Pennsylvania Department of Health
CORNER VIEW NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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CORNER VIEW NURSING AND REHABILITATION CENTER
Inspection Results For:

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CORNER VIEW NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance survey and an abbreviated survey in response to two complaints completed on March 22, 2024, it was determined that Corner View Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(i) Food safety requirements.
The facility must -

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

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

Based on a review of facility policies, observations and staff interviews, it was determined that the facility failed to properly monitor food expiration dates on four of five nursing unit food pantries (Third, Fourth, Fifth, and Sixth Floor Nursing Unit Food Pantries), and properly store utensils for food on one of five nursing units (Fourth Floor) creating the potential for food-borne illness.

Findings include:

Review of facility policy "Food Safety Requirements- Use And Storage of Food And Beverage Brought In For Residents, Food Procurement", dated 1/15/24, indicated that food brought into the facility should be properly labeled and dated and will be used within three days or discarded.

Cross contamination refers to the transfer of harmful substances or disease causing microorganisms to food by hands, surfaces, sponges, cloth towels, or utensils which are not cleaned after touching raw food, and then touch ready to eat foods.

Physical Contamination of food are foreign objects that may inadvertently enter the food.

During an observation on 3/21/24, at 11:43 a.m. the Fourth Floor Pantry refrigerator contained two empty plastic containers that had residual amounts of food in them with no label or date, a plastic bowl that contained cabbage with no label or date, a plastic bowl that contained salad with no label or date, a container of mildly thick cranberry juice that was opened and had no date on it, and an ice scoop resting on top of the ice machine.

During an interview on 3/21/24, at 11:46 a.m. Licensed Practical Nurse (LPN) Employee E5 confirmed the above findings.

During an observation on 3/21/24, at 11:50 a.m. the Fifth Floor Pantry Refrigerator contained a bowl of shrimp with no label or date, and a sandwich with no label or date.

During an interview on 3.21.24, at 1:01 p.m. Nurse Aide Employee E6 confirmed the above findings.

During an observation on 3/21/24, at 12:54 p.m. the Third Floor Unit Pantry refrigerator had a plastic picture of apple juice with no date on it.

During an observation on 3/21/24, at 1:07 p.m. the Sixth Floor Pantry refrigerator contained a plastic bag that contained a bowl of fish and vegetables with no label or date, and two pancakes and sausages on a stick that had no label or date, a plastic pitcher of cranberry juice with no date, and a plastic bowl of fruit with no date.

During an interview on 3/21/24, at 1:11 p.m. Nurse Aide Employee E7 confirmed the above findings.

During an interview on 3/21/24, at 2:13 p.m. Dietary Manger Employee E8 confirmed that the facility failed to properly label and monitor food for expiration dates on four out of five nursing units, and failed to prevent physical contamination, and or cross contamination of ice by having an ice scoop on top of the ice machine for one of five nursing units creating the potential for food-borne illness.


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

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

28 Pa. Code: 211.6(c) Dietary services.





 Plan of Correction - To be completed: 04/18/2024

Food in the refrigerator pantry not properly labeled removed and disposed of properly.

Pantry refrigerators on units inspected and any food not properly labeled was removed and disposed of properly.

Administrator/designee to monitor pantry refrigerators on a routine basis to ensure and remove all food not properly labeled if necessary.

Education with Dietary Director/Designee and nursing staff by Administrator/Designee on F812 with a focus on properly monitoring food for expiration dates and ice scoop placed in ice scoop holder.

Audits to be completed by the Administrator/Designee weekly X8 weeks.
On food expiration dates.
Ice scoop is stored in the ice scoop holder.
Audit results will be submitted and reviewed at the quality assurance and performance improvement meetings.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to accommodate the call bell needs of four of four residents (Resident R5, R18, R75, and R86).

Findings include:

Review of facility policy "Answering the Call Light "dated 1/15 /24, indicated all residents who are in bed or confined to a chair be sure the call light is within easy reach of the resident.

Review of the clinical record indicated Resident R5 was admitted to the facility on 5/10/19.

Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/11/24, indicated diagnoses of hypertension (high blood pressure), heart failure (a progressive heart disease that affects pumping action of the heart muscles) and, Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior).

During an observation on 3/18/24, at 10:04 a.m. Resident R5 was observed lying in bed with his call light placed behind his dresser, completely out of the resident's reach.

Review of the clinical record indicated Resident R18 was admitted to the facility on 8/5/22.

Review of Resident R18's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/15/24, indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), hypertension and anxiety.

During an observation on 3/18/24, at 9:36 a.m. Resident R18 was observed lying in bed with his call light twisted up in a ball and hanging from the wall, completely out of the resident's reach.

Review of the clinical record indicated Resident 75 was admitted to the facility on 11/28/17.

Review of Resident R75's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/27/24, indicated diagnoses of stroke (damage to the brain from interruption of its blood supply), hypertension and, depression (a group of conditions associated with the elevation or lowering of a person's mood).

During an observation on 3/18/24, at 9:26 a.m. Resident R75 was observed sitting in his wheelchair beside his bed with his call bell on the floor, completely out of the resident's reach.

Review of the clinical record indicated Resident 86 was admitted to the facility on 6/21/23.

Review of Resident R86's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/28/24, indicated diagnoses of stroke (damage to the brain from interruption of its blood supply), hypertension and, depression (a group of conditions associated with the elevation or lowering of a person's mood).

During an observation on 3/18/24, at 9:40 a.m. Resident 86 was observed lying in his bed with his call bell on the floor, completely out of the resident's reach.

During an interview on 3/18/24, at 10:09 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed Resident R5, R18, R75 and R86's call bells where not accessible and unavailable for use to the resident.

During an interview on 3/22/24, at 9:56 a.m. the Director of Nursing confirmed that the facility failed to accommodate the call bell needs of four of four residents (Resident R5, R18, R75, and R86).

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

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

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


 Plan of Correction - To be completed: 04/18/2024

Call bell clips have been applied to the cord of the call bells for R5, R18, R75 and R86.

Resident's that do not have a call bell clip provided and attached to the call bell cord.

The Director of Nursing/designee will provide education to nursing, housekeeping and maintenance staff on F558 with a focus on accommodating the call bell needs of residents.
Audits to be completed by the Director of Nursing/Designee weekly X8 weeks. if no call bell clip-ONE will be provided and attached to the call bell cord.

Audit results will be submitted and reviewed at the quality assurance and performance improvement meetings.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on review of facility policies, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation that included statements from the witnesses and/or statements from the residents for injuries of unknown origin for one of six residents (Residents R38).

Findings include:

The facility "Incidents and Accidents-Investigating and Reporting" policy dated 1/15/24, indicated the charge nurse or nurse supervisor and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident. The name of witnesses and their accounts of the incident must be included.

The facility "Abuse Investigation and Reporting" policy, dated 1/15/24, indicated all injuries of unknown origin require a thorough investigation. It was indicated the person reporting the incident, any witnesses, the resident, and all staff members who had contact with the resident during the period of the alleged incident must be interviewed. All witness reports will be obtained in writing, either the witness will write his or her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him or her sign and date it.

Review of the clinical record indicated that Resident R38 was admitted to the facility on 1/27/23, with diagnoses which included major depression disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), insomnia (trouble falling and/or staying asleep), schizoaffective disorder (a mental health disorder that is marked by a combination of symptoms, such as hallucinations (an experience in which you see, hear, feel, or smell something that does not exist), depression or mania (mental state of elevated or intense mood and behavior). A review of Resident R38's Minimum Data Set (MDS- a periodic assessment of resident care needs), dated 1/24/24, indicated the diagnoses remained current.

Review of Resident R38's progress note dated 2/21/24, at 12:25 p.m. indicated the resident was transferred from 5 East to 3 East. It was indicated the resident was transferred via wheelchair with an assist of one person to the unit.

Review of Resident R38's progress note dated 2/21/24, at 12:46 p.m. indicated the resident was refusing to eat. The resident complained of left leg pain and would not allow staff to her left leg. The supervisor was notified to evaluate.

Review of Resident R38's progress note dated 2/21/24, at 1:32 p.m. entered by the Director of Nursing (DON), stated Resident R38's left leg was assessed due to pain. It was indicated the left leg appears to be slightly shorter than the right leg and has an outward rotation.

Review of Resident R38's progress note dated 2/21/24, at 8:59 p.m. entered by Registered Nurse (RN) Employee E10 indicated the physician from the hospital called and stated the resident has a hip fracture, and will most likely need surgery.

Review of Resident R38's investigation report dated 2/21/24, stated the patient was assessed due to complaint of pain of left hip. It was indicated the patient was unwilling to allow staff to visualize hip, unable to move extremity and unwilling to do so. A further review of Resident R38's investigation report failed to include signed and dated witness statements from the resident and all staff members who had contact with the resident during the period of the alleged incident.

A review of Resident R38's undated care plan provided by the facility on 3/21/24, indicated the resident had an activities of daily living (ADLS-fundamental skills required to independently care for oneself, such as eating, bathing, and mobility) self-care deficit related to left femur fracture. The resident required extensive assistance of two people with bed mobility, toileting, and transfers.

During an interview on 3/22/24, at 1:53 p.m. the Director of Nursing confirmed that the facility failed to complete an thorough investigation that included signed and dated witness statements from the resident and all staff members who had contact with the resident during the period of the alleged incident for one of six residents (Residents R38).


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

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

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



 Plan of Correction - To be completed: 04/18/2024

R38's investigation for the injury of unknown origin has been completed by the Director of Nursing to include statements for the witness and or resident that includes their signature.

Incidents of unknown origin will have witness statements obtained in writing (either by the witness themselves and signed and dated or the investigator may obtain a statement-read it back to the member and have him/her sign and date the statement.

Education to the Director of Nursing/Supervisors by the Administrator/Designee on F610 with a focus on initiating a thorough investigation that includes statements from witnesses and or statements from the witness that that includes the resident signature.

Injuries of unknow origin will be audits will to be completed by the Director of Nursing/Designee weekly X8 weeks.

Audit results will be submitted and reviewed at the quality assurance and performance improvement meetings and date.

483.21(b)(1)(3) 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.
483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on a review of clinical records, and staff interviews, it was determined that the facility failed to ensure that a comprehensive resident care plan was implemented related to post traumatic stress disorder status for one of three residents (Residents R114).

Findings include:

Review of Title 42 Code of Federal Regulations (CFR) - Comprehensive Care Plans, the facility must develop and implement a comprehensive care plan for each resident 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, and must be culturally competent and trauma informed.

Review of the clinical record revealed that Resident R114 was admitted to the facility on 4/13/21.

Review of Resident 114's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/13/24, indicated diagnoses of post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions), traumatic brain injury (brain dysfunction caused by an outside force), and dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory).

Review of Resident R114's plan of care revealed no care plan was developed to address Resident R114's post-traumatic stress disorder.

During an interview on 3/21/24, at 9:41 a.m. the Registered Nurse Assessment Coordinator Employee E9 confirmed that the facility failed to implement a comprehensive care plan for Resident R114 to address post-traumatic stress disorder.

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


 Plan of Correction - To be completed: 04/18/2024

Care plan for R114 had been developed.

Care plans for residents with a diagnosis of PTSD (Post traumatic stress disorder) have been developed.

New admissions to the facility will have a care plan developed if noted with a diagnosis of PTSD (Post traumatic stress disorder).

Education with Social Service by RNAC (Registered Nurse Assessment Coordinator)/designee on F656 with a focus on developing a comprehensive care plan for residents with PTSD (Post traumatic stress disorder) diagnosis.

Audits on (Post traumatic stress disorder) Care Plans to be completed by the Director of Nursing/Designee weekly X8 weeks.

Audit results will be submitted and reviewed at the quality assurance and performance improvement meetings.

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 review of facility policy, clinical records, and staff interview it was determined that the facility failed to obtain a physician order and notify a physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) level as ordered for two out of three residents (Resident R119 and R148).

Findings include:

Review of the clinical record indicated Resident R119 was admitted to the facility on 7/8/21, with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, dysphasia and atrial fibrillation (irregular and often very rapid heart rhythm).

Review of Resident R119's quarterly MDS assessment(minimum data assessment)- periodic assessment of resident care needs) dated 2/5/24, indicated the diagnosis remained current.

Review of Resident R119 nurse progress dated 1/1/2024 indicated that Resident R119 was sent out to the hospital.

Review of Resident R119's most recent physician order's indicate no order to send resident out to the hospital.

During an interview on 3/21/2024, at 2:23 p.m. the Director of Nursing confirmed that the facility failed to obtain a physcian order (Residents R119).

The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's.

The facility "Medication and Treatment Orders" policy dated 1/15/24, stated orders for medications and treatments will be consistent with principles of safe and effective order writing.

The facility "Diabetes-Clinical Protocol" policy dated 1/15/24, indicated the physician will order desired parameters for monitoring and reporting information relating to blood sugar management. It was indicated staff will incorporate such parameters into the Medication Administration Record (MAR) and care plan. He resident's blood sugar must be monitored three to four times a day while on a sling-scale insulin.

Review of Resident R148's was admitted to the facility on 2/22/24, with diagnoses of diabetes (metabolic disorder impacting organ function related to glucose (sugar) levels in the human body) and high blood pressure. Review of Resident R148's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 2/29/24, indicated the diagnoses were current.

Review of Resident R148's undated care provided by the facility on 3/21/24, indicated the resident had diabetes and staff must monitor, document, and report any signs and symptoms of high blood glucose.

Review of Resident R148's physician order dated 3/5/24, indicated to administer Novolog (insulin medication used for diabetics to manage blood sugar) subcutaneously (under the skin) via insulin pen with meals using blood glucose monitoring and the following protocol:
70-140=0 units
141-180=1 unit
181-220=2 units
221-260=3 units
261-300=4 units
301-340=6 units
340 or greater =7 units and call the doctor

Review of Resident R148's March 2024 Medication Administration Treatment (MAR) record indicated Resident R148's blood sugar was the following:
459 mg/dl on 3/9/24, at 4:30 p.m.
467 mg/dl on 3/10/24, at 4:30 p.m.
424 mg/dl on 3/12/24, at 4:30 p.m.
364 mg/dl on 3/13/24, at 7:30 a.m.
440 mg/dl on 3/13/24, at 4:30 p.m.
398 mg/dl on 3/15/24, at 4:30 p.m.
374 mg/dl on 3/17/24, at 7:30 a.m.
459 mg/dl on 3/17/24, at 4:30 p.m.
452 mg/dl on 3/19/24, at 4:30 p.m.

Review of Resident R148's progress notes dated 3/9/24, through 3/17/24, failed to include documentation that the physician was notified as ordered of the resident's blood sugar that was above 340 mg/dl.

During an interview on 3/18/24, at 9:35 a.m. Resident R148 indicated he had a concern for his blood sugars. He stated his blood sugar is high, and typically ranges within the "300-400s". He stated "that's why I am here, every day it is high."

During an interview on 3/21/24, at 10:04 a.m. Licensed Practical Nurse (LPN), Employee E5 indicated if a resident's blood sugar is above the parameter that is ordered on the sliding scale, then the nurse must administer the amount of insulin ordered, and notify the physician. It was indicated the notification to the physician is documented in a progress note. LPN, Employee E5 confirmed the facility failed to document the physician was notified when Resident R148's blood sugar was above the ordered parameters for the following days:
3/9/24, at 4:30 p.m.
3/10/24, at 4:30 p.m.
3/12/24, at 4:30 p.m.
3/13/24, at 7:30 a.m.
3/13/24, at 4:30 p.m.
3/15/24, at 4:30 p.m.
3/17/24, at 7:30 a.m.
3/17/24, at 4:30 p.m.
3/19/24, at 4:30 p.m.

During an interview on 3/21/24, at 1:22 p.m. the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the facility failed to notify a physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) level as ordered for one out of three residents (Resident R148).

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

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 04/18/2024

R119's physician was notified prior to the resident being transferred to the hospital emergency room on 12/31/23 with a late entry order placed in the electronic medical record.

Review of residents transferred to the hospital emergency room from 3/1/24 to present reviewed to determine that an order was obtained and entered into the electronic medical record for the transfer.

Residents transferred to the hospital emergency room will have orders reviewed by Director of Nursing/Designee following the transfer for the order of transfer.

Education by the Director of Nursing/Designee with the Nursing Supervisors on F684 with a focus on entering the orders obtained into the electronic medical record.

Audits to be completed by the Director of Nursing/Designee weekly X8 weeks.

Audit results will be submitted and reviewed at the quality assurance and performance improvement meetings.

R148's blood glucose levels have been reviewed by the resident's physician/practitioner.
Resident's with orders for blood glucose checks reviewed and if necessary reviewed with the physician/practitioner if any noted abnormal glucose levels as determined by orders.
Education provided to license nursing staff by the Director of Nursing/Designee on F684 with a focus on notifying a physician/practitioner or abnormal glucose readings as per orders.
Audits to be completed by the Director of Nursing/Designee 5 days a week X8 weeks.
Audit results will be submitted and reviewed at the quality assurance and performance improvement meetings.


483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

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

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

Based on review of clinical records, and staff interviews, it was determined that the facility failed to make certain that appropriate treatments and services were provided for the monthly change of a urinary catheter for one of five residents (Resident R15).

Findings include:

Review of the facility "Catheter Care, Urinary" policy dated 1/15/24, indicated the purpose of this policy is to prevent catheter-associated urinary tract infections. When indwelling catheters are changed the date and time the catheter care was given as well as name and title of individual providing catheter care must be documented.

Review of the clinical record indicated that Resident R15 was admitted to the facility on 11/7/23, with diagnoses that included paraplegia (a specific pattern of paralysis (which is when you can ' t deliberately control or move your muscles) that affects your legs) and stage 4 pressure ulcer (caused by prolonged pressure on the skin and results in skin and tissue loss with exposure of muscle, bones, tendons, or vital organs that develops from prolonged pressure to a direct area.)

A review of Resident R15's Minimum Data Set Assessment (MDS, periodic assessment of resident care needs) dated 2/9/24, indicated the diagnosis were current. Section H- Bladder and Bowel indicated the resident had an indwelling catheter.

A review of Resident R15's progress note dated 12/6/24, stated the resident returned from a appointment yesterday and a new 18 fr cudae (a catheter designed to maneuver around obstructions or blockages in the urethra (tube that connects the urinary bladder to the urinary meatus for the removal of urine from the body)). foley catheter was inserted. "PER MD continue with foley orders change foley Monthly."

A review of Resident R15's physician order dated 12/7/23, indicated to change the resident's 16 fr 10cc indwelling foley catheter in the morning every month starting on the 7th for 28 days. The order failed to include the correct size (18 fr cudae) of the catheter. The order was discontinued on 1/15/24.

A review of Resident R15's clinical record failed to include documentation that Resident R15's catheter was changed for the month of January 2024.

A review of Resident R15's physician order dated 2/4/24, indicated to change the resident's 16 fr 10cc indwelling foley catheter in the morning every month starting on the 18th for 28 days. The order failed to include the correct size of the catheter. The order was discontinued on 2/18/24. A review of Resident R15's physician order dated 2/4/24, indicated to change the resident's 16 fr 10cc indwelling foley catheter as needed. The order failed to include the correct size (18 fr cudae) of the catheter.

A review of Resident R15's clinical record failed to include documentation that Resident R15's catheter was changed for the month of February 2024.

During an interview and observation on 3/19/24, at 9:38 p.m. Resident R15 stated "They never changed my catheter." "I had it about 6-7 months. They tell you they change it whenever it goes bad. I was told you have to have doctor to change. I have asked them to change it, just like anything else around here." There was a large amount of sediment observed in Resident R15's catheter tubing.

During an interview on 3/20/24, at 9:41 a.m. Assistant Director of Nursing, Employee E11 stated catheter changes are normally ordered to be changed monthly. It was indicated there should be an order to change the catheter monthly and as needed. ADON, Employee E11 confirmed Resident R15's order was entered in correctly. ADON, Employee E11 confirmed she was unable to determine when Resident R15's foley catheter was last changed.

Review of Resident R15's undated care plan provided by the facility on 3/21/24, indicated the resident utilizes an indwelling urinary catheter related to urinary retention. It was indicated to change the catheter as per order.

During an interview on 3/21/24, at 1:12 p.m. the Director of Nursing (DON) stated he believed Resident R15's catheter was last changed in December at a Hospital. It was indicated the resident has a difficult anatomy and requires catheter changes to be completed outside of the facility.

During an interview on 3/22/24, at 10:31 a.m. the DON confirmed the facility failed to make certain that appropriate treatments and services were provided for the monthly change of a urinary catheter for one of two residents (Resident R15).

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

28 Pa code: 211.10 (c)(d) Resident care policies.

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


 Plan of Correction - To be completed: 04/18/2024

R15's indwelling catheter changed on 3/24/24 per physician order for size and frequency of the change.

Resident's with indwelling catheter orders reviewed with physician/practitioner for clarification of catheter orders if necessary.

Resident's with indwelling catheter orders reviewed routinely by Infection Control Preventionist for any clarification needed.

Education with licensed staff on F690 by the Director of Nursing/Designee on F690 with a focus on providing appropriate treatment and services regarding indwelling catheters being provided for the resident including the frequency of need to change the catheters.

Audits to be completed by the Director of Nursing/Designee on Resident's with indwelling catheter weekly X8 weeks.

Audit results will be submitted and reviewed at the quality assurance and performance improvement meetings

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Resident R107) and securely store oxygen for one of two storage locations.

Findings include:

Review of facility policy "Oxygen Administration" dated 1/15/24, indicated oxygen therapy via oxygen mask, nasal cannula (a lightweight tube placed in the nostrils to provide oxygen), and/or nasal catheter. Verify that there is a physician order for this procedure. Check that the tubing is connected to the oxygen and assure that it is free of kinks.

Review of the clinical record indicated Resident R107 was admitted to the facility on 1/10/24.

Review of Resident R107's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/9/24, indicated diagnoses of hypertension (high blood pressure), asthma (condition where the airways narrow and swell), and cancer (a disease caused by an uncontrolled division of abnormal cells in a part of the body).

Review of a physician's active orders dated 1/23/24, indicated to administer oxygen, two to five liters per minute, may titrate oxygen to maintain oxygen saturation greater than 90%. (Normal oxygen saturation is 95 % or above, some people with chronic lung disease can have normal levels around 90%).

Review of Resident R107's active physician orders failed to reveal an order to change oxygen respiratory tubing.

During an observation on 3/18/24, at 11:42 a.m. Resident 107 was sitting on the side of his bed receiving two liters per minute of oxygen via nasal cannula. No date was present on the nasal cannula tubing.

During an interview on 3/18/24, at 1:09 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that no date was present on Resident 107 ' s nasal cannula tubing.

During an interview on 3/22/24, at 9:46 a.m. the Director of Nursing confirmed that the facility failed to provide a policy concerning oxygen tubing. DON stated, "I cannot find an oxygen tubing policy specifically but the tubing gets changed every Sunday".

During an interview on 3/22/24, at 11:43 a.m. the Director of Nursing confirmed that the facility failed to provide appropriate respiratory care for one of one resident (Resident R107).

During an observation on 3/21/24, at 2:15 p.m. an estimated 140 full oxygen cylinders were observed outside the facility's laundry room behind a fenced in cage that was unsecured and unlocked. There was no lock present on the gate, the oxygen cylinders were easily accessible to anyone.

During an interview on 3/21/24, at 2:35 p.m. the Nursing Home Administrator confirmed the oxygen cylinders that were stored outside the laundry building were not secure and left unlocked. It was indicated maintenance brings in the oxygen cylinders depending on the supply on the floors. The NHA confirmed the facility failed to securely store oxygen for one of two storage locations (Outside Laundry Building).

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

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

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


 Plan of Correction - To be completed: 04/18/2024

R107's oxygen tubing was changed and dated. House audit was completed and all tubing dated properly
Residents on oxygen-orders reviewed for appropriate respiratory care orders including weekly tubing changes.

Education with licensed nursing staff on F695 with a focus providing respiratory care including weekly tubing changes.

Audits to be completed by the Director of Nursing/Designee weekly X8 weeks.
All O2 tubing is replaced and dated weekly

Audit results will be submitted and reviewed at the quality assurance and performance improvement meetings.

A lock was provided to secure and lock the fenced in area where the oxygen cylinders are stored.

Education with maintenance by the Administrator/Designee on F695 with a focus on storing oxygen.

Audits to be completed by the Director of Nursing/Designee randomly X8 weeks.
The outside O2 tanks are locked.

Audit results will be submitted and reviewed at the quality assurance and performance improvement meetings.

483.40 REQUIREMENT Behavioral Health Services:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations:

Based on review of clinical record review, and staff interviews it was determined that the facility failed to provide a resident with necessary behavioral interventions as ordered to maintain the highest practicable mental and psychosocial well-being for one out of eight sampled resident records (Resident R144).

Findings include:

Review of the facility's "Behavioral Assessment, Intervention and Monitoring" policy dated 1/15/24, indicated "the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care." Behavioral health services will be provided by qualified staff who have the competencies and skills necessary to provide appropriate services to the residents.

Review of Resident R144's admission record indicated Resident R144 was admitted on 1/26/24.

Review of Resident R144's MDS assessment (Minimum Data Set Assessment: A periodic assessment of resident care needs) dated 1/3/24, indicated she was admitted with the following diagnoses that included Depression, high blood pressure, and constipation. Resident R144's MDS assessment section C0200 Brief Interview for Mental Status ("BIMS", a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R3's BIMS score was a "14" indicating Resident R3 was cognitively intact.

Review of Resident R144's MDS assessment, dated 2/7/24, section D0150 Resident Mood Interview indicated that R144 answered "no" to the assessment questions. The questions include, "Do you have little interest or pleasure in doing things?" and "Are you feeling down, depressed, or hopeless? "

Review of Resident R144's progress note dated 2/15/24, indicated the resident stated he wanted a gun to kill himself. It was indicated the residents family and physician was notified. Nursing was made aware and "psychology was consulted."

Review of Resident R144's progress note dated 2/16/24, indicated the resident was seen for a follow-up for palliative care. It was indicated the resident "had an episode of saying "he wanted a gun to kill himself." It was indicated the patient denied any suicidal ideation or wanting to hurt others. It was indicated the social worker and psych were consulted

Review of Resident R144's clinical record revealed an absence note dated 2/17/24, from the psychological consult. It was indicated the reason for the absent visit was the resident was sleeping.

Review of Resident R144's clinical record failed to reveal any follow-up from psychology after 2/17/24.

During an interview on 3/20/24, at 11:23 a.m. Director of Social Services, Employee E2 indicated if a resident has suicidal ideation, a social worker would evaluate them and consult psychology services as needed. It was indicated if psychology misses a resident's appointment, it is expected that residents are followed up with at the next visit, or staff can ask psych to come sooner if needed. It was indicated psychology services are in the facility weekly to see residents. Director of Social Services, Employee E2 indicated the social work who oversees psych is on vacation.

Review of Resident R144's undated care plan provided by the facility on 3/21/24, indicated the resident was on antidepressant medication due to depression. The care plan failed to include interventions related to the resident's suicidal ideation.

During an interview on 3/21/24, at 9:43 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E9 confirmed Resident R144's care plan was not update to include his suicidal ideation.

During an interview on 3/21/24 at 10:08 a.m. LPN, Employee E5 confirmed Resident R144 was not followed up by psych since his missed appointment on 2/17/24.

During an interview on 3/21/24, at 1:22 p.m. the Director of Nursing confirmed psychology never followed up with Resident R144, and that the facility failed to provide residents with necessary behavioral healthcare, to maintain the highest practicable mental and psychosocial well-being for Resident R144 as required.

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

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

28 Pa. Code: 211.12 (d)(3)(5) Nursing Services.


 Plan of Correction - To be completed: 04/18/2024

R144 was assessed by the psychologist on 3/26/24 and per the evaluation the resident is to be managed for by psychiatrist and or medical physician. The resident with a BIMS of 14 was interviewed multiple times and does not recall making the statement. No further statements made regarding thoughts of suicide.

Resident's noted with verbalization of thoughts of suicide will be assessed to ensure safety as priority then resident's medical physician and psychiatrist to be consulted for plan of care moving forward.

Education with Social service and nursing supervisors by the Director of Nursing/Designee on F740 with a focus on providing a resident necessary behavioral intervention as ordered to maintain the highest practicable mental and psychological wellbeing.

Audits to be completed by the Director of Nursing/Designee weekly X8 weeks and residents verbalizing suicidal thoughts in the nursing notes.

Audit results will be submitted and reviewed at the quality assurance and performance improvement meetings.

205.6(a) LICENSURE Function of building.:State only Deficiency.
(a) No part of a building may be used for a purpose which interferes with or jeopardizes the health and safety of residents. Special authorization shall be given by the Department ' s Division of Nursing Care Facilities if a part of the building is to be used for a purpose other than health care.

Observations:

Based on facility records, observations and staff interview it was determined that the facility failed to notify the local State field office and request a modification for a new outpatient therapy and addiction center for ten out of 12 months (May 2023 through March 2024).

Findings include:

The facility "Nursing home addiction transfer agreement" indicated that the facility established a contract with the new outpatient addiction center on 5/1/23. The contract indicated that the outpatient therapy addiction center shared the same address as the nursing facility and agreed to comply with applicable Medicare and Medicaid statues.

During an interview on 3/18/24, at 9:59 a.m. the Nursing Home Administrator (NHA) stated: "The outpatient drug therapy service have front end of the building. Some of the residents come for group therapy. The therapists go up to do bedside service. They specialize in drug and alcohol therapy."

During an interview on 3/18/24, at 10:35 a.m. the Director of Social Services Employee E2 stated : " the outpatient drug and alcohol service has been here about three to four months. The services are coordinated by the Director of Nursing , myself and the Director of outpatient therapy addiction center Employee E3 ."

During an interview on 3/19/24, at 8:50 a.m. the Director of outpatient therapy and addiction center Employee E3 stated: "we have been in the building since July 2023 and I started in November 2023. We serve eight to nine nursing home residents."

Review of a listing of residents receiving services from the new outpatient therapy indicated that they provided therapy to the following residents: Residents R13, R18, R20, R26, R43, R51, R61, R62, R69, R91, R105, R114, R121, R122, and Resident R352.

Review of exceptions, waivers and modifications from March 2023 to March 2024 did not include a notification or request to add an outpatient therapy and drug rehabilitation center from the facility.

During an interview on 3/19/24, at 12:31 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to notify the local State field office and request a modification for a new outpatient therapy and addiction center in May of 2023 as required.


 Plan of Correction - To be completed: 04/25/2024

A modification to current outpatient waiver (Approved February 2013) will be submitted to state field office for outpatient addiction center.

Residents with a history of substance use disorder (SUD) will be assessed for risks including the potential to leave the facility without notification and use of illegal/prescription drugs. Care plan interventions will be implemented to include increased monitoring and supervision of the resident and their visitors

Upon admission the resident will be evaluated for the need and the willingness to participate in the drug and alcohol program.

Initial contact and referral to the outpatient counseling is completed by Social Service/Designee.

A safety policy for residents with substance use disorder was developed. Education provided to social service and nursing staff.

We will audit new admissions for referral to Legends once a week for 4 weeks.

Results will be reported to the quality assurance and process improvement meeting.
211.6(a) LICENSURE Dietary Services.:State only Deficiency.
(a) Menus shall be planned and posted in the facility or distributed to residents at least 2 weeks in advance. Records of menus of foods actually served shall be retained for 30 days. When changes in the menu are necessary, substitutions shall provide equal nutritive value.

Observations:

Based on observations, resident interviews, and staff interviews, it was determined the facility failed to post menus in the facility or distribute to residents at least two weeks in advance for all nursing units of the facility (2nd floor, 3rd Floor, 4th floor, 5th floor, and 6th floor).

Findings include:

Tour of the facility on 3/22/24, at 9:30 a.m., revealed current week (Week 1) of the menus were posted on all nursing units .

During an interview on 3/22/4, at 9:48 a.m. Resident R122 stated that she is not provided copies of the menu.

During an interview on 3/22/24, at 9:49 a.m. Resident R66 stated that he is not provided copies of the menu.

During an interview on 3/22/24,a t 9:54 a.m. Dietary Supervisor/ Cook Employee E4 confirmed that menus are not posted two weeks in advance as required.



 Plan of Correction - To be completed: 04/18/2024

2 weeks of menus have been posted.

Education with dietary manager/Designee by Administrator/Designee on P4920 with a focus on positing 2 weeks of menus in advance on the nursing units.

Audits to be completed by the Administrator/Designee randomly X8 weeks.
That the menus are posted

Audit results will be submitted and reviewed at the quality assurance and performance improvement meetings.


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