Nursing Investigation Results -

Pennsylvania Department of Health
SPRING CREEK REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SPRING CREEK REHABILITATION AND NURSING CENTER
Inspection Results For:
There are 305 surveys for this facility. Please select a date to view the survey results.

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SPRING CREEK REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid, State Licensure and Civil Rights survey and Abbreviated survey in response to four complaints completed on October 3, 2019, it was determined that Spring Creek Health & 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:

483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months:

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.

�483.20(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.

Observations:

Based on review of the Resident Assessment Instrument User's Manual, clinical record review and staff interview, it was determined that the facility failed to complete a quarterly assessment at least every three months for six of seven residents reviewed for resident assessments (Residents 2, 3, 4, 5, 7, and 323).

Findings Include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (federally-mandated assessments of a resident's abilities and care needs), dated October 2017, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and was to be completed no later than the ARD plus 14 calendar days.

Review of Resident 2's clinical record revealed a quarterly MDS assessment with an ARD of August 25, 2019. As of October 2, 2019, 38 days after the ARD, the quarterly MDS is not completed and is listed as "in progress."

Review of Resident 3's clinical record revealed a quarterly MDS assessment with an ARD of August 25, 2019. As of October 2, 2019, 38 days after the ARD, the quarterly MDS is not completed and is listed as "in progress."

Review of Resident 4's clinical record revealed a quarterly MDS assessment with an ARD of August 28, 2019. As of October 2, 2019, 35 days after the ARD, the quarterly MDS is not completed and is listed as "in progress."

Review of Resident 5's clinical record revealed a quarterly MDS assessment with an ARD of August 28, 2019. As of October 2, 2019, 35 days after the ARD, the quarterly MDS is not completed and is listed as "in progress."

Review of Resident 7's clinical record revealed a quarterly MDS assessment with an ARD of August 28, 2019. As of October 2, 2019, 35 days after the ARD, the quarterly MDS is not completed and is listed as "in progress."

Review of Resident 323's clinical record revealed a quarterly MDS assessment with an ARD of August 28, 2019. As of October 2, 2019, 35 days after the ARD, the quarterly MDS is not completed and is listed as "in progress."

During an interview with the Licensed Practical Nurse Assessment Coordinator (LPNAC) on October 3, 2019, at 9:09 AM she confirmed that the assessments are "late."

On October 3, 2019, at 11:40 AM the Nursing Home Administrator and Director of Nursing were made aware of the Resident assessments not being completed timely. At that time, the Nursing Home Administrator stated that the facility is working on a performance improvement plan to address the late MDS assessments.

28 Pa. Code 211.5(f) Clinical records.

Plan of Correction - To be completed: 12/02/2019

1. Residents 2 � Quarterly August MDS has been completed and submitted and accepted to CMS. Resident 3- Quarterly August MDS has been completed and submitted and accepted to CMS. Resident 4- Quarterly August MDS has been completed and submitted and accepted to CMS. Resident 5- Quarterly August MDS has been completed and submitted and accepted to CMS. Resident 7- Quarterly August MDS has been completed and submitted and accepted to CMS. Resident 323- Quarterly August MDS has been completed and submitted and accepted to CMS.
2. Current residents' assessment schedule with be reviewed to ensure a quarterly assessment is scheduled and completed timely. A quarterly assessment will be completed if needed.
3. Education will be provided to the MDS Coordinators on identifying, scheduling and completion of Quarterly assessments.
4. The Lead MDS Coordinator/designee will audit the OBRA schedule to ensure quarterly assessments are scheduled and completed timely. Audits will be weekly X 12 weeks.Results of the audits will be submitted to QA for review monthly.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

�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.

Plan of Correction - To be completed: 12/02/2019

1. There were no residents affected with negative outcomes related to the condition of the kitchen wall fans or the identified foods not properly labeled and dated in the main kitchen and on the Nursing Units.
2. All food items not dated or properly labeled were discarded upon discovery on 9/30, 10/1 and 10/2/2019. The wall fans were removed from the main kitchen.
3. The Director of Culinary Services/Designee will educate the Culinary Service Staff regarding facility policy for FOOD RECEIVING AND STORAGE. Foods delivered to the Nursing units from Culinary Services will be properly labeled and dated upon delivery. Staff Development/Designee will educate the Nursing Staff (Nurse Manages, CNAs, Licensed Nurses), and Management Team regarding food receiving and storage as it pertains to supplements, snacks, beverages and personal resident foods on the nursing units. A written guideline for providing and storing personal resident foods will be included in the Admissions process and communicated to the Resident Council. Foods belonging to the residents will be labeled and dated by the staff member receiving that food product.
4. All kitchen storage areas, dry and refrigerated, will be inspected on a routine basis by a Culinary Services Manager to ensure proper food storage. The Director of Culinary Services/Designee will conduct Food Storage audits in the Main Kitchen 3 times per week X 4 weeks then 2 X per week for 2 months. All nursing unit pantry areas will be inspected for safe food storage on a routine basis by the Director of Culinary Service/Designee. The Director of Culinary Service/Designee will conduct food storage audits on their unit 3 X per week X 4 weeks then 2 X per week for 2 months. The findings will be reviewed at the monthly Quality Assurance meetings to identify need for further revisions and/or recommendations.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

�483.60(d) Food and drink
Each resident receives and the facility provides-

�483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

�483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Plan of Correction - To be completed: 12/02/2019

1. There were no residents with negative outcomes related to food palatability. Resident #114, #1 and # 85 will be interviewed by a member of the Culinary Services Team as a follow up to their expressed mealtime concerns.
2. The heated pellet dispenser was repaired and a quote was received to increase the existing number of pieces of equipment. The dish machine was repaired thus eliminating use of disposable tray service which directly impacts food temperatures.
3. Food quality and temperatures will become a routine topic for discussion each monthly Food Committee Meeting. Minutes will be recorded at each meeting. A member of the Culinary Service Supervisory staff will be responsible for checking the operation of all pellet and food warming systems prior to the start of each meal service. The Director of Culinary Service/Staff Development/Designee will educate the Culinary Service Staff, Nursing Staff (CAN's, Nurse Managers, and Licensed Nurses) regarding provision of food and drink that is palatable, attractive, and at a safe and appetizing temperature. Education to include measures taken for keeping hot foods hot and cold foods cold.
4. 4.The Director of Culinary Services/Designee will conduct Test Tray Audits, 10 Trays, 3X per week for 4 weeks then 5 trays, 2X per week for 2 month. The Director of Culinary Services/Designee will conduct random Customer Service Audits a min of 10 per week X 4 weeks then 5 per week X 2 mo. The findings will be reviewed at the monthly Quality Assurance meetings to identify need for further revisions and/or recommendations.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:

�483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of �483.95(g).

Observations:

Based on personnel file review and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for two of five nurse aides reviewed. (Nurse Aide 1 and Nurse Aide 2).

Findings Include:

Review of the documentation for the annual nurse aid education revealed that Nurse Aide (NA) 1 only had 1.75 hours of the required education. NA 2 only had 6.5 hours and NA 3 only had 8.5.

NA 1 was hired May 30, 2018. As of October 3, 2019, NA 1 did not have an annual performance review completed.

During an interview with the Human Resources Director on October 3, 2019, at 10:14 AM she confirmed that NA 1 did not have an annual performance review completed. She stated that NA 1 did not hand in the self evaluation which triggers the supervisor to do the annual performance review.

During an interview with the Assistant Director of Nursing 1 on October 3, 2019, at 9:50 AM, she confirmed that the 12 hours on annual training was not completed.

During an interview with the Nursing Home Administrator on October 3, 2019, at 10:15 AM, she confirmed that the staff did not have the required hours.

28 Pa. Code 201.14(a) Responsibility of licensee.

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

Plan of Correction - To be completed: 12/02/2019

1. NA 1 performance review and in- servicing was completed. NA 2 is no longer employed by Spring Creek, therefore evaluation and in servicing will not be completed. NA 3 completed the required in-servicing.
2. Current NA files were reviewed for uncompleted performance review evaluations and uncompleted in-service training of 12 hr/yr. NA's not compliant were completed
3. Current NA's will be educated on the importance of keeping current with completing their self performance evaluation and the assigned in-service training. New process was identified and put into place to ensure performance evaluations and in-servicing are completed in a timely manner
4. Human Resources/designee will audit completion of performance evaluations by running a report of employees with a hire date for each month. Audit will be of that list to ensure performance evaluations were completed at the end of the month. Audit monthly X 3 months. Staff Development/designee will complete an audit on In-service training for NA's. Audit will be 10 NA's per week x 4 weeks then 20 NA's x 2months. Audit results will be reviewed in QAPI

483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination:

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(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

�483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

�483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

�483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

�483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.

Observations:

Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to ensure one of 41 residents reviewed were provided the right to self-determination in regards to medication refusal (Resident 231).

Findings include:

Review of Resident 231's clinical record on September 30, 2019, at approximately 11:27 AM, revealed diagnoses including cerebral infarction (stroke - sudden decrease or loss of blood supply to parts of the brain which can result in severe, permanent impairment or death), and major depressive disorder (mental health disorder characterized by persistent low mood, decreased involvement in pleasurable activities, sleep and appitite pattern disruptions).

Review of Resident 231's comprehensive plan of care revealed a care plan with the focus of, "[Resident 231] [has] a behavior problem [related to] non-compliance with care/transfers, medications and labs..." which was initiated on November 13, 2018, and last revised September 23, 2019. Review of the interventions for the care planned behaviors revealed an intervention of, "reapproach and may crush [medications] and put in food," which was initiated on March 14, 2019.

Resident 231's comprehensive plan of care also included a care plan with the focus of, "[Resident 231] [has] (Actual) Injury [related to] Resistance to Care as evidenced by refusal of (medications) [related to] Anxiety," which was initiated on August 20, 2019, and last revised on September 30, 2019. Review of the interventions for the care plan revealed an intervention which stated, "Allow me [Resident 231] to make decisions about treatment regime, to provide sense of control. Reaffirm my rights to make my own choices, informing me/family/caregiver of risks and consequences of those choices. Assist me [as-needed] in making decisions and encourage follow through," which was initiated on August 20, 2019.

Review of nursing progress note dated March 14, 2019, at 12:18 PM, revealed Registered Nurse (RN) documented "care plan updated for resident after speaking with resident who nodded his head when medication is offered to him to put in pudding or applesauce, jello , ice-cream and mixed in his food. Certified Registered Nurse Practitioner (CRNP) aware of resident refusal of past medications and acceptance with mix in meals..." Review of Resident 231's physician orders revealed a physician order for, "May crush medication together and administer except the do not crush. Benefits out ways the risk," dated March 15, 2019.

During initial tour on September 30, 2019, at approximately 9:30 AM, a unit roster sheet (facility document which lists residents who reside on a unit and any information that may be pertinent for floor staff to have quick access to; utilized to document information to provide on-coming nursing staff at shift change), revealed that under the "miscellaneous" section for Resident 231 there was a statement of, "[care plan] [and] put in food [without] Resident [231] knowing."

During an interview with Licensed Practical Nurse (LPN) 4 on October 2, 2019, LPN 4 was asked about the note on note on the unit roster sheet and LPN 4 stated, "yeah, when he refused [his medications], we [the nursing staff] put it in his food..usually his oatmeal or something that we know he's going to eat. If he refused, we put it in his food so he doesn't know." LPN 4 was asked where Resident 231 consumes his meals, LPN 4 stated, "He eats in his room." During the interview, LPN 4 was asked how Resident 231 is monitored to ensure he received all of the medication that Resident 231 is provided, LPN 4 stated "We [nursing staff] have to go back and make sure he ate it."

During a staff interview on October 3, 2019, at approximately 11:30 AM, Assistant Director of Nursing revealed that residents should be provided the right to refuse medications and treatments and it was believed that Residetn 231 was informed of his medications being put in food, further, that nurses should provide constant observation of residents while residents are taking medications.

28 Pa Code 201.29(a)(j) Resident rights

Plan of Correction - To be completed: 12/02/2019

1. Resident 231s roster was updated to reflect that meds may be put in pudding or applesauce if resident requests.
2. All residents and residents' rosters were checked to ensure the wording of placement of medications in food without their knowledge was not written
3. Nursing staff will be educated on residents rights and the foods with medication pass policy. DON/or designee will audit 10 residents and rosters weekly x4, then monthly x2.
4. Audits will be reviewed at the monthly QAPI meetings to ensure compliance for quality improvement.

483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing:

�483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

�483.20(b) Comprehensive Assessments
�483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

�483.20(b)(2) When required. Subject to the timeframes prescribed in �413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in �413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.

Observations:

Based on review of the Resident Assessment Instrument User's Manual, clinical record review and staff interview, it was determined that the facility failed to ensure that the comprehensive Minimum Data Set assessments were completed in the required time frame for two of 48 residents reviewed (Residents 1 and 6).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2017, indicated that an admission MDS assessment was to be completed no later than 14 days following admission. A significant change MDS completion date is on the 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days).

Review of Resident 1's clinical record revealed that she was admitted to the facility on August 29, 2019. Further review of Resident 1's clinical record revealed that she had an admission MDS dated September 5, 2019, which was incomplete and listed as "in progress."

As of October 3, 2019, 35 days after Resident 1's admission to the facility, her admission MDS was still incomplete.

Review of Resident 6's clinical record revealed a significant change MDS assessment with an ARD of August 28, 2019. As of October 2, 2019, 35 days after the ARD (the last day of the assessment's look-back period) , the significant change MDS is not completed and listed as "in progress."

During an interview with the Licensed Practical Nurse Assessment Coordinator (LPNAC) on October 3, 2019, at 9:09 AM she confirmed that the assessment were late.

On October 3, 2019, at 11:40 AM the Nursing Home Administrator and Director of Nursing were made aware of the comprehensive assessments not being completed timely. The NHA confirmed that the facility currently has a performance improvement plan in place to address late MDS assessments.

28 Pa. Code 211.5(f) Clinical records.

Plan of Correction - To be completed: 12/02/2019

1. Resident 1-- Admission assessment submitted and accepted by CMS. Resident 6-- Significant change has been completed and accepted by CMS.
2. All current residents' assessment schedule with be reviewed to ensure an admission assessment is scheduled and completed with -in 14 days of admission date. All current residents' status will be reviewed for significant change in status including residents signing on and off Hospice. A significant change assessment will be scheduled and completed with- in 14 days from the date the change was identified.
3. Education will be provided to all MDS Coordinators on OBRA assessments timing, scheduling and completion dates. MDS Coordinators will read the nursing 24- hour report daily to identify changes in status. Social Service will update and send a Hospice report to the IDT weekly. Residents with a new Hospice change have a Significant Change MDS completed within 14 days
4. The lead MDS Coordinator /Designee will audit all newly admitted residents and residents on hospice to ensure assessments are scheduled and completed timely. Audits will be weekly x 12 weeksWeekly the lead MDS Coordinator will audit Results of the audits will be submitted to QA monthly.

483.20(b)(2)(ii) REQUIREMENT Comprehensive Assessment After Signifcant Chg:

�483.20(b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)

Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure each resident who experiences a significant change is comprehensively assessed within 14 days for one of 48 residents reviewed (Resident 253).

Findings Include:

Review of Resident 253's clinical record revealed diagnoses that included Chronic Obstructive Pulmonary Disease (common lung disease which makes it hard to breathe; the two main forms of COPD: Chronic bronchitis, which involves a long-term cough with mucus and Emphysema, which involves damage to the lungs over time), Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain; it is the most common cause of premature senility), and Protein-Calorie Malnutrition (a form of malnutrition that is defined as a range of pathological conditions arising from coincident lack of dietary protein and/or energy (calories) in varying proportions).

Further review of Resident 253's physician orders revealed order dated of April 16, 2019, for "Hospice with Residential, Dx (diagnosis) Protein Caloric Malnutrition."

Review of Resident 253's clinical record failed to reveal that a Significant Change Minimum Data Set (MDS- a tool used to assess all care areas specific to the resident) had been completed.

During an interview with Lead MDS Co-coordinator (LMC) on October 3, 2019, at approximately 10:00 AM, LMC revealed that Resident 253 had started receiving hospice services on April 22, 2019, and that completion of the required Significant Change MDS had been missed.

During an interview with Nursing Home Administrator (NHA) on October 3, 2019, at 11:45 AM, NHA revealed the expectation that the Significant Change MDS should have been completed.

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

Plan of Correction - To be completed: 12/02/2019

1. Resident 253�significant change will be corrected and submitted and accepted to CMS.
2. Current residents' status will be reviewed for significant change in status including residents signing on and off Hospice. A significant change assessment will be scheduled and completed with- in 14 days from the date the change was identified.
3. Education will be provided to MDS Coordinators on identifying, scheduling and completion of Significant change in status MDS. MDS Coordinators will read the nursing 24- hour report daily to identify changes in status. Social Service will update and send a Hospice report to the IDT weekly. Residents with a new Hospice change have a Significant Change MDS completed within 14 days
4. The lead MDS Coordinator/designee will audit residents with significant change in status and residents on Hospice to ensure the MDS is scheduled, accurate and completed timely. Audits will be weekly x 12 weeksResults of the audits will be submitted to QA monthly

483.20(g) REQUIREMENT Accuracy of Assessments:

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

Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 51 residents reviewed (Residents 196, and 210).
Findings include:

Review of Resident 196's clinical record on October 1, 2019, at approximately 9:45 AM, revealed diagnoses including diabetes mellitus (disease that affects the ability of the body to produce or use insulin for the transport of glucose from the blood stream to the cells for nourishment) and chronic kidney disease stage IV (severely diminished ability of the kidneys to filter toxins from the blood and requiring the use of a medical machine to filter blood).

Review of Resident 196's annual Minimum Data Set (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) , dated August 7, 2019, revealed Resident 196 was coded as not receiving dialysis (medical procedure that removes blood from the body for a machine to remove toxins prior to returning blood to the body) services while a resident of the facility.

Review of Resident 196's clinical record revealed that Resident 196 had received dialysis within 14 days of the MDS assessment.

During an interview with the lead MDS coordinator on October 3, 2019, at 10:20 AM it was revealed that the August 7, 2019, MDS was coded in error.

During a staff interview on October 3, 2019, at approximately 11:30 AM, Assistant Director of Nursing revealed that Resident 196's MDS should have reflected receiving dialysis services.

Review of Resident 210's clinical record revealed diagnoses that included poliomyelitis (infectious viral disease that affects the central nervous system and can cause temporary or permanent paralysis) and idiopathic peripheral autonomic neuropathy (damage to the peripheral nervous system because of an undetermined cause).

Review of Resident 210's June 2019, MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed an order to cleanse right shin with normal saline solution, apply calcium alginate (substance applied to a wound to speed healing and absorb excess fluid) and cover with a dry dressing. Change daily until healed. The order was effective June 18, 2019. Further review of the MAR revealed that this treatment was documented as having been done on June 18, 19, 20, 2019.
Review of Resident 210's June 21, 2019, admission MDS revealed that the assessment was not coded to indicate that there was application of a nonsurgical dressing other than to feet.

During an interview with the lead MDS coordinator on October 3, 2019, at 9:06 AM she revealed that the June 21, 2019, MDS was coded in error.

During an interview with the Assistant Director of Nursing (ADON) 1 () on October 3, 2019, at 11:47 AM, she confirmed that she was made aware of the error in Resident 210's MDS.

28 Pa. Code 211.5(f) Clinical records.

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

Plan of Correction - To be completed: 12/02/2019

1. Resident 196 � MDS will be corrected and then submitted & accepted to CMS. Resident 210 �MDS will be corrected and then submitted & accepted to CMS.
2. Current residents receiving Dialysis and skin treatments will be reviewed for accurate coding on their most recent MDS. Any coding discrepancies will be corrected and submitted to CMS. Residents newly introduced to Dialysis will have a Significant Change scheduled and completed timely.
3. Education will be provided to the MDS Coordinators per the RAI Manual, Chapter 3 O0100J � section O page 4 and Chapter 3 M1200G section M page 37.MDS Coordinators will read the nursing 24- hour report daily to identify residents with changes in Dialysis and weekly wound report for residents with skin treatments. Medical records will update and send a Dialysis report to the IDT weekly.
4. The Lead MDS Coordinator/designee will audit the Dialysis residents and the list of residents with skin treatments for accurate coding on their MDS's. Audits will be weekly x 12 weeks. Results of the audits will be reported to QA monthly.

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

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

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

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement a baseline care plan for each resident within 48 hours of resident's admission for two of 51 residents reviewed (Residents 210, and 309).

Findings include:

Review of Resident 210's clinical record revealed diagnoses that included heart failure (heart's inability to pump an adequate supply of blood) and history of poliomyelitis (infectious viral disease that affects the central nervous system and can cause temporary or permanent paralysis).

Further review of Resident 210's clinical record revealed an admission date of June 14, 2019.

Review of Resident 210's care plan revealed that it was initiated on June 17, 2019, more than 48 hours after admission.

Review of Resident 309's clinical record revealed diagnoses that included cerebral infarction (area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain) and bipolar disorder (mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior).

Further review of Resident 309's clinical record revealed an admission date of June 28, 2019.

Review of Resident 309's care plan revealed that it was initiated on July 1, 2019, more than 48 hours after admission.

During an interview with the Assistant Director of Nursing (ADON) 1 on October 3, 2019, at 8:54 AM, she revealed that expectation that the care plans should have been initiated and implemented within 48 hours of admission.

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

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

Plan of Correction - To be completed: 12/02/2019

1. Resident 210 & 309's care plans were updated to reflect the baseline care plan.
2. All residents care plans were audited to ensure all items of the baseline care plan were addressed.
3. Nursing staff will be educated on the baseline care plan. DON/or designee will audit all new admissions weekly x4, then 10 new admissions monthly x2.
4. Audits will be reviewed at the monthly QAPI meetings to ensure compliance for quality improvement.

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

�483.25(d) Accidents.
The facility must ensure that -
�483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

�483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on observations and staff interview it was determined the facility failed to ensure the resident environment is free from accident hazards for two of 377 residents observed (Residents 108, and 661).

Findings Include:

Review of Resident 108's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and Diabetes Mellitus (a group of diseases that result in too much sugar in the blood (high blood glucose)).

Observation on September 30, 2019, at 12:37 PM revealed a Humalog insulin pen with a needle attached, a Lantus insulin pen (medication used for Diabetes) with a needle attached, a deep sea nasal spray bottle, and Restasis (eye drops) sitting on Resident 108's bedside table. Observation on October 1, 2019, at 9:00 AM revealed Restasis eye drops and deep sea nasal spray sitting on Resident 108's bedside table. Observation on October 2, 2019, at 9:48 AM revealed two Lantus insulin pens with a needle attached to both, on Resident 108's bedside table.

On October 2, 2019, at 12:03 PM the Assistant Director of Nursing (ADON) 1 was made aware of the above findings. She stated that Resident 108 does not have an assessment to self-administer his medications.

Review of Resident 661's clinical record revealed diagnoses that included hypertension and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).

Observation on September 30, 2019, at 1:00 PM revealed a small, pink colored pill in a medicine cup on Resident 661's bedside table. When asked about it, Resident 661 stated he had about "10 pills to take" and "must have missed that one." Resident was unable to offer any additional information about the pill.

During an interview with ADON 1 on October 2, 2019, at 12:03 PM she stated that Resident 661 does not have an assessment to self administer his medications.

During an interview with the Nursing Home Administrator on October 2, 2019, at 2:47 PM she agreed that the medications shouldn't be left at the bedside. No additional information was provided.

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

Plan of Correction - To be completed: 12/02/2019

1. Resident 661's medications were removed from his room and resident 108 had a self-administration evaluation and orders received for resident to self-administer certain medications.
2. All residents' rooms were checked for prescription medications and self-administration assessments completed is needed.
3. Nursing staff will be educated on the self medication administration policy. DON/or designee will audit 10 resident rooms weekly x4, then monthly x2.
4. Audits will be reviewed at the monthly QAPI meetings to ensure compliance for quality improvement.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:

�483.25(g)(4)-(5) Enteral Nutrition
(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)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

�483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

Observations:

Based on observation, interview and policy review, it was determined that the facility failed to ensure a resident receiving enteral feeding received the appropriate care and services to prevent complications of enteral feeding for one of 48 residents reviewed (Resident 94).

Findings include:

A review of the facility policy titled, "Enteral Feedings-Safety Precautions," last revised May 2014, states that the enteral formula has a hang time of 24-48 hours, this was confirmed with the label on the formula.

Review of the checklist used by the facility during competency training for enteral tube medication administration states that staff are to date and label the enteral formula, syringe, and flush bag at the start of the procedure.

Review of the clinical record for Resident 94 on October 1, 2019, revealed clinical diagnoses that included Dysphagia (inability/difficulty swallowing) and Tracheostomy (tube inserted through the neck to assist breathing) and Gastrostomy Tube (a feeding tube placed directly into the stomach for long-term enteral feeding).

Observation of Resident 94 on September 30, 2019, at 9:19 AM, revealed the enteral formula (a nutritionally complete feed, containing protein, carbohydrate, fat, water, minerals and vitamins, directly into the stomach, duodenum or jejunum) hanging and running at 60 ml/hour (milliliters/hour-metric measurement), both the enteral formula bottle and the flush bag (water) were not dated, timed, or initialed to determine when the formula was started or when it expires.

During an interview with Licensed Practical Nurse (LPN) 1 she revealed that the enteral formula should be dated, initialed, and timed when initiated. LPN 1 also examined the formula bottle, and bag of fluids, and she was unable to find any documentation on the bag/bottle to determine when it were initiated.

During an interview with the Nursing Home Administrator (NHA) on October 2, 2019, at 2:48 PM the expectation was confirmed that enteral formula and flush should be dated, initialed, and timed by staff, when initiated.

28 Pa. Code 211.12(d)(1)(2)(5)Nursing services.

Plan of Correction - To be completed: 12/02/2019

1. Resident 94's tube feeding bottle and bag were changed and dated, timed, & initialed.
2. All resident with a continuous tube feed were audited to ensure that the bottle and bag were dated, timed, & initialed.
3. Nursing staff will be educated on the tube feed policy. DON/or designee will audit all tube feeds weekly x4 and monthly x2 to ensure all tube feeding bottles and bags are dated, timed, & initialed.
4. Audits will be reviewed at the monthly QAPI meetings to ensure compliance for quality improvement.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

�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 review of facility policy, clinical record review and staff interview it was determined that the facility failed to ensure that the pharmacy regimen review was accurately completed, and that the physician responded to and provided an appropriate rationale to the recommended changes for one of five residents reviewed for unnecessary medications (Resident 294) and that the recommendation was acted upon as indicated by the reviewing practitioner for one of 5 residents reviewed for unnecessary medications (Resident 192).

Findings include:

Review of facility policy titled, "Psychotropic Medication Review," Effective April 2015, last revised May 2016, revealed "the primary health care provider will oversee and coordinate with the psychiatrist the gradual dose reduction of the medications."

Review of facility policy titled, "drug regimen review requirement," dated 2019, revealed "a drug regimen review will be completed monthly by the consultant pharmacist and reviewed and addressed by the physician within one month." "If the physician elects not to agree with the recommendations, he/she will document that on the drug regimen review form with a reason that the recommendation is not being accepted."

Review of facility policy, Medication Regimen Review (Monthly Report) revealed "Recommendations are reviewed and acted upon and documented by the facility staff or the prescriber."

Review of Resident 192's clinical record revealed diagnoses that included dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events).

Review of Consultant Pharmacist Review Physician Report dated January 2019, revealed that the recommendation to, "please clarify Risperdal [antipsychotic medication] diagnosis of Anxiety". Further review of the report revealed that the practitioner agreed with the recommendation, provided an alternate diagnosis of "delusions" (unshakable belief in something untrue), and signed off on the report on February 1, 2019.

Review of Resident 192's current physician order summary revealed the order remained Risperdal for anxiety effective November 28, 2018.

During an interview with Assistant Director of Nursing (ADON) 2 on October 2, 2019, at 2:02 PM she confirmed that the order was not updated as indicated by the practitioner in response to the pharmacy recommendation. She also revealed the expectation that it should have been updated.

Review of Resident 294's clinical record revealed diagnoses including major depressive disorder (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and or daily routine) and hypertension (elevated blood pressure).

Further review of Resident 294's clinical record revealed that the consultant pharmacist made recommendations on April 22, 2019, "please evaluate if Quetiapine (antipsychotic medication) and/or Citalopram (antidepressant medication) dosage reductions could be attempted at this time." The physician response to this recommendation was "Disagree: please see consultant psychiatric services eval/tx (treatment) for GDR details".

Further review of Resident 294's clinical record revealed that Resident 294 had not been seen by consultant psychiatric services at that time.

Interview with the Assistant Director of Nursing 1 on October 3, 2019, at 8:45 AM. revealed that the resident had not been seen by consultant psychiatric services and that the physician's response was not appropriate.

28 Pa. Code 211.2(a) Physician services.

28 Pa. Code 211.5(f) Clinical records.

28 Pa. Code 211.10(c) Resident care policies.

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

Plan of Correction - To be completed: 12/02/2019

1. Resident 192's Risperdal was discontinued and resident 294 received an order for Med Options to review a GDR.
2. All September pharmacy recommendation responses were checked for accuracy and to ensure the order changes were carried out.
3. Nursing staff will be educated on carrying out the orders written on pharmacy recommendations and the physician groups will be educated on accurate responses to pharmacy recommendations. DON/or designee will audit all pharmacy recommendations monthly x3.
4. Audits will be reviewed at the monthly QAPI meetings to ensure compliance for quality improvement.

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