Pennsylvania Department of Health
SUMMIT AT BLUE MOUNTAIN NURSING AND REHABILITATION CENTER, T
Patient Care Inspection Results

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SUMMIT AT BLUE MOUNTAIN NURSING AND REHABILITATION CENTER, T
Inspection Results For:

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SUMMIT AT BLUE MOUNTAIN NURSING AND REHABILITATION CENTER, T - 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 Compliance Survey completed on January 25, 2024, it was determined that The Summit at Blue Mountain Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
§483.12 Freedom from Abuse, Neglect, and Exploitation
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.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:


Based on a review of the facility's abuse prohibition policy, information submitted by the facility, clinical records, select investigative reports, and contractual service provider agreements, and resident and staff interviews it was determined that a facility contracted service provider neglected to provide a resident with the necessary services to prevent physical harm, resulting in a fractured knee cap, to one resident (Resident 4) and failed to ensure that one resident (Resident 23) was free from physical abuse perpetrated by another resident (Resident 28) out of 13 sampled residents.


Findings include:

According to regulatory guidelines "Neglect," as defined at means "the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

A review of facility policy titled "Abuse, Neglect, and Exploitation", dated July 20, 2023, revealed that it is the facility's policy to "provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that profit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The policy defines physical abuse as "includes, but is not limited to, hitting, slapping, punching, biting, and kicking." Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

A review of Resident 4's clinical record revealed that the resident had diagnoses of muscle weakness, age related physical debility, chronic fatigue, severe morbid obesity, difficulty walking, and abnormalities of gait and mobility. The resident was cognitively intact and required the extensive assistance of two people for activities of daily living, including bed mobility, and was totally dependent on two people for transfers.

According to information dated June 26, 2023, submitted by the facility, Resident 4 was picked up by EMS transport van for a routine medical appointment at 8:45 AM that morning. The resident left facility with EMS attendant and CNA (Employee 5) in electric powered wheelchair. Received call from CNA stating that the resident suffered a fall during transport. Per CNA statement, resident was secured to the medical van with 2 straps to the front of the electric wheelchair. The resident was not secured with electric wheelchair seat belt, or medical van seat belt. CNA reported that as the medical transport van turned to the left, the resident fell out of electric wheelchair. Resident fell onto knees. 911 was contacted and EMS transported resident to St. Luke's Carbon emergency room for evaluation. Spoke with transport company, awaiting statement from EMS attendant.

An incident note dated June 26, 2023, at 8:58 AM, revealed that Employee 5, a nurse aide called the facility while out on transport to an appointment with Resident 4, to report that during transport, Resident 4 fell forward out motorized jazzy chair while in transport van. According to Employee 5, there was no safety seat belt secured on the resident's wheelchair, securing the resident in the wheelchair seat during the van transport. Employee 5, called 911 (emergency response) for assistance and the resident was transported to the emergency room for further evaluation.

A CT scan (a diagnostic imaging test) was completed at the ER and the results dated June 27, 2023, revealed that Resident 4 had sustained a right acute non-displaced patella (knee cap) fracture as a result of the fall in the van during transport.

A review of hospital discharge summary dated June 30, 2023, indicated orthopedic was consulted who ordered a long brace, weight bearing as tolerated, and follow up in 1 week.

A review of the facility's contract, that was in affect at the time of the incident on June 26, 2023, with the local community ambulance service provider, dated April 16, 2018, revealed that the ambulance service" shall provide the medical transport services in accordance with applicable federal, state, and local statutes, rules, regulations and ordinances, and the highest professional standards applicable in (name of transport service) industry and community."

A facility Incident Report entitled fall dated June 26, 2023, at 8:58 AM, indicating call was received from Employee 5, nurse aide, out on transport with resident, resident fell forward out motorized jazzy chair while in transport van. Resident 4 left the facility in her electric wheelchair with Contract Employee 6, EMS attendant transporter, and Employee 5, for routine medical appointment, and during transport the resident suffered a fall from her wheelchair.
Ongoing education to staff members of the importance of safety on EMS transport. Overview of investigation determined that the resident was not secured to the medical van during routine transport by Employee 6, EMS attendant transporter.

A review of facility provided transcript, Emergency Response (911), dated June 26, 2023, indicated that upon arriving on the scene the resident was located on her knees in front of the wheelchair with her face pressed against the lift gate. History revealed that the patient was being transported by ambulance transport for an eye appointment, and when the transport van was making a turn she had fallen from the chair and onto the floor. The resident stated she was not properly buckled in using restraints around her chest as had previously been done before. Crew admits to not checking for the restraints being properly placed.

A review of the facility's completed investigative report form \ for investigation of alleged abuse, neglect, misappropriation of property dated June 26, 2023, revealed an allegation of neglect of Resident 4 with serious physical injury, by Contract Employee 6. The facility's conclusion was that Contract Employee 6, EMS attendant transporter, failed to properly restrain the resident during transport. Per EMS Director of Operations, education was provided to Contract Employee 6, EMS attendant transporter on patient safety and patient safety restraint devices.

A review of a witness statement dated June 26, 2023, from Employee 5, revealed that when "\ got into the van I witnessed (Contract Employee 6, transport attendant) putting on the front straps on the front wheels of the wheelchair. I then went into the van and sat in the front seat waiting for (Contract Employee 6, transport attendant) to get done strapping in the resident. He in a couple of minutes got into the van and we left. We were talking and laughing the whole ride until we made the left hand turn when I heard \ yell. I looked back to find the resident on her knees in front of the van door. After the fall, I heard the resident state that she didn't have her seat belt on in her chair." A follow-up witness statement dated June 27, 2023, from Employee 5 indicated that "a couple of minutes after the fall, she heard \ state "I forgot to put my seat belt on chair."

A review of a witness statement dated June 26, 2023, entitled "Incident Narrative" from Contract Employee 6, EMS attendant transporter, indicated that he arrived at the facility at approximately 8:30 AM, met the resident and Employee 5 at the nurses station, and Employee 5 stated that the electric wheelchair had its own seatbelt which was already on. Resident 4 was loaded into the transport vehicle and made sure the safety belts were secured to the wheelchair. While making a left turn, Employee 5 (NA) yelled "oh no", and I realized Resident 4 came out of her wheelchair.

An untitled facility provided document, dated July 3, 2023, revealed a witness statement from Resident 4, indicating that she normally has her seatbelt on and they (EMS transport), put a belt across her legs. She stated "we both forgot to do our jobs." Asked if the resident was secured with the van straps, she responded, "I don't think I was."

During an interview with Resident 4 on January 24, 2024, at approximately 1:15 PM, indicated that the resident was in her electric wheelchair, and when the van turned left, she fell out of the chair onto her knees and was pinned up against the van's door. She further stated having no seat belt on, either her seatbelt, on her motorized wheelchair or the van's seatbelt.

The facility identified that it was Contract Employee 6's responsibility to secure the resident in the van and not their nursing employee, Employee 5, nurse aide, accompanying the resident to the medical appointment.

A review of facility "On the Spot Education" dated June 27, 2023, Topic Transportation Safety, stating "when a resident leaves the facility on a medical transport, they are still under our care and guidance. We should advocate for resident safety throughout transport process". Verbally confirm that resident's wheelchair is secured to van and seat belt is in place.

A review of facility provided email communication between the Skilled Nursing Facilities Nursing Home Administrator (NHA) and the Ambulance Transport Company Director of Operations, revealed that on June 30, 2023, the results of the transports company internal investigation findings concluded that the outcome of the investigation was their employee, Contract Employee 6, EMS attendant transporter, was failed to adhere to patient safety and patient safety restraint device procedures as trained.

During an interview with the Nursing Home Administrator (NHA) on January 24, 2024, at approximately 1:45 PM, indicated that the facility no longer utilizes the services of the ambulance company, that directly employed Contract Employee 6.

A review of the facility's contract that was in affect at the time of the incident on June 26, 2023, with the local community ambulance service, dated April 16, 2018, revealed that the ambulance service" shall provide the medical transport services in accordance with applicable federal, state, and local statutes, rules, regulations and ordinances, and the highest professional standards applicable in (name of transport service) industry and community."

During an interview with the NHA on January 25, 2024, at approximately 8:50 AM, the NHA confirmed that the facility contracted transportation driver providing services to the resident neglected to provide the necessary services to prevent this avoidable incident and serious injury to the resident.

A clinical record review revealed that Resident 28 was admitted to the facility on September 12, 2018, with diagnoses to include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities).

A Minimum Data Set assessment dated August 3, 2023, revealed that Resident 28 was severely cognitively impaired.

Resident 28's care plan revealed that the facility identified that the resident has behaviors related to dementia initiated on September 12, 2018. Resident 28's care plan indicated that at times she has aggressive physical behaviors, scratching, wandering into residents' rooms, and going through their clothing. Interventions planned included diverting as needed, one-to-one time, back rubs, repositioning, holding hands, tactile stimulation, and redirecting to a new area if she is becoming aggressive.

A clinical record review revealed that Resident 23 was admitted to the facility on March 30, 2020, with diagnoses to include hypertensive heart disease and chronic kidney disease with heart failure.

An MDS assessment dated November 8, 2023 revealed that Resident 23 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool to assess cognitive function).

A review of a facility investigation dated October 20, 2023, revealed that on October 20, 2023, at 9:50 AM, Resident 28 made an attempt to take Resident 23's gloves. Resident 23 took her gloves back, and Resident 28 slapped Resident 23's left forearm.

A witness statement dated October 20, 2023, provided by Employee 1, Activities, indicated that on October 20, 2023, at 9:50 AM in the 2nd Floor Dining Room, Resident 28 reached for Resident 23's gloves. Resident 23 grabbed her gloves and said "no" to Resident 28. Resident 28 proceeded to slap Resident 23 on the left forearm. Resident 28 was moved to another area. Resident 23 indicated that she was okay.

A witness statement dated October 20, 2023 revealed Employee 4, Registered Nurse (RN) witnessed the incident. Employee 4, RN, indicated that Resident 28 hit Resident 23 on the left forearm in the dining room at 9:50 AM. Resident 28 was redirected and removed from the dining room.

The facility conducted an interview with Resident 23, to obtain a witness statement, dated October 20, 2023, at 11:35 AM, indicated that Resident 23 explained that she was attending morning activities and had her gloves on the table in front of her. Resident 23 stated that Resident 28 entered the dining room and attempted to grab her gloves. Resident 23 explained that she pulled the gloves away, and Resident 28 slapped her left forearm. Resident 23 had no no injuries or pain. Resident 23 stated that she understands that Resident 28 is confused.

A nursing incident note dated October 20, 2023, at 9:50 AM indicated that Resident 28 has no agitation noted. The resident was self-propelling throughout the unit and placed on every 15-minute \ checks.

A nursing incident note dated October 20, 2023, at 9:50 AM indicated that Resident 23 denied pain. No bruising, tenderness, erythema, or swelling to \ left forearm.

During an interview on January 25, 2024, at 9:45 AM, Resident 23 stated that she was in the dining room for a coffee activity when Resident 28 came up to her and slapped her on the arm. She stated that the resident was after her gloves. Resident 23 explained that she understands that Resident 28 is confused, but feels upset and annoyed that she was slapped. Resident 23 also stated that this was not the first time she had problems with Resident 28. Resident 23 stated that there is a stop sign that is used so Resident 28 does not wander into her room and bother her or her roommate.

During an interview on January 25, 2024, at approximately 10:15 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that it is the facility's responsibility to ensure that residents have the right to be free from abuse and verified that Employee 1 witnessed Resident 23 slap Resident 28 on October 20, 2023.


28 Pa. Code 201.14 (a) Responsibility of Licensee

28 Pa. Code 201.29(a) Resident rights.

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






 Plan of Correction - To be completed: 03/09/2024

Residents 4 cannot be retroactively corrected to secure the resident in the wheelchair transport van.
Ambulance service involved in incident does not provide services to this facility as of July 2023.
Education to be given to staff in regards to powerchairs not to be utilized for any scheduled appointments outside of the facility.
Facility designee to complete audit weekly x4, monthly x2 that powerchairs are not used on scheduled transport.

The incident between Resident 4 and Resident 23 cannot be retroactively corrected to prevent encounter.
Resident 23 was placed on q15 minute checks to closely monitor behavior.
Resident 4's doorway had mesh stop sign placed to deter wandering residents.
Will review behaviors of Resident 23 weekly x4, monthly x2, report to QAPI.

483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions: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(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.
Observations:

Based on a review of clinical records and staff interviews, it was determined that the facility failed to afford residents the right to participate in their treatment and assure that the residents are fully informed of their total health status and condition for three residents out of 13 sampled (Residents 19, 20, and 31).


Findings include:

A clinical record review revealed that Resident 31 was admitted to the facility on April 1, 2020, with a diagnosis of cerebral infarction (brain damage that results from the lack of blood).

A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 12, 2023 revealed that Resident 31 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

An MDS Assessment dated December 12, 2023, revealed that Resident 31's preferred language is Mandarin and that the resident indicated that he needs and/or would like an interpreter to communicate with a doctor or health care staff.

The resident's current care plan revealed that Resident 31 has a communication problem related to a language barrier initiated upon the resident's admission. The care plan noted that the resident prefers to communicate in Mandarin Chinese, has pictures in his room that he uses to communicate basic needs to staff, understands some basic English, will nod his head "yes" or "no" appropriately or will use hand gestures, and that the facility will provide a translator to communicate with the resident.

A psychiatry note note dated January 2, 2024, at 5:53 AM indicated that on evaluation, the resident was calm and able to be engaged mostly with hand gestures. He was speaking minimal English and responding mostly with hand gestures. He stated that he is doing "ok" with stable appetite and sleep. Denies being depressed or frustrated. Denies any physical issues presently. He presents behaviorally stable at this time. The entry also indicated that the risks and benefits of treatment were not discussed with the patient and "N/A \ was noted, and "unable to comprehend fully due to language barrier."

There was no evidence that the facility's translation service was used during the psychiatry evaluation on January 2, 2024, to ensure that Resident 31 was able to discuss and participate in his treatment.

A clinical record review revealed that Resident 19 was admitted to the facility on July 9, 2020, with diagnoses that included Alzheimer's disease (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and Downs syndrome (a developmental genetic disorder that is associated with intellectual disability).

An quarterly MDS Assessment dated December 5, 2023, revealed that Resident 19 has problems with short-term memory recall (recalling information after 5 minutes) and long-term memory recall (recalling information from the past) and was severely cognitively impaired for daily decision-making.

The resident's care plan dated July 13, 2023, indicated that Resident 19 has psychosocial needs related to long-term placement, no discharge plan, and will remain long-term in the facility. The care plan indicated that Resident 19 and her family will receive information in order to make informed decisions regarding her care.

A psychiatry note dated July 30, 2023, at 3:22 PM indicated that Resident 19 was seen today for a follow-up for mood disorder, generalized anxiety disorder, dementia, and pervasive developmental disorder. She continues to experience on-and-off anxiety symptoms since the last visit. She continues on clonazepam 0.5 mg, twice a day. She continues to experience on-and-off anxiety symptoms. The note also indicated that the resident's medications were reviewed and updated as needed and that Resident 13 continues to receive Clonazepam (Klonopin) for anxiety. Also, the note indicated that the risks and benefits of treatment were not discussed, as the resident is unable to comprehend.

A psychiatry note dated November 10, 2023, at 1:00 PM indicated that Resident 19 was seen for a follow-up with a diagnosis of major depressive disorder, anxiety, dementia, intellectual disability, and pervasive developmental disorder. The entry indicated that the resident that the resident continued to experience on-and-off anxiety symptoms. The resident's medications were reviewed and updated, as needed, and that Resident 13 continued to receive Clonazepam (Klonopin) for anxiety. The note stated that the risks and benefits of treatment were not discussed, as the resident is unable to comprehend.

There was no documented evidence that the risks and benefits of treatment were discussed with the resident's representative as a result of the provider's inability to discuss the treatment with the resident due to cognitive impairment following the evaluations on July 30, 2023, or November 10, 2023.

Resident 20 was admitted to the facility on November 14, 2017, with a diagnosis of dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities).

An MDS Assessment dated November 30, 2023, indicated that Resident 20 was severely cognitively impaired with a BIMS score of 7. The resident had a designated agent for health care decisions as indicated by a a Durable Power of Attorney (POA), dated September 7, 2016.

A psychiatry note dated October 20, 2023, at 4:14 PM revealed that Resident 20 "is seen today for a follow up for major depressive disorder, psychosis, and dementia. She continues to experience ongoing symptoms since the last visit. She is seen in her bed, and spends most of her time in bed, napping off and on. Continues with cognitive decline due to dementia." The note included recommendations to continue Risperdal 0.5 mg and consider Prozac 10.0 mg daily. Also, the note indicated that the risks and benefits of treatment were not discussed, as the resident is unable to comprehend.

A psychiatric practitioner note dated January 13, 2024, at 9:48 AM revealed that Resident 20 "is seen today for a follow up with history of depression, psychosis and Neurocognitive disorder" and a plan included "continue current medications: Risperdal 0.5 mg po HS and Prozac 10 mg po daily." Also, the note indicated that the risks and benefits of treatment were not discussed, as the resident is unable to comprehend.

There was no documented evidence that the risks and benefits of treatment were discussed with the resident's POA as a result of the provider's inability to discuss the treatment with the resident due to cognitive impairment following the evaluations on October 20, 2023, or January 13, 2024.

During an interview on January 25, 2024, at approximately 11:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were unable to provide evidence that facility offered language assistance services to Resident 31 during the psychiatric evaluation and that the psychiatry provider informed Resident 19 and 20's representatives in advance of treatment risks and benefits, options, and alternatives prior to initiating treatment.

Refer F676

28 Pa. Code 201.29 (a) Resident rights.

28 Pa. Code 211.2 (d)(8) Medical director







 Plan of Correction - To be completed: 03/09/2024

Risks and benefits of current psychiatric treatment plan reviewed with resident representatives 19, 20. Consent was obtained for current treatment plan. Psychiatric consult reviewed and treatment plan discussed with resident via interpreter services.

All residents with psychiatric medications were reviewed and risks verse benefits of current treatment plans, were reviewed and consented with resident representatives. Procedure placed in facility for staff to assist with telemedicine visit at time of psychiatry consultation with resident representative. If the resident representative chooses not to attend, nursing will follow up with treatment plan.

Education provided to nursing staff that risks verse benefits will be reviewed with resident or resident representative for proposed treatment plan, following psychiatric consult. Nursing staff educated to explain new process of telemedicine visits with psychiatric consults.

Facility designee will complete weekly audit x 4, monthly x2 for all psychiatric consultations with telemedicine visit and ensure treatment plan discussion with resident and/or resident representatives. Findings to be reported to QAPI.

483.90(h)(1)-(4) REQUIREMENT Requirements for Dining and Activity Rooms: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(h) Dining and Resident Activities
The facility must provide one or more rooms designated for resident dining and activities.

These rooms must--
§483.90(h)(1) Be well lighted;

§483.90(h)(2) Be well ventilated;

§483.90(h)(3) Be adequately furnished; and

§483.90(h)(4) Have sufficient space to accommodate all activities.
Observations:

Based on observation and staff interview, it was determined that the facility failed to provide
dining tables to accommodate speciality seating chairs in the dining room for two residents out of 13 sampled (Residents 5 and 26).

Findings include:

Observation on January 23, 2024, at 11:48 AM during the lunch meal in the dining room located on the second floor, revealed that Resident 5 and Resident 26, were both seated in Broda chairs (specialty seating system with a tilt-in-space positioning feature, often positioned closer to the floor), at two separate dining room tables. However, the table height was elevated to a level, which prevented the residents from easily accessing the table and table top for dining.

A second observation at the lunch meal on January 24, 2024, at 12:05 PM revealed Resident 5 and 26 were again seated in Broda chairs, at two separate dining tables, that were not at the necessary height to accommodate the residents' Broda chairs and allow the residents to easily reach the table top.

Theres observations revealed that the tabletops were too high for the Residents 5 and 26 and the height of the tables did not provide the residents with clear visibility and access to their food, making it difficult for these residents to feed themselves.

During an interview with the Director of Nursing at the time of the second observation on January 24, 2024, at 12:05, confirmed that the tabletops were too high for Residents 5 and 26 and that the tables in the dining room did not have the ability to be lowered to accommodate the residents' needs while seated in a Broda chair.


28 Pa. Code 205.24 Dining rooms







 Plan of Correction - To be completed: 03/09/2024

New tables ordered and are in-service with adjustable heights for Residents 5 & 26.

Facility wide audit will be performed to ensure all residents are at proper table height if eating out of bed. Residents who are in broda chairs will dine at the new adjustable tables in the dining room.

Education will be provided to nursing and dietary staff to ensure that residents who are in broda chairs are at the proper adjustable tables for meals.

Facility designee to complete audit weekly x4, monthly x2 ensuring all residents are at the
proper tables for meals.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records: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(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:
Based on interviews with staff and residents, it was determined that the facility failed to ensure that mail was promptly delivered to residents six days a week, including deliveries to two of the two residents interviewed during a resident group interview (Residents 4 and 23).

Findings include:


Definitions under the regulatory guidance for indicated that "promptly" means delivery of mail or other materials to the resident within 24 hours of delivery by the postal service (including a post office box) and delivery of outgoing mail to the postal service within 24 hours, except when there is no regularly scheduled postal delivery and pick-up service.

During a resident group interview on January 24, 2024, at 10:00 AM, Residents 4 and 23 stated that they do not receive their incoming mail on Saturdays. The residents explained that they must wait until Monday for any mail that is delivered to them, care of the facility on the weekend. The residents stated that the facility staff assigned to deliver their mail do not work on the weekends and as a result the residents do not receive mail on Saturdays as they would in the community.

During an interview on January 24, 2024, at 12:15 AM, Employee 2, Billing Specialist, stated that she is responsible for retrieving the mail from the facility mail room and delivering it to the residents. Employee 2 confirms that she works Monday through Friday and is not available to deliver mail to the residents on weekends.

During an interview on January 24, 2024, at 1:15 PM, Employee 1, Activities, stated that she delivers the mail to residents when Employee 2 is not available. She stated that her shift is also Monday through Friday. Employee 1 explained that weekend mail is delivered to the residents on Mondays.

During an interview on January 25, 2024, at approximately 10:45 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that residents have the right to prompt mail delivery and confirmed that residents were not receiving their mail promptly if it arrived at the facility on a Saturday.



28 Pa. Code 201.29(a) Resident rights.




 Plan of Correction - To be completed: 03/09/2024

Residents 4, 23, cannot be retroactively corrected to deliver mail on previous Saturdays.

Facility courier services educated that mail needs to be picked up from post office and distributed 6 days a week to the residents of The Summit Nursing & Rehabilitation. New process change to incorporate Lehighton Post Office in Saturday morning courier route.

Facility courier services contacted regarding need for delivery on Saturdays. Charge RN will deliver mail to residents once received from the facility courier.

Audit to be performed weekly x 3 months to ensure delivery of mail to residents by facility designee and reported to QAPI.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(g)(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 a review of clinical records, facility documentation, and an interview with staff, it was determined that the facility failed to provide the required advance notice, through a Notice of Medicare Non-Coverage (CMS 10123-NOMNC), regarding the termination of Medicare services for one of the three residents sampled (Resident 143).

Findings include:

A closed record review revealed that Resident 143 was admitted to the facility on October 13, 2023, and was discharged on November 8, 2023.

A closed record review revealed that the facility provided Resident 143's representative with a Notice of Medicare Non-Coverage (CMS 10123-NOMNC) letter dated November 6, 2023. The notice indicated that Medicare would likely not pay for the resident's skilled services after November 7, 2023 (one day notice).

A facility must notify the beneficiary of the decision to terminate covered Medicare services no later than two days before the proposed end of the services.

During an interview on January 25, 2024, at approximately 10:45 AM, the Director of Nursing (DON) confirmed that the facility failed to notify Resident 143 or Resident 143's representative of the decision to terminate covered Medicare services no later than two days before the proposed end of the services.

28 Pa. Code 201.29(a) Resident rights.

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




 Plan of Correction - To be completed: 03/09/2024

Resident 143 cannot be retroactively correct for NOMNC notification.
Education provided to Director of Nursing regarding time frame for NOMNC notification to resident and or resident representative.
Inter-disciplinary procedure will be updated to confirm exact dates for issuing NOMNC notification to resident and or resident representative.
Facility designee will complete weekly audit x 4, monthly x 2 for correct dates and notifications of NOMNC issuance. Findings to be reported to QAPI.

483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 13 sampled (Residents 24).

Findings include:

According to the RAI User's Manual, Section I, "Active Diagnoses: Active Diagnoses in the Last 7 Days", dated October 2023, items in this section assesses active diseases and infections that drive the current plan of care during the seven day look back period.

A review of Resident 24's Annual MDS Assessment dated August 8, 2023, Section I indicated that the resident did not have an active diagnosis of Post-Traumatic Stress Disorder (PTSD) (a disorder that develops in some people who have experienced a shocking, scary, or dangerous event).

A review of Resident 24's clinical record revealed the resident had an active diagnosis of PTSD as of April 23, 2023.

Interview with the Nursing Home Administrator on January 25, 2024, at 9:26 AM, confirmed that Resident 24's MDS annual assessment was not accurate.










 Plan of Correction - To be completed: 03/09/2024

PTSD diagnosis was added to Resident 24's medical diagnosis list.
Will perform audit of all residents with psychiatric consults to reflect that all diagnosis match diagnosis list on medical record.
Education will be provided to RNAC and nursing staff to ensure all new diagnosis are added to diagnosis list.
Facility designee to complete audit weekly x4, monthly x2 ensuring psychiatric consult diagnosis match medical record diagnosis.

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

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

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

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

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

§483.24(b)(3) Elimination-toileting,

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

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

Based on a review of clinical records and staff and resident interviews, it was determined that the facility failed to consistently provide a functional communication system for a resident to maintain the resident's ability to communicate for one resident out of 13 sampled (Resident 31).

Findings include:

A clinical record review revealed that Resident 31 was admitted to the facility on April 1, 2020, with a diagnosis of cerebral infarction (brain damage that results from the lack of blood).

A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 12, 2023, revealed that Resident 31 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). The MDS assessment also indicated that the resident's preferred language is Mandarin and that he needs and/or would like an interpreter to communicate with a doctor or health care staff.

The resident's care plan, initiated upon admission indicated that the resident had communication problem related to a language barrier. The care plan indicated that Resident 31 prefers to communicate in Mandarin Chinese, he has pictures in his room that he uses to communicate basic needs to staff, he understands some basic English and will nod his head "yes" or "no" appropriately or will use hand gestures. The care plan included the approach of providing a translator to communicate with the resident.

A psychiatry note dated January 2, 2024, at 5:53 AM indicated that the resident was seen for an evaluation. The resident was engaged mostly with hand gestures. He was seen in a wheelchair, wearing mask, speaking minimal English and responding mostly with hand gestures. He stated he was doing "ok" with stable appetite and sleep. Denied being depressed or frustrated. The resident denied any physical issues at the time of the evaluation was noted to be behaviorally stable at that time. The progress note also indicated that the risks and benefits of treatment were not discussed with the resident, and "N/A" \ was noted. It was noted that the resident was "unable to comprehend fully due to language barrier."

There was no indication that the facility's translation service was used during the psychiatric evaluation on January 2, 2024, to communicate with Resident 31 and to facilitate a discussion with the practitioner regarding the resident's treatment plan.

A practitioner progress note dated January 15, 2024, at 17:29 PM indicated that Resident 31 was evaluated today in his wheelchair propelling through the unit. The entry noted that the resident was is in no acute distress and that "he is able to communicate verbally, but this is limited."

There was no evidence that the practitioner utilized the facility's translation service on January 15, 2024, to communicate with Resident 31 during the evaluation.

The resident's clinical record failed to reveal evidence that staff consistently used translation services when communicating, interacting with or providing care to Resident 31.

During an interview on January 25, 2024, at 8:50 AM, facilitated through the facility's contracted translation service (ASCOM) via an IPAD, Resident 31 conveyed that he is frustrated that staff do not understand him and that he doesn't understand the facility staff. Resident 31 relayed that staff rarely utilize the communication service when interacting with him or providing his care. He explained that when staff do not utilize the translator service, he is not able to understand. Resident 31 indicated that the staff tries to communicate using other methods, but he does not understand. He reported that the communication barrier is causing him distress and confusion about his care.

Following inquiries made during the survey, an additional care intervention was added for staff to utilize translator iPad to communicate with Resident 31, initiated on January 25, 2024, following surveyor inquiry.

During an interview on January 25, 2024, at approximately 11:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) indicated that they were not aware of Resident 31's concerns with his communication abilities. The NHA and DON were unable to provide evidence that staff were consistently implementing the use of the available translation service or other functional communication systems when providing care for or interacting with Resident 31.

Refer F552


28 Pa. Code 201.29 (a) Resident rights.

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





 Plan of Correction - To be completed: 03/09/2024

Primary care physician requested to review most recent visit and recommendation via translator application with Resident 31. Most recent psychiatric consult and treatment plan reviewed by nursing staff.
During admission process, identify non-English speaking residents, and provide translator services.
Education to be provided to physicians that if a resident is non-English speaking, an interpreter service is required to be used during visit and when reviewing plan of care with resident. Education to staff requiring translator services to be used when speaking to a non-English speaking residents.
Facility designee to complete audit weekly x4, monthly x2 for residents requiring interpreter services. Will ensure interpreter service utilized for all physician visits and


483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on a review of clinical record and and staff interview, it was determined that the facility failed to provide person-centered quality care by failing to follow physician orders for pre -surgery preparation for one resident out of 13 residents sampled (Resident 14).

Findings include:

A review of the clinical record revealed that Resident 14 was admitted to the facility on April 25, 2022, with 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 dental caries (permanently damaged area in teeth that develop into tiny holes).

A physician order dated January 21, 2024, was noted for the resident to be NPO (nothing by mouth) after midnight (January 21, 2024, into January 22, 2024) for a scheduled oral surgical procedure on January 22, 2024.

A nurses note dated January 22, 2024, at 8:51 AM noted that the resident was given a breakfast tray and ate 100% of his scrambled eggs.

A nurses note dated January 22, 2024, at 9:10 AM noted that the physician was made aware of the resident consuming eggs and the physician informed the facility that the resident's oral surgery would need to be rescheduled.

Interview with the Director of Nursing on January 23, 2024, at 2:00 PM confirmed the facility failed to follow the physician's order for the resident to be NPO prior to the scheduled oral surgery, which required the resident's surgery to be rescheduled to a later date.



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








 Plan of Correction - To be completed: 03/09/2024

Resident 14's oral surgery appointment is rescheduled.

All current diet orders reviewed for appropriateness.
Audit performed for diet entry and correctly reflecting in dietary electronic printing system. Upon NPO order being received, nurse entering order must confirm with dietary to ensure proper dates of NPO time frame have been entered correctly.

Education to nursing staff on proper diet entry.

Facility designee to complete audit weekly x4, monthly x2 to ensure diet accurately reflecting in electronic health record and dietary electronic printing system.


483.25(m) REQUIREMENT Trauma Informed Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.
Observations:

Based on a review of clinical records and staff interviews, it was determined that the facility failed to develop and implement an individualized person-centered plan to provide trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 13 residents reviewed (Resident 24).

Findings include:

A review of the clinical record revealed that Resident 24 was admitted to the facility on August 12, 2022, with diagnoses that included depression.

During the resident's stay in the facility, it was noted that on April 23, 2023, Resident 24 received a diagnosis of Post Traumatic Stress Disorder (PTSD).

The resident's current care plan, in effect at the time of review beginning January 23, 2024, did not identify the resident's PTSD symptoms or triggers related to this diagnosis and did not identify resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization.

Interview with Employee 3 (Social Services Director) on January 24, 2024, at 11:05 AM confirmed that the facility had not identified symptoms or triggers related to Resident 24's PTSD diagnosis.

The facility failed to develop and implement an individualized person-centered plan to address this resident's diagnosis of PTSD according to standards of practice to promote the resident's emotional well-being and safety.

Interview with the Nursing Home Administrator on January 24, 2024, at 11:10 AM, confirmed the facility was unable to demonstrate that the facility provided trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident.


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




 Plan of Correction - To be completed: 03/09/2024

PTSD triggers were reviewed with Resident 24's representative. Triggers were added to care plan for staff to avoid. Facility wide audit performed to address PTSD diagnosis. Education provided to nursing staff and social services requiring identification of PTSD diagnosis, to identify that residents with PTSD diagnosis require care plan addressing triggers and/or symptoms. Facility designee to complete audit weekly x4, monthly x2 for trauma informed care plans and PTSD diagnosis.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on a review of nurse staffing and the resident census and staff interviews, it was determined that the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for 11 shifts out of 63 reviewed.

Findings include:

A review of the facility's weekly staffing records and resident census revealed that on the following dates, the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:30 on the evening shift and 1:40 on the night shift, based on the facility's census.

The required LPN staff per shift is calculated by multiplying the required shift ratio by the facility census.

October 20, 2023- 1 LPN on the evening shift, versus the required 1.27 for a census of 38 residents.
October 23, 2023- 1 LPN on the evening shift, versus the required 1.23 for a census of 37 residents.
October 24, 2023- 1 LPN on the evening shift versus the required 1.27 for a census of 38 residents.
January 3, 2024-1 LPN on the evening shift versus the required 1.17 for a census of 35 residents.
January 8, 2024- 1 LPN on the evening shift versus the required 1.3 for a census of 39 residents.
January 8, 2024- 0 LPNs on the night shift versus the required 0.975 for a census of 39 residents.
January 19, 2024- 1 LPN on the evening shift versus the required 1.3 for a census of 39 residents.
January 21, 2024- 1 LPN on the evening shift versus the 1.3 required for a census of 39 residents.
January 22, 2024- 1 LPN on the evening shift versus the required 1.27 required for a census of 38 residents.
January 23, 2024- 1 LPN on the evening shift versus the 1.3 required for a census of 39 residents.
January 24, 2024- 1 LPN on the evening shift versus the 1.27 required for a census of 38 residents.

An interview with the Director of Nursing on January 25, 2024, at approximately 11:45 AM confirmed the facility had not met the required LPN per resident ratios on the above dates.




 Plan of Correction - To be completed: 03/09/2024

Staffing ratios cannot be retroactively corrected for previous dates noted out of ratio compliance.

Education provide to facility staff responsible for ratios regarding regulations and ratios for each shift. DON and/or NHA to confirm proper PPD and ratios per shift.

Facility designee to monitor for correct nursing rations weekly x 4, monthly x 2 to ensure compliance for staffing ratios. Findings to be reported to QAPI.


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