Pennsylvania Department of Health
CONCORDIA AT THE CEDARS
Patient Care Inspection Results

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CONCORDIA AT THE CEDARS
Inspection Results For:

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CONCORDIA AT THE CEDARS - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, and Abbreviated Survey related to complaints, completed on Mach 28, 2024, it was determined that Concordia at the Cedars was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulation as they relate to the Health portion of the survey process.


 Plan of Correction:


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

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

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:
Based on observation, review of facility policy, and staff interviews, it was determined that the facility failed to serve food/beverages in accordance with professional standards for food safety on one of one nursing units. (3rd Floor Nursing Unit)

Findings include:

Review of the facility policy, "Food Safety Requirements," dated 1/28/24, indicated food will be distributed and served in accordance with professional standards for food service safety. Foods and beverages shall be distributed in a manner to prevent contamination.

Observation of the lunch meal of the 3rd Floor nursing unit, on 3/27/28, at 11:40 a.m. through 12:40 p.m., revealed the following:

At 11:40 a.m. Residents were served meals from the steam table in the kitchenette to the tables in the dining room. All residents were served and eating at 12:05 p.m.

At 12:05 p.m. the steam table was transported from the kitchenette onto the end of the nursing unit and set up in the middle hallway of the 300-318 resident rooms. There was and approximate distance of 35 inches from the steam table to the handrail of the wall. Plates were noted to be on top of the steam table during transportation and not covered. A beverage cart, dessert cart, coffee cart, and tray cart were lined up beside the steam table in the hallway. A nurse was noted to pass by pushing a medication cart between the steam table and handrail.

During an interview with the Food Service Director, Employee E3 revealed the facility has been utilizing this process since May 2023.

Resident meals were assembled and delivered to resident rooms of the 300-318 hallway from the steam table. At 12:20 p.m. Dietary Aide Employee E2 touched the resident trays, plate covers, and meal tickets, then cut baked potatoes and plated them with hands without changing gloves or washing hands.

During an interview on 3/27/24, at 12:45 p.m. Dietary Aide Employee E2 confirmed the above finding and that tongs should have been used to plate the baked potatoes.

At 12:25 p.m. the steam table was then pushed past the Nursing Station onto the other end of the 3rd floor nursing unit in the hallway of resident rooms 319-331. Meal trays were assembled and served in the same manner from the steam table in the hallway of the nursing unit. From 12:25 p.m. to 12:40 p.m. when the last tray was delivered, five visitors carrying various items, one resident pushed in a wheelchair by staff, and one resident ambulating in a wheelchair passed between the steam table and the handrail of the nursing unit hallway.

At 12:40 p.m., all resident meals were served in the resident rooms and the steam table was transported back into the kitchenette on the 3rd Floor nursing unit.

During an interview on 3/27/24, at 12:50 p.m. Food Service Director Employee E3 confirmed the above findings and the facility failed to serve food/beverages in accordance with professional standards for food safety on the 3rd Floor Nursing Unit.

During an interview on 3/28/24, at 12:20 p.m. The Nursing Home Administrator (NHA) confirmed the facility has been utilizing the above meal service process on the 3rd Floor nursing unit from approximately 4/17/23.

28 Pa code 211.6(b)(d) Dietary services.







 Plan of Correction - To be completed: 04/17/2024

1. The facility is providing meal service following food safety requirements. The steam table is no longer in the hallways for meal service.

2. Current patients have the potential to be affected.

3. The director of dining services will educate the dietary staff on the facility policy on food safety requirements and the F 812. Food service delivery method will be tray service.

4. The director of dining services and/or designee will audit meal service twice a week for one month and then weekly thereafter to validate implementation of F 812. Results of this audit will be shared at the monthly Quality Assessment and Assurance Committee meeting.

483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to provide concern forms and grievance boxes assessable to residents and visitors from a wheelchair in the front lobby and on the third floor nursing unit, failed to have a grievance forms accessible on the third floor nursing unit, and failed to provide an opportunity for anonymous grievances in the front lobby and on the third floor nursing unit.

Findings include:

A review of the facility policy "Resident and Family Grievances" reviewed 1/19/23 and 1/28/24, indicated it is the policy of the facility to support each resident's and family member's right to voice grievances without discrimination, reprisal, or fear of discrimination. A grievance may be filed anonymously.

During an observation on 3/26/24, at 8:15 a.m. revealed the grievance box in the front lobby is not accessible by residents and visitors in a wheelchair, and the grievance box is within sight of the receptionist.

During an observation on 3/26/24, at 1:45 p.m. third floor nursing unit failed to have grievance forms available for residents and visitors, and the grievance box is not accessible to residents and visitors from a wheelchair, and the grievance box is within sight of the nurses station.

During an observation on 3/27/24, at 2:45 p.m. third floor nursing unit failed to have grievance forms available for residents and visitors, and the grievance box is not accessible to residents and visitors from a wheelchair, and the grievance box is within sight of the nurses station.

During an observation on 3/28/24, at 11:45 a.m. third floor nursing unit failed to have grievance forms available for residents and visitors, and the grievance box is not accessible to residents and visitors from a wheelchair, and the grievance box is within sight of the nurses station.

During an interview on 3/28/24, at 11:50 a.m. Registered Nurse Employee E1 confirmed the facility failed to provide grievance forms on the third floor nursing unit, stating "we must have run out."

During an interview on 3/28/24, at 11:53 a.m. the Nursing Home Administrator was informed the greivance boxes were not at a level that was accessible to residents and visitors in a wheelchair in the front lobby and third floor nursing unit, and failed to provide the opportunity for residents and visitors to file an anonymous grievance.

28 PA Code: 201.18(e)(4) Management.

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






 Plan of Correction - To be completed: 04/17/2024

1. An additional wheelchair height grievance box was placed in the activity room on the 3rd floor which will allow for anonymous submissions.

2. Current residents have the potential to be affected. Grievance boxes will be at wheelchair height and placed so submissions can be anonymous. Current patients will be educated on the new grievance box placement in resident council and in person by the nursing home administrator.

3. The clinical nurse consultant will educate the facility's grievance officer and the social service coordinator on the F 580 regulation.

4. The facility grievance officer will audit the grievance box to validate box is at wheel chair height and grievance forms are available twice a week for two months and then weekly thereafter. Results of this audit will be shared at the monthly Quality Assessment and Assurance Committee meeting.

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 facility policy and clinical record reviews and interview with staff, it was determined that the facility failed to review and revise the comprehensive care plan for two of seven residents. (Residents R8, and R39)

Findings include:

The facility was unable to provide a policy regarding care planning.

The "Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual," which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:

13 - 15: cognitively intact
8 - 12: moderately impaired
0 - 7: severe impairment

A review of the clinical record revealed that Resident R8 was admitted to the facility on 12/15/23, with diagnoses that included dementia (loss of thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), high blood pressure, and anxiety.

A review of the MDS dated 3/6/24, indicated the diagnoses remain current. Review of Section C: Cognitive Patterns, Question C0500 BIMS Summary Score revealed Resident R8's BIMS score was 7, indicating severe impairment.

A review of a H&P (history and physical) physician progress note dated 12/16/23, ar 1:00 p.m. indicated "Not oriented to time or location, difficult for her to engage in conversation and assessment."

A Review of a progress note dated 12/16/23, at 3:52 p.m. revealed "patient does best with crushed medication and mechanical soft food due to history of pocketing and trouble chewing/swallowing."

A review of a progress note dated 12/21/23, at 5:19 p.m. indicated Resident R8 was very forgetful and needed repeated instructions for medications and care.

A review of a progress note dated 3/26/24, at 5:00 p.m. indicated resident is alert to self, had increased anxiety, and was kept in high observation areas.

A review of a progress note dated 3/27/24, at 1:36 a.m. indicated "Resident is AOx1 (alert and oriented) with confusion. Takes meds crushed in applesauce."

A review of the care plan failed to reveal resident-centered interventions for Dementia.

A review of the clinical record indicated Resident R39 was re-admitted to the facility on 6/17/22, with diagnoses that included vascular dementia (condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain, and causes problems
with reasoning, planning, judgment, and memory), diabetes, and high blood pressure.

A review of the MDS dated 1/31/24, indicated the diagnoses remain current. Review of Section N: Medications, Question N0415: High-Risk Drug Classes: Uses and Indication reveal Resident R39 was taking an antipsychotic medication.

A review of a physician order dated 6/26/23, indicated Resident R39 was ordered Seroquel (may be used to calm and help diminish psychotic thoughts) 25 milligrams (mg) give 12.5 mg by mouth one time a day.

A review of the care plan failed to reveal interventions for antipsychotic medication use.

During an interview on 3/28/24, at 11:53 a.m. the Director of Nursing confirmed the facility failed to complete a resident-centered care plan for Residents R8 and R39.


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




 Plan of Correction - To be completed: 04/17/2024

1. R39 is no longer at the facility. R8 resident centered careplan has been updated.

2. Current patients on psychotropics and patients with diagnosis of dementia have the potential to be affected. The director or nursing and/or designee will complete and audit on these patients to determine if careplans are in place as needed. Identified patients from the audit will have immediate corrective action.

3. The Director of Nursing will educate the social worker, assistant director of nursing and the registered nurse assessment coordinator on the F 657. Patients with psychotic medication and diagnosis of dementia will have resident centered careplans established moving forward.

4. The director of nursing and/or designee will audit new admissions and new orders for psychotropic medications on a weekly basis to validate resident centered careplan implementation. Audit will be completed weekly for two months and then monthly thereafter. Results of this audit will be shared at the monthly Quality Assessment and Assurance Committee meeting.

211.12(f.1)(5) LICENSURE Nursing services. :State only Deficiency.
(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.
Observations:


Based on review of nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one Registered Nurse (RN) per 250 residents during the night shift for 17 of 21 days (3/6/24 through 3/25/24).

Findings include:

Review of the facility census data, nursing time schedules, and deployment sheets revealed the following Registered Nurse staffing shortages:

On 3/17/24, the census was 49, which required 1.0 RN's during the night shift. Review of the nursing time schedules revealed 0.0 RN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 3/18/24, the census was 50, which required 1.0 RN's during the night shift. Review of the nursing time schedules revealed 0.0 RN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 3/14/24, the census was 51, which required 1.0 RN's during the night shift. Review of the nursing time schedules revealed 0.0 RN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 3/13/24, the census was 52, which required 1.0 RN's during the night shift. Review of the nursing time schedules revealed 0.0 RN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 3/12/24, the census was 53, which required 1.0 RN's during the night shift. Review of the nursing time schedules revealed 0.0 RN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 3/6/24 and 3/11/24, the census was 54, which required 1.0 RN's during the night shift. Review of the nursing time schedules revealed 0.0 RN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 3/7/24, 3/8/24, and 3/9/24, the census was 55, which required 1.0 RN's during the night shift. Review of the nursing time schedules revealed 0.0 RN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 3/10/24 and 3/20/24, the census was 56, which required 1.0 RN's during the night shift. Review of the nursing time schedules revealed 0.0 RN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 3/21/24 and 3/24/24, the census was 57, which required 1.0 RN's during the night shift. Review of the nursing time schedules revealed 0.0 RN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 3/25/24, the census was 58, which required 1.0 RN's during the night shift. Review of the nursing time schedules revealed 0.0 RN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 3/22/24 and 3/23/24, the census was 59, which required 1.0 RN's during the night shift. Review of the nursing time schedules revealed 0.0 RN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

During an interview on 3/28/24, at 4:00 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum of one RN per 250 residents during the night shift on 17 of 21 days.





 Plan of Correction - To be completed: 04/17/2024

1. Facility implemented the staffing requirements according to the P5540regulation as of 4/17/2024.

2. Current Residents have the potential to be affected. The facility will provide additional nurse for the night shift to implement the RN requirement outlined in the P5540 regulation.

3. Administrator and or designee will educate Director of Nursing on the staffing ratio requirements that went into effect July 1, 2023. Concordia at the Cedars does meet the Hours Per Patient Day requirement; however, it is the RN requirement that was not met.

4. Director of Nursing, or designee will meet and audit the nursing schedule 5x per week for 2 weeks and then weekly for 2 months and monthly for 2 months to ensure the facility adheres to the new ratio requirements. Corrected process will be reviewed quarterly by the quality improvement and quality assurance committee for further analysis and recommendation to ensure ongoing compliance.


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