Pennsylvania Department of Health
SPRINGFIELD REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SPRINGFIELD REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are 109 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.


SPRINGFIELD REHABILITATION AND HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to three complaints, completed on June 3, 2024, it was determined that Springfield Rehabilitation and Healthcare Center, was not in compliance with the 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 related to the health portion of the survey process.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Observations:

Based on on the review of clinical records and facility documentation, observations, interview with residents and staff, it was determined that the facility did not ensure an environment was free of potential hazards related to medications left at bedside, a fall incident, and no railing around the loading dock for three of 30 residents' records reviewed (Rooms R326, R328, R329).

Findings include:

Review of facility policy named, " Safety and Supervision of Residents", initially adapted in 2001, stated; Resident safety and supervision and assistance to prevent accidents are facility-wide priorities...Resident supervision is a core component of the systems approach to safety.

On May 14, 2024 at 10:24 a.m. observation was made of Resident R326's room. Observation of the room revealed two medications bedside on the night stand. The medications at bed side included lactase enzyme 375 milligrams (mg) capsules and a bottle of Artificial Tears. Further observation of the lactase enzyme pill bottle revealed an expiration date of December 2023. Interview with Resident R326 revealed the resident takes them as needed before meals. Resident R326's stated the pills were not expired but rather the new bottle of pills were poured into the old bottle.

Interview with licensed nurse Employee E5 on May 14, 2024 at 10:30 a.m. revealed the resident did not have an order for either of these medications and there was no knowledge of the resident having these at bedside. Licensed nurse Employee E5 confirmed at 10:32 a.m. the medications were bedside, and she took them from Resident R326's possession.

On May 14, 2024 at 12:05 p.m. observation was made of Resident R328's room. Observation of the room revealed two inhalers located bedside on the resident's tray table. The inhalers included a Dulera inhaler and a Spiriva inhaler. Interview with the resident revealed the resident was discharged from the hospital on May 9, 2024 and brought the inhalers with her. The resident stated she has been using the Dulera two times a day and the Sprivia one time day since residing at the facility.

Interview with licensed nurse Employee E5 on May 14, 2024 at 12:15 p.m. revealed the resident did not have an order for either of these medications and there was no knowledge of the resident having these bedside. Licensed nurse E5 confirmed at 12:18 p.m. the medications were bedside, and she took them from Resident R328's possession.

On May 15, 2024 at 11:41 a.m. observation was made of Resident R329's room. Observation of the room revealed a Probiotic pill pack found bedside on the resident's nightstand. A care aide, hired by the resident's girlfriend to provide care while in the facility was in the resident's room and stated that the girlfriend gives the Probiotic pill to the resident once daily.

Interview with licensed nurse, Employee E5 on May 15, 2024 at 11:45 a.m. revealed the resident did not have an order for the pills and there was no knowledge of the resident having these bedside. Licensed nurse Employee E5 confirmed at 11:48 a.m. the medication was bedside, and she took them from Resident R329's possession.

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

28 Pa Code 211.10(d) Resident care policies

28 Pa Code 211.12(c) Nursing services

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

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

Plan of Correction - To be completed: 06/25/2024

1. R236, R328, and R329 had no adverse effects from medications that were found in their rooms and medications were immediately removed from the resident's room.
2. The facility conducted an audit of all resident rooms to ensure that there no medications in the resident's room without a physicians order. Variances were addressed on facility audit too.
3. Licensed professionals will be re-educated by the Director of Nursing/Designee on facility policy for medications at the bedside.
4. The Director of Nursing/Designee will audit 10 resident rooms weekly for 4 weeks followed by 10 resident rooms monthly for 2 months to ensure there are no medications at the bedside without a physician's order. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on prior audit findings.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on observation, review of facility policy and procedure, and interviews with staff, it was determined that the facility failed to maintain an effective infection control program, related with linen transportation, and personal protective equipment disposal for one of one resident observed during trancheotomy care. (Resident R56).

Findings include:

Observation on May 15, 2024, at 11:33 a.m., revealed that a Nurse Aide, Employee E15, was taking clean linen from the Linen Storeroom, located adjacent to Resident Room 102, was holding the clean linen letting it to touch the Nurse Aide's uniform of her upper body area, and was carrying the linen the same manner, up to Resident Room 5, located in the other nursing unit, for the use of residents.

At the time of the finding, interviewed with nurse aide, Employee E15, and confirmed that the linen should have been transported without letting it touch the employee's clothing, to prevent contamination and to maintain infection control.

Observation on May 16, 2024, at 1:41 p.m., revealed that a Licensed Practical Nurse (LPN) , Employee E16, after administering the tracheostomy care to Resident R56, of Room 12-B, who was on Enhanced Barrier Precautions, threw E16's used gown on the floor of Resident 12's door side, where the bed of the roommate (R12-A) was placed; since E16 could not find a trash bin to dispose the gown, used while treating Resident R56, the resident who was on Enhanced Barrier Precautions.

At the time of the finding, interviewed E16, and confirmed that the used gown should have been disposed, not on the floor, but in a container, dedicated for the disposal of used Personal Protective Equipment (PPE), in the room itself, of the resident, who was on Enhanced Barrier Precautions, to prevent contamination and to maintain infection control.

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

28 Pa Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 06/25/2024

1. There were no adverse effects from the alleged deficient practice. Employee E15 and E16 were educated by Staff Educator/Designee
2. An audit was completed to validate CNA staff were transporting linen per facility policy which includes not holding linen up against staff uniform to prevent contamination by the Staff Educator. An audit was completed to ensure that staff properly disposed of PPE in Enhanced Barrier Precaution rooms by the Staff Educator. No variances were identified.
3. Nursing staff will be re-educated by Director of Nursing/Designee on handling and transporting linen per facility policy which includes not holding linen against staff uniform to prevent contamination and the spread of infection. Nursing staff will be re-educated on the proper disposal of PPE in Enhanced Barrier Precaution rooms by Director of Nursing/Designee.
4. The Director of Nursing/Designee will complete an audit by observing 10 staff members per week for 4 weeks then monthly for 2 months to validate that CNA staff are handling and transporting linen in a manner that prevents the spread of infection. The Director of Nursing/Designee will complete an audit by observing 10 staff members per week for 4 weeks then monthly for 2 months to validate that staff are disposing PPE properly in Enhanced Barrier Precaution Rooms. Audit findings will be submitted to the Quality Assurance Performance Improvement committee for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of previously completed audit findings.

483.70(n)(2)(i)(ii)(3)-(5) REQUIREMENT Entering into Binding Arbitration Agreements:

§483.70(n) Binding Arbitration Agreements
If a facility chooses to ask a resident or his or her representative to enter into an agreement for binding arbitration, the facility must comply with all of the requirements in this section.

§483.70(n)(1) The facility must not require any resident or his or her representative to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility and must explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility.

§483.70(n)(2) The facility must ensure that:
(i) The agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands;
(ii) The resident or his or her representative acknowledges that he or she understands the agreement;

§483.70(n)(3) The agreement must explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it.

§483.70(n) (4) The agreement must explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility.

§483.70(n) (5) The agreement may not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman, in accordance with §483.10(k).

Observations:

Based on a review of facility documents and resident clinical records and interviews with staff and residents, it was determined that the facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for three of nine residents reviewed (Resident R226, R227 and Resident R228).

Findings include:

Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment

Review of admission record indicated Resident R226 was admitted to the facility on February 23, 2023.

Review of Resident R226's Minimum Data Set (MDS - a periodic assessment of care needs) dated March 17, 2024, indicated the diagnoses of fracture and orthopedic aftercare and a BIMS score of 3 - severe impairment of cognition.

Review of Resident R226's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated that she signed the document on admission on February 24, 2023.

Review of admission record indicated Resident R227 admitted to the facility on October 19, 2023.

Review of R227's MDS dated October 25, 2023, indicated the diagnoses of aphagia (comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain) and a BIMS score of 3 - severe impairment of cognition.

Review of Resident R227's Binding Arbitration Agreement indicated she signed it on admission on May 23, 2022.

Review of admission record indicated Resident R228 admitted to the facility on February 12, 2024.

Review of R228's MDS dated February 18, 2024, indicated the diagnoses of cerebral infarction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood) and a BIMS score of 6 - severe impairment of cognition.

Review of Resident R228's Binding Arbitration Agreement indicated he signed it on admission on February 13, 2024.

Interview on May 16, 2024, at 2:05 p.m. with the Nursing Home Administrator confirmed that these three residents had a low BIMS score, indicating severe cognitive impairment, and should not have been signing admissions documents including the binding arbitration agreement as they did not have the capacity to understand the terms of a binding arbitration agreement.

28 Pa. Code: 201.14(a)(c)(d)(e) Responsibility of licensee.

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

Plan of Correction - To be completed: 06/25/2024

1. R226, R227, and R228 have all been discharged from the facility.
2. An audit was completed for current residents Arbitration Agreements for competency level upon signing. Variances were addressed and outline on facility audit tool
3. NHA re-educated staff responsible for obtaining signatures for Arbitration Agreements on competency level.
4. The Administrator / Designee will complete weekly audits of 5 signed arbitration agreements for 4 weeks followed by 10 signed arbitration agreements monthly for 2 months. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§483.60(i) Food safety requirements.
The facility must -

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

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Findings include:

The Policy: "Food Receiving and Storage", which was revised in November 2022, states, "All foods stored in the refrigerator of freezer are covered, dated and labeled."

An initial tour of the Food Service Department was conducted on May 14, 2024, at 9:30 a.m. with Employee E3, Food Service Director (FSD), which revealed the following:

Observation in the mop room revealed the floor and walls were very dirty, the white mop sink was black with a heavy buildup of dirt and grime, and the floor was littered with debris and equipment.

Observation in the kitchen near the pot sink revealed the walls were spattered with food particles and the sanitizer mount on the wall had a thick buildup of dirt and dust.

Observation in the walk-in freezer revealed a box of breaded veal patties that was open and the inner plastic liner was open to the air.

Observation of the oven under the flat-top griddle revealed a heavy buildup of burned-on food spatters in the bottom and sides of the oven.

Interview with FSD at 9:45 a.m. on May 14, 2024, confirmed the above findings.

Review of facility policy titled, "Foods brought in by Family/Visitors undated revealed, "Food brought in to the facility by visitors or family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents." 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility prepared food. a. Non-perishable food items are stored in re-sealable containers with tight-fitting lids. Intact fresh fruit may be stored without a lid. b. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the "use by" date. 6. Nursing staff will discard perishable foods on or before the "use by" date.

Observation of the north wing unit on May 14, 2024 at 10:44 a.m. revealed licensed nurse, Employee E5 was at the Resident refrigerator throwing away plastic food containers and labeling food items for residents. The Director of Nursing Employee E2 was present during observation and stated there was a new night shift housekeeping supervisor that just started and would be resposible for evening sweeps of the resident refrigerators.

Observation of the food in refrigerator revealed several expired, unlabeled, and undated items. A bag of Chinese food take-out labeled April 29, 2024. Two small plastic cups of chocolate pudding undated and unlabeled. Thirteen small milk cartons with an expiration date of May 13, 2024. A take out bag with a cheeseburger and two apple pies undated and unlabeled. Take out food for a resident labeled with a date of May 1, 2024. Observation of the refrigerator also revealed human hair and spills throughout the floor and door of the refrigerator.

Observation of the resident freezer revealed a milkshake in freezer unlabeled and undated. A drink with a date of May 7, 2024. Observation revealed human hair and spills in the freezer.

Observation of the east wing refrigerator was made on May 14, 2024 at 11:11 a.m. Observation of the food in the refrigerator revealed several expired, unlabeled, and undated items. A large Styrofoam cup with vanilla pudding was labeled May 11, 2024. There was a small plastic chocolate pudding unlabeled and undated. There was a small plastic red Jello cup unlabeled and undated. There was a bottle of ranch dressing with an expiration of April 17, 2024. There was a yellow mustard bottle with an expiration date on March 27, 2024. A yogurt cup with an expiration date of March 25, 2024. The refrigerator had food spills both in the bottom and in the door.

Review of the freezer revealed liquid spills on the bottom of the freezer. A cup of half-eaten ice cream for a resident unlabeled and undated. Two blue 'Gatorade' frozen unlabeled and undated.

Further observations of the kitchenettes again May 16, 2024 at 10:10 a.m. revealed expired mustard still present in the refrigerator. There was chicken and rice take out unlabeled and undated. There was slice of pizza in between two plates unlabeled and unlabeled.

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

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

Plan of Correction - To be completed: 06/25/2024

1. There were no adverse effects noted related to the soiled mop room, dirty wall near the pot sink, dusty hand sanitizer mount, dirty oven, or opened container of veal patties. There were no adverse effects noted related to the food/beverage items discovered in the refrigerators on the nursing units.
2. Mop room, wall near pot sink, hand sanitizer mount, and oven were immediately cleaned upon inspection. Box of veal patties was sealed upon inspection. Center refrigerators were appropriately emptied and cleaned.
3. Dietary staff were re-educated by NHA/Designee for cleanliness and proper containment of food items in the kitchen. Center staff were re-educated by NHA/Designee on proper dating/labeling of items in refrigerators on the unit and monitoring for expiration dates.
4. Facility kitchen will be audited by FSD/Designee 3 times weekly for 4 weeks followed by weekly for 2 months to monitor cleanliness and proper containment of food. Refrigerators on nursing units utilized for resident food items will be audited 5 times a week for 4 weeks followed by 2 times weekly for 2 months to ensure food is properly labeled/dated and discarded prior to expiration date. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations. Further audit frequency will be determined based on prior audit findings.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:

Based on observations, review of facility policy, and interviews with staff and residents, it was determined that the facility did not ensure that residents were treated with dignity and respect for two of two residents reviewed. (Residents R13 and R47)

Findings Include:

Review of the "Resident Rights" policy with a revision date of October 2010 states, "Purpose-To provide general guidelines for resident rights while caring for the resident."
Preparation
1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including:
a. Preventing, recognizing and reporting resident abuse;
b. Resident dignity and respect;
c. Resident notification of rights, services, and health/medical condition;
d. Protection of resident funds and personal property;
e. Confidentiality of protected health information;
f. Resident right of refusal (medications and treatments);
g. Use of restraints;
h. Resident freedom of choice;
i. Resident/Family participation in care planning;
j. Resident access to information; and
k. Visitation.

A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

On May 16, 2024 Resident R13's clinical record was reviewed and there was an new order for the resident to be weighed weekly for four weeks on Wednesdays's starting May 15, 2024 due to the resident having a significant weight loss over the period of one month. Review of the resident's record showed the resident was not weighed on May 15, 2024 and there was no documentation of any refusal.

On May 16, 2024 at 12:10 p.m. licensed nurse Employee E5 was questioned as to why Resident R13's weight was not taken on the day prior May 15, 2024. Licensed nurse Employee E5 stated she was not sure but she would have the nurses aides complete it now. The surveyor went into the room to talk with Resident R13 and Resident R13's sister who was present in the room at the time. Licensed nurse Employee E5 came into the room at 12:15 p.m. and discussed the resident being "difficult to care for" while in front of the resident and the resident's sister.

Review of Resident R47 admissions Minimum Data Set (MDS- an assessment of residents' needs) dated May 4, 2024, indicated he was admitted to the facility on April 30, 2024. The resident was assessed as alert and oriented, able to make needs known, and with the diagnoses of hemiplegia (one side weakness) following a cerebral infarction (stroke) effecting the left side.

Review of facility documentation and the witness statement from the Food Service Director, Employee E3 indicated on May 10, 2024 the Social Worker, Employee E14 went to the facility's kitchen to order Resident R47's request for extra breakfast food. The social worker left the kitchen to deliver the food to Resident R47. Approximately fifteen minutes later Resident R47 went to the kitchen and made a duplicate request for breakfast The Food Service Director told the resident he just sent food to his room but Resident R47 told him he never got it. The witness statement from the Food Director stated, "That was a lot of stuff sent to him and we weren't giving him anymore food until lunch." The resident told him again he did not get his food and the Food Service Director told the resident to "Leave the kitchen.". The resident said he was not going to leave the kitchen until he got what he asked for, but the Director told him he wasn't going to get it. The resident asked who do you think you are? The Director said I am the boss of this food and he refused to give him another thing until lunch.

On May 16, 2024 at 2:00 p.m. the Social Worker confirmed the resident was not in his room when she delivered the food.

On May 16, 2024 at 2:34 p.m. the Food Service Director confirmed the witness statement was correct but he was not aware the resident was not in his room when the food was delivered. The Food Service Director stated, "If I could do it again differently I would. I didn't know he felt he didn't get his meal. It would have been better to just give it to him."

28 Pa Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 06/25/2024

This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report.
1. R13 and R47 had no adverse effects from the alleged incident. E5 was individually educated on resident rights. E3 no longer works at the center.
2. The facility completed an observational audit of staff interactions related to resident rights. No additional concerns were noted.
3. Center staff will be re-educated on resident rights by Director of Nursing/Designee.
4. The Director of Nursing/Designee will complete an audit by interviewing 10 residents weekly for week weeks followed by 10 residents monthly for 2 months regarding if their evening snack was received. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on prior audit findings.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

§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.

Plan of Correction - To be completed: 06/25/2024

1. R35, R51, R42, R51, R44, R28, R4, R63, R329, R7, R58, R30, and R34 had no adverse effects for alleged deficient practices. Center phones were restored to working condition. Call bells were checked and ensured to be within reach. AC unit was cleaned. Trash was removed from residents floor. Trash liners were placed in trash can as appropriate. Soiled linens were ensured to not be on the floor. Baseboard heater was fixed.
2. The center completed audits of resident phones, call bells being in reach, trash on the floor, trash can liners, AC units, baseboard heaters, and floors for cleanliness/linens. Variances were addressed and noted on facility audit tool.
3. Center staff will be in-serviced by NHA/Designee on resident rights for a clean and homelike environment.
4. NHA/Designee will conduct and audit of 10 random resident rooms weekly for 4 weeks followed by 10 random resident rooms monthly for 2 months. Audit will include ensuring call bells are within reach, trash is not on the floor in resident rooms, liners are present in resident trash cans, soiled linens are not on the floor, AC units are free of spills and that baseboard heaters are in good condition. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on prior audit findings.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§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 review of clinical records, interviews with staff and review of facility policy, it was determined that the facility failed to develop a comprehensive person-centered care plan for three of 21 resident reviewed (Residents R32, R46 and Resident 48).

Findings include:

Review of facility policy titled "Care Plans, Comprehensive Person-Centered" revised on March 2022, states that it includes measurable objective and timetables to meet the resident's physical, psychosocial and functional needs and is developed and implemented for each resident.

Review of Resident R32's clinical record revealed that the resident was admitted to the facility on February 6, 2024, with the diagnosis of Type Two Diabetes Mellitus (a chronic condition that causes high blood glucose levels (hyperglycemia).

Review of Resident R32's progress notes revealed on February 9, 2024 the resident was transferred to the hospital when he was hypoglycemic (low blood glucose levels) and found with fecal impaction (chronic constipation, hard dry stool stuck in the rectum).

Further review of Resident R32's clinical record revealed the facility failed to develop a person-centered care plan related to the resident's chronic constipation.

Review of Resident R46's clinical record revealed the resident was admitted on March 28, 2024 due to a fall from home needing hospitalization and lymphoma (cancer involving the lymphatic system).

Review of Resident R46's physician's progress note dated March 29, 2024 stated in the hospital the resident had suicide ideations and was seen by psychiatry.

Further review of Resident R46's clinical record revealed the facility failed to develop a person-centered care plan related to the resident's thoughts of suicide.

Review of the admission sheet dated February 7, 2023, of Resident 48, revealed diagnoses including Dementia (Dementia is not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities; it is a progressive disease that destroys memory and other important mental functions).

Review of Minimum Data Set assessment (MDS- an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated May 7, 2024, revealed that Resident R48 had active diagnoses of Non Alzheimer's Dementia.

Review of MDS revealed that Resident R 48 received Antipsychotic (Antipsychotic medications have the effect of changing a person's behavior, mood, and emotions), and Anti-Depressant Medications (Antidepressant medications help relieve symptoms of depression, and anxiety disorders).

On May 15, 2024, at 2:14 p.m., review of Resident 48's interdisciplinary plan of care revealed no care plan with measurable goals and interventions to address the care and treatment need related with dementia care of Resident R48.

During an interview on May 15, 2024, at 2:243 p.m., the Director of Nursing (DON), confirmed the finding, and the DON stated that the facility tried to make the care plans as specific as possible. No additional information was received.

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

28 Pa. Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 06/25/2024

1. Care plans were updated for R32, R46, and R48. R32, R46, and R48 had no adverse effects related to comprehensive care plan
2. The facility completed an audit of all current residents with a diagnosis of dementia. Variances were addressed and noted on facility audit too. The facility completed an audit of all residents admitted in a 7 day look back period by reviewing their hospital discharge summary and hospital history and physical for constipation and suicidal ideations. Variances were addressed and noted on facility audit too.
3. The interdisciplinary team was educated by the Director of Nursing/Designee on comprehensive care plans
4. The Director of Nursing/Designee with complete an audit of 10 new admission records weekly for 4 weeks followed by monthly for 2 months to ensure dementia, constipation, and suicidal ideations are captured in the resident's comprehensive care plan as appropriate. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on prior audit findings

483.25 REQUIREMENT Quality of Care:

§ 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 observations and interviews with residents and staff it was determined the facility did not ensure physicians order were followed related to medication administration and care to a pleurax catheter for two of 21 residents reviewed. (Residents R326 and R329)

Findings Include:

During Resident Council held on May 15, 2024 at 2:00 p.m. Resident R326 stated during medication administration this morning, she dropped a pill, told the nurse, the nurse did not come back with a replacement pill, and she still hadn't gotten it for the day. The resident was asked by the surveyor if she knew what pill it was and she stated, "No, but I have it still I saved it in my room"

At the end of Resident Council, the surveyor approached licensed nurse, Employee E5 and stated what Resident R326 had said during Resident Council. The surveyor went into Resident R326's accompany by licensed nurse, Employee E5. Observation of resident's room on May 15, 2024 at 2:40 p.m. with Licensed nurse, Employee E5 revealed a purple and orange pill sitting on the resident bed-side tray table.

Licensed nurse, Employee E5 obtained the pill and confirmed at the medication cart on the unit that it was the resident's Acebutolol HCI Oral Capsule 200 milligrams. The physican order for the medication was "give 1 capsule by mouth every 12 hours related to essential primary Hypertension".

Review of Resident 329's nursing progress note dated May 5, 2024 at 9:58 p.m. stated, "80 y/o male admitted to facility from... hospital by ambulance via stretcher x 2 assist. Resident AOX3 (alert and oriented to person, time and place). Incontinent to B&B (bowel and bladder)... Pleurx catheter present to RUQ (right upper quadrant) abdomen, spouse stated she will come and drain catheter every other day..."

Nursing progress note from May 9, 2024 at 9:18 a.m. stated, "as per resident R/P (responsible/party) she will empty his pleurax catheter which is done every other day, MD (physician) made aware, plan of care updated, nursing will continue to monitor him."

Nursing note from May 10, 2024 at 1:59 p.m. stated "Resident refused for this nurse to drain Pleurx Cath, stating that his girlfriend does it, no distress noted at this time."

Nursing progress note from May 15, 2024 at 11:53 a.m. stated, "Pleurax catheter being drained by girlfriend"

The Director of Nursing, Employee E2, was interviewed on May 17, 2024 at 9:40 a.m. regarding Resident R329's girlfriend providing nursing care to the resident while in the facility, and was questioned if she had any training from the facility. The Director of Nursing, Employee E2 confirmed that the girlfriend did the Pleurax catheter care draining one time and was then educated on not being able to do it while he was at the facility. The Director of Nursing, Employee E2 confirmed there was no documentation regarding this discussion with the girlfriend.

28 Pa Code 211.10(c) Resident care policies

28 PA Code 211.12(d)(1)(3) Nursing services

Plan of Correction - To be completed: 06/25/2024

1. Resident R326 does not have the desire to self-administer medication at this time. R326's medications will be administered by the licensed nurse. Employee E5 was educated on facility policy regarding self-administration which includes but is not limited to obtaining a physician's order. Resident R329 was receiving Pleurx catheter care by the nursing staff.
2. An audit was completed by NHA/designee for medication at bedside and documentation of education for any family members providing Pleurx catheter care. Variances were addressed at the time of the audit.
3. Licensed professionals will be reeducated by DON/designee on policy and procedure of medication administration, resident self-administration of medications which includes obtaining a physician's order and procedure for education and documentation for family members providing Pleurx care.
4. DON/designee will perform audits to validate medication are not left at bedside, residents who self-administer medications have an order in place and education and documentation for family members providing Pleurx care. These audits will be completed for 10 residents weekly for 4 weeks followed by 10 residents monthly for 2 months. Audit results will be submitted to the Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on prior audit findings.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§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 observations, review of facility policy, review of clinical records, and interviews with staff it was determined that the facility failed to monitor a resident's needs to maintain acceptable parameters of nutritional status for one of 21 residents reviewed for nutritional status. (Resident R13).

Findings Include:

Review of the facilities policy titled, "Weight Assessment and Intervention" with a revision dated on March 2022 state, "Resident weights are monitored for undesirable and unintended weight loss or gain."

Review of Resident R13's clinical record revealed the diagnoses of muscle wasting and atrophy, hyperlipidemia, hypothyroidism, diverticulitis of large intestine without perforation or abscess without bleeding, unspecified hearing loss, abnormalities of gait and mobility, dysphagia, and cognitive communication deficit.

Review of Resident R13's clinical record revealed that the resident was to receive feeding assistance of 1:1 at all meals.

Review of Resident R13's hospital discharge records from April 3, 2024 revealed the resident has a weight recorded on April 4, 2024 of 162 pounds.

Review of Resident R13's clinical record revealed that the and the resident had a significant weight loss over a period of a month. On April 10, 2024 Resident R13 had a weight of 162.8 pounds. A week later the resident was weighed and her weight was 142.8 pounds. This weight was labeled as "incorrect" and the resident was re-weighed on April 18, 2024. On April 18, 2024 the resident's weight was 134.4 pounds. The resident was then weighed on April 27, 2024 and she weighed 134.0 pounds. A weight was then taken on May 2, 2024 and then resident weighed 133.4 pounds. The resident was then weighed on May 13, 2024 and the resident's weight was 136.8 pounds.

Observation made on May 15, 2024 at 12:37 p.m. revealed the resident was in her room with her sister. The surveyor asked if her lunch was satisfactory and the resident's sister stated, she took one or two bites, she does better with things like sandwiches. The resident's sister asked for a peanut butter and jelly sandwich.

Review of Nutrition note completed on May 1, 2024 states, "The husband mentioned in the care conference that the resident has the tendency to pocket foods and prefers to drink liquids with a straw, more finger foods and sandwiches are preferred by the resident. Preferences updated."

Observation was made during the lunch meal on May 15, 2024 the resident was not receiving finger foods. The resident was not receiving sandwiches as preferred. No documentation regarding preferences was made in the resident's clinical record.

Review of the resident's clinical record revealed a nutrition note from May 14, 2024 stating, "Resident is at risk for malnutrition r/t (related to): Poor intake, meeting only 30-40% needs. Intervention: Encourage PO (by mouth) intake and supplements; ensure and magic cup, Proving assistance and supervision during meal times, Weekly weights x 4."

Weekly weights were ordered to be completed on Wednesdays starting on May 15, 2024. Review of the resident's record on May 16, 2024 revealed there was no weight taken for the resident on May 15, 2024 and there was no documentation of any attempt of refusal to complete weekly weight as ordered.

Interview held with the Registered Dietician, Employee E11 on May 16, 2024 confirmed Resident R13 did have a significant weight loss over the period of a month. Employee E11 stated the kitchen would be educated on Resident R13's preferences and need for finger foods during meals.

Observation was made of the lunch time meal on May 17, 2024. The lunch cart arrived at 12:29 p.m. Resident R13's meal was brought to her room at 12:35 p.m. Scheduler, Employee E12 and Human Resources Director, Employee E13 went into the resident's room at 12:47 p.m. The surveyor checked in with licensed nurse Employee E5 and 12:50 p.m. and was questioned who would be providing Resident R13 with feeding assistance for lunch. Licensed nurse Employee E5 stated, "anyone can, I was about to go in there now". The surveyor and licensed nurse Employee E5 went into the room at 12:51 p.m. and no staff was present in the room. Observation was made of the Resident's tray revealed no meal ticket and baked fish, brussel sprots, and scalloped potatoes present on the plate. There were still no finger foods served for Resident R13.

Interview held at 12:54 p.m. with scheduled Employee E12 and Employee E12 stated, "oh no, I fed her." When questioned about Resident R13's feeding and no one being in the room for more than two minutes, Employee E12 stated, "oh no I fed her today for breakfast and lunch".

Review of unit Nurse Aide Assignment sheet showed Resident R13 was not listed as a "feeder" on nurse aide Daily Assignment Sheet from 5/17, 5/16, 5/15, 5/14, and 5/13.

Review of Resident R13's clinical record revealed the residents percentage of meals eaten over the last thirty days were not recorded for the following dates:
April 21, 2024 not recorded for breakfast and lunch.
April 22, 2024 not recorded for breakfast and lunch.
May 5, 2024 not recorded for dinner.
May 12, 2024 not recorded for breakfast or lunch.
May 15, 2024 not recorded for dinner.

28 Pa. Code 211.10 (c) Resident care policies

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

Plan of Correction - To be completed: 06/25/2024

1. R13 no longer resides at the facility.
2. The facility conducted an audit of weight completion, feeding assistance, resident meal preferences, and documentation of meal intake. Variances were addressed on facility audit tool
3. Nursing staff will be re-educated on weight assessment and intervention policy, providing feeding assistance, following resident meal preferences, and documentation of meal intake.
4. The Director of Nursing/Designee will conduct audits to validate weight completion, feeding assistance, meal preferences, and documentation of meal intake. These audits will be completed for 10 residents weekly for 4 weeks followed by 10 residents monthly for 2 months. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on prior audit findings.

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime:

§483.60(f) Frequency of Meals
§483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

§483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

§483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.

Observations:

Based on resident council interviews, review of the established meal time schedule, and clinical record review, it was determined that the facility failed to ensure a nourishing snack was provided when in between meals for five of 21 residents reviewed. (Residents R275, R22, R326, R14, and R13).

Findings Include:

Resident Council was held on May 15, 2024 at 2:00 p.m. When asked if the resident's receive snacks in the evening four out of five residents stated that they have never received a snack in the evening.

Review of Resident R275's evening snack record revealed, no snack was given on May 14, 2024.

Review of Resident R22's evening snack record revealed, no snack was given on April 20, April 26. May 1, May 2, May 4, May 5, May 14, 2024.

Review of Resident R326's evening snack record revealed, no snack was given on May 11, May 14, and May 16, 2024.

Review of Resident R14's evening snack record revealed, no snack was given on May 6, May 9, and May 14, 2024.

Review was made of Resident R13's clinical record due to the resident having a significant weight loss over the period of a month. Review of Resident R13's evening snack record revealed, no snack given on April 18, April 21, April 22, April 28, May 1, May 13, May 16, 2024.

28 Pa. Code 201:14 (a) Responsibility of licensee

Plan of Correction - To be completed: 06/25/2024

1. R22 had no known adverse effects directly related to evening snack documentation. R275, R326, R14, and R13 no longer reside at the facility.
2. The facility conducted an audit to validate evening snacks are being offered and documented. Variances were addressed on facility audit tool
3. Center staff will be re-educated by the Director of Nursing/Designee on providing evening snacks to residents and documenting evening snacks accordingly.
4. The Director of Nursing/Designee will perform audits to validate evening snacks are being offered and documented appropriately. These audits will be conducted for 10 residents weekly for 4 weeks followed by 10 residents monthly for 2 months. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on prior audit findings.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:

§483.60(i)(4)- Dispose of garbage and refuse properly.

Observations:

Based on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly.

Finding include:

An initial tour of the Food Service Department was conducted on May 14, 2024, at 9:30 a.m. with Employee E3, Food Service Director (FSD), which revealed the following:

Observation in the receiving area revealed one of three dumpsters with the lid open revealing the contents including cardboard boxes.

Further observations revealed that the employee smoking area was adjacent to the loading dock and that the ground all around the loading dock was littered with hundreds of cigarette butts.

Interview with the FSD on May 14, 2024, at 9:35 a.m. confirmed the above findings.

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

28 Pa. Code 201.14(a) Responsibility of Licensee

Plan of Correction - To be completed: 06/25/2024

1. The facility experienced no adverse effects from the dumpster lid being open or from cigarette butts being on the ground.
2. The facility dumpsters were emptied allowing the lid to close. The back lot was cleaned and made free of cigarette butts.
3. Facility staff were re-educated by NHA/Designee to ensure dumpster lids are closed. Facility staff were re-educated by NHA/Designee to ensure cigarette butts are disposed of properly.
4. The NHA/Designee will audit the facility dumpsters to ensure closure 5 times weekly for 4 weeks followed by 2 times weekly for 2 months. The NHA/Designee will audit loading dock grounds to ensure proper cigarette butt disposal 5 times weekly for 4 weeks followed by 2 times weekly for 2 months. Audit results will be submitted to the Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on prior audit findings.

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ:

§483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Observations:

Based on observation and staff interview, it was determined that the facility failed to ensure that the loading dock was in safe conditions.

Findings include:

Observations during the tour of the kitchen on May 14, at 9:30 a.m. revealed a loading dock door that was open leading to the receiving area where there was a wooden loading dock structure that was five feet off the ground with no railing or chain to restrict access and provide safety for staff, delivery drivers and anyone who may exit the rear door including wandering residents.

Interview with Food Service Director, Employee E3, on May 14, at 9:30 a.m. confirmed that the loading dock door was open due to receiving a delivery that morning, and that the loading dock structure does not have any safety railing and that Dietary staff receive deliveries there daily. The FSD indicated that while this is an employee only area, residents have entered the hallway leading to the receiving area to come to the kitchen and that if no one was in the area and the receiving door was open, they could wander out to the loading dock and fall.

Interview with the Administrator on May 16, 2024, at 11:00 a.m. confirmed that there is no safety railing around the loading dock.

28 Pa Code: 201.14(b) Responsibility of licensee

Plan of Correction - To be completed: 06/25/2024

1. There were no adverse effects at the facility related to the loading dock not having a railing
2. A railing was added to the loading dock.
3. A review of the facility revealed no similar variances.

§ 201.18(b)(2) LICENSURE Management.:

(2) Protection of personal and property rights of the residents, while in the facility, and upon discharge or after death, including the return of any personal property remaining at the facility within 30 days after discharge or death.

Observations:

Based on a review of closed clinical records and staff interview, it was determined that the facility failed to protect the personal and property rights upon the discharge/death of two of three residents reviewed (R72 and R74).

Findings include:

Review of the closed clinical record for Resident R72 revealed that this resident was admitted to the facility on December 5, 2023, and discharged to the hospital on February 20, 2024. Further review of the closed clinical record failed to reveal documentation regarding the final disposition of this resident's personal property.

Review of the closed clinical record for Resident R73 revealed that this resident was admitted to the facility on March 18, 2024, and was expired at the facility on April 16, 2024. Further review revealed that there was no documentation regarding the final disposition of this resident's personal property.

In an interview with the Nursing Home Administrator and Director of Nursing at 1:15 p.m. on May 17, 2024, the above findings were confirmed that the facility had failed to document the disposition of these resident's personal property upon discharge/death.

Plan of Correction - To be completed: 06/25/2024

1. There were no belongings located in the facility for resident R72 and R73.
2. The facility completed a review of residents who expired or returned to the hospital during a 7 day look back period from survey exit. Variances were addressed and noted on facility audit tool.
3. Licensed Professionals will be re-educated by the Director of Nursing/Designee regarding the disposition of resident's personal property
4. The Director of Nursing/Designee with review the records of residents who expire or return to the hospital weekly for 4 weeks then monthly for 2 months to ensure there was a proper disposition of personal property. Audit results will be submitted to the Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on prior audit findings.

§ 211.5(f)(i)-(xi) LICENSURE Medical records.:

(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a resident ' s medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death.

Observations:

Based on review of closed clinical records and an interview with facility staff, it was determined that the facility failed to complete a discharge summary within the required 30 days of death for one of the closed resident records reviewed. (Resident R74).

Findings include:

Review of Resident R74's clinical record revealed that the resident was admitted to the facility on March 18, 2024, and died in the facility on April 16, 2024. Review of the closed clinical record of Resident R74 revealed that the facility failed to complete a discharge summary including a recapitulation of his stay within the required 30 days of death.

An interview with the facility Administrator and Director of Nursing on May 17, 2024, at 1:15 p.m. confirmed this finding.

Plan of Correction - To be completed: 06/25/2024

1. The facility cannot retro-actively correct the alleged deficient practice.
2. The facility completed a review of residents who expired or returned to the hospital during a 7 day look back period from survey exit. Variances were addressed and noted on facility audit tool.
3. Center physicians will be educated by NHA/Designee on documentation required for a discharge summary
4. The Director of Nursing/Designee will audit the records of all residents that expire at the center or return to the hospital weekly for 4 weeks then monthly for 2 months to ensure that a proper discharge summary is completed by the physician. Audit results will be submitted to the Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on prior audit findings.

§ 211.9(j.1) (1) - (5) LICENSURE Pharmacy services.:

(j.1) The facility shall have written policies and procedures for the disposition of medications that address all of the following:
(1) Timely and safe identification and removal of medications for disposition.
(2) Identification of storage methods for medications awaiting final disposition.
(3) Control and accountability of medications awaiting final disposition consistent with standards of practice.
(4) Documentation of actual disposition of medications to include the name of the individual disposing of the medication, the name of the resident, the name of the medication, the strength of the medication, the prescription number if applicable, the quantity of medication and the date of disposition.
(5) A method of disposition to prevent diversion or accidental exposure consistent with applicable Federal and State requirements, local ordinances and standards of practice.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide a disposition and count of unused medications at discharge for two of three closed records reviewed. Residents (R72 and R73).

Findings include:

Review of R72's clinical record revealed that this resident was admitted to the facility on December 5, 2023, and discharged to the hospital on February 20, 2024. Further review of the closed clinical record revealed that there was no documentation to indicate the method of disposition or quantity of the resident's medications at discharge.

Review of the closed clinical record for Resident R73 revealed that this resident was admitted to the facility on March 18, 2024, and was expired at the facility on April 16, 2024. Further review revealed that there was no documentation to indicate the method of disposition or quantity of the resident's medications at discharge.

In an interview with the Nursing Home Administrator and Director of Nursing at 1:15 p.m. on May 17, 2024, the above findings were confirmed that the facility had failed to document the disposition of these resident's medications upon discharge/death.

Plan of Correction - To be completed: 06/25/2024

1. The facility cannot retroactively correct the alleged deficient practice.
2. A search of the facility revealed that no medications remained in the facility for R72 and R72
3. The facility completed a review of residents who expired or returned to the hospital during a 7 day look back period from survey exit. Variances were addressed and noted on facility audit tool.
4. Licensed Professions will be re-educated by the Director of Nursing/Designee regarding disposition of medications upon discharge, death, or re-hospitalization for a resident.
5. The Director of Nursing/Designee will audit all residents that expire at the center or return to the hospital weekly for 4 weeks then monthly for 2 months to ensure proper disposition of medications was documented. Audit results will be submitted to the Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on prior audit findings.

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