 (a)(d) Resident care policies

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

1. Resident 31 was evaluated for the need for a voiding trial.
2. Bowel and Bladder audit completed by DON/Designee for current residents. Toileting schedules and care plans updated accordingly.
3. Reeducation by DON/Designee to licensed staff on bowel and bladder protocol.
4. Audits will be conducted by DON/Designee on all incontinent residents to ensure bowel and bladder protocol's are followed. Audits will be conducted weekly x4 weeks. Audits will be reported to QAPI for review and further recommendation as needed.

483.20(g) REQUIREMENT Accuracy of Assessments:

Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate assessments for one of three closed records reviewed (Resident 71).

Findings include:

Review of Resident 71's progress notes revealed the resident was discharged home from the facility on February 19, 2024.

Review of Resident 71's Discharge - Return Not Anticipated MDS (Minimum Data Set - periodic assessment of resident care needs) dated February 19, 2024, revealed the resident was coded as being discharged to a short term, general hospital.

Interview with licensed nurse Employee E2 on May 9, 2024, at 11:15 a.m. confirmed Resident 71's Discharge MDS was coded inaccurately.

28 Pa. Code: 211.5(f) Clinical records

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

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

I hereby acknowledge the CMS 2567-A, issued to BRINTON MANOR NURSING AND REHABILITATION CENTER for the survey ending 05/10/2024, AND attest that all deficiencies listed on the form will be corrected in a timely manner.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:
Based on document review and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents on both day and evening shifts and one nurse aide per 20 residents on the overnight shift, for five of twenty-one days reviewed for staffing ratio (December 29, 2023, December 30, 2023, December 31, 2023, February 11, 2024, February 16, 2024).

Findings Include:

Review of the facility provided staffing ratio information on December 29, 2023, during the night shift, revealed a census of 77 residents. The information also revealed 2.22 nurse aide staff working during that shift; therefore, not meeting the minimum number of 3.85 nurse aides required per the facility census of residents on that shift.

Review of the facility provided staffing ratio information on December 30, 2023, during the evening shift, revealed a census of 76 residents. This information also revealed 5.22 nurse aide staff working during that shift; therefore, not meeting the minimum number of 6.33 nurse aides required per the facility census of residents on that shift.

Review of the facility provided staffing ratio information on December 31, 2023, during the night shift, revealed a census of 76 residents. The information also revealed 3.08 nurse aide staff working during that shift; therefore, not meeting the minimum number of 3.80 nurse aides required per the facility census of residents on that shift.

Review of the facility provided staffing ratio information on February 11, 2024, during the evening shift, revealed a census of 76 residents. The information also revealed 5.33 nurse aide staff working during that shift; therefore, not meeting the minimum number of 6.33 nurse aides required per the facility census of residents on that shift.

Review of the facility provided staffing ratio information on February 16, 2024, during the evening shift, revealed a census of 76 residents. The information also revealed 3.27 nurse aide staff working during that shift; therefore, not meeting the minimum number of 3.80 nurse aides required per the facility census of residents on that shift.

An interview with the Nursing Home Administrator on May 10, 2024, at 12:14 PM, confirmed the facility had not met the required nurse aide ratio for the dates listed above.

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

1. Nurse aide staffing ratios will be reviewed for last 7 days to evaluate if nurse aide ratios were met.
2. Administration and scheduler will continue to contact the multiple agencies under contract and in house staff to fill callouts and meet ratios.
3. Nursing administration and scheduler will be reeducated on nurse staffing and ratio requirements
4. Audits of nurse aide ratios will be conducted weekly x4 weeks by NHA/Designee to ensure nurse aide ratio is met. Audits will be reported to QAPI for review and further recommendations as needed.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:
Based on document review and staff interview, it was determined that the facility failed to ensure a minimum of one Licensed Practical Nurses (LPN) per 25 residents on day shift, one LPN per 30 residents on during the evening shifts and one LPN per 40 residents on the overnight shift, for three of twenty-one days reviewed for staffing ratio (December 29, 2023, December 30, 2023, December 31, 2023, February 11, 2024, February 16, 2024).

Findings include:

Review of the facility provided staffing ratio information on December 29, 2023, during the night shift, revealed a census of 77 residents. The information also revealed 1.78 LPNs worked during that shift; therefore, not meeting the minimum number of 2.05 LPNs required per the facility census of residents on that shift.

Review of the facility provided staffing ratio information on December 31, 2023, during the evening shift, revealed a census of 76 residents. The information also revealed 2.70 LPNs worked during that shift; therefore, not meeting the minimum number of 3.80 LPNs required per the facility census of residents on that shift.

Review of the facility provided staffing ratio information on February 17, 2024, during the night shift, revealed a census of 77 residents. The information also revealed 3.14 LPNs worked during that shift; therefore, not meeting the minimum number of 3.29 LPNs required per the facility census of residents on that shift.

An interview with the Nursing Home Administrator on May 10, 2024, at 12:14 PM, confirmed the facility had not met the required LPN ratio for the dates listed above.

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

1. LPN staffing ratios will be reviewed for last 7 days to evaluate if LPN ratios were met.
2. Administration and scheduler will continue to contact the multiple agencies under contract and in house staff to fill callouts and meet ratios.
3. Nursing administration and scheduler will be reeducated on nurse staffing and ratio requirements
4. Audits of LPN ratios will be conducted weekly x4 weeks by NHA/Designee to ensure LPN ratio is met. Audits will be reported to QAPI for review and further recommendations as needed.

§ 211.12(i)(1) LICENSURE Nursing services.:

(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:
Based on document review and staff interview, it was determined that the facility failed to ensure the total number of nursing care hours provided in each 24-hour period should be a minimum of 2.87 hours, after July 1, 2023, of direct care for each resident for two of twenty-one days of staffing hours reviewed (December 30, 2023, and December 31, 2023).

Findings Include:

Review of the nurse staffing information dated December 30, 2023, revealed the total number of direct care hours provided to residents documented as 2.76 hours.

Review of the nurse staffing information dated December 31, 2023, revealed the total number of direct care hours provided to residents documented as 2.84 hours.

An interview with the Nursing Home Administrator on May 10, 2024, at 12:14 PM, confirmed the facility had not met the required minimum staffing hours of 2.87 on the dates listed above.

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

1. HPPD will be reviewed for last 7 days to evaluate if 2.87 minimum HPPD was met.
2. Administration and scheduler will continue to contact the multiple agencies under contract and in house staff to fill callouts and meet the minimum HPPD requirements.
3. Nursing administration and scheduler will be reeducated on HPPD minimum regulations
4. Audits of HPPD will be conducted weekly x4 weeks by NHA/Designee to ensure 2.87 minimum HPPD was met. Audits will be reported to QAPI for review and further recommendations as needed.

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