Nursing Investigation Results -

Pennsylvania Department of Health
SUBURBAN WOODS HEALTH & REHABILITATION CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SUBURBAN WOODS HEALTH & REHABILITATION CENTER
Inspection Results For:

There are  182 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.
SUBURBAN WOODS HEALTH & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to a complaint, completed on October 21, 2021, it was determined that Suburban Woods Health and Rehabilitation Center, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.



 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(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, review of facility policies and facility documentation and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Findings include:

An initial tour of the Food Service Department was conducted on October 18, 2021, at 11:15 a.m. with Employee E3, Food Service Director (FSD), which revealed the following:

Observation in the outside receiving area revealed a dumpster with a missing lid which had 4-5 bags of garbage inside exposed.

Observation in the hall storage room revealed a box of Dinex lids on the top shelf which was less than the required 18" from the sprinkler head.

Observation in the dry storage room revealed that there was no designated area for dented cans. Interview on October 18, 2021, at 11:30 a.m., with the FSD revealed that they do not have a designated area for dented cans.

Observation in the walk-in cooler revealed two gallons of milk and a quart of liquid eggs which were open, but not dated. Interview on October 18, 2021, at 11:30 a.m., with the FSD confirmed that the open containers should have been dated when opened.

Observation in the prep area revealed a faucet in the prep sink which was leaking with a steady flow of water.

Observation in the production area revealed two stacked convection ovens with a heavy build up of black baked on food on the inside floors and walls of the ovens.

Observation of the floor in the pot washing area revealed a heavy build up of dirt and grime on the floor under the sink and shelf next to the sink and where the wall meets the floors.

Observation in the prep area revealed a reach-in refrigerator with broken and torn gaskets especially on the left door.

Observation on a follow up tour of the kitchen on October 19, 2021, revealed a box of thickener next to the oven with the scoop sitting inside the product and the lid open to the air.

During an interview on October 18, 2021, at 11:30 a.m., the FSD confirmed the above findings.

The facility failed to store, prepare and serve food in accordance with professional standards for food service safety.

42 CFR 483.35 (j) Food/Procure/Store/prepare/Serve-Sanitary

28 PA Code: 201.14(a) Responsibility of licensee.

28 PA Code: 201.18(e)(1) Management.

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








 Plan of Correction - To be completed: 11/23/2021

1. Missing lid was replaced on dumpster. Box of Dinex lids on the top shelf were removed from the sprinkler head. The dry storage room has a designated area for dented cans. Two gallons of milk and a quart of liquid eggs were discarded at the time of survey. The prep sink leak has been repaired. The two stacked convection ovens were cleaned. Observation of the floor in the The pot washing area has been cleaned. The reach-in refrigerator has had the gaskets ordered. The scoop was removed from the box of thickener and lid was closed.
2. To identify others with the potential to be affected, a kitchen inspection was conducted to identify any cleanliness concerns and identified areas corrected.
3. To prevent this from reoccurring, Dietary staff have been educated on cleaning procedures.
4. Ongoing monitoring for compliance, NHA/designee will complete a weekly kitchen audit for 90 days.
5. Results will be provided to the QA Committee for review and revision as needed.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

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

Based on observations, reviews of the work schedules for housekeeping staff, personal linen procedures and staff interviews, it was determined that the facility failed to provide a clean, comfortable environment in resident rooms on two of two nursing units (first and second floor nursing units).

Findings include:

Observations of rooms 218, 220, 226, 224, 225 and 221 on October 18, 19 and 20, 2021 revealed that these rooms were heavily soiled with food spillage, dirt and debris along the entire perimeter of the flooring. Windows were heavily soiled which obstructed the view to the outdoors. Residents cleaned clothing was placed on top of their wardrobes or chairs and not placed inside drawers or hung inside the closets. Wall areas inside these rooms contained marring, missing paint, unknown brown stains and dried food spillage that was adhearing to walls and cove molding of the resident's bedrooms.

Room 226 contained a soiled and stained towel that had been placed underneath the air conditioning/heating unit inside the resident's room to prevent water over flow from the disrepaired window unit. Fifty plush animals were placed directly on the floor surrounding the right side and front of this residents bed.

Malorderous smells were evident on this second floor nursing unit thoughout the survey on October 18, 19 and 20 2021. There was no specific time of day that this unit was without offensive odors. Room 218 revealed a strong pungent odor on October 18, 2021.

Observation on October 19, 2021, at 9:45 a.m. of room 200 revealed a strong pungent odor upon entering the room. There was debris scattered on the floor in front of the curtain of bed 200A and a large amount of debris under the bed of 200A to include cups and other unknown debris.

Interview with the Director of housekeeping and maintenance, Employee E9 at 10:00 a.m., on October 19, 2021 revealed that the facility was not fully and competently staffed with housekeeping personnel. Employee E9 reported that he began employment for the facility four weeks prior to the beginning of the survey on October 18, 2021. At that time, the facility did not have two full time employees each on second floor and first floor. Employee E9 explained that in order for the residents rooms, hallways, nurses station, dining areas and lounges to be clean, sanitary and home-like the second floor as well as the first floor required four full time employees on the day shift tour of duty. Two housekeepering staff for the first floor nursing unit and two housekeeping staff for the second floor nursing unit. Employee E9 confirmed that the facility failed to have sufficient housekeeping services for the second floor nursing unit.


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

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






 Plan of Correction - To be completed: 11/23/2021

1. Rooms 218, 220, 226, 224, 225 and 221 have been cleaned to remove heavily soiled with food spillage, dirt and debris along the entire perimeter of the flooring. Windows were cleaned in rooms 218, 220, 226, 224, 225, and 211. Residents cleaned clothing was placed in their drawers and closets. Rooms 218, 220, 226, 224,225, and 221 have had wall areas inside these rooms repaired, cleaned and painted as needed. Room 226 the towel was removed underneath the air conditioning/heating unit and this window unit was repaired. The plush animals were placed in an area off the floor. Odors were removed on the second floor unit. Room 218 and 200 have had odors were addressed. Observation on Room 200A has had debris removed.
2. To identify others with potential to be affected, a house audit was completed to identify areas of concern and an appropriate schedule of routine cleaning of rooms will be created and followed.
3. To prevent this from reoccurring, Housekeeping Director and housekeeping staff will be educated regarding adherence to cleaning schedules.
4. NHA or designee(s) will complete audit of weekly audit of 10 rooms for 90 days.
5. Results will be provided to the QA Committee for review and revision as needed.

483.90(g)(2) REQUIREMENT Resident Call System: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.
483.90(g) Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area.

483.90(g)(2) Toilet and bathing facilities.
Observations:

Based on observations and interviews with residents and staff and review of the maintenance log, it was determined that the facility failed to ensure that call bells were functioning for four of 22 residents reviewed (Resident R98, R60, R66 and R67).

Findings include:

Observations during the resident screening process on October 18, 2021, at 11:00 a.m. revealed four residents who had call bells that were not operating.

Interview with Resident R98 on October 18, 2021, at 11:00 a.m. revealed that the resident had been trying to use the call bell, but no one was responding. When the call bell was pushed, the light did not light. Further interview revealed that she was having chest pains and wanted the nurse.

Interview with the Nursing Home Administrator on October 18, 2021, at 11:30 a.m. confirmed that Resident R98's call bell had been pulled out of the wall and was not functioning.

Interview with Resident R66 on October 18, 2021, at 11:10 a.m. revealed that he indicated that the call bell was not working, and he pointed to the wall where the call bell cord was connected to a white box that was pulled out of the wall and hanging by two thin wires. When the call bell was pushed, the call light did not activate. It was noted that his roommate's (Resident R60) call bell was also plugged into this box.

Interview with Resident R60 on October 18, 2021, at 11:12 a.m. revealed that he had a tap bell on his bed. When it was pushed, the call light did not activate.

Interview with the Nursing Home Administrator on October 18, 2021, at 11:30 a.m. confirmed that the call bell system in Room 113, occupied by Resident R60 and R66, had been pulled out of the wall and was not functioning,

Observations of the call light system for Resident R67 on October 18, 2021 at 11:00 a.m. revealed that the resident's call bell was not functioning. The facility had provided the resident with a tap bell that was placed on the resident's over bed table in her room.

Reviews of the maintenance log for the call light system for room 232 that requests for maintenance to ensure that the call light system in room 232 for Resident R67 was functioning properly dated back to July, August and October, 2021.

Interview with Nursing Home Administrator on October 19, 2021 at 2:30 p.m., confirmed that the facility was having on-going issues with the call light system in room 232, since July 2021. The administrator indicated that the call bell wiring system was not operational.


28 Pa. Code 205.67(j) Electric requirements for existing and new construction








 Plan of Correction - To be completed: 11/23/2021

1. R 98, R66, R60, and R67's call bells are working properly
2. To identify others with the potential to be affected, a full house audit was completed to identify any call bell issues. Vendor ADT was in facility on 10/19/2021 to check system.
3. To prevent this from reoccurring, DON/designee will educate staff to view call bell box in rooms to ensure the box is not off the wall, if box is noted off the wall staff will validate call bell is working and notify Maintenance and Supervisor if not working and to provide a tap bell at that time.
4. Ongoing monitoring for compliance, Maintenance Director will complete Call bell audits will be completed 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 2 times a week for 4 weeks.
5. Results will be provided to the QA Committee for review and revision as needed.

483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident: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.
483.24(c) Activities.
483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
Observations:

Based on observations of residents and the activities programing, reviews of activities calendars, interviews with staff and residents, it was determined that the facility failed to employee sufficient support staff to provide a recreational programs to meet the psychosocial, emotional and care needs on one of two nursing units (Second floor nursing unit).

Findings include:

Observations of the second floor nursing unit on October 18, 19 and 20, 2021 revealed resident gathered at the nurses station from 8:30 a.m. til noon. Resident were heard asking the nursing staff where do I go? Some sat in chairs set directly in front of the nurses station and watched the happenings at the nurses desk; then fell asleep in the chairs. Others ambulated over to the non-functioning pay phone near the elevators and others walked the hallways aimlessly. Resident R11 never came out of her room all days of the survey, October 18 through October 21, 2021. The family member for Resident R11 was interviewed over the telephone at 9:30 a.m. on October 21, 2021 and reported that this resident enjoys one to one visits especially with family. This family member also reported that she was not informed that family visitation was opened for her to visit Resident R11. The family member reported that she likes to visit Resident R11, a dear friend of hers on a weekly basis.

Clinical record review for Resident R11 who resided on the second floor nursing unit revealed a annual comprehensive assessment (MDS-an assessment of care needs) dated June 21, 2021. The assessment indicated that this resident had a diagnosis of dementia and depression. This assessment indicated that this resident had daily activities preferences of family involvement, listening to music and doing this with groups of people.

Clinical record review for Resident R17 who resided on the second floor nursing unit revealed an annual comprehensive assessment dated June 26, 2021 that indicated this resident had diagnosis of psychotic disorder. This assessment also indicated that the activities and socialization were important daily routines for this resident and that the resident preferred going outside for fresh air.

Clinical record review for Resident R13 who resided on the second floor nursing unit revealed a annual comprehensive assessment (MDS-an assessment of care needs) dated July 10, 2021. The assessment indicated that this resident had a diagnosis of dementia. This resident wandered throughout the second floor nursing unit with little engagement with staff or the activities department.

Clinical record review for Resident R12 who resided on the second floor nursing unit revealed a annual comprehensive assessment dated March 26, 2021 that indicated that this resident had a diagnosis of schizophrenia and anxiety. The resident's preferred activities were religious, pet visits, news and current events, books magazines, family involvement and outdoor activities weather permitting.

Clinical record review for Resident R205 who resided on the second floor nursing unit revealed an admission assessment dated September 25, 2021 that indicated that this resident was wandering daily. Observations of this resident on all days of the survey revealed the resident sitting at the nurses station asking for help to find an apartment and telling anyone who would take the time to listen that he did not belong at the facility.


A review of the activities calendars for October 18, 2021 revealed that Bingo was scheduled for 11:00 a.m. and Snack Cart Trolley was scheduled for 2:00 p.m. These activities did not take place on the second floor nursing unit.

A review of the activities calendars for October 19, 2021 revealed that Country Breakfast was planned for 8:30 a.m. following by Daily Chronicle at 10:00 a.m. then at 10:30 a.m. Moving and Grooving, at 2:00 p.m. Music therapy with Molly. The only activity that occurred on the second floor nursing unit was moving and grooving and two residents attended out of 56 residents living on the second floor nursing unit.

A review of the activities calendars for October 20, 2021 revealed that Daily Chronicle was planned for 10:00 a.m., at 10:30 a.m. Moving and Grooving was planned and at 11:00 a.m. Rosary with Legions of Mary was planned. None of these activities were provided on the second floor nursing unit.

Interview with the Director of Recreational Activities, Employee E8, on October 20, 2021 at 1:00 p.m. revealed that the activities department did not have sufficient staff to conduct activities programs to meet the needs of the all residents on the second floor nursing unit.

The Activities Director reported that she was offering/over seeing/providing the activities as planned for the first floor residents. The director of activities also reported that a nursing assistant will occasionally be assigned to conduct an activity on the second floor nursing unit once or twice a week.

In addition, Employee E8 reported that staff were not transporting residents off the second floor nursing unit to the first floor or outside the facility. The activities being offered by outside organizations have been conducted for a select few of the residents on the first floor nursing unit only.

The Director of Activities, Employee E8, reported that for the facility to provide activities to meet the needs of all the residents there has to be a full time activities person to offer/over-see and institute the second floor activities plan. Residents living on the second floor nursing unit have a variety of activity needs and interests. Some have behavioral health needs, some have dementia care needs.


28 Pa. Code: 211.11(a)(b)(c) Resident care plan

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

28 Pa. Code: 201.29(a)(b)(c)(j) Resident rights





 Plan of Correction - To be completed: 11/23/2021

1. R 11, R13, and R205 will have their activity needs reviewed and adjusted as needed. The activity calendar will be followed on the second floor.
2. To identify others with the potential to be affected, a review of residents activity needs on the second floor will be reviewed by the activity director and/or designee monthly X 3 months and with all new admissions and planning will be developed as appropriate.
3. To prevent this from reoccurring, Activity Director was educated on activity programming. Facility will add to the activity calendar with outside vendors, hospice partners, and with other members of the team assisting department with activities.
4. Ongoing monitoring for compliance, NHA/designee will audit activity programming 3 times week for 90 days.
5. Results will be provided to the QA Committee for review and revision as needed.

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 clinical record review and staff interview, it was determined that the facility failed to complete quarterly review assessments timely for four of 22 clinical records reviewed (Resident R6, R5, R29, and R2).

Findings include:

Review of Resident R6's clinical record revealed an Annual Minimum Data Set (MDS- assessment tool completed at specific intervals to determine resident care needs) completed on June 2, 2021. Further review of the resident's clinical record revealed no quaterly assessment completed since the annual assessment of June 2, 2021.

Review of Resident R5's clinical record revealed an Annual Minimum Data Set, (MDS- assessment tool completed at specific intervals to determine resident care needs) completed on May 26, 2021. Further review of the resident's clinical record revealed no quarterly assessment completed since the annual assessment of May 26, 2021.

Review of Resident R29's clinical record revealed a Quaterly Minimum Data Set, (MDS-an assessment tool completed at specific intervals to determine resident care needs) completed on May 26, 2021. Further review of the resident's clinical record revealed no quarterly assessment completed since the assessment of May 26, 2021.

Review of Resident R2's clinical record revealed a Quaterly Minimum Data Set (MDS-an assessment tool completed at specific intervals to determine resident care needs) completed on May 24, 2021. Further review of the resident's clinical record revealed no quarterly assessment assessment completed since the assessment of May 24, 2021.

Interview with licensed nursing staff, Employee E4, October 21, at 2:35 p.m. confirmed the above mentioned quaterly MDS Assessments still had not been completed and were over due.


28 Pa. Code 211.5(f) Clinical records

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








 Plan of Correction - To be completed: 11/23/2021

1. R5, R6, R29, and R2 have had their assessments completed.
2. To identify others with the potential to be affected, a look back for the last quarter was completed to ensure quarterly assessments were completed.
3. To prevent this from reoccurring, DON/designee completed training with the RNAC and Interdisciplinary team.
4. Ongoing monitoring for compliance, RNAC will audit MDS timely completion 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 2 times a week for 4 weeks. RNAC will report during Clinical morning meeting any required MDSs.
5. Results will be provided to the QA Committee for review and revision as needed

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, a family interview, and a staff interview, it was determined that the facility failed to ensure that the resident's representative was notified timely about a hospital transfer for one of 22 residents reviewed (Residents R27).

Findings include:

A review of medical records revealed that Resident R27 was admitted to the facility on August 19, 2021, with diagnosis to include COPD (chronic obstructive pulmonary disease, a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough). Further review revealed a nursing note stating that on the morning of August 31, 2021, Resident R27 was experiencing shortness of breath, wheezing and labored breathing and her hands were visibly blue, and that the call to the MD went to the answering center, a message was left for the MD to call the facility, and being unable to wait for this call, the resident was sent out to the hospital using 911 emergency services.

A telephone interview with Resident R27's daughter, and responsible party, on October 21, 2021, at approximately 10:30 a.m. revealed that she was concerned about not being notified when her mother was sent out to the hospital on August 31, 2021, for four days and she was never notified until after her mother returned to the facility.

An interview with the Social Worker, Employee E7, on August 21, 2021, at approximately 10:45 a.m., confirmed that the nursing notes did not indicate that the daughter was notified of her mother's hospitalization as she should have been. She further indicated that she had contacted Resident R27's daughter after she returned from the hospital to attend a September 24, 2021, meeting about her Resident R27's decline.

Interview with the Administrator and Director of Nursing on August 21, 2021, at approximately 11:00 a.m., confirmed that Resident R27's responsible party was not notified of her mother's hospitalization.



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



 Plan of Correction - To be completed: 11/23/2021

1. R27's responsible party is being communicated with for any changes.
2. To identify others with potential to be affected, A 30 day review was completed of transfers to the hospital to ensure the Responsible party had been notified.
3. To prevent this from reoccurring, licensed staff have been educated to notify the Responsible party of any changes in condition, to include transfers to the hospital.
4. Ongoing monitoring for compliance, DON/designee will audit 5 times a week during Clinical morning meeting to ensure Responsible party has been notified of changes.
5. Results will be provided to the QA Committee for review and revision as needed.

483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing: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.
483.20 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 clinical record review and staff interview, it was determined that the facility failed to complete comprehensive annual assessments timely for three of 22 clinical records reviewed (Resident R3, R1, and R4).

Findings include:

Review of Resident R3's Significant Change Minimum Data Set, (MDS- an assessment tool completed at specific intervals to determine resident care needs) revealed that the assessment was completed on August 12, 2020. The next annual MDS assessment was due on August 13, 2021. Further review of the resident's clinical record revealed the annual assessment due on August 13, 2021 had not been completed.

Review of Resident R1's Annual Minimum Data Set (MDS- assessment tool completed at specific intervals to determine resident care needs) revealed that the assessment was completed on November 27, 2020, with a quarterly MDS's completed on February 27, 2021, April 27, 2021, and May 18, 202. The next annual MDS was due on August 18, 2021. Further review of the resident's clinical record revealed the annual assessment of August 18, 2021 still had not been completed.

Review of Resident R4's Annual Minimum Data Set (MDS- assessment tool completed at specific intervals to determine resident care needs) completed on December 8, 2020, with a quarterly MDS's completed on March 10, 2021, April 5, 2021, and May 25, 2021. The next MDS was due on August 25, 2021. Further review of the resident's clinical record revealed the annual assessment of August 25, 2021 still had not been completed.

Interview with licensed nursing staff, Employee E4, October 21, at 2:35 p.m. confirmed that the above mentioned MDS assessments still had not been completed and were over due.


28 Pa. Code 211.5(f) Clinical records

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






 Plan of Correction - To be completed: 11/23/2021

1. R1, R3, R4 have had their MDSs completed.
2. To identify others with the potential to be affected, an audit was conducted to identify other assessments that are outside of the 120 day completion date.
3. To prevent this from reoccurring, NHA has reeducated the Social Service Director on the timely completion of MDS.
4. Ongoing monitoring for compliance, RNAC will audit MDS timely completion 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 2 times a week for 4 weeks. RNAC will report during Clinical morning meeting any required MDSs.
5. Results will be provided to the QA Committee for review and revision as needed.

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

Based on a review of clinical records and staff and resident interviews, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two residents out of 22 clinical records reviewed. (Residents R99 and R107).

Findings include:

During the initial tour of the facility on October 18, 2021, at 11:15 a.m., Resident R99, stated that she has a Purewick female external catheter that her physician had ordered for her and that she was currently utilizing.

Review of Resident R99's clinical record revealed the resident was admitted to the facility on August 18, 2021, with a diagnosis to include morbid (severe) obesity due to excess calories. The resident's physician orders included an order for a Purewick External Catheter: Change External Catheter every 12 hours and as needed with a start date of August 21, 2021.

Review of Resident R99's clinical record revealed a PPS 5-day scheduled Minimum Data Set (MDS- assessment of care needs) dated October 1, 2021, revealed under Section H - Bladder and Bowel... Appliances. A- Indwelling catheter (including suprapubic catheter and nephrostomy tube) was selected by facility staff.

The facility incorrectly coded the resident as having an indwelling catheter instead of an external catheter.

A review of resident R107's closed clinical record revealed an August 16, 2021, MDS coded Discharge Assessment - return not anticipated, which had a discharge status in Section A, Line 2100 - Discharge Status which was coded 3, indicating discharged to Acute Hospital.

Further review of resident R107's closed clinical record revealed a nursing progress note which indicated
Resident R107 was discharged against medical advice.

Interview with Employee E4, Registered Nurse Assessment Coordinator, confirmed that she wrote the discharge note which indicated that the resident was discharged against medical advice.

Further review of resident R107's closed clinical record revealed a social service progress note which indicated that Resident R107 ws discharged against medical advised.

Interview with Employee E7, Social Worker, confirmed that she wrote the social service discharge note which indicated that the resident was discharged against medical advice.



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

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







 Plan of Correction - To be completed: 11/23/2021

1. R99 and R97 had their MDS's corrected.
2. To identify others with the potential to be affected, a review of MDS from the past 30 days will be completed to ensure accuracy.
3. To prevent this from reoccurring, RNAC has been educated on ensuring MDS accuracy.
4. Ongoing monitoring for compliance, Interdisciplinary team will review the MDS in coordination with care conference schedule for accuracy.
5. Results will be provided to the QA Committee for review and revision as needed.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:

Based on a review of clinical records, observations, and interviews with staff and residents, it was determined that the facility failed to ensure that comprehensive person-centered care plans were developed to reflect the individual needs for two of 22 resident records reviewed (Residents R312 and R41 ).

Findings include:

During the initial tour of the facility on October 18, 2021, at 2:24 p.m. where Resident R312 was interviewed and he stated that he has a implantable cardioverter-defibrillator (small device that's placed (implanted) in a person's chest to help control your heartbeat) that required to be monitor.

Review of Resident R312's clinical record revealed the resident was admitted to the facility on August 9, 2021, with a diagnosis to include congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should).

Review of Resident R312's hospital record dated July 28, 2021, revealed as an active problem the resident was listed as having an implantable cardioverter-defibrillator.

Review of the resident's admission care plan revealed that there no care plan developed for the resident's implantable cardioverter-defibrillator.


Review of Resident R41's psychiatric consultation dated August 14, 2021 indicated that the resident had psychiatric diagnosis that included dementia with behavioral disturbances (a group of symptoms that affects memory, thinking and interferes with daily life), schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), depression, bipolar disorder, (a serious mental illness characterized by extreme mood swings) disorder, anxiety (intense, excessive and persistent worry and fear about everyday situations), and adjustment disorder (a short term condition arising due to difficulty in managing the stressful life change)with mixed anxiety and depression (intense, excessive and persistent worry and fear about everyday situations).

Review of the August 2021 physician orders indicated a physician's order for Cymbalta, 20 milligrams (a medication prescribed to treat depression and anxiety) with a start date of October 2020. The medication was discontinued on August 31, 2021 by the nurse practitioner due to the resident's refusal to take it.

Review of the resident's current person-centered plan of care revealed no plan of care developed for the resident's mental health diagnosis, and psychosocial needs.



28 Pa Code 211.5(f) Clinical records.

28 Pa Code 211.11(c) Resident care plan.

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



 Plan of Correction - To be completed: 11/23/2021

1. R41 and R312 have had their care plans updated.
2. To identify others with the potential to be affected, Residents' care plans will be reviewed for accuracy.
3. To prevent this from reoccurring, licensed nurses will be educated regarding updating the care plan and maintaining accuracy.
4. Ongoing monitoring for compliance, RNAC will audit 5 residents a week to ensure accuracy of care plans for 90 days.
5. Results will be provided to the QA Committee for review and revision as needed.

483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

483.24(b)(2) Mobility-transfer and ambulation, including walking,

483.24(b)(3) Elimination-toileting,

483.24(b)(4) Dining-eating, including meals and snacks,

483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
Observations:


Based on observations, and inteviews with resident and staff, it was determined that the facility failed to assist a resident with grooming and bathing preferences for one of 22 sampled residents reviewed. (Resident R63)

Findings include:

Observations conducted of Resident R63 on October 18, 2021 at 11:30 a.m. revealed that that the resident was in bed wearing a hospital gown and was unshaved. There was a pungent odor in the resident's room.

Review of Resident R63's quarterly assessment (MDS- an assessment of care needs) dated August 23, 2021, revealed that the resident was assessed has cognitively intact. The assessment also indicated that this resident was totally independent and required physical assist of one staff member for bathing ( how a resident takes a full-body bath/shower and transfers in/out of the tub). Further review of the MDS revealed that Resident R63 used a wheel chair for mobility and had no functional limitations in range of motion of the upper and lower extremities.

Interview with Resident R63 on October 18, 2021 at 11:45 a.m., revealed that the resident wanted to receive a shower or tub bath. The resident reported that he did not think he was fully washed and clean with a bed bath. The resident reported that it was weeks ago or last month since he was assisted with a shower/tub bath. Resident R63 said that he would prefer daily shaving with an electric razor, since that was his customary routine at home.

Interview with the Director of Nursing and the licensed nurse, Employee E6 on October 18, 2021 at 1:00 p.m. revealed that the facility's policy was to provide a shower or tub bath to all residents at least twice a week. Employee E6 reported that resident was groomed daily or as needed and in accordance with each resident's preference.

Review of bathing and grooming documentation from September 21, 2021 through October 20, 2021 revealed that Resident R63 was coded as not applicable for a shower or tub bath without no other justification as to why the resident was not offered and assisted with a shower or a tub bath.


28 Pa. Code: 201.29(j) Resident rights

28 Pa. Code 211.10(d) Resident care policies





 Plan of Correction - To be completed: 11/23/2021

1. R 63 is receiving showers per plan and his preferred shaving needs are being met.
2. To identify others with the potential to be affected, Residents shower schedules were reviewed with residents and adapted if needed. Showers will be provided per schedules and prn.
3. To prevent this from reoccurring, DON/designee has educated Nursing staff regarding offering showers, following the shower schedules and providing showers if requested.
4. Ongoing monitoring for compliance, DON/designee will interview 10 residents a week for 4 weeks, 8 residents a week for 4 weeks, and 5 residents a week for 4 weeks.
5. Results will be provided to the QA Committee for review and revision as needed.

483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on observations, review of clinical records, and staff interview, it was determined that the facility failed to ensure that physican orders were obtained for the use of oxygen therapy for one out of 22 sampled residents reviewed (Resident R311).

Findings included:

Review of Resident R311's clinical record revealed the resident was admitted to the facility on September 1, 2021, with a diagnosis to include chronic obstructive pulmonary disease (A group of lung diseases that block airflow and make it difficult to breathe) and acute respiratory failure.

Observation on October 19, 2021, at 12:48 p.m. revealed the resident was utilizing oxygen via a nasal cannula which was set at 3 liters per minute.

Review of the resident's clinical record revealed no physician order was obtained for the resident's oxygen usage.

Interview with the Director of Nursing on October 20, 2021, at 11:42 a.m. where she confirmed that Resident R311 was using oxygen therapy and she confirmed that a physician order had not been obtained.


28 Pa. Code 211.5 (f) Clinical Records

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

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









 Plan of Correction - To be completed: 11/23/2021

1. R311 oxygen order was placed on order sheet.
2. To identify others with the potential to be affected, a review of residents receiving oxygen will be audited to ensure physician orders are in place.
3. To prevent this from reoccurring, licensed nurses will be educated to ensure orders are entered accurately.
4. Ongoing monitoring for compliance, Concierge members will audit resident rooms twice a week to identify any residents with oxygen to ensure orders are in place.
5. Results will be provided to the QA Committee for review and revision as needed.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that that each resident received assistance to maintain ambulation for one of 22 residents reviewed. (Resident R63)

Findings include:

Review of Resident R63's quarterly comprehensive assessment (MDS- an assessment of care needs) dated August 23, 2021 revealed that this resident was cognitively intact. The assessment also indicated that Resident R63 required supervision and physical assist of one person for ambulation in the corridor and walking in the room.

Interview with Resident R62 On October 18, 2021 at 11:35 a.m. revealed that this resident was concerned that he was not being assisted to ambulate, at least once a day.

Review of Resident R63's physical therapy evaluation dated September 1, 2021, indicated that this resident was able to walk 40 feet with care giver assistance. On October 7, 2021 the physical therapist documented that Resident R63 was able to walk 225 feet with a wheeled walker with supervision and modified independence.

Review for Resident R62 current care plan indicated that the resident was to ambulate 75 feet with a wheeled walker and supervision and assistance.

Review of documentation related to ambulation from September 21, 2021 through October 20, 2021, revealed that staff documented two days of this 30 day period that Resident R62 was assisted/ supervised for ambulation.

Interview with the licensed nurse, Employee E6,on October 20, 2021 at 1:20 p.m. confirmed the lack of documentation to indicated that Resident R62's restorative ambulation program was effective and implemented to meet this resident's ambulation needs.

28 Pa. Code: 211.11(a)(b)(c) Resident care plan

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

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

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



 Plan of Correction - To be completed: 11/23/2021

1. R62 is receiving restorative ambulation and it is being documented.
2. To identify others with the potential to be affected, an audit was conducted on residents on a restorative program to ensure restorative was placed in tasks for staff documentation of completion.
3. To prevent this from reoccurring, DON/designee will educate nursing staff on restorative documentation in PCC.
4. Ongoing monitoring for compliance, DOR/designee will audit residents that are on a restorative nursing program to ensure it is completed and present in PCC.
5. Results will be provided to the QA Committee for review and revision as needed.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills: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(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, clinical records review and staff interviews, it was determined that the facility failed to follow physician's orders related to enteral nutrition for one of 22 sampled residents reviewed (Resident R60).

The findings include:

Review of Resident R60's clinical record revealed the resident was admitted to the facility on July 1, 2021, with a diagnosis to include dysphasia (condition with difficulty in swallowing food or liquid, which may interfere in a person's ability to eat and drink).

Review of Resident R60's physician order dated May 13, 2021, for enteral feeding two times a day for nutrition (diabetes, an enteral formula designed for tube feedings for patients with diabetes) at 70 ml per hour for 12 hours up at 8:00 p.m. and down at 8:00 a.m.

Observation on October 19, 2021, at 10:00 a.m. revealed that Resident R60's tube feeding of was running at 70 ml per hour. Interview with Resident R60 during the observation revealed that he was saying it was too much and he was too full from the tube-feeding.

Interview on October 19, 2021, at 10:00 a.m. with licensed nursing staff, Employee E12, confirmed that the tube-feeding was still running and that he was going to check the orders. Follow up interview on October 19, 2021, at 11:30 a.m. with Employee E12, revealed that the order was for 12 hours, and that he took the tube-feeding down shortly after 10 a.m. after checking the orders, and that it should have been taken down at 8:00 a.m.

During an interview with the Administrator and Director of Nursing on October 19, 2021, at approximately 3:00 p.m. acknowledged the error which caused Resident R60's tube-feeding to run for an extra two hours.


28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.12(c) Nursing services

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





 Plan of Correction - To be completed: 11/23/2021

1. R 60 had no adverse effects.
2. To identify others with the potential to be affected, residents receiving tube feeding were audited to review tube feeding hang times.
3. To prevent this from reoccurring, licensed nurses were reeducated on following the prescribed tube feeding hang times.
4. Ongoing monitoring for compliance, DON/designee will audit the tube feeding residents 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 2 times a week for 4 weeks.
5. Results will be provided to the QA Committee for review and revision as needed.

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 review of facility policy, review of clinical records and interviews with staff, it was determined that the facility failed to ensure that behaviors were properly monitored and documented, after the discontinuation of a psychotropic medication, and failed to implement a gradual dose reduction and/or non-pharmacological interventions in an effort to reduce the use of psychotropic medications for two of 22 residents reviewed (Residents R75 and R41).

Findings include:

Review of facility policy, "Psychoactive Medication Policy," dated revised May 26, 2021, stated that residents receiving psychoactive medication will have their potential for a gradual dose reduction of psychoactive medication monitored and documented.

Further review of the policy indicated that the behavior/intervention flow record will be updated with any changes in psychoactive medication, dosage, new behaviors and/or side effects by the nurse on duty at the time of the change.

Continued review of the policy also stated that residents receiving psychoactive medications will be reviewed at a minimum, every quarter, by the interdisciplinary team to determine the effectiveness of the medication and interventions by reviewing behavioral flow sheets to determine if the behaviors the resident has been exhibiting are stable and to determine if the resident is exhibiting any side effects from the psychoactive medications.

Review of the clinical record for Resident R75 revealed a quarterly Minimum Data Set (MDS-an assessment of care needs) dated August 9, 2021, which indicated that the resident was admitted to the facility on May 26, 2021, with diagnoses of anxiety disorder and depression. Continued review of the clinical record for Resident R75 revealed a physician order dated July 20, 2021, and continuing to present, for the use of the psychotropic drugs (Depakote, Duloxetine and Alprazolam).

The psychiatrist's initial progress note dated July 24, 2021, indicated that Resident R75 had diagnoses of major depression and anxiety disorder, had intermittent anxiety disorder, agitation, flat effect and was non-compliant with safety precautions.

The psychiatrist's progress note dated September 18, 2021, indicated that Resident R75 was receiving psychotropic medications: Depakote (mood stabilizer) for bipolar disorder, Duloxetine (anti-depressant) for major depressive disorder and Alprazolam (antianxiety agent) for anxiety disorder.

There was no clinical record documentation to indicate that a gradual dose reduction had been attempted for
Resident R75. Additionally, there was no documentation that any behavioral interventions had been attempted in an effort to discontinue the use of the psychotropic drugs.

Interview with Employee E2, director of nursing, and Employee E6, licensed nurse, on October 21, 2021, at 10:15 a.m., confirmed that there was no documentation to indicate that the facility had attempted to implement a gradual dose reduction for the use of psychotropic drugs for Resident R75 and failed to implement any non-pharmacological interventions for Resident R75. Employees E2 and E6 further confirmed that the clinical record failed to indicate a reason why a gradual dose reduction was clinically contraindicated for Resident R75.

Review of the October 2021 physician orders for Resident R41 indicated diagnosis that included: depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (high blood pressure), morbid obesity, and arthritis.

Review of the August 2021 physician orders indicated a physician's order for Cymbalta, 20 milligrams (a medication prescribed to treat depression and anxiety) with a start date of October 2020. The medication was discontinued on August 31, 2021 by the nurse practitioner due to the resident's refusal to take it.

Review of the interdisciplinary notes from August 2021 through September 2021 did not show evidence of any monitoring and documentation from nursing staff related to the discontinuation of the psychotropic medication. During a discussion with the Director of Nursing on October 21, 2021 at approximately 10:00 a..m. it was confirmed that there was no evidence that staff properly monitored and documented the resident after the discontinuation of Cymbalta.


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

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

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









 Plan of Correction - To be completed: 11/23/2021

1. R 75 had psychiatric medications evaluated and no GDR is recommended. R 41 had no adverse effects noted.
2. To identify others with the potential to be affected, an audit to ensure documentation that a GDR was not warranted was conducted.
3. To prevent this from reoccurring, DON/designee will educate Psychiatric services on appropriate documentation regarding GDR. Licensed staff will be reeducated to document the monitoring of residents with a psychotropic medication changes.
4. Ongoing monitoring for compliance, DON will monitor Psychiatric documentation every week for 90 days. DON/designee will audit documentation post psychotropic medication changes 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 2 times a week for 4 weeks.
5. Results will be provided to the QA Committee for review and revision as needed.

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ: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.
483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
Observations:

Based on observation, and resident and staff interview, it was determined that the facility failed to ensure that equipment for personal laundry was in a safe operating condition.

Findings include:

Observations conducted of the laundry area with the Director of housekeeping and maintenance, Employee E9 at 10:30 a.m. on October 19, 2021 revealed that the personal laundry area for residents use located on the basement floor of the facility was not easily accessible for residents desiring to do their personal laundry.

The residents were required to be escorted to the laundry area by a nursing assistant; because the area contained door and elevator codes that the residents were not given. Observations of the washing machine revealed that it was in disrepair; it contained a heavy build of rust on its lid; which would easily leak brown liquid onto any clothing inside the washer. The laundry area was not equipt with soap or detergent for resident use.

A review of the personal linen procedures that were given to the residents upon admission to the facility, revealed that the facility failed to mention the residents personal laundry area located in the basement of the facility. Interviews with Residents R8, R63 and R 75 at 1:15 p.m. on October 20, 2021, revealed that these residents were unaware that a personal washer and dryer existed for residents choosing to launder their items of clothing and that it was located on the basement level of the facility.


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

28 Pa. Code 205.26(e) Laundry

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


 Plan of Correction - To be completed: 11/23/2021

1. Washing machine has been repaired appropriately with no remaining rust and detergent vendor has filled the dispensers with solution according to manufacturer guidelines.
2. All residents will be educated on the availability of the personal laundry facilities located centrally between the physical therapy gym and the beauty salon. Signs indicating location and availability will be posted in each resident room.
3. To ensure all new residents are educated, the location and availability of personal laundry have been added to the new resident admission & welcome packet.
4. The cleaning solutions vendor has added the detergent to the list of weekly checks and will refill once low. Maintenance or designee will monitor for any physical repairs needed.
5. Results will be provided to the QA Committee for review and revision as needed.

211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. 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 2.7 hours of direct resident care for each resident.
Observations:

Based on a review of nursing staffing schedules and staff interviews, it was determined that the facility failed to comply with the state minimum requirement of nursing care hours to provide sufficient nursing personnel as required.

Findings include:

A review of the facility's nursing staffing schedules dated April 3, 2021, through April 9, 2021, revealed that one of the seven days reviewed were below 2.7 hours of direct resident care, the state minimum requirement. Nursing staffing schedules dated April 4, 2021, revealed direct resident care hours of 2.48.

A review of the facility's nursing staffing schedules dated September 4, 2021, through September 10, 2021, revealed that one of the seven days reviewed were below 2.7 hours of direct resident care, the state minimum requirement. Nursing staffing schedules dated September 10, 2021, revealed direct resident care hours of 2.46.

A review of the facility's nursing staffing schedules dated October 14, 2021, through October 20, 2021, revealed that one of the seven days reviewed were below 2.7 hours of direct resident care, the state minimum requirement. Nursing staffing schedules dated October 16, 2021, revealed direct resident care hours of 2.69.

An interview with the Administrator and Director of Nursing on October 21, 2009, at 2:00 p.m., confirmed that on the above dates the nursing care hours were below the state minimum requirements.





 Plan of Correction - To be completed: 11/23/2021

1. Staffing cannot be retroactively changed.
2. Facility will staff at a minimum 2.7 PPD
3. DON/designee will educate supervisors and staffing coordinator to alert NHA or DON immediately if staffing may fall below 2.7 for the day.
4. DON/designee will review staffing daily to ensure 2.7 minimum is met.
5. Results will be provided to the QA Committee for review and revision as needed.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port