Pennsylvania Department of Health
 HAMPTON HOUSE REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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HAMPTON HOUSE REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  119 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
HAMPTON HOUSE REHABILITATION AND NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Abbreviated Complaint Survey, and Revist Survey completed on August 23, 2024, it was determined that Hampton House failed to correct the deficiencies cited during the survey completed July 2, 2024, and continued to be out of 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 Licensure Regulations.









 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency 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 review of facility policy, observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

A review of a facility policy entitled "Cleaning Dishes: Manual Dishwashing" last reviewed by the facility on April 17, 2024, indicated that sink 1 - wash procedure should include cleaning the sink and measure the appropriate amount of water into the sink to the water line and determine the amount of detergent to be used, following the manufactures directions for use. Sink 2 - rinse procedure was to include preparing the sink with hot water (120 degrees - 140 degrees Fahrenheit) and rinse the dishes thoroughly before placing in the sanitizing sink. Sink 3 - sanitize procedure was to include measuring the appropriate amount of sanitizing chemical into the appropriate amount of water (following manufacture's guidelines) and testing the sanitizing solution using the manufacture's suggested test strips to assure appropriate level before placing the dishes into the sanitizing sink.

Further review of a posted procedure guide entitled "Pot and Pan Cleaning and Sanitizing Procedures" revealed the level of sanitation testing solutions should be between 200 - 400 parts per million (PPM is a unit of measurement used to express concentrations of a substance in a solution or mixture).

The initial tour of the kitchen conducted with the facility's Food Service Manager on August 20, 2024, at 8:58 a.m., revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness:

Observed inside the 3-compartment sink (is a piece of manual equipment used for cleaning and sanitizing dishes, utensils, and equipment used in the kitchen) labeled "sanitize" observed that cooking/baking equipment, such as whisks, pans, pots, etc., were soaking inside of the compartment in a pale pink solution. A test strip test was conducted, and the test strip turned an orange color and indicated zero (0) parts per million (ppm) of sanitation solution.

The Food Service Manager confirmed the observation and the test strip results and indicated the sanitize compartment should have read between 200 - 400 PPM and was not sure why the sanitize solution was so weak.

Observations of the ceiling tiles of the dietary department revealed several tiles throughout the department that were splattered with a brownish colored substance.

Outside of the dish room area and near the cook's preparation area, mobile garbage reciprocal with no lid was overflowing with bagged trash.

Observed that the wall exiting the kitchen and leading into the dining room had an accumulation of dust and debris adhered to the wall surfaces.

Observations of the exhaust hood over the stove/cook top revealed two dried, hard, discolored white rags that stuck inside two corners of the hood.

Observed a white plastic container with a label "bulk hard-boiled eggs" with dry white rice stored inside. Also, one of the four lid corners was cracked and exposed the contents making it available to contamination.

Further observation of the dietary department revealed the hosing attached to the water filter and coffee maker were heavily corroded with dust and debris.

Interview with the Food Service Manager on August 20, 2024, at 9:30 a.m., confirmed the above observations and indicated the kitchen areas should be maintained in a sanitary manner to prevent opportunities for contamination and foodborne illness.

28 Pa. Code 201.18 (e)(1) (2.1) Management

28 Pa. Code 211.6 (f) Dietary Services




 Plan of Correction - To be completed: 09/17/2024

Issues cited during the survey have been corrected.

Regional Dietary Manager/designee will conduct an initial Audit to identify any other concerns regarding kitchen sanitation.

Food Service Director/designee will re-educate staff on Kitchen Sanitation policy, Food Safety and Sanitation Policy, Garbage and Rubbish Disposal Policy, Manual Dishwashing policy, and sanitation job assignments.

Audits will be conducted weekly by the Regional Dietary Manager/designee to identify and correct any deficient areas of sanitation. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.

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 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(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 a review of clinical records and staff interview, it was determined the attending physician failed to act upon pharmacist identified irregularities in the medication regimen of four of 20 residents sampled (Resident 12, 47, 86, and 46).

Findings include:

A review of the clinical record revealed Resident 12 was admitted to the facility on March 29, 2024, and had diagnoses that included bipolar disorder (serious mental illness characterized by extreme mood swings, a mood disorder that causes radical emotional changes and mood swings, from manic, restless highs to depressive, listless lows. Most bipolar individuals experience alternating episodes of mania and depression).

A review of an April 2024 "Note to Attending Physician/Prescriber" revealed the consultant pharmacist indicted the resident was recently admitted with an order for Quetiapine Fumarate (antipsychotic medication) oral tablet 25mg three times a day related to bipolar disorder and the medication needed to be evaluated for the effectiveness and if a GDR (gradual dose reduction) could be attempted.

Further review revealed the resident's attending physician failed to write an appropriate response to the pharmacy recommendation. Instead, the facility's consultant psychiatric CRNP (certified registered nurse practitioner) had responded to the pharmacy recommendation and signed off as she (CRNP) reviewed it.

A review of the clinical record revealed Resident 47 was admitted to the facility on September 14, 2021, and had diagnoses that included depressive disorder and mood disorder.

A review of a January 2024 "Note to Attending Physician/Prescriber" revealed the consultant pharmacist indicted the resident has an order for Depakote sprinkles (anti-seizure medication that is effective to treat bipolar disorder) 250mg by mouth one time a day for mood. The medication was due for an assessment in accordance with CMS (Centers for Medicare Medicaid Services) guidelines for psychopharmacological medications and if no dose reduction is indicated, please include a brief resident specific rationale.

A second recommendation was made by the pharmacist during the month of January 2024 indicating the resident had an order for Lexapro (antidepressant) 15 mg for depressive disorder. This medication was due for an assessment in accordance with CMS guidelines for psychopharmacological medications and if no dose reduction was indicated please include a brief resident specific rationale.

Further review revealed the resident's attending physician failed to write an appropriate response to the pharmacy recommendation. Instead, the facility's consultant psychiatric CRNP (certified registered nurse practitioner) had responded to the pharmacy recommendation and signed off as she reviewed it.

A review of a March 2024 "Note to Attending Physician/Prescriber" revealed the consultant pharmacist indicted the resident had an order for Seroquel 25mg every day for reoccurring depressive disorder. The pharmacist noted the resident's behaviors appear to occur mostly around bedtime, but the medication was being administered at 9:00 AM. The medication was due for an assessment in accordance with CMS guidelines for psychopharmacological medications and if no dose reduction is indicated, please include a brief patient specific rationale.

Further review revealed the resident's attending physician failed to write an appropriate response to the pharmacy recommendation. Instead, the facility's consultant psychiatric CRNP (certified registered nurse practitioner) had responded to the pharmacy recommendation and signed off as she reviewed it.

A review of the clinical record revealed Resident 86 was admitted to the facility on November 10, 2023, and had diagnoses that included dementia.

A review of a May 2024 "Note to Attending Physician/Prescriber" revealed the consultant pharmacist indicted the resident had an order for Seroquel (antipsychotic) 50 mg twice a day for unspecified dementia. The medication was due for an assessment in accordance with CMS guidelines for psychopharmacological medications and if no dose reduction is indicated, please include a brief patient specific rationale.

Further review revealed the resident's attending physician failed to write an appropriate response to the pharmacy recommendation. Instead, the facility's consultant psychiatric CRNP (certified registered nurse practitioner) had responded to the pharmacy recommendation and signed off as she reviewed it.

A review of Resident 64's clinical record revealed that the resident was admitted to the facility on March 30, 2022, with diagnoses that included Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior and is a gradually progressive condition).

A review of a January 2024 "Note to Attending Physician/Prescriber" revealed the consultant pharmacist indicted the resident had an order for Depakote 250 mg three times per day for a mood disorder. The medication was due for an assessment in accordance with CMS guidelines for psychopharmacological medications and if no dose reduction is indicated, please include a brief patient specific rationale.

Further review revealed the resident's attending physician failed to write an appropriate response to the pharmacy recommendation. Instead, the facility's consultant psychiatric CRNP (certified registered nurse practitioner) had responded to the pharmacy recommendation and signed off as she reviewed it.

A review of a Resident 64's May 2024 "Note to Attending Physician/Prescriber" revealed the consultant pharmacist indicted the resident had an order for Trazadone 25 mg daily at bedtime for anxiety disorder. The medication was due for an assessment in accordance with CMS guidelines for psychopharmacological medications and if no dose reduction is indicated, please include a brief patient specific rationale.

Further review revealed the resident's attending physician failed to write an appropriate response to the pharmacy recommendation. Instead, the facility's consultant psychiatric CRNP (certified registered nurse practitioner) had responded to the pharmacy recommendation and signed off as she reviewed it.

Further review revealed the resident's attending physician failed to document an individualized response to the pharmacy recommendations. Instead, the facility's consultant psychiatric CRNP had responded to the pharmacy recommendation and signed off as she reviewed the recommendations.

In an interview with the Director of Nursing on August 23, 2024, at approximately 1:30 PM confirmed that consultant psychiatric CRNP was responding to the pharmacy recommendations and not the resident's attending physician as noted in the regulation.


28 Pa. Code 211.9 (k) Pharmacy services.

28 Pa. Code 211.12 (c) Nursing services.

28 Pa. Code 211.2 (d)(3) Medical Director









 Plan of Correction - To be completed: 09/17/2024

Residents 12, 47, 86, and 64 have had their drug regimens reviewed again and the attending physician has acted upon the recommendation with an appropriate response to the recommendation if declined.

Resident pharmacy recommendations from August 2024 will be reviewed again to ensure that the attending physician has acted upon the recommendation with an appropriate response to the recommendation if declined.

Staff Development/designee(s) will re-educate Nurse Managers, attending physicians, and the Medical Director on the facility's Drug Regimen Review policy.

Resident pharmacy recommendations from September 2024 will be audited to ensure that the attending physician has acted upon the recommendation with an appropriate response to the recommendation if declined. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.

483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program: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)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.
Observations:

Based on observations, a review of facility pest service records and staff interview, it was determined the facility failed to maintain an effective pest control program throughout multiple areas of the facility.

Findings include:

An observation of the A hall nursing unit medication room on August 22, 2024, at approximately 9:05 AM revealed a strong mildew and sewage smell throughout the room. A flying bug was seen in the med room.

An observation of the A hall nursing unit shower room on August 22, 2024, at approximately 9:15 AM revealed a large amount of sewer flies in the shower room. These flies were noted to be covering the walls of the shower room. They were noted by the tub and in both shower stalls. There was multiple dead flies noted on the floor, in the tub, or flattened on the wall.

An interview with Employee 1 LPN (license practical nurse) on August 22, 2024, at approximately 9:25 AM revealed the employee stated the bugs have been an ongoing issue in the facility. She stated that they have been a problem for at least four months and have become worse over the summer. The employee stated she has observed the bugs in the shower room and in the medication room.

A review of the contracted pest control company's service reports for general pest control maintenance for the facility revealed the pest control company did not begin to treat for the flies until July 9, 2024, despite staff indicating the fly infestation has been going on for at least four months.

A review of a pest control report dated July 9, 2024, revealed the company treated the A wing shower room for drain flies. The pest company failed to provide recommendations to the facility about providing treatments to the drains to ensure the flies would be controlled between visits.

A review of a pest control report dated July 23, 2024, revealed the flies remained a problem in the A wing shower room and a treatment was provided again. The pest control once again failed to provide any recommendations to the facility on how to continue to treat the drains to ensure the files would be controlled between visits.

A review of a facility work order dated July 30, 2024, revealed the treatment to the drains did not work and it was reported there were bugs that were all over the walls of the A wing shower room. At that time the facility sprayed to kill the flies, but no treatments were provided to the drains to try to eradicate the flies.

A review of a pest control report dated August 6, 2024, revealed once again the pest company noted the presence of flies in the shower room and now in the medication room of the A wing nursing unit. The pest company applied the same treatment as the last two visits that failed to work. The pest control company suggested at that time that better sanitation and treatment should be completed but failed to identify the treatment should.

An interview with the Nursing Home Administrator (NHA) on August 23, 2024, at 1:30 PM, confirmed that the facility failed to complete the necessary measures to maintain an effective pest control program.


28 Pa. Code 201.18 (e)(2.1) Management



 Plan of Correction - To be completed: 09/17/2024

The cited pest control issues in the A wing shower room and A wing medication room have been addressed.

An initial tour of the facility med rooms and showers rooms showed no further pest issues or smells.

NHA/Designee will educate Maintenance staff regarding Pest Control regulations.

NHA/designee will audit the cited areas 2 times a week for 4 weeks and then 1 time per week for 2 months. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.


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 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observation, and staff interviews it was determined the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment.

Findings include:

An observation on August 20, 2024, at approximately 1:30 PM revealed in Room B14 Resident 25's tube feeding pump and pole were soiled with dried tube feeding solution dried to the pump and pole. In addition there were dried spots of tube feeding solution on the floor.

An observation of the A hall nursing unit medication room on August 22, 2024, at approximately 9:05 AM revealed there was dirt and debris on the floor. A strong mildew and sewage smell was noted throughout the room. A flying bug was observed flying around in this medication room.

An observation of the A hall nursing unit shower room on August 22, 2024, at approximately 9:15 AM revealed a large amount of sewer flies in the shower room. These flies were noted to be covering the walls of the shower room. They were observed by the tub and in both shower stalls. There were multiple dead flies noted on the floor, in the tub, or splattered on the walls. There were wet clumps of paper on the shower room floor. The shower curtain was noted to have brown stains on the bottom. There were cracked tiles observed on the wall near the floor.

An observation on August 23, 2024, at approximately 8:55 AM revealed Room B14, Resident 25's tube feed pump and pole still had dried tube feeding solution on the pump and pole. The dried spots tube feeding solution remained on the floor.

Interview with the Director of Nursing and Nursing Home Administrator on August 23, 2024, at approximately 1:30 PM confirmed the facility is to be maintained on a daily basis to ensure a clean and sanitary environment for the residents.


Refer F925

28 Pa. Code 201.18 (e)(2.1) Management






 Plan of Correction - To be completed: 09/17/2024

Maintenance/Housekeeping will correct cited areas related to resident tube feeding poles, A Hall medication room, and A Hall shower room.

Administrator/designee will conduct an initial audit of these cited areas to ensure that the environment is safe, clean, comfortable, and homelike.

The Maintenance Staff, Housekeeping Staff, and CNAs will be educated by NHA/designee on keeping the environment safe, clean, comfortable, and homelike for residents. The facility will also re-educate the Maintenance Director and Housekeeping Director on existing preventative maintenance and cleaning policies.

NHA/designee will audit the cited areas 2 times a week for 4 weeks and then 1 time per week for 2 months. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:

Based on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an effective individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of 20 residents reviewed (Resident 86).

Findings include:

A review of Resident 86's clinical record revealed the resident was admitted to the facility on November 10, 2023, with diagnoses to include dementia (a progressive brain disorder that affects memory, thinking, and behavior)

A review of Resident 29's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 13, 2024, revealed the resident was severely cognitively impaired.

A review of progress notes in the resident's clinical record dated from February 01, 2024 to August 24, 2024, revealed the resident exhibited behaviors of intrusive wandering, striking out, screaming, and agitation.

The resident's current care plan in effect at the time of the survey ending August 23, 2024, did not address her diagnosis of Dementia.

The facility failed to develop and implement an individualized person-centered plan to address, modify and manage this resident's dementia-related behaviors. The resident's care plan for dementia failed to include individualized interventions based on an assessment of the resident's preferences, social/past life history, customary routines, and interests in an effort to manage, modify or decrease the resident's dementia-related behavioral symptoms.

The facility failed to demonstrate the provision of necessary care and services, including individualized interdisciplinary non-pharmacological approaches to care, purposeful and meaningful activities, that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. There was no evidence the facility provided the resident with specialized services and supports, such specialized activities, nutrition, and environmental modifications, based on the individual's abilities and dementia related behaviors

Interview with Nursing Home Administrator on August 23, 2024, at approximately 10:00 a.m., confirmed the facility was unable to provide evidence of the development and implementation of an individualized person-centered plan to address the resident's dementia-related behaviors.



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





 Plan of Correction - To be completed: 09/17/2024

Resident 86 has an individualized person-centered care plan to address the resident's behavioral symptoms.

DON/designee will audit current residents with Dementia diagnosis to ensure that the resident has an individualized person-centered care plan to address the resident's behavioral symptoms.

Staff Development/designee will re-educate licensed nursing staff, RNAC, and the Social Worker on implementing an effective individualized person-centered care plan to address a resident's dementia-related behavioral symptoms.

DON/designee(s) will audit new resident admissions and residents newly diagnosed with dementia to ensure that an individualized and person-centered care plan is developed. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.

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 a review of clinical records and select facility policies and staff interview, it was determined the facility failed to consistently and accurately monitor resident weights to
timely identify changes in nutritional parameters for two of 20 sampled residents (Residents 40 and 91).

Findings include:

The facility policy "Weight Policy" dated as revised June 2024, indicated that any resident with weight changes of five or more pounds will be re-weighed within 72 hours post the original weight by the assigned CNA/designee and nurse. The Dietician will review the medical record of residents with significant weight changes (greater than or equal to 5% in 1 month, greater than or equal to 7.5% in 3 months, and greater than or equal to 10% in 6 months). Interventions will be recommended, as needed. Interventions that are initiated in response to a weight change will be reflected in the care plan. Residents with significant weight loss/gain will be further reviewed by the IDCPT (interdisciplinary care plan team) meetings.

A review of Resident 's 40's clinical record revealed the resident was admitted to the facility on November 10, 2023, with diagnoses to include diabetes (commonly referred to as diabetes, is a group of metabolic diseases in which there are high blood sugar levels over a prolonged period) and heart disease.

A Dietary Progress Note created by the Registered Dietitian (RD) dated July 18, 2024, revealed Resident 40 weighed 167 lbs. on July 4, 2024, and 133 lbs. on July 18, 2024, which was a 19.9% weight loss in 30 days, losing 34 lbs. in 2 weeks. Further review indicated the RD questioned the accuracy of the weight however, a reweigh confirmed the significant weight loss. There were no new interventions implemented at the time of the weight loss. The RD did not implement a new intervention until August 6, 2024, at which time she recommended the addition of a magic cup (nutritional supplement to enhance weight gain) three times a day.

Review of Resident 40's current nutritional care plan in place at the time of survey ending August 23, 2024, revealed no revisions were made since April 4, 2024.

Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 23, 2024, at approximately 9:20 AM, confirmed the facility failed to follow the facility's weight policy.

A review of Resident 91's clinical record revealed the resident was admitted to the facility on April 15, 2024, with diagnoses that included anoxic brain damage (is damage to the brain due to a lack of oxygen supply), alcohol abuse, alcohol induced pancreatitis (inflammation of the pancreases that is caused by chronic, excessive alcohol consumption), and dysphagia (difficulty swallowing).

Additionally, Resident 91 was NPO (nothing by mouth) and required a feeding tube, a medical device used to provide nutrition to which cannot be obtained by mouth, are unable to swallow safely, or need nutritional supplementation. The state of being fed by a feeding tube is also referred to as an enteral feeding or tube feeding. The tube feeding would assist the resident to meet his estimated calorie, protein, hydration, and other essential nutrients related to the inability to safely consume foods and fluids orally.

A review of Resident 91's readmission comprehensive nutritional assessment completed by the Registered Dietitian (RD) dated May 21, 2024, at 8:00 AM, revealed the resident's current weight upon readmission was 110 pounds and the weight prior to hospitalization was 150 pounds and noted the resident had frequent weight changes due to "jerky" movements in the mechanical lift causing inaccurate weights. Continue with weekly weights as able and continue with current tube feeding regimen and update as needed (PRN).

A review of Resident 91's weight record indicated the following weights:

June 11, 2024, at 9:38 AM, via mechanical lift - 143.2 pounds
June 14, 2024, at 2:35 AM, via mechanical lift - 127 pounds
June 18, 2024, at 2:08 AM, via mechanical lift - 127.3 pounds

There was no documented evidence the facility obtained a timely re-weight (72-hours) between June 14, 2024, and June 18, 2024, after a significant weight loss of 16.2 pounds in less than a week.

A review of Resident 91's clinical record revealed a weight change note completed by the RD on June 18, 2024, at 9:17 PM, which identified the resident had a significant weight change and indicated the weight changes were secondary to jerky movements during the weight being taken. It was noted the resident continued enteral feed order, no intolerances per nursing, running as ordered. Tube feeding providing 2400 calories, 111 grams protein and was adequate to meet the resident's higher end of the estimated nutrient needs and continue to monitor weight status, no new recommendations at this time.

Additionally, a weight change note completed by the RD on July 24, 2024, at 8:25 PM, indicated the resident continued with fluctuating weight status between 125 and 140 pounds and that weight "appears stable." Tube feeding continues at goal and meeting upper end of estimated nutrient needs. Will continue to monitor.

Further review of the resident's weight record revealed the following recorded weekly weights:

July 25, 2024, at 3:46 PM via mechanical lift - 132 pounds
July 30, 2024, at 2:03 PM via mechanical lift - 127 pounds (loss of 5-pounds in five days)
August 8, 2024, at 1:38 PM via mechanical lift - 136.5 pounds (gain of 9.5-pounds in eight days)
August 13, 2023, at 2:09 p.m., via mechanical lift- 132-pounds (loss of 4.5 pounds in five days)

The facility failed to timely obtain re-weights and attempt to obtain accurate methods of weighing a dependent resident to perform an accurate assessment of nutritional requirements.

An interview with the Nursing Home Administrator on August 23, 2024, at 10:25 AM confirmed that re-weights were not obtained in a timely manner and that alternative methods of weighing the dependent resident was not explored to ensure accurate estimations of nutritional requirements.

28 Pa. Code Management

28 Pa Code 211.5(f)(ix) Medical records

28 Pa. Code Resident care policies

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










 Plan of Correction - To be completed: 09/17/2024

Residents 40 and 91 are being weighed per policy and have interventions in place to attempt to prevent further significant weight loss. A wheelchair scale was purchased to obtain more accurate weights for dependent residents with the inability to remain still during weights.

Current residents with significant weight loss in the past 30 days will be reviewed by the Dietitian/designee to ensure that they are being weighed per policy and that they have interventions in place to attempt to prevent further weight loss.

Staff Development/designee will re-educate the nursing staff, the Dietitian, & the Certified Dietary Manager (CDM) on the facility's weight policy. Regional Dietitian/designee will also re-educate the Dietitian and the CDM on the facility's Weight Assessment and Intervention policy.

DON/Designee(s) will audit resident weights weekly to ensure that they are being done per the facility's weight policy. DON/designee(s) will also audit weekly any significant weight losses to ensure that the dietitian has implemented an intervention timely. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

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

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

Based on review of select facility policy, clinical records, and staff interview, it was determined the facility failed to implement individualized approaches for inontinence to provide maintenance care to the extent possible for one out of 20 sampled residents (Resident 25).

Findings include:

A review of facility policy entitled "Urinary and Bowel Incontinence Evaluation and Management" last reviewed April 17, 2024, indicated if a resident is not a candidate for a schedule, they will be placed on Incontinence Care and Comfort (checked and changed every two to three hours).

A review of Resident 25's clinical record revealed the resident was admitted to the facility on December 22, 2015, with diagnoses which included dementia (a decline in cognitive abilities that can affect a person's ability to perform everyday activities) and muscle wasting.

A review of the resident's bladder and bowel evaluation dated July 21, 2024, revealed the resident was always incontinent of bowel and bladder, has poor a potential for a toileting schedule, and was placed on an incontinence care and comfort plan.

A review of the resident's current plan of care failed to identify the resident's urinary incontinence and interventions to provide care and services.

A review of the resident's clinical record revealed the facility failed to document the resident's incontinence care and comfort care plan was being implemented and completed each shift.

Interview with the Director of Nursing on August 23, 2024, at approximately 1:30 PM confirmed the facility failed to provide maintenance care to Resident 25.



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





 Plan of Correction - To be completed: 09/17/2024

Resident 25 has a care plan for urinary incontinence which includes individualized approaches to provide incontinence care and comfort and has a task developed in the electronic medical records to document the incontinence care and comfort provided.

Current residents placed on Incontinence care and comfort will be audited to ensure that they have an individualized urinary incontinence care plan and a task to document the incontinence care and comfort provided. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.

Staff Development/designee will Inservice nursing staff on the bowel and bladder policy, to include the creation of an individualized urinary incontinence care plan and a task to document the urinary care and comfort provided.

The DON/designee will audit weekly the new admissions, re-admissions, and urinary changes in status to ensure that those placed on incontinence care and comfort have an individualized urinary incontinence care plan and a task to document the incontinence care and comfort provided.

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 records, and staff interview, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure physician ordered medication, an antibiotic, and additive were timely obtained and administered to treat a urinary tract infection for one resident (Resident 93) out of 20 sampled residents.

Findings include:

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care:

Assessments
Clinical problems
Communications with other health care professionals regarding the patient
Communication with and education of the patient, family, and the patient's designated support person and other third parties.

A review of Resident 93's clinical record revealed the resident was admitted to the facility on July 5, 2024, with diagnoses that included Guillain-Barre Syndrome (a disorder of the immune system where the nerves are attacked by immune cells that causes weakness and tingling in arms and legs), neuromuscular dysfunction of the bladder (a type of bladder dysfunction caused by nerve, brain, or spinal cord damage with symptoms that include loss of bladder control and retaining urine), and urine retention (an inability to completely empty the bladder).

A review of urine analysis (UA is a common diagnostic test that evaluates the content, concentration, and appearance of urine and helps detect and manage a wide range of disorders such as urinary tract infections, kidney disease, and diabetes), and culture and sensitivity (urine culture is a method to grow and identify bacteria that may be in the urine. The sensitivity test helps select the best medicine to treat the infection) results that were received by the facility on July 24, 2024, at 11:03 a.m., revealed that Resident 93 had positive urine cultures and confirmed a urinary tract infection.

A review of a nurse progress noted completed by Employee 1, a Licensed Practical Nurse (LPN), dated July 25, 2024, at 2:28 p.m., revealed that C& S results were reviewed with the CRNP (Certified Registered Nurse Practitioner) with new orders for Ceftriaxone (an antibiotic in the form of an injection that treats bacterial infections), give 1 gram (gm) intramuscularly ( a technique used to deliver a medication deep into the muscles) for 7 days. The Physician, resident, and responsible party (RP) were aware.

A review of a physician's order dated July 26, 2024, at 4:12 p.m., revealed an order for an antibiotic, Ceftriaxone SodiumInject 1 gram intramuscularly one time a day for UTI for 7 Days reconstitute (restore to a former condition by adding water) with Lidocaine (numbing medication).

A review of Resident 93's medication administration record (MAR) is the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) dated July 2024, revealed on July 27, 2024, the resident did not receive the prescribed IM antibiotic Ceftriaxone Sodium.

Further review of the clinical record revealed an order administration note completed by Employee 1, dated July 27, 2024, at 7:01 p.m., indicated the Ceftriaxone Sodium Injection was not administered due to the facility waiting for Lidocaine from the pharmacy.

During an interview with the Director of Nursing (DON) on August 22, 2024, at 1:45 p.m., it was reported that in the event a physician prescribed treatment was not provided by the facility's primary contracted pharmacy, nursing staff were to contact the contracted emergency pharmacy to prevent a delay in the medication administration.

Resident 93's clinical record failed to reveal the resident's physician was timely notified of the missed dose of antibiotic therapy. The facility failed to ensure that Resident 93 received the antibiotic doses as prescribed by the physician to treat the UTI and failed to utilize services of the facility's contracted emergency pharmacy to prevent a delay in treatment.

Interview with the DON on August 23, 2024, at 11:00 a.m., confirmed the facility failed to administer physician ordered medication as prescribed, and failed to ensure the MD was notified of a missed dose. Additionally, the DON confirmed that nursing staff failed to implement emergency provisions to contact the contracted emergency pharmacy to prevent a delay in treatment.

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





 Plan of Correction - To be completed: 09/17/2024

Resident 93 has completed her course of antibiotics.

Resident's currently prescribed antibiotics for a urinary tract infection will be audited to ensure that the medications are being timely obtained and administered.

Staff Development/designee will re-educate licensed nursing staff on the medication administration, to include that medications are administered in accordance with physician orders including any required timeframes. Staff Development/designee will also re-educate the licensed nursing on the procedure for obtaining emergency medications.

The DON/designee will audit newly prescribed antibiotics for urinary tract infections to ensure that they are being timely obtained and administered. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on clinical record review and staff interviews, it was determined the facility failed to develop person-centered care plans that include individual medication therapy for one resident out of 20 sampled (Resident 12).

Findings include:

A review of the clinical record revealed Resident 12 was admitted to the facility on March 29, 2024, with diagnoses to include hypertension (high blood pressure).

A review of a physician order, initially dated April 30, 2024 revealed the resident was receiving Eliquis Oral Tablet 2.5 MG (anticoagulant medication-commonly known as a blood thinner, chemical substance that prevents or reduces the coagulation of blood, prolonging the clotting time) give twice a day for history of pulmonary embolism (blood clot in the lung).

A review of the current resident's plan of care revealed the resident's care plan failed to identify the resident's anticoagulant therapy and interventions to monitor for bleeding.

Interview with the Nursing Home Administrator and Director of Nursing on August 23, 2024, at approximately 1:30 PM confirmed the facility failed to ensure that comprehensive care plans were developed.


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



 Plan of Correction - To be completed: 09/17/2024

Resident 12's care plan has been updated to include an anticoagulant care plan with intervention(s) to monitor for bleeding.

Residents who are prescribed anticoagulant medications will have their care plans reviewed to ensure that they include an anticoagulant care plan with intervention(s) to monitor for bleeding.

Staff Development/designee will re-educate licensed nursing staff and the interdisciplinary managers on the facility's Comprehensive Care Plan policy.

The DON/designee will audit new resident admissions and residents newly prescribed an anticoagulant to ensure that an anticoagulant care plan is developed to include intervention(s) to monitor for bleeding. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
§483.15(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 review of written facility initiated transfer notices and staff interview it was determined the facility failed to provide sufficiently detailed written notices of facility initiated transfers to the hospital to the resident and the residents' representative for seven out of 20 residents reviewed (Resident 32, 87, 91, 46, 66, 31, and 40).

Findings include:

A review of the clinical record of Resident 32 revealed that the resident was transferred to the hospital on April 8, 2024, and returned to the facility on April 10, 2024.

A review of the clinical record of Resident 87 revealed that the resident was transferred to the hospital on May 8, 2024, and returned to the facility on May 14, 2024.

A review of the clinical record of Resident 91 revealed that the resident was transferred to the hospital on May 10, 2024, and returned to the facility on May 20, 2024.

A review of the clinical record of Resident 46 revealed that the resident was transferred to the hospital on May 30, 2024, and returned to the facility on June 2, 2024.

A review of the clinical record of Resident 66 revealed the resident was transferred to the hospital on July 16, 2024, and returned to the facility on July 25, 2024. The resident was transferred to the hospital again on July 29, 2024 and returned on August 5, 2024.

A review of the clinical record of Resident 31 revealed the resident was transferred to the hospital on August 13, 2024, and returned to the facility on August 15, 2024.

A review of the clinical record of Resident 40 revealed the resident was transferred to the hospital on June 2, 2024 and returned to the facility on June 11, 2024.

A review of the facility's "Notice of Transfer on Discharge" revealed the written notices lacked the correct address and phone number for assistance with the appeal process, and lacked the correct address, phone number, and email address for the advocacy of persons with disabilities and mental health to seek the assistance of the Disability Rights Pennsylvania.

During an interview with the Nursing Home Administrator on August 23, 2024 at approximately 1:30 PM confirmed the information provided to the residents was incorrect.


28 Pa. Code 201.29(h) Resident rights

28 Pa. Code 201.14(a) Responsibility of Licensee



 Plan of Correction - To be completed: 09/17/2024

The facility does not have the opportunity to correct cited residents. Resident 87 passed away on 8/27/24.

The facility does not have the opportunity to correct residents in a similar situation previous to survey.

The Administrator has corrected the Notice of Resident Transfer or Discharge so that they are sufficiently detailed and accurate. Staff Development/designee will re-educate the licensed on the facility transfer and discharge policy as well as the updated Notice of Resident Transfer and Discharge.

The DON/designee will audit the resident discharges weekly to ensure that the updated Notice of Resident Transfer and Discharge was utilized and completed correctly. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.


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