Pennsylvania Department of Health
LAUREL LAKES REHABILITATION AND WELLNESS CENTER
Patient Care Inspection Results

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LAUREL LAKES REHABILITATION AND WELLNESS CENTER
Inspection Results For:

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LAUREL LAKES REHABILITATION AND WELLNESS CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey completed on April 2, 2024, it was determined that Laurel Lakes Rehabilitation and Wellness Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.55(a)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in SNFs: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.
483.55 Dental services.
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

483.55(a) Skilled Nursing Facilities
A facility-

483.55(a)(1) Must provide or obtain from an outside resource, in accordance with with 483.70(g) of this part, routine and emergency dental services to meet the needs of each resident;

483.55(a)(2) May charge a Medicare resident an additional amount for routine and emergency dental services;

483.55(a)(3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility;

483.55(a)(4) Must if necessary or if requested, assist the resident;
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services location; and

483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay.
Observations:

Based on a closed record review, staff interviews, and policy review, the facility failed to assist the resident in obtaining and emergency dental services for one of 15 residents reviewed (Resident 13).

Findings include:

Review of the facility's policy, titled "Emergency Dental Care", last reviewed April 2007, stated emergency dental care is available on a 24 hour basis. Emergency dental services include services to treat broken, or otherwise damaged teeth.

Review of Resident 13's closed clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and dysphagia (difficulty swallowing).

Resident 13 was admitted to the facility on September 7, 2023, and discharged to home on February 8, 2024.

A review of the closed clinical record nursing note dated September 22, 2023, statesd, "lower dentures broken. Resident stated last night staff was cleaning them and accidentally dropped dentures on to the floor causing them to break in half. Call out to RR [Resident Representative] for update. No issues noted with meal this AM. MD made aware."

A review of the nutrition note dated October 26, 2023, stated "resident has broken bottom dentures and is requesting pureed textures for now from regular textures. Nursing will follow-up to get dentures fixed."

No additional progress notes were identified regarding the broken dentures.

A review of Resident 13's physician orders during his stay failed to reveal any dental visits for replacement of the dentures.

During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 1, 2024, they confirmed that the dentures were accidently broken by staff. They also confirmed that Resident 13 was sent to the dentist on December 18, 2023, for a final denture fitting and minor adjustment. The dental practice informed the facility at that time that the dentures are ready for pick-up upon final payment.

A review of correspondence dated March 30, 2024, from the dental practice revealed that Resident 13 has been calling the office everyday asking why he has not received his dentures. The dental practice also notified the facility regarding the non-payment and informed the facility they are going to report the concern to the Department of Health. The dental practice stated the dentures were broken on December 13, 2023, but the DON confirmed that the dentures were broken on September 22, 2023.

During an interview with the DON on April 2, 2024, the DON provided the correspondence sent by the NHA to the facility's corporate office. It was confirmed that the corporate office has not paid the bill to the dental practice as of April 2, 2024. It was also confirmed that correspondence to corporate by the NHA has been ongoing since the dentures have been ready for pick-up on December 18, 2023.

During an interview with the DON on April 2, 2024, the DON confirmed that Resident 13's dentures should have been received immediately after his visit and final adjustment.

28 Pa. Code 201.14(g)Responsibility of licensee
28 Pa. Code 211.10(c)Resident care policies


 Plan of Correction - To be completed: 04/23/2024

1. Payment for Resident 13's dentures have been made to the dental office.
2. A facility audit was completed and there are no other outstanding denture repairs requiring payment at this time.
3. The Nursing Home Administrator will re-educate the Business Office Manager and Assistant Business Office Manger on notifying the Nursing Home Administrator when resident denture repairs are completed, and payment not received within 14 days.
4. The Nursing Home Administrator or designee will complete audits on open dental invoices weekly X 4 to ensure denture repair payments are made in a time manner. The results of the audits will be reviewed at the monthly QA and A meeting.

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a significant change assessment was completed for one of four residents reviewed (Resident 8).

Findings include:

A review of Resident 8's clinical record on April 1, 2024, revealed diagnoses that included Paraplegia (the inability to voluntarily move the lower parts of the body) and Atrial Fibrillation (irregular and rapid heartbeat).

A review of Resident 8's usual weight range prior to January 1, 2024, was documented as 168.3 to 172.0 pounds.

A review of the clinical record for Resident 8 on April 1, 2024, revealed Resident 8 had a significant weight loss of 15 % in February 2024. Resident 8's weight on January 1, 2024, was 168.3 pounds, and on February 7, 2024, weighed 143.0 pounds.

Resident 8 was diagnosed with a stage 2 pressure ulcer (ulcer involving loss of the top layers of the skin) on February 21, 2024.

Resident 8 was weighed again on March 4, 2024, and weighed 134 pounds, an additional 9-pound weight loss.

A review of the clinical record on April 1, 2024, revealed no significant change Minimum Data Set (MDS - periodic assessment of resident's needs) was ever completed for Resident 8 for weight loss and development of the pressure ulcer.

Written correspondence from the facility on April 2, 2024, at 10:55 AM, stated that the facility decided on February 20, 2024, they would continue to monitor, implement interventions, and hold off on developing a significant change assessment.

During an interview with the Director of Nursing (DON) on April 2, 2024, at 1:30 PM, the DON confirmed that a significant change assessment should have been completed on Resident 8 for weight loss and development of the stage 2 pressure ulcer.

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


 Plan of Correction - To be completed: 04/23/2024

1. Resident 8 cannot have a significant change Minimum Data Set completed retroactively. Resident care plan was updated to address the significant weight loss and new pressure ulcer.
2. Minimum Data Set Coordinator or designee will obtain a list of residents with current weight loss and any new pressure ulcers to determine if a significant change in status Minimum data set is needed.
3. The Minimum data set (MDS) department staff will be re-educated on determining significant change in status based on the Resident Assessment Instrument manual criteria for determining a significant change.
4. The nursing and dietary department will report to the Minimum Data Set department weekly any residents with new pressure ulcers or weight loss. The Minimum Data Set staff will evaluate the resident and determine if significant change criteria are met or not. Minimum Data Set staff will document findings of their determination in the nursing progress notes and if an assessment reference date for a significant change assessment has been set. Audits for significant changes will be conducted weekly X 4. The results of the audits will be reviewed at the monthly QA and A meeting.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Based on staff interview, policy review, and facility investigation, it was determined that the facility failed to prevent potential accidents/hazards for controlled substances for one nursing unit (B Wing) and a wandering resident (Resident 11).

Findings include:

A review of the facility policy, titled "Controlled Substances", last revised April 2019, Line 4, stated, Access to controlled medications remains locked at all times; and Line 12, C. stated, Any discrepancies in the controlled substance count are documented and reported to the Director of Nursing immediately.

A review of the event investigation dated March 25, 2024, revealed that Employee 1 (Licensed Practical Nurse)
delivered and reconciled with Employee 2 (Licensed Practical Nurse) a card containing 30 tablets, 15 milligrams each tablet, of morphine (a non-synthetic narcotic with a high potential abuse and is derived from opium and is used for the treatment of pain). The delivery of the medication occurred on March 24, 2024, at approximately 7:30 PM.

Based on Employee 2's statement, the medication bag was placed on the medication cart pole because Employee 2 had to respond to resident wanting to return to bed. Employee 2 stated that, during the shift, she had forgotten the medication was not secured until she saw the pink slip that was delivered with the medication laying on top of her medication cart. Just prior to the end of her shift on March 25, 2024, at 6:00 AM, Employee 2 reached for the medication bag, but the card of morphine was not in the bag.

Employee 2 reported to Employee 3 on March 25, 2024, at 6:00 AM, that the morphine card was missing and Employee 3 stated she informed Employee 2 she will have to let the Supervisor know. Employee continued to look for the medications.

On March 25, 2024, at 6:35 PM, the Director of Nursing (DON) was notified that the morphine was missing. The DON informed the staff that she would be there in 20 minutes, and also informed the staff to check the rooms of the residents that wander the hall. While the DON was enroute, she received a call from the staff that the morphine card was found in Resident 11's bottom drawer of her bedside stand. Employee 2 added that eight of the morphine tablets were popped out of the card, and all but one tablet was found in the drawer and on the floor. The DON arrived and continued the search for the final morphine tablet, but it was never found.

Resident 11, along with her roommates, were assessed and there was no change in status.

Resident 11 had a BIMS (brief interview of mental status) of three, and unable to be interviewed.

Resident 10, who resides in the room and had a BIMS of 15, denied seeing Resident 11 with the medication.

Resident 14, who resides in the room, had a BIMS of 11 and denied seeing Resident 11 with the medication.

Resident 15, who resides in the room, had a BIMS of 5 and not able to be interviewed.

The physician was notified.

Employee 2's employment was officially terminated on March 26, 2024, for gross negligence in failing to secure the narcotics upon arrival to the unit. All licensed staff were re-educated on securing controlled substances at all times.

During an interview with the DON on April 2, 2024, the DON confirmed that the policy for securement of controlled substances was not followed and that notification to the DON was not timely.

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


 Plan of Correction - To be completed: 04/23/2024

1. Employee 2's employment has been terminated.
2. A facility audit was completed, and no other controlled substances were unsecured.
3. The Staff Development Coordinator or designee will re-educate current licensed nurses the policy entitled, "Controlled Substances" and the need to secure/lock-controlled substances immediately upon delivery from the pharmacy.
4. The Director of Nursing or designee will complete audits to ensure controlled substances are secured weekly X 4. The results of the audits will be reviewed at the monthly QA and A meeting.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:

Based on review of facility policy, facility investigation, and staff interview, it was determined that the facility failed to follow procedures to secure controlled medications on one of five nursing units (B Wing).

Finding include:

A review of the facility policy on April 2, 2024, titled, "Controlled Substances", last revised April 2019, stated that any discrepancies in the controlled substance count are documented and reported to the director of nursing (DON) services immediately; controlled substances are stored in the medication room in a locked container, separate from containers for any non-controlled medications; and the DON services investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties, and reports the findings to the administrator.

A review of the facility's event investigation dated March 25, 2024, revealed that Employee 1 (Licensed Practical Nurse) was delivered and reconciled with Employee 2 (Licensed Practical Nurse) a card containing 30 tablets with 15 milligrams each of morphine (a non-synthetic narcotic with a high potential abuse and is derived from opium and is used for the treatment of pain). The delivery of the medication occurred on March 24, 2024, at approximately 7:30 PM.

A review of the written statement by Employee 2 revealed that the morphine was never secured per the facility policy. Employee 2 stated that she hung the medication on the pole of the medication cart, and then realized it at the end of the shift the card of morphine was missing.

The card of morphine was found approximately 10 hours later in the bottom drawer of Resident 11's bedside stand, who frequently wanders on the unit. Eight of the pills were popped out of the card, and all but one of the pills were found.

Resident 11 and her roommates were assessed and no change in status was identified. The physician and pharmacy were notified.

Employee 2's employment was terminated on March 26, 2024, for failing to follow policy and failure to secure the morphine upon arrival.

All licensed staff were reeducated on the immediate securement of controlled substances, always maintain securement, and to report discrepancies immediately per policy.

During an interview with the DON on April 2, 2024, she confirmed that controlled substance should always be secured immediately upon arrival to the nursing units, and that what Employee 2 did was gross negligence and required immediate termination.

28 Pa. Code 211.19(a)(1)Pharmacy services
28 Pa. Code 211.12 (d)(3)(5) Nursing services


 Plan of Correction - To be completed: 04/23/2024

1. Employee 2's employment has been terminated.
2. A facility audit was completed, and no other controlled substances were unsecured.
3. The Staff Development Coordinator or designee will re-educate current licensed nurses the policy entitled, "Controlled Substances" and the need to secure/lock-controlled substances immediately upon delivery from the pharmacy.
4. The Director of Nursing or designee will complete audits to ensure controlled substances are secured weekly X 4. The results of the audits will be reviewed at the monthly QA and A meeting.


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