Nursing Investigation Results -

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

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LAUREL LAKES REHABILITATION AND WELLNESS CENTER
Inspection Results For:

There are  124 surveys for this facility. Please select a date to view the survey results.

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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 a Medicare/Medicaid Recertification, State Licensure and Civil Rights, and a complaint survey in response to one complaint completed on January 17, 2020, 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 Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.70 REQUIREMENT Administration: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.
483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Observations:


Based on a review of staffing and interview it was determined that the facility failed to meet the Pennylvania Department of Health's staffing regulations for the three week review.

Findings include:

Staffing was reviewed for December 22, 2019 through December 28, 2019, December 29, 2019 through January 4, 2020, and January 9, 2020 through January 15, 2020.

There were four days during the week of December 22, 2019 Through December 28, 2019 that staff hours per resident day fell below 2.70 as required by state regulation.

The average number of hours provided by the facility was 2.6 hours of care per resident day.

During an interview with the Nursing Home Administrator on January 17, 2020, at approximately 10:00 AM, and he stated that they are aware of the staffing shortage and continue to fill vacancies, as candidates apply, and are appropriate for the positions.

28 Pa. Code 211.12(i) Nursing services
Previously cited 12/2019

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




 Plan of Correction - To be completed: 02/25/2020

Facility Administrator, Director of Nursing and Nursing Scheduler will review the nursing schedule and staff deployment daily Monday through Friday, including projected weekend hours, to validate appropriate direct resident care hours. Adjustments will be made as necessary.
Facility residents have the potential to be affected by this practice.
Registered Nurse supervisors and nursing scheduler will be re-educated concerning these requirements, the calculation of hours and appropriate response to unplanned variation in hours. Direct care hours per resident will be audited and reported by the nursing scheduler to the Administrator and Director of Nursing during the daily staffing review. Audits will be conducted daily Monday through Friday for a period of three months.
The consolidated results of the audits will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.10(f)(10)(iv)(v) REQUIREMENT Notice and Conveyance of Personal Funds: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(f)(10)(iv) Notice of certain balances.
The facility must notify each resident that receives Medicaid benefits-
(A) When the amount in the resident's account reaches $200 less than the SSI resource limit for one person, specified in section 1611(a)(3)(B) of the Act; and
(B) That, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI.

483.10(f)(10)(v) Conveyance upon discharge, eviction, or death.
Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility must convey within 30 days the resident's funds, and a final accounting of those funds, to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law.
Observations:

Based on review of resident trial balance accounts and staff interview, it was determined that the facility failed to close residents' financial accounts within 30 days after discharge or death for four of 78 residents reviewed with resident trust accounts (Residents 166, 365, 366, 367).

Findings include:

Review of the facility's trial balance accounts effective January 14, 2020, revealed that Resident 166's date of death was November 6, 2019 and that a balance of $367.38 remained in the trial balance account as of the date of review. The facility failed to close the account and pay out the funds to the responsible party within thirty days of the resident's death.

Review of the facility's trial balance accounts on January 14, 2020, revealed that Resident 365's date of death was September 19, 2019 and that a balance of $958.67 remained in the trial balance account as of the date of review. The facility failed to close the account and pay out the funds to the responsible party within thirty days of the resident's death.

Review of the facility's trial balance accounts on January 14, 2020, revealed that Resident 366's date of death was December 5, 2019, and that a balance of $1,644.31 remained in the trial balance account as of the date of review. The facility failed to close the account and pay out the funds to the responsible party within thirty days of the resident's death.

Review of the facility's trial balance accounts on January 14, 2020, revealed that Resident 367's date of death was November 21, 2019 and that a balance of $.72 remained in the trial balance account as of the date of review. The facility failed to close the account and pay out the funds to the responsible party within thirty days of the resident's death.

An interview with the Nursing Home Administrator on January 16, 2020, at 1:11 PM, confirmed that the above funds were not distributed to the responsible party as required within thirty days of discharge.


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









 Plan of Correction - To be completed: 02/25/2020

Facility will close accounts, provide final statements and complete refunds for
residents 166, 365, 366, 367.
Business Office Manager or designee will conduct an audit of discharged resident accounts to validate timely conveyance of funds. Concerns will be addressed upon discovery.
Business office staff will be re-educated concerning these requirements. Administrator or designee will conduct an audit of discharged resident financial accounts weekly for three weeks and monthly for three months to validate timely conveyance of funds. Concerns will be addressed upon discovery.
Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

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



Based on observations and interviews it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Findings include:

Observation on January 12, 2020, at approximately 10:50 AM revealed the door at the rear of the building on the receiving dock, was a sliding door that was off the track and utilized as a swing door, once put back in the track there was a gap of approximately 1 inch (a unit of measure) between the 2 doors from the lower third of the door to the floor.

During an interview with Food Service Director 1 (FSD 1) on January 12, 2020, at approximately 10:55 PM it was revealed that the door has been broken, maintenance is aware and it is in the process of being fixed, the door is a special order, it takes 6-8 weeks for the doors to come in, and they should be installed this week or next.

During an interview with the Nursing Home Administrator on January 14, 2020, at approximately 3:00PM it was revealed that the doors don't operate automatically, staff manually open the door and must push it closed, but the doors do close, and there shouldn't be a gap.

Observation with the Nursing Home Administrator on January 16, 2020, at approximately 01:45 PM revealed the door to be closed with a 1 inch gap between the 2 doors. At that time the Nursing Home Administrator did open and close the door, then manually push the 2 doors together, and there still remained a gap of approximately 3/4 of an inch between the 2 doors.

During an interview with the Nursing Home Administrator on January 16, 2020, at approximately 01:45 PM it was revealed that maintenance has tried to replace the weather stripping and it no longer will stay affixed to the door.

Review of the pest control invoices for monthly service revealed that on the following dates it was noted "Receiving introduction point exit door doesn't close/seal properly, install/replace door sweep" for the following dates: December 17, 2019; November 21, 2019; October 24, 2019; July 22, 2019; June 26, 2019; and May 29, 2019. Further review of a pest control invoice dated May 29, 2019 revealed structural concerns: receiving (introduction point) exit door doesn't close/seal properly, door does not seal per maintenance director door will be replaced. Action needed: install/replace door sweep, install weather stripping."

Pa code 207.2 (a) Administrator's Responsibility









 Plan of Correction - To be completed: 02/25/2020

Replacement doors for the receiving dock were ordered on November 7, 2019 and installed on February 4, 2020.
Facility residents have the potential to be affected by this practice.
Plant operations staff will be re-educated concerning these requirements. Plant operations Director or designee will conduct an audit of dock door function weekly for three weeks and monthly for three months. Audit results will be reported to the Administrator. Concerns will be addressed upon discovery.
Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.60(i)(3) REQUIREMENT Personal Food Policy: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)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.
Observations:



Based on policy review, observations, and interviews it was determined that the facility failed to implement a policy for the use and storage of foods brought to residents by family/visitors to ensure safe and sanitary storage, and consumption in three of 5 unit pantries observed (Units A, B, and C).

Findings include:

Review of facility policy, Safe Food Handling, with revision date October 2, 2017, revealed "all foods and beverages in the facility that belongs to employees are stored in employee refrigerators or other designated areas and labeled with the employee's name and the date the item was placed in the facility storage area."
Review of facility policy Safe Handling of Food Brought In By Family/Friends for Patient/Resident Consumption, with revision date October 2, 2017, revealed "Foods are labeled to identify the patient/resident's name, container contents, and the date it was prepared. Food items are stored in disposable, tightly covered containers, or sealable plastic bags. Items will be stored for three days. Expired and unlabeled items will be discarded."

Observation in the A unit pantry on January 12, 2020, at approximately 11:00 AM revealed: one brown paper bag with 2 egg rolls, and a container of rice and a breaded chicken entree without a name or date; one open bag of celery without a name or open date; one open bag of mini carrots without a name or open date; one bottle of mango ice tea open without a name or date; one container of sliced deli turkey open without a name or open date, 2 containers of high protein nutritional shake, not supplied by the facility, without a name; one glass container of pasta salad without a name or date; 1 open bottle of ranch dressing without a name or open date; 1 open jar salsa con queso dip without a name or date; 1 open bag of fresh mixed vegetables without a name or date; 2 bottles of a cola product, not supplied by the facility, one opened, both without a name or date; 1 frozen pocket sandwich item without a name; one box of frozen pancake sausage on a stick without a name, one bag of frozen whole grain and vegetable medley without a name on it.

During an interview with Food Service Director 1 (FSD 1) on January 12, 2020, at approximately 11:14 AM it was revealed that pantry refrigerators are for staff and resident food items, however all items should have a name, a date or open date, and should be disposed of after 3 days.

Observation in the B unit pantry on January 12, 2020, at approximately 11:26 AM revealed: one bag of frozen French toast stick without a name; one box of frozen chicken fettuccini dinner without a name; one box clementine's, on the counter, that contained 9 clementine's without a name; and one sandwich bag of a cold cereal product without a label, name or date.

During an interview with Food Service Director 1 (FSD 1) on January 12, 2020, at approximately 11:28 AM it was revealed that the aforementioned items should be labeled with a resident's name and a date.

Observation in the C unit pantry on January 12, 2020, at approximately 11:35 AM revealed: one open bag of mini chocolate frosted doughnuts with a resident's name, and an expiration date of 12/15/19; two containers of chocolate chip cookie dough without a name; a store bought milk shake without a name or date; and one opened bottle of natural artesian water open without a name or date.

During an interview with Food Service Director 1 (FSD 1) on January 12, 2020, at approximately 11: 38 AM it was revealed that the aforementioned items should contain a name and a date; and the chocolate frosted doughnuts were expired, and should have been disposed of.

During an interview with the Nursing Home Administrator on January 15, 2020, at approximately 3:00 PM it was revealed that items in the pantries should contain a name and a date.


28 Pa Code 211.6(c) Dietary services.



 Plan of Correction - To be completed: 02/25/2020

Pantry items referenced were discarded upon discovery, according to policy.

Facility residents have the potential to be affected by this practice.

Facility staff will be re-educated concerning these requirements and safe food handling policies. Facility has designated routine responsibility for monitoring unit pantry food items to night shift nursing and dietary staff during pantry stocking. Dietary Manager or designee will conduct a random audit of nutrition pantries weekly for three weeks and monthly for three months to validate labeling and dating of food items. Audit results will be reported to the Administrator and Director of Nursing. Concerns will be addressed upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

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 observations, and interviews it was determined that the facility failed to store food in accordance with professional standards for food safety for one of one dry storerooms in the kitchen.

Findings include:

Observation on January 12, 2020, at approximately 10:10 AM in the dry storage room revealed one storage bin that contained brown sugar, and one storage bin that contained confectionery sugar, the tops of both bins contained a white and tan dried on sticky substance, and grains of white rice.

During an interview with Food Service Director 1 (FSD 1) on January 12, 2020, at approximately 10:45AM it was revealed that the lids to the aforementioned food storage bins should be cleaned.


28 Pa code 211.6(b)(d) - Dietary Services



 Plan of Correction - To be completed: 02/25/2020

Storage bins were cleaned upon discovery by the Dietary Manager.

Facility residents have the potential to be affected by this practice.

Dietary staff will be re-educated concerning these requirements and daily cleaning checklists by the Dietary Manager. Dietary Manager or designee will conduct a random audit of kitchen sanitation weekly for three weeks and monthly for three months, and report results to the Administrator. Concerns will be addressed upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs: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.
483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

483.45(d)(1) In excessive dose (including duplicate drug therapy); or

483.45(d)(2) For excessive duration; or

483.45(d)(3) Without adequate monitoring; or

483.45(d)(4) Without adequate indications for its use; or

483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
Observations:



Based on clinical record review, facility document review, and staff interview, it was determined that the facility failed to ensure residents received a psychoactive medication with proper monitoring, and adequate indication for use for one of eight residents reviewed for unnecessary medications (Resident 91).

Findings include:


Review of Resident 91's clinical record on January 14, 2020 at approximately 11:30 AM, revealed diagnoses including major depressive disorder (mental health disorder characterized by decreased enjoyment of pleasurable activities, decreased mood, possible sleep and appetite changes significant enough to impact daily life), and dementia (progressive, irreversible degenerative brain disease which results in decreased contact with reality and decreased ability to perform daily activities of living).

Review of Resident 91's clinical record revealed Resident 91 was admitted to the facility on October 19, 2019. Review of Resident 91's physician's orders revealed an order for Depakote Delayed Release (psychoactive medication used to treat seizures and mental health disorders), 125 milligrams (mg - metric unit of measure) by mouth each evening for polyneuropathy (pain caused by the nervous system in multiple areas) which was dated November 26, 2019.

Review of Federal Drug Administration's (FDA - Governmental body responsible for reviewing and approving medications for diseases and/or illnesses) revealed that polyneuropathy was not an FDA approved indication for the use of Depakote. Further, review of FDA document, "Depakote (divalproex sodium) Tablets for Oral use - FDA Approved Labeling Text dated October 7, 2011," stated, "Since [Depakote] may interact with concurrently administered drug which are capable of enzyme induction, periodic [blood] plasma concentration determinations of [Depakote] and concomitant drugs are recommended during the early course of therapy Review of Resident 91's clinical record revealed no blood laboratory test(s), nor any physician orders, for a blood Depakote level as of January 14, 2020.

During a staff interview on January 14, 2020 at approximately 11:00 AM, the Director of Nursing revealed that she could not recall the clinical rational for the use of Depakote for polyneuropathy for Resident 91. On January 15, 2020, at approximately 9:30 AM, the Director of Nursing submitted the abstract (summary of a research study) in support of the use of Depakote for polyneuropathy. Review of the information revealed no clear support for the use of Depakote for polyneuropathy.

During a staff interview on January 16, 2020, at approximately 11:30 AM, the Director of Nursing provided State Surveyors with an order for Resident 91 to have a laboratory blood test for the Depakote (Valproic acid) study the following day (January 16, 2020). The facility had no further information to provide regarding why there was not a laboratory study performed prior to January 16, 2020.



28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing Services.
Previously cited: 8/18/17,4/17/17

28 Pa. Code 211.9(k) Pharmacy Services.

28 Pa. Code 211.2 (a) Physician's Services.



 Plan of Correction - To be completed: 02/25/2020

A valproic acid level was obtained for resident 91 on 1/16/20, and her Depakote was discontinued on 1/17/20.

Director of Nursing or designee will audit current residents with orders for Depakote to validate appropriate indication for use and associated lab studies have been conducted as recommended by the Food and Drug Administration. Concerns will be corrected upon discovery.

Prescribing physicians and consultant pharmacist will be educated concerning these requirements and Food and Drug Administration recommendations concerning Depakote usage by the Director of Nursing or designee. Consultant pharmacist or designee will audit drug regimen of current residents monthly, provide recommendations for psychoactive medication utilization, and communicate them to the Director of Nursing and Administrator. Concerns related to Depakote utilization will be addressed upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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.
483.25(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:


Based on clinical record review, surveyor observation, and staff interviews it was determined that the facility failed to ensure the resident received care consistent with professional standards to prevent pressure ulcers for four of 58 residents reviewed (Resident 13, 22, 58 and 160).

Findings include:

Review of facility policy titled, "Skin and Wound Management: Wound Care," last reviewed August 15, 2019, revealed subsection 13 of, "Steps in the Procedure," stated, "Dress wound. Pick up sponge with paper and apply directly to area. Mark tape with initials, time, and date and apply to dressing."

Review of Resident 13's clinical record on January 13, 2020, at approximately 12:30 PM, revealed diagnoses including a Stage 4 pressure injury (a wound, typically over a bony prominence, that is caused by pressure and which involves loss of tissue do the point of underlying tissue structures such as bone and/or tendons and ligaments), and chronic pain.

During wound dressing change observations for Resident 13, on January 14, 2020, at approximately 10:32 AM, RN 2 was observed removing the old dressing. Observations of the old dressing revealed there was no tape and no markings of the nurses initials, time, nor date the prior dressing was placed. During a staff interview directly after the observation, RN 2 confirmed that there was no initials, date, or time observed on the old dressing; further RN 2 revealed that RN 2 did not place the wound dressing on the prior day. RN 2 further revealed that RN 2 was the facility's "Wound Nurse," (nursing staff in charge of assessing residents' wounds, communicating with the physician about wounds, and corroborating any care needed for the wound), it was her expectation that staff initial, time and date the dressing upon placing it.

During a staff interview on January 15, 2020, at approximately 2:30 PM, Director of Nursing revealed it was the facility expectation that staff date, time, and initial wound dressings when they are placed.

Review of Resident 22's clinical record revealed diagnoses that included muscle weakness (a condition when your full effort doesn't produce a normal muscle contraction or movement) and Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment).

Review of Resident 22's current physician orders revealed a physician order for: "Weekly Body Audit every day shift every Wed; 0-NO skin breakdown/no new area identified; 1- Newly identified area (progress note)."

Review of Resident 22's Treatment Administration Record (TAR) for the months of December 2019 and January 2020 revealed that since admission this treatment was marked with a check mark, indicating administered, and not with a 0-NO skin breakdown/no new area identified or 1- Newly identified area as was directed in the physician order.

Review of Resident 22's nursing progress notes revealed that there were no body audit progress notes written for the weeks of December 11, 2019 and December 25, 2019.

Interview with Director of Nursing on January 15, 2020 at 2:45 PM revealed that the facility has no written policy or procedure for conducting body audits.

Interview with Licensed Practical Nurse (LPN) 1 on January 16, 2020 at 11:10 AM revealed when conducting body audits, the audits are marked as "administered" on the TAR rather than 0-NO skin breakdown/no new area identified or 1- Newly identified area as was directed in the physician order because the Electronic Medical Record (EMR) does not allow for such an option. Because of this LPN1 says it is policy to write a follow up progress note documenting findings of the audit.

Interview with LPN2 on January 16, 2020 at 11:14 AM revealed that when conducting body audits she marks them as "administered" on the TAR and then proceeds to write a progress note with her findings.

Interview with Registered Nurse 1 on January 16, 2020 at 11:26 AM revealed that when conducting body audits the facility's LPNs are to document them as "administered" on the TAR and then write a progress note to document their findings.

During an interview with the NHA on January 16, 2020 at 1:12 PM he provided progress notes from Resident 22's EMR for the body audits that were conducted during the weeks of December 11, 2019 and December 25, 2019. The progress notes were created January 16, 2020 and the NHA revealed that they should have been labeled "Late Entry".

Review of Resident 58's clinical record revealed diagnoses that included Dysphagia (difficulty swallowing), Chronic Pain, History of Falling, Fracture of left Tibia (the inner and typically larger of the two bones between the knee and the ankle) and Fracture of Lower end of Right Femur (bone of the thigh).

Review of Resident 58's physician orders and administration documentation for a variety of orders directed to treating various pressure injuries from November 1, 2019, through January 14, 2020, revealed the following findings: Review of November 2019 TAR (Treatment Administration Record) revealed order for "Hinged knee brace left leg-keep locked in full extension-knee immobilizer right leg-Remove every shift to check skin integrity and for care. Every shift skin check" with a start date of November 7, 2019, and stop date of November 13, 2019. No documentation for this order was revealed for night shift of November 12, 2019, or the Day shift on December 9, 2019.

Review of Resident 58's December TAR revealed order for "Cleanse left inner buttock with wound cleanser, pat dry and apply hydrocolloid dressing (wafer type of dressing that contains gel-forming agents in an adhesive compound laminated onto a flexible, water-resistant outer layer) every day shift every 3 days' with noted start date of November 15, 2019, and stop date of December 17, 2019. Review of Resident 58's December 2019, TAR revealed that this care was not documented as completed on December 6 or 9, 2019.

Review of Resident 58's December TAR also revealed order "Right heel wound cleanse with wound cleaner and pat dry. Skin prep to periwound area. Apply honey gel and cover with foam. Apply skin prep to left heel for protection. Every day shift for open area" with a noted start date of November 26, 2019, and a stop date of December 31, 2019. Review of the TAR failed to reveal documentation of completion for December 5 and 9, 2019. This TAR also revealed order for "VS (vital signs) with progress note every day shift every Monday for eval (evaluation) of heel wound" with a noted start date of December 2, 2019 and no stop date indicated. Further review of this TAR failed to reveal documentation this order was completed on Monday December 9, 2019.

Review of Resident 58's December TAR also revealed order Santyl Ointment (prescription medicine that removes dead tissue from wounds so they can start to heal) 250 Unit/GM (gram) (Collagenase) apply to right heel topically every day shift for pressure injury use as directed under treatment with an indicated start date of January 1, 2020. Review of the TAR failed to reveal that this care was documented for January 3, 2020.

Further review of Resident 58's Janaury TAR revealed order for "Treatment to unstageable pressure injury on right heel every day shift for pressure injury cleanse with NORMAL SALINE ONLY Apply skin prep to peri-wound. apply santyl nickel depth covered with bordered gauze" with an indicated start date of January 1, 2020. Further review of this TAR failed to reveal administration documentation for this care on January 3, 2020.

During an interview with Director of Nursing (DON) on January 16, 2020, at approximately 1:30 PM, expectation was revealed that "if the care was provided she would expect there would have been documentation."


Review of Resident 160's clinical record revealed diagnoses that included paraplegia (impairment in motor or sensory function of the lower extremities) and pressure ulcer of left buttock (injury to the skin and its underlying tissue due to prolonged pressure on it).

Review of Resident 160's January 2020 physician order summary revealed an order for treatment to stage 4 pressure injury to left ischium (lower and back part of the hip bone) every day shift - cleanse with wound cleaner, apply skin prep (liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) to peri-wound, apply honey sheet, apply calcium alginate (natural wound care dressing), and cover with adhesive bordered foam. The order was effective October 23, 2019. Review of Resident 160's November 2019, December 2019 and January 2020 TAR (Treatment Administration Record - form used to document physician orders as well as when and how treatments are administered to a resident) revealed that this treatment was not documented as being completed on November 21, 2019, December 21 and 26, 2019, and on January 2, 2020.

Further review of Resident 160's January 2020 physician order summary revealed orders to cleanse left knee with wound cleanser, pat dry, and apply border gauze every day shift as well as an order to cleanse right thigh with wound cleanser and apply dry dressing until healed. Both orders were effective December 31, 2019. Review of Resident 160's January 2020 TAR revealed that neither of these treatments was documented as being completed on January 2, 2020.

Additional review of Resident 160's January 2020 physician order summary revealed orders to cleanse left outer leg wound with wound cleanser, pat dry, apply skin prep, allow to air dry, cover wound bed with either honey gel or impregnated gauze, and cover with border foam dressing. This order was effective December 29, 2019. Review of Resident 160's January 2020 TAR revealed that this treatment was not documented as being completed on January 2 and 5, 2020.

Review of Resident 160's January 2020 physician order summary also revealed an order for treatment to venous ulcer left lateral leg (sore on the leg that's very slow to heal, usually because of weak blood circulation in the limb) - cleanse with normal saline, apply skin prep, apply Santyl nickel depth (ointment used to remove dead tissue so wound can start to heal), cover with bordered gauze, change daily. This order was effective January 1, 2020. Review of Resident 160's January 2020 TAR revealed that this treatment was not documented as being completed on January 2, 2020.

Additional information regarding missing documentation for the aforementioned treatments was requested on January 16, 2020, at 1:11 PM, but was not provided by the conclusion of the survey.


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



 Plan of Correction - To be completed: 02/25/2020

Residents 13, 22, 58 and 160 were assessed by a Registered Nurse upon discovery and were not determined to have experienced adverse effects of the observations.
Facility residents requiring wound care have the potential to be affected by this practice.
Licensed nurses will be re-educated concerning dressing administration, body audit protocol and treatment administration documentation by the Director of Nursing. Wound care Registered Nurse will conduct a random audit of five treatments weekly for three weeks and monthly for three months to validate initialing and dating of dressings. Unit Managers or designee will conduct a random audit of five body audit orders and treatment administration records weekly for three weeks and monthly for three months to validate complete/accurate documentation of skin care. Audit results will be reported to the Administrator and Director of Nursing. Concerns will be addressed upon discovery.
Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:


Based on clinical record review and staff interview it was determined that the facility failed to notify the resident/resident representative and the representative of the Office of the State Long-Term Care Ombudsman of resident transfers in writing to include to include the following; the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman for seven of 32 resident records reviewed (Residents 5, 22, 72, 84, 129, and 157).

Findings include:
Review of Resident 5's clinical record revealed diagnoses that included heart failure (heart's inability to pump an adequate supply of blood) and chronic kidney disease (gradual loss of kidney function).

Review of nursing progress notes dated December 29, 2019, revealed that Resident 5 was transferred to the hospital for lethargy, loose stool, as well as nausea and vomiting and was subsequently admitted for observation.

Review of Resident 5's clinical record revealed that no letter was provided to the Resident/Resident representative regarding the transfer which included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred to, contact and address information for the Office of the State Long-Term Care Ombudsman, as well as information for the agency responsible for the protection and advocacy of individuals with intellectual or developmental disabilities and mental disorders or related conditions.

Notice of transfer for Resident 5's hospital transfer and admission which included the above information was requested on January 16, 2020, at 1:11 PM but was not provided by the conclusion of the survey.

Review of Resident 22's clinical record revealed diagnoses that included muscle weakness (a condition when your full effort doesn't produce a normal muscle contraction or movement) and Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment).

Review of nursing progress note dated January 1, 2020, at 9:26 AM, revealed Resident 22 was transferred to the hospital and subsequently admitted with pneumonia (an infection that inflames the air sacs in one or both lungs).

Review of Resident 22's clinical record revealed that no letter was provided to the Resident/Resident representative regarding the transfer and including the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred to, contact and address information for the Office of the State Long-Term Care Ombudsman, as well as information for the agency responsible for the protection and advocacy of individuals with intellectual or developmental disabilities and mental disorders or related conditions.

During an interview with Nursing Home Administrator (NHA) on January 16, 2020, at 9:34 AM, the NHA revealed that the required transfer information should have been provided.

Review of Resident 72's clinical record revealed diagnoses that included chronic kidney disease (gradual loss of kidney function) and Crohn's Disease of small and large intestines [Crohn's disease is an inflammatory bowel disease (IBD). It causes inflammation of your digestive tract, which can lead to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition].

Review of nursing progress notes dated December 26, 2019, revealed that Resident 72 was transferred to the hospital for acute febrile illness, to rule out sepsis and rule out intra-abdominal abscess.

During an interview with the facility and a review of the hospital transfer notice the following information was not provided in the transfer notice: reason for the transfer, effective date of the transfer, location to which the resident was transferred to, contact and address information for the Office of the State Long-Term Care Ombudsman, as well as information for the agency responsible for the protection and advocacy of individuals with intellectual or developmental disabilities and mental disorders or related conditions.

During an interview with the spouse and Resident 72 on January 17, 2019, the spouse confirmed they have received a transfer notice for all hospitalizations but that he never reads them.

During an interview with the Director of Nursing on January 15, 2020, at approximately 3:30 PM it was revealed that the facility's current transfer form fails to include the reason for the transfer, effective date of the transfer, location to which the resident was transferred to, contact and address information for the Office of the State Long-Term Care Ombudsman, as well as information for the agency responsible for the protection and advocacy of individuals with intellectual or developmental disabilities and mental disorders or related conditions, as required.

Review of Resident 84's clinical record revealed diagnoses that included: end stage renal disease (loss of kidney function), and diabetes (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine).

Further review of Resident 84's clinical record revealed a transfer to the hospital on October 22, 2019. Review of Resident 84's Transfer Form (a form that includes the resident's current medical information) dated October 22, 2019, failed to contain the following information: statement of the resident's appeal rights, and name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman.
Review of Resident 129's clinical record revealed diagnoses that included non-Hodgkin lymphoma (group of blood cancers with symptoms that can include enlarged lymph nodes, fever, night sweats, weight loss and tiredness) and cerebral infarction (area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain).

Review of nursing progress notes dated September 29, 2019, revealed that Resident 129 was transferred to the hospital on this date following a change in condition and was subsequently admitted with pneumonia.

Review of Resident 129's clinical record revealed that no letter was provided to the Resident/Resident representative regarding the transfer which included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred to, contact and address information for the Office of the State Long-Term Care Ombudsman, as well as information for the agency responsible for the protection and advocacy of individuals with intellectual or developmental disabilities and mental disorders or related conditions.

Notice of transfer for Resident 129's hospital transfer and admission which included the above information was requested on January 16, 2020, at 1:11 PM but was not provided by the conclusion of the survey.

Review of Resident 157's clinical record revealed diagnoses that included cerebral infarction (an area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain).

Further review of Resident 157's clinical record revealed transfers to the hospital on November 27, 2019, and December 28, 2019. Review of the Resident 157's Transfer Forms (a form that includes the resident's current medical information) dated November 27, 2019, and December 28, 2019; failed to contain the following information: statement of the resident's appeal rights, and name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman.

During an interview with the Director of Nursing on January 14, 2020 at approximately 3:15 PM it was revealed that the facility contacts the Resident Representative upon a resident's transfer to the hospital which is documented in the progress notes.

During an interview with the Director of Nursing on January 15, 2020, at approximately 3:30 PM it was revealed that the aforementioned transfer form is sent to the hospital with the resident.



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



 Plan of Correction - To be completed: 02/25/2020

Facility has reinitiated use of a resident transfer form that contains required information. Transfer dialogue for residents 5, 22, 72, 84, 129, and 157 is referenced as indicated in the progress notes.

Facility residents transferring from the facility have the potential to be affected by this practice.

Licensed nurses will be re-educated concerning these requirements by the Director of Nursing. Unit Managers or designee will conduct an audit of resident transfers weekly for three weeks and monthly for three months to validate transfer information was reviewed fully at the time of transfer and that a copy of the transfer form has been retained. Audit results will be reported to the Administrator and Director of Nursing. Concerns will be addressed upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.10(f)(10)(vi) REQUIREMENT Surety Bond-Security of Personal Funds: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(f)(10)(vi) Assurance of financial security.
The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility.
Observations:

Based on record review and interview, it was determined that the facility failed to maintain a surety bond (a guarantee that protects the resident's fund amount against losses resulting from the facility's failure to meet the obligation) in a sufficient amount to protect resident funds for two of two months reviewed (November and December 2019).

Findings include:

Review of the facility surety bond on January 15, 2020, revealed that the facility had a bond in the amount of One hundred thousand dollars ($100,000.00), dated effective August 1, 2019.

A review of the bank statement dated November 1, 2019, to November 30, 2019, revealed that on November 1, 2019 through November 5, 2019, the ledger balance exceeded the amount of the surety bond. The highest ledger balance during this time frame was one hundred seven thousand, five hundred eighteen dollars and eighty-five cents ($107,518.85).

A review of the bank statement dated December 1, 2019 to December 31, 2019, revealed that on December 1, 2019 through December 5, 2019, the ledger balance exceeded the amount of the surety bond. The highest ledger balance during this time frame was one hundred eleven thousand, six hundred forty-one dollars and eighty-nine cents ($111,641.89)

During an interview with the Nursing Home Administrator on January 16, 2020, at 1:11 PM PM he confirmed that the surety bond was not in a sufficient amount to cover the resident trust fund account balance.


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









 Plan of Correction - To be completed: 02/25/2020

Facility surety bond amount was increased to $160,000 on January 17, 2020.

Facility residents have the potential to be affected by this practice.

Business office staff will be re-educated concerning these requirements, including appropriate communication of anticipated ledger balances to ensure surety bond adequacy. Administrator or designee will conduct an audit of trust fund accounting monthly to validate surety bond adequacy. Concerns will be addressed upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

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 surveyor observations, review of select facility documents and staff interviews, it was determined that the facility failed to ensure that resident needs were accommodated regarding accessibility of call bells for two of 32 residents reviewed (Residents 20 and 105).

Findings include:

Review of Resident 20's clinical record revealed diagnoses that include Muscle Weakness, Severe Obesity, Left Above Knee Amputation and Anxiety Disorder (a group of mental disorders characterized by significant feelings of anxiety and fear; anxiety is a worry about future events, and fear is a reaction to current events; the feelings may cause physical symptoms, such as a fast heart rate and shakiness).

Review of Resident 20's Admission Minimum Data Set ( MDS- assessment tool used to determine resident's care and services needs) dated for October 30, 2019, revealed that the resident is cognitively intact as is coded a 15 out 15 with coding of 15 being the highest level.

Review of Resident 20's current active Care Plan (no identified date of creation) revealed a care Focus area of "At risk for falls due to muscle weakness, ... actual fall" with an associated Intervention of "Call bell in reach" with a noted Date Initiated of November 5, 2019."

During an interview with Resident 20 in her room on January 12, 2020, at 12:00 PM, resident requested surveyor to hand her the call bell, stating it had fallen on the floor "a while ago." It was observed, while honoring this request, that the cord was caught up behind her dresser back leg and that the dresser needed to be moved in order to retrieve the call bell for resident to be able to use it.

During an interview with Director of Nursing (DON) on January 14, 2020, at 3:11 PM, the expectation was revealed that Resident 20's call bell should have been accessible.

Review of Resident 105's clinical record revealed diagnoses that include Cerebral Infarction (an area of necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain) and hypertension (elevated blood pressure).

During an interview with Resident 105 in her room on January 12, 2020, at 10:30 AM, the resident was asked if she could reach her call bell that was dangling from the wall at the side of her bed and she stated "no." Staff NA 3 was requested to view dangling call bell and she stated the call bell should be within reach of the resident and attached it to Resident 105's bed within reach.

During an interview with Director of Nursing (DON) on January 14, 2020, at 2:56 PM, the expectation was revealed that Resident 105's call bell should be within reach of the resident.



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








 Plan of Correction - To be completed: 02/25/2020

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Laurel Lakes Rehabilitation & Wellness Center agrees with the allegations and citations listed on the statement of deficiencies. Laurel Lakes Rehabilitation & Wellness Center maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Laurel Lakes Rehabilitation & Wellness Center's written credible allegation of compliance.

By submitting this plan of correction, Laurel Lakes Rehabilitation & Wellness Center does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Laurel Lakes Rehabilitation & Wellness Center reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

Call lights for residents 20 and 105 were placed within reach as indicated upon discovery.

Facility residents have the potential to be affected by this practice.

Facility staff will be re-educated concerning the requirement to have call lights accessible by the Director of Nursing. Unit Managers or designee will conduct a random audit of call light accessibility weekly for three weeks and monthly for three months. Audit results will be reported to the Director of Nursing. Concerns will be addressed upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly: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.
483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:


Based on observation and interviews it was determined that the facility failed to ensure that waste is properly contained in the dumpster, and that the area surrounding the dumpster is free from debris for one of two dumpsters observed.

Findings include

Observation of the receiving/trash removal area on January 12, 2020, at approximately 10:25 AM revealed an open dumpster that was filled with trash piled 2 to 3 feet above the top opening of the dumpster; several trash bags were torn open with exposed soiled briefs not covered. To the left of the aforementioned dumpster was observed a trash compactor/dumpster with the doors closed.

During an interview with Food Service Director 1 (FSD 1) on January 12, 2020, at approximately 10:55 AM it was revealed that the trash compactor was broken, and the Nursing Home Administrator had ordered another dumpster to be utilized for trash until the trash compactor was fixed. It was also revealed that the trash should be covered and should not be above the top of the dumpster.

Observation of the receiving/trash removal area on January 12, 2020, at approximately 12:49 PM revealed an open dumpster that was filled with trash piled 2 to 3 feet above the top opening of the dumpster; several trash bags were torn open with exposed soiled briefs not covered.

During an interview with Maintenance Director 1 (MD 1) on January 12, 2020, at approximately 12:49 PM revealed that the trash compactor was not working and the aforementioned dumpster was brought in to be utilized for trash. It was also revealed that the trash compactor was functioning at the time of the aforementioned observations, however the refuse company wouldn't pick up the trash in the open top dumpster until all trash is below the line at the top of the trash receptacle.



 Plan of Correction - To be completed: 02/25/2020

The temporary dumpster was removed on January 14, 2020.
Facility residents have the potential to be affected by this practice.
Facility staff will be re-educated concerning the requirement to maintain appropriate outside refuse storage and a dumpster area free of debris. Administrator of designee will conduct a random audit of the dumpster area weekly for three weeks and monthly for three months to validate appropriate refuse storage. Concerns will be addressed upon discovery.
Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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.
483.60(d) Food and drink
Each resident receives and the facility provides-

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

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


Based on observation, and interview it was determined that the facility failed to provide food and beverage that are palatable, and at a safe and appetizing temperature for one of one meal observed on the 300 hallway.

Findings include:

On January 13, 2020, during several resident interviews concerns were voiced pertaining to food temperatures during meal service.

A test tray was completed on January 14, 2020, in the B/C unit dining room upon completion of meal service at approximately 12:24 PM. Test tray temperatures were taken by Food Service Director 1 (FSD1) on January 14, 2020, at approximately 12:25 PM at the B unit nursing station, and revealed the following:

Wing Dings, 105.4 degrees Fahrenheit, palatable for temperature
Sweet Potato Tater Tots, 113 degrees Fahrenheit, not palatable for temperature
Coleslaw, 36 degrees Fahrenheit, palatable for temperature
Apple juice, 52 degrees Fahrenheit, not palatable for temperature
Pudding, 44 degrees Fahrenheit, palatable for temperature
Coffee, 154 degrees Fahrenheit, palatable for temperature.


During an interview with the FSD1 on January 14, 2020, at approximately 12:40 PM it was revealed that food and beverages should be served at palatable temperatures.

During an interview with the Nursing Home Administrator on January 14, 2020, at approximately 3:00 PM it was revealed that food and beverages should be served at palatable temperatures.


28 Pa code 211.6(b)(d) - Dietary Services





 Plan of Correction - To be completed: 02/25/2020

The observation identified was from a test tray at the time of the last service to a resident. No resident was involved in the observation.

Facility will conduct a tray temperature check at the point of last service in the three dining areas to validate appropriate warming table function. Concerns will be corrected upon discovery.

Facility has designated supplemental personnel to assist with meal delivery timeliness. Nursing and dietary staff will be educated concerning prompt tray delivery by the Administrator or designee. Dietary manager or designee will audit 2 trays per meal to validate appropriate food temperatures at the point of last service weekly for three weeks and monthly for three months. Issues identified will be corrected at the time of discovery. Administrator will review audit results.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

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 clinical record review and staff interview it was determined that the facility failed to ensure the presence of adequate medical justification/diagnosis for use of an antipsychotic drug, duplicate drug therapy, and PRN antipsychotic drug for two of 5 residents reviewed (Residents 97 and 144) .

Findings include:

Review of Resident 97's clinical record on January 13, 2020, at approximately 2:00 PM, revealed diagnoses including dementia (irreversible, progressive degenerative disease of the brain the results in decreased reality contact and daily functioning) and psychotic disorder (mental health disorder characterized by irrational thoughts, hallucinations and/or delusions).

Review of Resident 97's physician orders revealed an order for Ativan (psychoactive medication used to treat anxiety) 0.25 milligrams (mg - metric unit of measure) sublingually (under the tongue) every 4 hours as-needed for anxiety/agitation. Review of the order revealed the order and start date of the medication was October 25, 2019.

Review of the clinical record revealed no clinical rational was provided by the physician as to why the as-needed medication had been ordered beyond 14 days. Review of Resident 97's clinical record on January 14, 2020, at approximately 10:30 AM, revealed that the December pharmacy medication regimen record review had the recommendation which alerted the physician that Resident 97's as-needed Ativan order my not has been compliant with the Centers for Medicare and Medicaid Services (CMS) regulation.

Review of Resident 97's clinical record on January 16, 2020, at approximately 9:30 AM, revealed that the physician signed the medication regimen review recommendation on January 15, 2020.

During a staff interview on January 16, 2020, at approximately 1:10 PM, the Nursing Home Administrator revealed that Resident 97's as-needed Ativan order should have been ordered for 14 days, or a clinical rational provided by the physician if the order extended beyond 14 days.

Review of Resident 144's clinical record revealed diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and Psychotic Disorder with Hallucinations (severe mental disorders that cause abnormal thinking and perceptions; persons with psychoses lose touch with reality; two of the main symptoms are delusions and hallucinations) and Major Depressive Disorder (is characterized by a persistent feeling of sadness or a lack of interest in outside stimuli).

Review of Resident 144's Physician's Orders active as of December 20, 2020, revealed orders for "Mirtazapine 30 mg (milligrams) TAB Give 1 tablet orally at bedtime related to Major Depressive Disorder" with an indicated start date of August 27, 2020; "Zoloft tablet 50 MG (Sertraline HCL) give 1 tablet by mouth one time a day related to Major Depressive Disorder" with a start date of December 17, 2019, and "Zyprexa tablet 5MG (Olanzapine) Give 1 tablet by mouth in the morning for Major Depressive Disorder."

Review of a facility Report of Consultation form completed by a Med Options (outside contract provider of behavioral health services to skilled nursing and assisted living facilities) CRNP (Certified Registered Nurse Practioner) dated November 6, 2019, revealed a recommendation to decrease Zoloft to 25 mg daily and to correct the diagnoses for Zyprexa "Zyprexa is psychotic ...due to another medical condition, with hallucinations..." Review of Resident 144's clinical record (clinical progress notes and Medication/Treatment Administration Records) revealed one progress note from November 1, 2019, through January 16, 2020, for a documented event of a behavior which was dated December 30, 2019, in a medication administration note and read "Resident spit pills back out and swatted the spoon away when attempting to administer meds."

In summary, as of January 16, 2020, Resident 144 continued to have three different medications prescribed for Major Depressive Disorder, and whereby the Zyprexa, despite recommendation otherwise, continues to have Major Depressive Disorder written as diagnoses to medically justify its use and also facility did not provide information regarding physician addressing recommendation to decrease Zoloft.

Facility did not provide any additional comment by the conclusion of the survey.


28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing Services.
Previously cited: 8/18/17,4/17/17

28 Pa. Code 211.9(k) Pharmacy Services.

28 Pa. Code 211.2 (a) Physician's Services.

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



 Plan of Correction - To be completed: 02/25/2020

Resident 97s Ativan order and resident 144s Zyprexa and Zoloft orders were clarified upon discovery.

Director of Nursing or designee will review the latest consultant pharmacist drug regimen review and validate that recommendations for psychotropic indication of use, gradual dose reduction and clinical justification for Pro Re Nata psychotropic orders greater than 14 days have been appropriately addressed. Concerns will be corrected upon discovery.

Licensed nurses will be educated concerning these requirements by the Director of Nursing or designee. Director of Nursing or designee will conduct a random audit of psychotropic medication orders weekly for three weeks and monthly for three months to validate appropriate order structure and clinical rationale for use. Audit results will be communicated to the Administrator. Concerns will be addressed upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

483.45(c)(2) This review must include a review of the resident's medical chart.

483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:


Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the licensed pharmacist's report of a medication irregularity was reviewed and acted upon for one of 5 residents reviewed for unnecessary medications (Resident 160).

Findings include:

Review of facility policy, "Consultant Pharmacist Monthly Reports," dated October 23, 2019, revealed, "The consultant pharmacist provides administration a report each month reviewing the facility's use of medication. Administration disseminates the reports to the nursing and medical staff. After the reports are acted upon, administration reviews the reports to verify that sufficient action has been taken on the reports....The consultant pharmacist reviews the nursing unit each month. Findings and comments regarding the review are documented in a monthly report...All information requiring staff follow-up are included in a monthly report...Monthly reports are typed and provided to the facility in a spreadsheet...A second report is generated for the medical staff...The physician may agree or disagree with the consultant pharmacist. Should the physician agree, then a correlating order or comment should be made. If the physician does not agree with the consultant pharmacist, then the physician must document the reason why on the appropriate form. Nurses should act upon the consultant pharmacist comments on the bottom of the spreadsheet that require nursing assessment or intervention...Nurses should document on the spreadsheet that action has been done. This can be done by simply initialing the item on the report. Consultant pharmacist reports that have been completely reviewed by the nursing staff and acted upon should be returned to the Director of Nurses and Administrator."

Review of Resident 160's clinical record revealed diagnoses that included paraplegia (impairment in motor or sensory function of the lower extremities) and major depressive disorder (mental disorder characterized by at least two weeks of low mood that is present across most situations).

Review of pharmacy Medication Regimen Review tracking form revealed that the pharmacist reviewed Resident 160's medication regimen on June 23, 2019, and on July 10, 2019. For each of these dates the pharmacist indicated with a check mark, "See report for any noted irregularities and/or recommendations."

Pharmacy recommendations with physician response that corresponded with the above review dates were requested on January 15, 2020, and again on January 16, 2020, at 1:11 PM, but were not provided by the conclusion of the survey.

Review of pharmacy Drug Regimen Review form revealed the following suggestions/ recommendations were made by the consulting pharmacist: Imdur (used to treat chest pain in patients with certain heart conditions) timing change to "upon arising" was suggested September 20, 2019, CBC (Complete Blood Count) lab test due to iron supplement usage was suggested October 18, 2019, CBC due to iron supplement usage was again suggested December 18, 2019, placing limits on duration of use of nitroglycerin (used to relieve chest pain in persons with certain heart conditions) was suggested on December 18, 2019, clarification of diagnosis for Risperdal (antipsychotic medication) was suggested on December 18, 2019, and clarification of the dosage for Morphine Sulfate (opioid pain medication) was also suggested on December 18, 2019.

Physician response to the aforementioned recommendations was requested on January 15, 2020, and again on January 16, 2020, at 1:11 PM but was not provided by the conclusion of the survey.


28 Pa. Code 211.2(a) Physician services.

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



 Plan of Correction - To be completed: 02/25/2020

Resident 160s orders for Risperdal, nitroglycerin and morphine sulfate were clarified with the physician on 1/15/20. Follow up laboratory testing was interpreted by the physician on 1/22/20, with no associated new orders and noting stable status.

Director of Nursing or designee will review the latest consultant pharmacist drug regimen review and validate physician response to her recommendations. Concerns will be corrected upon discovery.

Nursing leadership will be re-educated concerning these requirements and the Consultant Pharmacist Monthly Reports protocol by the Director of Nursing. Director of Nursing or designee will cross reference monthly reviews with physician response according to policy monthly to validate recommendations have been acted on and will report audit results to the Administrator. Concerns will be addressed upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

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 clinical record review, staff and resident family interview, it was determined that the facility failed to ensure psychological services were provided for one of one residents reviewed (Resident 91). Findings include:

Review of Resident 91's clinical record on January 14, 2020 at approximately 11:30 AM, revealed diagnoses including major depressive disorder (mental health disorder characterized by decreased enjoyment of pleasurable activities, decreased mood, possible sleep and appetite changes significant enough to impact daily life), and dementia (progressive, irreversible degenerative brain disease which results in decreased contact with reality and decreased ability to perform daily activities of living).

Review of Resident 91's clinical record revealed that Resident 91 was admitted to the facility on October 19, 2019.
Review of Resident 91's physician orders revealed an order provided via phone, dated November 26, 2019 for psychiatric (mental health) consultation.

During a family interview on January 13, 2020, at approximately 1:03 PM, Resident 91's family member relayed that, to the best of their knowledge, there had not been any psychiatric consultations since admission.

Review of Resident 91's clinical record revealed that there had been no psychatric referral, nor a psychiatric evaluation as of January 14, 2020.

During a staff interview on January 15, 2020, at approximately 12:00 PM, the Director of Nursing revealed that the facility did have services provided to residents for psychiatric services through, Medoptions.

As of January 16, 2020, at 1:00 PM, the facility did not provide any further information regarding Resident 91's psychiatric consultation that was ordered on November 26, 2020.



28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing Services.
Previously cited: 8/18/17,4/17/17

28 Pa. Code 211.2 (a) Physician's Services.




 Plan of Correction - To be completed: 02/25/2020

Resident 91 will receive a consultation with facility contracted psychiatric services provider.

Social Services Director or designee will audit active residents with a psychiatric services consult order to validate service provision. Concerns will be corrected upon discovery by scheduling with the provider.

Director of Nursing or designee will identify new physician orders for psychiatric services Monday-Friday during clinical morning meeting and communicate them to the Director of Social Services. Director of Social Services will notify the contracted psychology services provider, validate the contracted services provider's caseload list for inclusion and validate consults occurred as ordered on a tracking log. Social services staff and nursing managers will be educated on this protocol. Administrator or designee will audit psychiatric services consult tracking log weekly for three weeks and monthly for three months. Concerns will be addressed upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

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

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

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

Based on review of facility records it was determined that the facility failed to maintain acceptable parameters of nutritional status when it failed to communicate the results of weight assessments to the attending physician for two of 12 residents reviewed for nutrition (Residents 13 and 97).

Findings include:

Review of facility policy titled, "Subject: Physician Communication/Change in Condition," last revision 7/1/2016, revealed it stated that the facility staff were to, "Complete [an] assessment of the resident/patient...," complete an "SBAR," (standardized form that includes the residents' situation, background information, assessment findings, and recommendations). Review of the policy revealed that when a resident had a change in condition the staff were to, "Notify the physician of the change in medical condition. [sic] The nurse will document all assessments and changes in the patient's/resident's condition in the medical record." Further, staff were to notify the residents' family member/legal representative of the change and that, "All attempts to notify physicians and family members/legal representatives will be thoroughly documented in the patient's/resident's medical record."

Review of Resident 13's clinical record on January 13, 2020, at approximately 2:10 PM, revealed diagnoses of stage IV pressure (a wound, typically over a bony prominence, that is caused by pressure and which involves loss of tissue to the point of underlying tissue structures such as bone and/or tendons and ligaments), and hypertension (elevated/high blood pressure).

Review of Resident 13's weight assessments revealed that on October 12, 2019, Resident 13 was assessed for an initial weight and documented as weighing 213.3 pounds. Review of documented weight on January 7, 2020 was 190.1 pounds which represented a significant weight loss of 10.88% in three months.

Review of Resident 13's clinical record on January 13, 2020 revealed the no note(s) nor order(s) by nursing, dietary, or physician staff addressing Resident 13's significant weight loss.

On January 15, 2020, at approximately 9:45 AM, the facility provided a progress note documented on January 14, 2020 at 2: 05 PM by Registered Dietician 1 (RD 1), which noted a weight loss during the prior month but did not account for the significant weight loss of 10.88% during the prior three months.

Review of Resident 13's clinical record revealed that no significant weight loss was communicated with the attending physician, nor was there any further information regarding Resident 13's weight loss documented after the progress note entered by RD 1 or any nursing/administrative staff.

As of January 16, 2020, at approximately 1:00 PM, the facility did not provide any further information regarding identification of a significant weight loss on or around January 7, 2020, nor any further information regarding notification of the attending physician.

Review of Resident 97's weight history revealed that on October 16, 2019 Resident 97 was weighed at 87.6 pounds. On November 13, 2019, at 9:59 AM, a weight for Resident 97 was documented as 79.2 pounds which indicated a 9.5% weight loss which was considered a significant weight loss. Review of Resident 97's interdisciplinary progress notes revealed that Registered Dietician 1 (RD 1) identified Resident 97's weight loss in a November 13, 2019 progress note. Review of RD 1 note, and Resident 97's clinical record revealed no identified communication of the significant weight loss to the attending physician.

On November 23, 2019, a weight was documented for Resident 97 which was documented as 87.6 pounds. On November 26, 2019, Director of Nursing struck out the November 13, 2019 weight of 79.2 pounds and documented, "Incorrect documentation," however no further explaination as to how the facility determined that the weight on November 13, 2019 of 79.2 pounds was incorrect was found or provided by the facility. Review of Resident 97's progress notes revealed no progress note regarding the struck out weight documented on November 13, 2019. On December 11, 2019, 17 days after the Director of Nursing struck out the weight of 79.2 pounds and had been reviewed by the dietician and identified as significant weight loss, a weight of 77.4 pounds was documented for Resident 97 which was a decrease of 10.2 pounds from both the October 16, and November 23, 2019 weight of 87.6 pounds. The weight documented on December 11, 2019 indicated a significant weight loss of 11.6%. On January 8, 2020, Resident 97 had a documented weight of 77.2 pounds.

Review of Resident 97's clinical record on January 14, 2020, at approximately 10:00 AM, revealed no information or documentation, including dietician review, physician notification and review, nor nursing and/or dietary assessment/review/interventions were made.

As of January 16, 2020, at approximately 1:00, the facility did not provide any further information regarding notification of the attending physician of Resident 97's identified significant weight change.



28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing Services.
Previously cited: 8/18/17,4/17/17



 Plan of Correction - To be completed: 02/25/2020

Physician was notified of resident 13s weight change, and resident is now on hospice caseload with an order for no further weights. Physician will be notified of resident 97s weight change and additional nutritional interventions implemented.

Director of Nursing or designee will review current month resident weight records and validate attending physicians have been notified if a significant change is indicated. Concerns will be corrected upon discovery.

Licensed nurses will be re-educated concerning these requirements and the electronic medical record weight change alert process by the Director of Nursing. Unit Managers or designee will conduct an audit of weight change alerts weekly for three weeks and monthly for three months to validate physician notification and appropriate intervention. Audit results will be reported to the Administrator and Director of Nursing. Concerns will be addressed upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on observation, clinical record review, and interviews it was determined that the facility failed to review and revise the resident plan of care for two of 32 residents reviewed (Resident 97, and 150).

Findings include:

Review of Resident 97's clinical record on January 13, 2020, at approximately 2:00 PM, revealed diagnoses including dementia (irreversible, progressive degenerative disease of the brain the results in decreased reality contact and daily functioning) and psychotic disorder (mental health disorder characterized by irrational thoughts, hallucinations and/or delusions).

Review of Resident 97's weight history revealed that on October 16, 2019 Resident 97 was weighed at 97.6 pounds. On November 13, 2019, at 9:59 AM, a weight for Resident 97 was documented as 79.2 pounds which was an 18.9% weight loss which was considered a significant weight loss. Review of Resident 97's interdisciplinary progress notes revealed that Registered Dietician 1 (RD 1) identified Resident 97's weight loss in a November 13, 2019 progress note. Review of Resident 97's quarterly Minimum Data Set (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial needs), dated November 23, 2019 revealed that assessment question, K0300, "[Has the resident had weight] loss of 5% or more in the last month or loss of 10% or more in the last 6 Months?" was answered as, "Yes, [the resident was] not on a physician-prescribed weight loss regimen."

Review of Resident 97's weight history revealed that on November 23, 2019, at 11:39 AM, a weight of 87.6 pounds (the same amount documented on October 16, 2019). Review of the weight documentation further revealed that on November 26, 2019 the weight documented on November 13, 2019 was "Struck out" by the Director of Nursing at 1:16 PM with a statement of, "Incorrect Documentation. However, subsequent weights documented on December 11, 2019 at 7:14 AM and January 8, 2020 at 11:21 AM, revealed resident's weight was assessed as 77.4 and 77.2 respectively.

During a staff interview on January 15, 2020, at approximately 2:30 PM, Director of Nursing could not recall why the November 13, 2019 weight of 79.2 pounds was struck out as incorrect documentation. Review of Resident 97's clinical record, including the interdisciplinary progress notes, for dates between October 16, 2019 and January 13, 2020, revealed no change was made to Resident 97's plan of care, further no changes to address the weight loss was identified in Resident 97's care plan addressing nutrition and weight loss, after the November 13, 2019 weight of 79.2 pounds, nor the weights on December 11, 2019 of 77.4 pounds and January 8, 2020 weight of 77.2 pounds.

During a staff interview on January 15, 2020 at approximately 2:30 PM, the Director of Nursing could not recall any specific interventions initiated to address Resident 97's significant weight loss.

As of January 16, 2020, at 1:00 PM, the facility did not have any further information to submit.

Review of the facility's investigation on January 13, 2020, of an incident that occurred on September 27, 2019, between Resident 150 and Nursing Assistant 2 (NA 2) revealed the facility initiated an intervention to provide or have readily available gowns and face shields for staff to use as a protective measure as Resident 150 had behaviors of being aggressive towards and spitting at staff.

Review of Resident 150's clinical record revealed diagnoses that included: osteoarthritis (degeneration of joint cartilage and the underlying bone, causes pain and stiffness, especially in the hip, knee and thumb joints), dementia with behavioral disturbance (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), psychotic disorder with delusions (a thought or mood disorder, a belief or altered reality that is persistently held despite evidence or agreement to the contrary), and depression (feelings of severe despondency and dejection). Further review of Resident 150's clinical record revealed during an annual assessment dated September 27, 2019, Resident 150 was unable to complete the Brief Interview for Mental Status (BIMS test used to get a quick snapshot of how well one ins functioning cognitively at that moment).

Review of Resident 150 plan of care on January 13, 2020, revealed a problem area, dated July 2, 2019, for "mood and behavior related to diagnoses of dementia, psychotic disorder with delusions, chronic pain, dysuria (discomfort when urinating), depression ....refusing care, physical behavior towards others ..." Review of the approaches for the aforementioned problem area failed to reveal the use of gowns and face shields as a protective measure for staff.

During an interview with the Director of Nursing on January 15, 2020, at approximately 3:00 PM it was revealed that Resident 150 does have behaviors with being resistant to care, aggressive towards staff, and does spit. Staff are aware that face shields and gowns are available, at one time there was a supply in the resident's room for staff to wear, however if the aforementioned items are not available in the room, each unit has a supply closet that is stocked with those items.

During an interview with the Nursing Home Administrator on January 16, 2020, at approximately 1:19 PM it was revealed that the aforementioned care plan should be updated to include the intervention put into place as the outcome of the aforementioned facility investigation; to have gowns and face shields readily available for staff to utilize for their protection as Resident 150 is known to have behaviors to include spitting at staff.


28 Pa. Code 211.11(d) Resident Care Plans



 Plan of Correction - To be completed: 02/25/2020

Resident 97s care plan was updated to include additional nutrition interventions. Resident 150s care plan was revised to incorporate behavioral interventions and was provided.
Facility residents with compromised nutrition or mood and behavior needs have the potential to be affected by this practice.
Interdisciplinary care plan team will be re-educated concerning resident-specific care planning by the lead Nurse Assessment Coordinator. Lead Nurse Assessment Coordinator or designee will conduct a random audit of five comprehensive care plans weekly for three weeks and monthly for three months to validate appropriate nutritional and mood/behavior interventions are in place based on identified need. Audit results will be reported to the Administrator and Director of Nursing. Concerns will be addressed upon discovery.
Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

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 clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 32 residents reviewed (Resident 150).

Findings include:

Review of Resident 150's clinical record revealed diagnoses that included Feeding Difficulties and Dementia with Behavioral disturbances (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning).

Review of Resident 150's current active Care Plan (no creation date identified) revealed the care Focus area of "Nutrition for (resident's name): predicted suboptimal intake r/t (due to) dementia,..." with an initiation date of September 13, 2019" with an associated Intervention of "Weights d/c'd (discontinued) r/t (due to) physically resisting staff when trying to obtain weights" with a noted initiated date of September 13, 2019.

Review of Resident 150's vitals/weights documentation in her Electronic Health Record revealed her last actual weight was taken/recorded on June 17, 2019.

Review of Resident 150's September 27, 2019, comprehensive Annual MDS (Minimum Data Set - an assessment tool used to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed that the assessment was coded in Section K Swallowing Nutritional Status in subsections Weight Loss and Weight Gain with a dash (-) which indicates "Not Assessed."

As per instruction of the Resident Assessment Manual, the two sub-sections in Section K should have been coded with a "0" as Resident 150's weight was "Unknown" as the resident's weight was no longer to be determined.

During an interview with the Registered Nurse Assessment Coordinator (RNAC) 1) on January 16, 2020, at 11:08 AM, the RNAC confirmed that the assessment should have been coded with a "0" as the resident's weights were no longer to be taken.


28 Pa. Code 211.5(f) Clinical records.

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

Previously cited 2/02/2018



 Plan of Correction - To be completed: 02/25/2020

Minimum Data Set assessment has been corrected and submitted for resident 150.

Registered Nurse Assessment Coordinator will audit comprehensive assessments since January 1, 2020 to identify coding opportunities related to weight change. Concerns will be corrected upon discovery.

Nurse Assessment Coordinators and Registered Dietitian will be re-educated concerning weight coding accuracy by the Lead Registered Nurse Assessment Coordinator. Lead Registered Nurse Assessment Coordinator or designee will conduct an audit of five Minimum Data Set Assessments weekly for three weeks and monthly for three months to validate weight coding accuracy. Audit results will be reported to the Administrator. Concerns will be addressed upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

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 review of the Resident Assessment Instrument (RAI-a standardized process is the basis for the accurate assessment of each nursing home resident), clinical record review, and staff interview it was determined that the facility failed to conduct an accurate comprehensive assessment for each residents function capacity for one of 3 residents reviewed for substantial weight loss (Resident 157).

Findings include:

Review of the Resident Assessment Instrument (RAI-a standardized process is the basis for the accurate assessment of each nursing home resident) dated October 2018, page K-5, revealed the coding instructions for weight loss; Code 0, no or unknown: if the resident has not experienced weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days or if information about prior weight is not available. Code 1, yes on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was planned and pursuant to a physician's order. In cases where a resident has a weight loss of 5% or more in 30 days or 10% or more in 180 days as a result of any physician ordered diet plan or expected weight loss due to loss of fluid with physician orders for diuretics, K0300 can be coded as 1.


Review of Resident 157's clinical record revealed diagnoses that included; cerebral infarction (an area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain).

Further review of Resident 157's clinical record revealed the following weight history:
12/23/2019 = 239.2 Lbs. (Lbs., pounds, unit of measure)
12/16/2019 = 238.6 Lbs.
12/16/2019 = 238.5 Lbs.
12/13/2019 = 238.8 Lbs.
12/12/2019 = 238.6 Lbs.
12/9/2019 = 246.3 Lbs.
12/8/2019 = 245.0 Lbs.
12/7/2019 = 245.3 Lbs.
12/6/2019 = 244.6 Lbs.
11/22/2019 = 268.8 Lbs.
11/18/2019 = 251.2 Lbs.
11/17/2019 = 264.5 Lbs.
11/16/2019 = 264.7 Lbs.


Review of Resident 157's 5 day Minimum Data Set (MDS - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with a reference date of December 12, 2019, revealed section K-300 for weight loss was documented as "No or unknown." Resident 157 weighed 238.6 lb on December 12th, and 264.7 lb on November 16th; a 26 lb weight loss in one month (10% loss in one month).

Review of Resident 157's discharge Minimum Data Set with a reference date of December 28, 2019, revealed section K-300 for weight loss was documented as" No or unknown." Resident 157 weighed 239 lb on December 23rd, and 268.8 lb on October 22nd; a 30 lb weight loss in one month (11% loss in one month).

During an interview with Registered Nurse 2 (RN 2) on January 15, 2020, at approximately 2:00 PM it was determined the 5 day MDS with the reference date of December 12th and the discharge MDS with the reference date of December 28th should have been documented as a significant weight loss.

28 Pa. Code 211.5(f) Clinical records.












 Plan of Correction - To be completed: 02/25/2020

Minimum Data Set assessments have been corrected and resubmitted for resident 157 and Registered Dietitian has been reeducated concerning section K-300 coding.

Registered Nurse Assessment Coordinator will audit comprehensive assessments since January 1, 2020 to identify coding opportunities related to weight change. Concerns will be corrected upon discovery.

Nurse Assessment Coordinators and Registered Dietitian will be re-educated concerning weight coding accuracy by the Lead Registered Nurse Assessment Coordinator. Lead Registered Nurse Assessment Coordinator or designee will conduct an audit of five Minimum Data Set Assessments weekly for three weeks and monthly for three months to validate weight coding accuracy. Audit results will be reported to the Administrator. Concerns will be addressed upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.12 REQUIREMENT Free from Misappropriation/Exploitation: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
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
Observations:


Based on policy review, interviews, and review of facility investigation regarding an allegation of misappropriation it was revealed that the facility failed to ensure residents are free from misappropriation of property and exploitation, as evidence by one resident who provided monetary assistance to staff, after staff had made the resident believe that she was in a financial crisis, for one of one allegation of misappropriation reviewed (Resident 146).

Findings include:

Review of facility policy, Abuse, Neglect, Exploitation or Mistreatment, revised September 12, 2017, revealed "The facility's leadership prohibits .... Misappropriation of a patient's/resident's property and/or funds."

Review of the facility's investigation of alleged misappropriation as reported on August 7, 2019, to RN 1 regarding an incident between Resident 146 and Nursing Assistant 1 (NA 1). The allegation was initially reported to the facility by Resident 146. It was alleged, that Resident 146 gave NA 1 one hundred dollars to buy her items several weeks ago, and the resident has not received the requested items and/or her money has not been returned.

The facility's interview on August 7, 2019, with Resident 146 revealed that Resident 146 asked NA 1 to buy Resident 146 a vape cartridge, about 3 months ago. Resident 146 wasn't aware that staff weren't allowed to do that. NA 1 took Resident 146's one hundred dollars, and NA1 hasn't bought the vape cartridge and/or returned Resident 146's money.

On August 8, 2019, the facility interview with the alleged perpetrator revealed that NA 1 denied offering to buy Resident 146 a vape pen, taking one hundred dollars from Resident 146, using Resident 146's cell phone, or asking to borrow five dollars. NA 1 was suspended from the facility on August 8, 2019.

The Pennsylvania State Police initiated an incident investigation on August 9, 2019.

The facility's interview with Resident 24, Resident 146's roommate, on August 13, 2019, revealed that she overheard NA 1 asked to borrow money from Resident 146. When NA 1 left the room, Resident 24 asked Resident 146 if she gave NA 1 money. Resident 146 stated she gave NA 1 one hundred dollars because she felt sorry for her.

The facility completed a follow up interview with Resident 146 on August 14, 2019, which revealed that Resident 146 told NA 1 that she needed a new vape pen, and NA 1 told her she could get it. Resident 146 gave NA 1 one hundred dollars, and months went by so Resident 146 began asking NA 1 for the vape pen and/or the money. NA 1 kept giving a story to Resident 146 as to why she couldn't give the money back. Resident 146 also stated, "just the other night NA 1 used my cell phone, and asked to borrow five dollars because NA 1 was out of gas. At that point Resident 146 told NA 1 Resident 146 then went on to inform Social Worker 1 (SW 1) that NA 1 called Resident 146 the night she got in trouble, and told Resident 146 that she had her money and a gift for her, but she wasn't allowed to go back and see her. NA 1 also told Resident 146 that if anyone asked her questions about this situation to deny everything.

Corrective Action form dated August 19, 2019, revealed that NA1 was terminated due to a substantiated allegation of misappropriation of property.

During an interview with Resident 146 on January 16, 2020, at approximately 11:51 AM it was revealed that a while ago a staff member did ask to borrow some money so she could pay her rent and feed her children. Resident 146 stated she felt bad so she lent the NA 1 one hundred dollars. She forgot about it, NA 1 didn't repay her, and Resident 146 remembered some time afterward and reported it to the facility. The facility was in to talk with her, and called the police. The police did come into the facility and talked with her, but she didn't want to press charges. Resident 146 was aware that the facility fired the staff member. NA 1 did call Resident 146 the evening she reported it to the facility, and told Resident 146 that if the facility asks her anything about the money that was lent to her; to lie about it. However Resident 146 had already reported it to the facility. NA 1 has not been in touch with Resident 146 since then. The facility didn't offer to reimburse the money to Resident 146. Resident 146 admitted that she gave money to the staff member of free will, she was not coerced or harassed and didn't feel she was in danger or felt unsafe at any time, she just felt bad for NA 1. She has had no issues with missing items or providing items to staff prior to that time, or since then.

During an interview with RN 2 on January 16, 2020, at approximately 4:35 PM it was revealed that staff should not ask residents for anything, and/or accept or borrow gifts from residents.

Pa code 201.18(2) Management
Pa code 201.29(a) Resident rights



 Plan of Correction - To be completed: 02/25/2020

The allegation of misappropriation involving resident 146 was identified, reported and resolved appropriately as indicated. Nursing Assistant 1 was terminated at the conclusion of the facility investigation in August 2019. The facility will reimburse resident 146 for the money involved.

Facility residents have the potential to be affected by this practice.

Facility staff will be re-educated concerning misappropriation of resident property by the Administrator. Social Service staff or designee will conduct five random resident interviews weekly for three weeks and monthly for three months to identify concerns related to misappropriation of property.

Interview results will be reported to the Administrator. Concerns will be addressed upon discovery.
Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(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 observation as well as resident and staff interviews, it was determined that the facility failed to provide a clean, comfortable, homelike interior in resident rooms on one of 6 units observed (E unit).

Findings include:

Observation in Resident 129's room on January 12, 2020, at 11:04 AM revealed an approximately one foot by three foot section of wall behind Resident 129's bed extending to his wardrobe that was patched and unpainted. During an immediate interview with Resident 129, he was unaware of what had happened to the wall.

Observation in Resident 160's room on January 13, 2020, at 10:40 AM revealed an approximately two foot by three foot section of wall near the entrance of the room which was roughly patched and unpainted. Additionally, the corner of the wall outside of the bathroom door was damaged. During an immediate interview with Resident 160, he expressed concern with the appearance of the wall stating that "maintenance don't want to do nothing."

During an interview with MD 1 (Maintenance Director) on January 14, 2020, at 9:45 AM he confirmed that there were no pending work orders or completed work orders looking back to September 1, 2019, for either Resident 129's or Resident 160's rooms.

During a tour of the previously noted rooms with MD 1 on January 14, 2020, at 9:50 AM, he confirmed that Resident 129's room was not finished but needed to be and that Resident 160's wall was "atrocious" and would be taken care of as soon as possible.

During an interview with the Nursing Home Administrator on January 15, 2020, at 1:53 PM, he revealed the expectation that repairs should have been completed to make Resident 129's and Resident 160's rooms more homelike.


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








 Plan of Correction - To be completed: 02/25/2020

Walls in residents 129 and 160's rooms were patched and painted upon discovery.

Director of Plant Operations or designee will audit resident rooms to identify other concerns related to wall repair. Concerns will be logged in the electronic work order system for appropriate resolution.

Plant Operations staff will be re-educated concerning these requirements and the resident room inspection checklist by the Director of Plant Operations. Director of Plant Operations or designee will conduct a random audit of 5 resident rooms weekly for three weeks and monthly for three months to identify wall repair concerns. Audit results will be reported to the Administrator. Concerns will be addressed upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:

Based on review of select facility documentation and staff interview, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage for two of two residents reviewed who remained in the facility for long-term care (Residents 43, 111).

Findings include:

A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility on January 14, 2020, revealed that Medicare coverage for Resident 43 started on November 7, 2019, and that her last covered day was December 22, 2019. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. Further review of the form revealed that an Advanced Beneficiary Notice of Non-coverage (ABN - a notice given to Medicare beneficiaries to convey that Medicare is not likely to provide coverage for a skilled service) was not provided to the resident or her representative at the time that Medicare Part A was discontinued.

A SNF Beneficiary Protection Notification Review form, completed by the facility on January 14, 2020, revealed that Medicare coverage for Resident 111 started on August 5, 2019, and that his last covered day was August 30, 2019. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. Further review of the form revealed that an Advanced Beneficiary Notice of Non-coverage was not provided to the resident or his representative at the time that Medicare Part A was discontinued.

During an interview with Social Worker 1 (SW 1), on January 15, 2020, at 11:20 AM, she confirmed she did not provide the Advanced Beneficiary Notice of Non-coverage to the above residents as they were not requesting any additional skilled services.
During an interview with the Nursing Home Administrator on January 16, 2020 at 01:11 PM he revealed the expectation that the notice should have been provided to Residents 43 and 111.


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









 Plan of Correction - To be completed: 02/25/2020

Social worker 1 was re-educated on Advanced Beneficiary Notice requirements by the Case Manager.
Facility residents have the potential to be affected by this practice.
Social Services staff will be re-educated concerning Advanced Beneficiary Notice requirements. Business Office Manager or designee will conduct a random audit of documentation associated with residents ending Medicare coverage weekly for three weeks and monthly for three months. Audit results will be reported to the Administrator. Concerns will be addressed upon discovery.
Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

LICENSURE Corridor:State only Deficiency.
Corridor--A passageway, hallway or other common avenue used by residents and personnel to travel between buildings or sections of the same building to reach a common exit or service area. The service area includes, but is not limited to, living room, kitchen, bathroom, therapy rooms and storage areas not immediately adjoining the resident's sleeping quarters.
Observations:

Based on observations it was determined that the facility failed to ensure that the resident corridor was not used for storage of wheelchairs and lifts, blocking access to the resident corridor handrail, for five of five halls observed.Findings include:

Observations on the B unit hall way on January 13, 2020, at approximately 9:47 AM, revealed four wheelchairs stored, unused in the resident corridor and against the wall blocking access to the handrail. Observations of the same area at approximately 11:20 AM revealed the four wheelchairs had not been moved.

Observations of the C unit on January 12, 2020, at approximately 1:55 PM, revealed six wheelchairs stored, unused in the resident corridor against the handrail and blocking access to the handrail. Observations of the C unit on January 13, 2020 at approximately 10:11 AM revealed seven wheelchairs stored, unused in the resident corridor and against the wall blocking access to the handrail. During observations at approximately 11:45 AM, it was observed that the seven wheelchairs were still in the resident corridor against the handrail, and an additional lift was in the hallway stored, unused blocking access to the handrail.

Observation of the B unit hall on January 14, 2020, at approximately 9:36 AM, revealed six wheelchairs and one lift were stored in the resident corridor against the wall and blocking access to the handrail. Observations at approximately 10:32 AM revealed the wheelchairs and lift were in their originally observed area.

Observations of the E unit hall on January 14, 2020, at approximately 9:38 AM, revealed three wheelchairs stored in the resident corridor against the wall and blocking access to the handrail. Observations of the E unit hall at 1:00 PM revealed the three wheelchairs were in their originally observed area.

Observations of the A unit hall on January 14, 2020, at approximately 9:45 AM, revealed five wheelchairs stored in the resident corridor against the wall blocking access to the handrail. Observations at approximately 12:52 PM revealed the five wheelchairs were in their originally observed areas.

On January 15, 2020, at approximately 2:00 PM, the Nursing Home Administrator was informed of the aforementioned observations. As of January 16, 2020, at 1:00 PM, the facility did not have anything further to provide regarding the wheelchairs and/or lifts being stored in the resident corridor and in a manner that blocked access to the resident handrail.



 Plan of Correction - To be completed: 02/25/2020

Facility will free closet, storage room and resident room space for storage of wheelchairs when not in use to ensure corridor handrails are accessible.
Facility residents have the potential to be affected by this practice.
Facility staff will be re-educated concerning these requirements and the need to ensure hallway handrail access for residents. Plant operations Director will conduct a random audit of hallway handrail access weekly for three weeks and monthly for three months. Audit results will be reported to the Administrator and Director of Nursing. Concerns will be addressed upon discovery.
Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

211.5(d) LICENSURE Clinical records.:State only Deficiency.
(d) Records of discharged residents shall be completed within 30 days of discharge. Clinical information pertaining to a resident's stay shall be centralized in the resident's record.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to ensure that records of discharged residents were completed within thirty days of discharge for one of 3 closed records reviewed (Resident 166).

Findings include:

Review of Resident 166's clinical record revealed a date of death of November 6, 2019.

Further review revealed that the Physician's Discharge Summary was completed and dated on January 16, 2020, more than thirty days beyond Resident 166's discharge date.

During an interview with the Nursing Home Administrator on January 16, 2020, at 3:24 PM, he confirmed that the discharge summary was not completed within thirty days of the resident's discharge from the facility.



 Plan of Correction - To be completed: 02/25/2020

Resident 166 no longer resides in the facility.
Medical Records Director will audit discharge summaries for residents discharging since January 1, 2020 to validate completion. Concerns will be corrected upon discovery.
Resident 166's physician and Medical records staff will be re-educated concerning these requirements. Medical records or designee will conduct an audit of discharge resident discharge summaries weekly for three weeks and monthly for three months to validate timeliness. Audit results will be reported to the Administrator and Director of Nursing. Concerns will be addressed upon discovery.
Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.


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