Pennsylvania Department of Health
COMMUNITIES AT INDIAN HAVEN, THE
Patient Care Inspection Results

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COMMUNITIES AT INDIAN HAVEN, THE
Inspection Results For:

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COMMUNITIES AT INDIAN HAVEN, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on March 21, 2024, it was determined that The Communities at Indian Haven was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan: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.
483.21 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:


Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that baseline care plans included the information and instructions needed to provide person-centered care for four of 36 residents reviewed (Residents 77, 78, 79, 82).

Findings include:

The facility's policy regarding baseline care plans, dated January 15, 2024, indicated that a baseline plan of care to meet the resident's immediate needs would be developed for each resident within forty-eight hours of admission. The interdisciplinary team would review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including, but not limited to the following: initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services.

Admission information for Resident 77 revealed that she was admitted to the facility on March 14, 2024. Physician's orders, dated March 14 and 15, 2024, included orders for the resident to receive 7.5 milligrams (mg) of warfarin (anticoagulant medication-blood thinner) at bedtime for atrial fibrillation (irregular heart rhythm), 40 mg of furosemide (diuretic- water pill) in the morning for heart failure, and 250 mg of Levaquin (antibiotic) one time a day for cellulitis (bacterial skin infection).

Resident 77's baseline care plan (developed within 48 hours of a resident's admission and must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission), dated March 14, 2024, did not include information regarding the care or services the resident required for the treatment with an anticoagulant, diuretic, or antibiotic medication.

Interview with the Nursing Home Administrator on March 20, 2024, at 12:13 p.m. confirmed that she could not find any information on Resident 77's baseline care plan regarding the treatment with an anti-coagulant, diuretic or antibiotic medication.


Admission information for Resident 78 revealed that she was admitted to the facility on March 10, 2024. Physician's orders, dated March 10, 2024, included orders for the resident to receive 15 mg of temazepam (sleeping pill ) at bedtime as needed for insomnia (trouble sleeping) and 2 liters per minute of oxygen as needed every shift for dyspnea (difficulty breathing). The Medication administration Record (MAR) for March 2024 revealed that the resident received temazepam March 11 through 19, 2024.

Resident 78's baseline care plan, dated March 10, 2024, did not include information regarding the care or services the resident required for the treatment with a sleeping pill for insomnia or regarding the care and services required for the use of oxygen.

Interview with the Nursing Home Administrator on March 21, 2024, at 10:32 a.m. confirmed that she could not find any information on Resident 78's baseline care plan regarding the treatment with a sleeping medication or use of oxygen.


Admission information for Resident 79 revealed that she was admitted to the facility on March 8, 2024. Physician's orders, dated March 8, 2024, included orders for the resident to receive 0.5 mg of lorazepam (anti-anxiety medication) at bedtime for anxiety (feeling of fear, dread, and uneasiness) and 40 mg of paroxetine (anti-depressant medication) daily for depression.

Resident 79's baseline care plan, dated March 8, 2024, did not include information regarding the care or services the resident required for the treatment with an antianxiety or antidepressant medication.

Interview with Nursing Home Administrator on March 20, 2024, at 2:43 p.m. confirmed that she could not find any information on Resident 79's baseline care plan regarding the treatment with an anti-anxiety or anti-depressant medication.


Admission information for Resident 82 revealed that she was admitted to the facility on March 13, 2024. Physician's orders, dated March 13, 2024, included orders for the resident to receive 2.5 mg of apixaban (anticoagulant medication) twice a day following joint replacement surgery and to cleanse the skin tear on the right shin with normal saline solution (mixture of sodium chloride and water) and cover with a bordered dressing every day.

Resident 82's baseline care plan, March 13, 2024, did not include information regarding the care or services the resident required for the treatment with an anticoagulant medication or regarding the care and services required for a skin tear.

Interview with the Nursing home Administrator on March 20, 2024, at 12:00 p.m. confirmed that she could not find any information on Resident 82's baseline care plan regarding the treatment with an anti-coagulant medication or treatment to the skin tear.

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




 Plan of Correction - To be completed: 05/03/2024

The facility is unable to retroactively correct the observations for Residents 77, 78, 79, and 82, as they are past events.

An audit of resident baseline care plans for current residents will be completed from April 4, 2024 forward to assure that baseline care plans include the information and instructions needed to provide person-centered care.

Facility Registered Nurse Supervisors and the Registered Nurse Assessment Coordinator (RNAC) will receive education regarding completion of baseline care plans including the information and instructions needed to provide person-centered care.
Audits will be completed by the RNAC or designee weekly for 4 weeks and monthly for 2 months to assure that baseline care plans include the information and instructions needed to provide person-centered care. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:


Based on review of facility policies, observations, and staff interviews, as well as medication package inserts, it was determined that the facility failed to discard expired medication in one of two medication rooms reviewed (Medication Room 1), failed to discard multiple bags of outdated IV (fluid that is administered into the vein) stock solution, and failed to administer insulin as per manufacture's instructions.

Findings include:

The facility's policy regarding medication storage, dated January 15, 2024, revealed that the facility would not use outdated drugs or biologicals.

Observations in Medication Room 1 on March 19, 2024, at 9:10 a.m. revealed that one Forteo (a man-made hormone that stimulates new bone growth) injection pen was labeled with an expiration date of March 18, 2024, and there were five 100 cc bags of outdated IV stock solution, two that expired in July 2023 and three that expired in December 2023.

Interview with Registered Nurse 4 on March 19, 2024, at 9:20 a.m. confirmed that the Forteo injection pen and the five IV solution bags were expired and should have been discarded.

Interview with the Nursing Home Administrator on March 19, 2024, at 2:15 p.m. confirmed that the medication injection pen and the five IV solution bags were outdated and should have been discarded.

28 Pa. Code 211.9(a)(1) Pharmacy Services.




 Plan of Correction - To be completed: 05/03/2024

The facility is unable to retroactively correct the observations regarding the expired medications, as it is a past event.

The expired Forteo and 5 bags of IV stock solution were discarded following these observations.

An audit of facility medication rooms will be conducted to assure that stored medications are unexpired. The Director of Nursing or designee will audit stored medications weekly to assure that medications in storage are unexpired.

Current, agency, and newly hired licensed nursing staff will receive education regarding monitoring medications to assure that stored medications are unexpired.

Random audits will be completed by the Director of Nursing or designee weekly for 4 weeks and monthly for 2 months to assure that medications stored in the medication rooms are unexpired. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee.
483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 20 residents reviewed (Resident 20).

Findings include:

The facility's medication administration policy, dated January 15, 2024, revealed that medications were to be administered as prescribed.

Manufacturer's instructions for Aspart, revised February 2015, indicated that the medication should be administered within five or ten minutes of a meal.

Physician's orders for Resident 20, dated December 9, 2023, included orders for the resident to receive 10 units of insulin Aspart (fast-acting insulin) in the morning before breakfast, 10 units before lunch, and 10 units before dinner.

Medication Administration Records (MAR) for Resident 20 for January, February, and March 2024 revealed that he received his insulin at 9:00 a.m., 10:00 a.m. and 3:00 p.m. However, meal times were 8:10 a.m. for breakfast, 11:40 a.m. for lunch, and 4:40 p.m. for dinner. Resident 20's insulin administration was not within five to ten minutes of receiving his meal.

Interview with the Director of Nursing on March 20, 2024, at 2:18 p.m. confirmed that Resident 20 was not receiving his insulin per the manufacturer's instructions and that he should have been.

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



 Plan of Correction - To be completed: 05/03/2024

The facility is unable to retroactively correct the observation for Resident 20, as it is a past event.

An audit of residents currently receiving insulin Aspart will be completed to assure that the medication is administered according to manufacturer instructions.

Current, agency, and newly hired licensed nursing staff will receive education regarding administration of medications according to manufacturer instructions, including Aspart insulin.

Random audits will be completed by the Director of Nursing or designee weekly for 4 weeks and monthly for 2 months to assure that residents receiving insulin Aspart receive the medication according to manufacturer instructions. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 36 residents reviewed (Residents 63).

Findings include:

The facility's policy regarding controlled substances, dated January 31, 2024, indicated that accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance was administered, the licensed nurse administering the medication was to immediately enter the following information on the accountability record and Medication Administration Record (MAR): date and time of administration, amount administered, remaining quantity, and the initials of the nurse administering the dose, completed after the medication is actually administered.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 63, dated January 20, 2024, revealed that the resident was cognitively intact and required assistance of staff for daily care needs. Current physician's orders for Resident 63 included an order for the resident to receive 5-325 mg of Oxycodone (narcotic pain reliever) every eight hours as needed for severe pain.

The resident's MAR for February 2024 indicated that one dose of Oxycodone was signed-out for administration to the resident on February 18 at 8:28 a.m. and 4:48 p.m. The resident's controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for February 2024 indicated that one dose of Oxycodone was signed-out for administration to the resident on February 11 at 6:00 a.m., February 12 at 3:30 p.m., February 15 at 12:45 p.m., February 17 at 4:45 p.m., and February 21 at 11:40 a.m. However, the resident's clinical record, including the MAR controlled drug record and nursing notes, contained no documented evidence that the signed-out doses of Norco were actually administered to the resident on these dates and times.

Interview with the Director of Nursing on March 21, 2024, at 11:15 a.m. confirmed that there was no documented evidence that staff administered signed-out doses of Oxycodone to Resident 63 on the above dates and times.

28 Pa. Code 211.9(a)(h) Pharmacy Services.

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



 Plan of Correction - To be completed: 05/03/2024

The facility is unable to retroactively correct the observation for Resident 63, as it is a past event.

An audit of residents currently receiving oxycodone will be completed to assure that the medication is documented on the Medication Administration Record (MAR) and the controlled medication sign-out flow sheet for each dose that is administered to rule out misappropriation.

Current, agency, and newly hired licensed nursing staff will receive education regarding required documentation on the Medication Administration Record (MAR) and the controlled medication sign-out flow sheet for each dose of oxycodone that is administered.

Random audits will be completed by the Director of Nursing or designee weekly for 4 weeks and monthly for 2 months to assure that documentation is present on the Medication Administration Record (MAR) and the controlled medication sign-out flow sheet for each dose of oxycodone that is administered. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee.

483.25(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to administer pain medications as ordered by the physician for two of 36 residents reviewed (Residents 78, 82).

Findings include:

The facility's policy regarding pain medications, dated January 15, 2024, indicated that staff were to administer pain medications as ordered by the physician.

Physician's orders for Resident 78, dated March 11, 2024, included orders for the resident to receive 5-325 milligram (mg) tablet of hydrocodone-acetaminophen (narcotic pain medication) every twelve hours as needed for a pain rating of 6 to 10 (on a scale of 1-10, with 10 being the worst pain).

Resident 78's Medication Administration Record (MAR) for March 2024 revealed that staff administered hydrocodone-acetaminophen for a pain rating that was less than six on March 14 at 8:39 p.m., March 15 at 10:09 p.m., and March 19 at 7:51 p.m.


Physician's orders for Resident 82, dated March 18, 2024, included orders for the resident to receive 5 mg of oxycodone (narcotic pain medication) every four hours as needed for a pain rating of 6 to 10.

Resident 82's MAR for March 2024 revealed that staff administered oxycodone for a pain rating that was less than six on March 14 at 8:24 p.m., March 15 at 8:46 p.m., March 18 at 11:46 a.m. and 7:49 p.m., March 19 at 5:58 p.m., and March 20 at 7:24 a.m.

An interview with the Nursing Home Administrator on March 21, 2024, at 10:32 a.m. confirmed that Resident 78's hydrocodone-acetaminophen and Resident 82's oxycodone were not administered as ordered by the physician.

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



 Plan of Correction - To be completed: 05/03/2024

The facility is unable to retroactively correct the observations for Residents 78 and 82, as they are past events.

An audit of current residents receiving oxycodone and hydrocodone will be completed to assure that medications are administered within the parameters ordered by the physician.

Current, agency, and newly hired licensed nursing staff will receive education regarding following the parameters ordered by the physician for residents with orders for oxycodone and hydrocodone.

Random audits will be completed by the Director of Nursing or designee weekly for 4 weeks and monthly for 2 months to assure that oxycodone and hydrocodone are administered following the parameters ordered by the physician. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that monitoring of the resident's restorative nursing programs for range of motion and transferring did not reflect the resident's progress toward program goals for two of 36 residents reviewed (Residents 3, 14).

Findings include:

The facility's policy regarding restorative nursing, dated January 15, 2024, revealed providing nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. The restorative nursing care programs are designed and designated to assist the resident in achieving and maintaining an optimal level of self-care and independence. Reassessment of progress, goals, and duration/frequency was part of the care plan process. Documentation of reassessment in the medical record with evidence of periodic evaluation was completed by a licensed staff member (at least quarterly). Documentation should include the following: If and how the resident has participated overall in the procedure or any changes in the resident's ability to participate in the procedure.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated August 5, 2023, revealed that the resident was understood, understands, and had a diagnosis which included dementia and Parkinson's disease. A care plan for the resident, dated April 6, 2023, revealed that the resident was on a nursing rehab/restorative transfer program, and that the resident will transfer from his bed to his power chair with one assist from staff. Staff was to cue the resident to sit back into his chair and use a folding wheeled walker.

However, there was no documented evidence in Resident 3's clinical record of a periodic evaluation of the progress or lack of progress toward meeting the resident's goals being completed by a licensed staff member at least quarterly.

A quarterly MDS assessment for Resident 14, dated February 5, 2024, revealed that the resident was understood, understands, and had a diagnosis which included Cerebral Vascular Accident (CVA - commonly referred to as a stroke) with hemiplegia (paralysis to one half of the body). A care plan for the resident, dated August 25, 2022, revealed that the resident was on a nursing rehab/restorative for passive range of motion (the joints are moved by another person) to her bilateral upper extremities and staff was to complete three sets of 10 reputations. A care plan, dated September 15, 2023, revealed that the resident was on a nursing rehab/restorative for passive range of motion to her lower extremities each a.m. and p.m. to prevent contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) and skin injury.

However, there was no documented evidence in Resident 14's clinical record of a periodic evaluation of the progress or lack of progress toward meeting the resident's goals being completed by a licensed staff member at least quarterly.

Interview with the Nursing Home Administrator on March 20, 2024, at 12:23 p.m. confirmed that there was no documented evidence in Resident 3's and Resident 14's clinical records of a periodic evaluation of the progress or lack of progress toward meeting the resident's goals being completed by a licensed staff member at least quarterly.

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



 Plan of Correction - To be completed: 05/03/2024

The facility is unable to retroactively correct the observations for Residents 3 and 14, as they are past events.
A periodic evaluation of progress or lack of progress in restorative nursing programs for Residents 3 and 14 will be completed.

An audit of residents currently receiving restorative nursing programs will be completed to assure that periodic review of restorative nursing programs is completed on at least a quarterly basis by a licensed staff member.

The Registered Nurse Assessment Coordinator or designee will receive education regarding the requirement to complete periodic review of restorative nursing programs is completed on at least a quarterly basis by a licensed staff member.

Random audits will be completed by the Director of Nursing or designee weekly for 4 weeks and monthly for 2 months to assure that periodic review of restorative nursing programs is completed on at least a quarterly basis by a licensed staff member. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee.

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


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for four of 36 residents reviewed (Residents 6, 25, 57, 67).

Findings include:

The facility's policy regarding care plans, dated January 15, 2024, indicated that nursing staff and/or the interdisciplinary team were to update care plans as information about the residents and the residents' conditions change.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated January 17, 2024, revealed that the resident was understood; could understand; was cognitively intact; had diagnoses that included osteoarthritis (degeneration of the joints), high blood pressure and anxiety; wore bilateral hearing aides; and was dependent on staff for daily care needs.

Observations of Resident 6 in bed on March 18, 2024, at 11:41 a.m. revealed that her hearing aides were not in her ears. Her roommate stated that they are kept in the medication cart.

A Medication Administration Record Note for Resident 6, dated December 5, 2023, indicated that, in order to prevent her hearing aides from becoming lost during the night, the nurse would collect them at bedtime and store them in the medication cart.

A care plan for Resident 6, dated January 10, 2024, indicated that the resident had a communication care plan; however, it did not speak to the use of hearing aides or the need to keep them in the medication cart at night. In addition, there was no documentation reflecting the need to put them back in in the morning.

Interview with Licensed Practical Nurse 1 on March 20, 2024, at 8:59 a.m. revealed that there is a task for collecting the hearing aides at night but nothing regarding putting them back in the morning.

Interview with the Nursing Home Administrator on March 20, 2024, at 9:22 a.m. confirmed that Resident 6's care plan was not revised to reflect the use of hearing aides to instruct staff that they are collected in the evening, stored in the medication cart, and placed back in the resident's ears in the morning, and it should have been.

A quarterly MDS assessment for Resident 25, dated January 5, 2024, revealed that the resident was cognitively intact, required moderate assistance from staff for daily care tasks, had diagnoses that included diabetes, and a care plan that indicated the resident had a Dexcom 6 (a glucose monitor that sends blood sugar results to an electronic device) attached to her abdomen, with needle changes due every ten days.

Interview with Resident 25 on March 19, 2024, at 1:05 p.m. revealed that she has not had the Dexcom since she was admitted, because they do no accept that device in the facility. The resident went on to say that staff obtain accuchecks (a needle stick to obtain blood sugar results) four times a day.

Interview with the Nursing Home Administrator on March 19, 2024, at 2:16 p.m. confirmed that Resident 25's care plan was not revised to reflect that the she does not use a Dexcom, and it should have been.

A quarterly MDS assessment for Resident 57, dated February 15, 2024, revealed that the resident was cognitively intact, required moderate assistance from staff for daily care tasks, had a care plan that indicated the resident was at risk for urinary tract infections and sepsis (a life threatening infection in the blood), and had diagnoses that included chronic kidney disease with recent left nephrostomy tube placement (a tube placed in the kidney to drain urine).

Physician's orders for Resident 57, dated January 18 and 21, 2024, respectively, included orders for staff to flush the nephrostomy tubing with 5-10 cc sterile saline as needed for blockage and to change the nephrostomy collection bag every night shift on Sunday.

There was no documentation on Resident 57's, care plan regarding the orders to flush the nephrostomy tubing with 5-10 cc sterile saline as needed for blockage and to change the nephrostomy collection bag every night shift on Sunday.

Interview with the Nursing Home Administrator on March 19, 2024, at 2:16 p.m. confirmed that Resident 25's care plan was not updated to reflect that staff were to flush the nephrostomy tubing and change the nephrostomy collection bag every Sunday as ordered, and it should have been.

A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 67, dated January 20, 2024, indicated that the resident was cognitively intact and required assistance of staff for daily care needs.

A care plan for Resident 67, dated November 20, 2023, indicated that the resident had a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) care plan and an intravenous (a way of giving a drug or other substance through a needle inserted into a vein) medication care plan.

Physician's orders, dated January 15, 2024, included an order to discontinue the urinary catheter. Physician's orders, dated February 12, 2024, included an order to discontinue intravenous medication.

There was no documented evidence to reflect that Resident 67's care plan was updated to reflect that the urinary catheter and intravenous medication was discontinued.

Interview with the Nursing Home Administrator on March 20, 2024, at 2:04 p.m. confirmed that Resident 67's care plan was not updated to reflect that the urinary catheter and intravenous medication was discontinued and it should have been.

28 Pa. Code 201.24(e)(4) Admission Policy.

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



 Plan of Correction - To be completed: 05/03/2024

The care plan for Resident 6 will be updated to include interventions to use of hearing aids, with instructions to collect the hearing aides in the evening, store in the medication cart, and place the hearing aides back in the resident's ears in the morning. The care plan for Resident 25 will be updated to reflect discontinuation of the Dexcom device. The care plan for Resident 57 will be updated to reflect nephrostomy tube flushes and changing the nephrostomy collection bag weekly. The care plan for resident 67 will be updated to reflect discontinuation of the urinary catheter and intravenous medication.

An audit of resident comprehensive care plans for current residents will be completed from April 4, 2024 forward to assure that care plans related to hearing aid use, Dexcom Continuous Glucose Monitoring (CGM) devices, nephrostomy tube flushes and collection bag changes, urinary catheters and intravenous medications are updated to reflect resident current status, and related to resident care plans reflecting current care needs.

Facility Registered Nurse Supervisors and the Registered Nurse Assessment Coordinator (RNAC) will receive education regarding updating care plans related to hearing aid use, Dexcom Continuous Glucose Monitoring (CGM) devices, nephrostomy tube flushes and collection bag changes, urinary catheters and intravenous medications, and related to resident care plans reflecting current care needs.

Audits will be completed by the RNAC or designee weekly for 4 weeks and monthly for 2 months to assure that care plans related to hearing aid use, Dexcom Continuous Glucose Monitoring (CGM) devices, nephrostomy tube flushes and collection bag changes, urinary catheters and intravenous medications are updated to reflect resident current status, and related to resident care plans reflecting current care needs. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the ombudsman about hospitalizations for three of 36 residents reviewed (Residents 24, 49, 57).

Findings include:

The facility's current policy for Transfer and Discharge Notification indicated that upon transfer to the hospital the ombudsman would be notified.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated December 29, 2023, indicated that the resident was cognitively intact, usually understood and could sometimes understand, required assistance from staff for her daily care needs, and had diagnoses that included congestive heart failure (inability of the heart to pump blood throughout the body sufficiently) and coronary artery disease (a condition that limits blood flow to the heart).

Resident 24 was transferred to the hospital on March 15, 2024, for a cardiac evaluation.

There was no documented evidence that a written notice of Resident 24's transfer to the hospital was provided to the State Long-Term Care Ombudsman.

An admission MDS for Resident 49, dated December 25, 2023, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, and had diagnoses that included hypertension (the pressure in the blood vessels is too high). A nursing note for Resident 49, dated March 15, 2024, at 12:15 a.m. revealed that he was sent to a local emergency room for complaints of feeling tired and a low blood pressure. Resident 49 was admitted to the medical intensive care unit with a diagnosis of hypotension.

There was no documented evidence that a written notice of Resident 49's transfer to the hospital was provided to the State Long-Term Care Ombudsman.

An admission MDS assessment for Resident 57, dated February 15, 2024, indicated that the resident was cognitively intact, usually understood and could usually understand, required assistance from staff for her daily care needs, and had diagnoses that included kidney failure and hydronephrosis (excess fluid in the kidney due to a backup of urine).

Resident 57 was transferred to the hospital on March 10, 2024, due to her nephrostomy tube (a tube that drains urine from the kidney).

There was no documented evidence that a written notice of Resident 57's transfer to the hospital was provided to the State Long-Term Care Ombudsman.

Interview with the Nursing Home Administator on March 21, 2024, at 11:23 a.m. confirmed that there was no written notification to the State Long-Term Care Ombudsman of the hospitalizations for Residents 24, 49 and 57, and there should have been.

28 Pa. Code 201.25 Discharge Policy.

28 Pa. Code 201.29(f)(g) Resident Rights.




 Plan of Correction - To be completed: 05/03/2024

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

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

The facility will send the required monthly list of transfer notifications to the ombudsman for Residents 24, 49, and 57.

The Social Service Director or designee will review resident transfers from April 4, 2024 forward to assure that ombudsman transfer notifications are submitted, and a list of transfers will be sent at the end of each month to the ombudsman going forward.

The Social Service Director and designee will receive education from the Nursing Home Administrator or designee regarding the requirement to send a list of resident transfers at the end of each month.

Audits will be completed by the Nursing Home Administrator or designee weekly for 4 weeks and monthly for 2 months to assure that the ombudsman is notified of resident transfers. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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.
483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of 483.95(g).
Observations:


Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for one of three nurse aides reviewed (Nurse Aide 3).

Findings include:

A list of nurse aides provided by the facility revealed that based on their months and days of hire, an annual performance evaluation for Nurse Aide 3 was due February 13, 2024. As of March 21, 2024, there was no documented evidence that the annual performance evaluation was completed as required for Nurse Aide 3.

Interview with the Human Resource Director on March 21, 2024, at 11:38 a.m. confirmed that she could not provide evidence that the annual performance evaluation for Nurse Aide 3 was completed as required.

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

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

28 Pa. Code 201.20(a)(c) Staff Development.








 Plan of Correction - To be completed: 05/03/2024

The facility is unable to retroactively correct the observation for Nurse Aide 3, as it is a past event.

A performance evaluation for Nurse Aide 3 was completed on March 21, 2024.

An audit will be conducted by Human Resources Director or designee for currently employed Nurse Aides to assure that an annual performance evaluation has been completed.

Current, agency, and newly hired registered nurse supervisors will receive education regarding the requirement to complete annual Nurse Aide performance evaluations.
Audits will be completed by the Director of Nursing or designee weekly for 4 weeks and monthly for 2 months to assure that annual Nurse Aide performance evaluations are completed as required. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee.

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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for two of 36 residents reviewed (Residents 57, 63).

Findings include:

The facility's policy regarding implementation of physican orders indicated that changes to the plan of care will be recorded, communicated, and implemented as ordered by the medical provider.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 57, dated February 15, 2024, revealed that the resident was cognitively intact, required moderate assistance from staff for daily care tasks, had a care plan that indicated the resident was at risk for urinary tract infections and sepsis (a life threatening infection in the blood), and had diagnoses that included chronic kidney disease with a left nephrostomy tube (a tube placed in the kidney to drain urine) placed in January.

Physician's orders for Resident 57, dated February 12, 2024, included orders for staff to check the nephrostomy tube for patency every eight hours.

A nursing note, dated March 9, 2024, for Resident 57 indicated that the resident's nephrostomy tube sutures were out and the tube was out approximately seven to eight centimeters. On March 9, 2024, the resident was started on Keflex (an antibiotic). The following day blood was noted in her nephrostomy tube and drainage bag, and the resident was then sent to the hospital to replace the nephrostomy tube.

A review of Resident 57's clinical record revealed that the patency of the nephrostomy tube was not assessed for one eight-hour period on February 16, 19, 22, 25, 26, and March 6, 12, 18, 2024.

Interview with Licensed Practical Nurse 2 on March 20, 2024, at 10:41 a.m. confirmed that Resident 57's clinical record indicated that staff did not assess the patency of the nephrostomy tube per physician orders. She further indicated that it is very important to do so especially because the resident has a history of her sutures coming out, and assessing the patency of the tube every eight hours can help prevent overall complications with the nephrostomy tube.

Interview with the Nursing Home Administrator on March 20, at 11:10 a.m. confirmed that Resident 57's nephrostomy tube should have been checked for patency every eight hours as per physican's orders.

A quarterly MDS assessment for Resident 63, dated January 20, 2024, revealed that the resident was cognitively intact and required assistance of staff for daily care needs. Resident 63 had a diagnosis of Type 2 Diabetes Mellitus.

Physician's orders for Resident 63, dated January 19, 2024, included orders for the resident's blood sugar to be checked before meals. The resident's Medication Administration Record (MAR) for February 2024 revealed that the resident's blood sugar level on February 19 at 4:00 p.m. was 486 mg/dl, on February 20 at 7:30 a.m. was 414 mg/dl, on February 24 at 7:30 was 457 mg/dl and 11:00 a.m. was 429 mg/dl, and on February 25 at 7:30 a.m. was 433 mg/dl. However, there was no documented evidence that the physician was notified about the resident's elevated blood sugars.

Interview with the Director of Nursing on March 21, 2024, at 11:15 a.m. confirmed that there was no documented evidence that the physician was notified about Resident 63's elevated blood sugars.

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



 Plan of Correction - To be completed: 05/03/2024

The facility is unable to retroactively correct the observations for Residents 57 and 63, as they are past events.

An audit of orders for nephrostomy tube flushes and patency checks and blood sugars above ordered parameters will be completed from April 4, 2024 forward to assure that nephrostomy tube flushes are completed as ordered, and that the physician is notified of blood sugars above ordered parameters.

Current, agency, and newly hired licensed Nursing Staff will receive education regarding following orders for nephrostomy tube flushes and patency checks and of notifying the physician of blood sugars above ordered parameters.

Random audits will be completed by the Director of Nursing or designee weekly for 4 weeks and monthly for 2 months to assure that orders for nephrostomy tube flushes and patency checks are completed as ordered, and that the physician is notified of blood sugars above ordered parameters. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee.

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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans that included specific and individualized interventions to address specific care needs for three of 36 residents reviewed (Residents 20, 27, 72).

Findings include:

The facility's policy regarding care plans, dated January 15, 2024, indicated that resident's care plans would be developed based on their needs.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 20, dated Feburary 3, 2024, indicated that the resident was alert and oriented and able to make his needs known. A physician's order, dated August 30, 2023, included an order for the resident to receive 2.5 milligrams (mg) Xarelto (blood thinner) two times per day.

Review of Resident 20's Medication Administration Record, dated February and March 2024, revealed that the resident received Xarelto twice a day.

Resident 20's care plan revealed that it did not include any information or interventions related to the resident's anticoagulant.

Admission information for Resident 27 revealed that the resident was admitted to the facility on December 30, 2022, and that he had a cardiac pacemaker. A quarterly MDS assessment, dated February 3, 2024, indicated that the resident was cognitively intact and that he had a pacemaker. Physician's orders for Resident 27, dated March 1, 2024, included an order for the resident to have a pacemaker check on March 20, 2024.

Resident 27's care plan revealed that it did not include any information or interventions related to the resident's cardiac pacemaker.

An interview with the Nursing Home Administrator on March 19, 2024, at 11:54 a.m. confirmed that Resident 20's and 27's care plans did not include anything regarding the use of an anticoagulant or the resident's cardiac pacemaker and they should have.

An admission MDS assessment for Resident 72, dated February 8, 2024, revealed that the resident was cognitively intact and received an anti-depressant, diuretic (water pill), anti-platelet (used to reduce the risk of blood clot formation), and hypoglycemic (used to treat diabetes) medications.

Physician's orders, dated February 1, 2024, included orders for the resident to receive 81 mg of aspirin (anti-platelet medication) daily, 30 mg of Duloxetine (anti-depressant) daily for depression, 40 mg of furosemide (diuretic) daily for edema (swelling), 75 mg of clopidogrel bisulfate (anti-platelet) daily to prevent blood clots, 100 mg of doxycycline (anti-biotic) twice a day for prophylaxis (prevent infection), and 12.5 mg of Jardiance (hypoglycemic) daily for diabetes.

There was no documented evidence that the facility had a care plan in place for Resident 72's use of an anti-platelet, anti-depressant, diuretic, antibiotic, or hypoglycemic medication.

Interview with the Nursing Home Administrator and Assistant Director of Nursing on March 20, 2024, at 12:00 p.m. confirmed that a care plan related to the use of an anti-platelet, anti-depressant, diuretic, antibiotic, or hypoglycemic medication was not developed.

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





 Plan of Correction - To be completed: 05/03/2024

The comprehensive care plans for Resident 20 will be updated to include interventions related to anticoagulant use, Resident 27 will be updated to include interventions related to the resident's cardiac pacemaker, and Resident 72 will be updated to include interventions related to use of an anti-platelet, anti-depressant, diuretic, antibiotic, and hypoglycemic medication.

An audit of resident comprehensive care plans for current residents will be completed from April 4, 2024 forward to assure that comprehensive care plans include interventions related to cardiac pacemakers, anti-platelet medication, anti-coagulant medication, anti-depressant medication, diuretics, antibiotics, and hypoglycemic medications.

Facility Registered Nurse Supervisors and the Registered Nurse Assessment Coordinator (RNAC) will receive education regarding completion of comprehensive care plans to include interventions related to cardiac pacemakers, anti-platelet medication, anti-coagulant medication, anti-depressant medication, diuretics, antibiotics, and hypoglycemic medications.

Audits will be completed by the RNAC or designee weekly for 4 weeks and monthly for 2 months to assure that comprehensive care plans include interventions related to cardiac pacemakers, anti-platelet medication, anti-coagulant medication, anti-depressant medication, diuretics, antibiotics, and hypoglycemic medications. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee.

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


Based on review of the Long-Term Care Facility Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for five of 36 residents reviewed (Residents 20, 27, 31, 58, 72).

Findings include:

The Resident Assessment Instrument User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that Section B0700 was to be coded zero (0) if the resident was understood, one (1) if the resident was usually understood, two (2) if the resident was sometimes understood, and three (3) if the resident was rarely/never understood. Section B0800 was to be coded zero (0) if the resident could understand others, one (1) if the resident usually understood others, two (2) if the resident sometimes understands others and three (3) if the resident rarely/never understands others. Section C0100 was to be coded zero (0) if the resident is rarely/never understood or one (1) if the resident should be interviewed. Section D0100 was to be coded zero (0) No if a mood interview was not to be conducted with the resident because the resident was rarely/never understood and/or unable to respond, and one (1) Yes if a mood interview should be conducted with the resident. The RAI Manual indicated that a mood interview should be attempted with all residents. Section J0100 was to be completed after interviewing the resident regarding their pain. Section K0200 was to be completed using the resident's height and weight.

A quarterly MDS assessment for Resident 20, dated February 3, 2024, revealed that the resident had clear speech, was understood, and understood others. However, Sections C, D, and K were coded with dashes (-), indicating that the areas were not assessed.

A quarterly MDS assessment for Resident 27, dated February 3, 2024, revealed that Sections B, C, D, and J were coded with dashes (-), indicating that the areas were not assessed.

A quarterly MDS assessment for Resident 58, dated February 22, 2024, revealed that Sections B, J, and K were coded with dashes (-), indicating that the areas were not assessed.

An interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on March 18, 2024, at 1:35 p.m. confirmed that Resident 20, 27, and 58's MDS assessments were not done and that they should have been. She stated that the facility utilizes a remote RNAC that does not come to the building to assess the residents.

The Long-Term Care Facility RAI User's Manual, dated October 2023, indicated that Section B was to be completed for each resident to document the resident's ability to understand and communicate with others. Section B0700 was to be coded zero (0) if the resident was understood by others, one (1) for usually understood, two (2) for sometimes understood, and three (3) for rarely/never understood. Section C was to be completed for each resident to identify his/her cognitive status. Section C0100 was to be coded No (0) or Yes (1) depending on whether a Brief Interview for Mental Status (BIMS) should be attempted with the resident and coded in Sections C0200 through C0500. The instructions for determining if a BIMS interview should be attempted indicated that if the resident was at least sometimes understood (verbally or in writing) then the BIMS interview was to be attempted with the resident. If the resident was rarely/never understood, then the BIMS interview was not to be attempted and a Staff Assessment of Mental Status was to be completed instead and coded in Sections C0600 through C1000.

The Long-Term Care Facility RAI User's Manual, dated October 2023, revealed that Section F0300 (Should Interview for Daily and Activity Preferences be conducted?) was to be coded (0) No (resident was rarely/never understood and family/significant other not available) skip to and complete F0800 Staff Assessment of Daily Activity Preference, or (1) Yes, continue to F0400 Interview for Daily Preferences. Section F0400 Interview for Daily Preferences revealed staff were to show the resident the response options and say "While you are in this facility..." and code (1) very important, (2) somewhat important, (3) not very important, (4) not important at all, (5) important but can't do, or no choice, and (9) no response or non-responsive for questions, (A) how important is it for you to choose what clothes to wear?, (B) how important is it to you to take care of your personal belongings or things?, (C) how important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?, (D) how important is it to you to have snacks available between meals?, (E) how important is it to you to choose your own bedtime?, (F) how important is it to you to have your family or a close friend involved in discussions about your care?, (G) how important is it to you to be able to use the phone in private?, and (H) how important is it to you to have a place to lock your things to keep them safe?

An Annual MDS assessment for Resident 31, dated February 15, 2024, revealed that Section B0700 was coded zero (0), indicating that the resident was understood by others. However, Section C0100 was coded (0) No, indicating that the resident was rarely/never understood by others, and Sections C0200 through C0500 (the BIMS interview) were not completed. Section F0300 and Section F0400 A, B, C, D, E, F, G and H were coded "not assessed."

Interview with the RNAC on March 18, 2024, at 1:35 p.m. confirmed that Section C0100 and Sections F0300 and F0400 were coded inaccurately on the above MDS assessment for Resident 31.

The RAI User's Manual, dated October 2023, revealed that Section F0300 (Should Interview for Daily and Activity Preferences be conducted?) was to be coded (0) No (resident was rarely/never understood and family/significant other not available) skip to and complete F0800 Staff Assessment of Daily Activity Preference, or (1) Yes, continue to F0400 Interview for Daily Preferences. Section F0400 Interview for Daily Preferences revealed staff were to show the resident the response options and say "While you are in this facility..." and code (1) very important, (2) somewhat important, (3) not very important, (4) not important at all, (5) important but can't do, or no choice, and (9) no response or non-responsive for questions, (A) how important is it for you to choose what clothes to wear?, (B) how important is it to you to take care of your personal belongings or things?, (C) how important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?, (D) how important is it to you to have snacks available between meals?, (E) how important is it to you to choose your own bedtime?, (F) how important is it to you to have your family or a close friend involved in discussions about your care?, (G) how important is it to you to be able to use the phone in private?, and (H) how important is it to you to have a place to lock your things to keep them safe?

An admission MDS assessment, dated February 8, 2024, revealed that Resident 72 could make herself understood and understand others and Section F0300 was coded (1) Yes, to continue to F0400 Interview for Daily Preferences; however, Section F0400 A, B, C, D, E, F, G and H were coded "not assessed."

Interview with the RNAC on March 18, 2024, at 1:35 p.m. confirmed that Section F0300 and F0400 were coded inaccurately on the above MDS for Resident 72.

28 Pa. Code 211.5(f) Clinical Records.




 Plan of Correction - To be completed: 05/03/2024

The facility is unable to retroactively correct the observations for Residents 20, 27, 31, 58, and 72, as they are past events.

An audit of Minimum Data Sets (MDS) completed from April 4, 2024 forward will be completed to assure that Sections B, C, D, F, J, and K were thoroughly completed, and that the MDS is accurately completed.

The Registered Nurse Assessment Coordinator (RNAC), Social Service Director, Dietician, and Activity Director will receive education by the Nursing Home Administrator or designee regarding thorough assessment and accurate completion of MDS Sections B,C,D,F,J, and K, and that the MDS is accurately completed.

Audits will be completed by the RNAC or designee weekly for 4 weeks and monthly for 2 months to assure completion of assessment of MDS Sections B,C,D,F,J, and K, and that the MDS is accurately completed. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee.

483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing: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.
483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

483.20(b) Comprehensive Assessments
483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

483.20(b)(2) When required. Subject to the timeframes prescribed in 413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in 413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.
Observations:


Based on review of the Resident Assessment Instrument User's Manual and clinical records, the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set (MDS) validation report, as well as staff interviews, it was determined that the facility failed to ensure that the Care Area Assessment Process of comprehensive Minimum Data Set assessments and comprehensive assessments were completed in the required time frame for three of 36 residents reviewed (Residents 17, 68, 71).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that for admission MDS assessments, the assessment completion date and the Care Area Assessment (CAA - the process of completing an in-depth assessment of triggered, potentially problematic care areas) completion date (Item V0200B2) were to be no later than the resident's admission date plus 13 calendar days and there must be an MDS every 92 days.

A comprehensive MDS assessment for Resident 17 revealed that the ARD was February 17, 2024. The MDS assessment was dated as completed on March 3, 2024, which was one day late.

A comprehensive MDS assessment for Resident 68 revealed that the ARD was February 14, 2024. The MDS assessment was dated as completed on February 29, 2024, which was three days late.

A comprehensive MDS assessment for Resident 71 revealed that the ARD was February 21, 2024. The MDS assessment was dated as completed on March 7, 2024, which was one day late.

Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on March 18, 2024, at 1:35 p.m. confirmed that the above comprehensive MDS assessments were not completed in the required time frames.

28 Pa. Code 211.5(f) Clinical Records.




 Plan of Correction - To be completed: 05/03/2024

The facility is unable to correct the observations for Residents 17, 68, and 71, as they are past events.

An audit of the comprehensive Minimum Data Set (MDS) MDS assessment schedule from April 4, 2024 forward will be completed to assure comprehensive MDS assessments are completed within the required time frame.

The Registered Nurse Assessment Coordinator (RNAC) will receive education from the Nursing Home Administrator or designee regarding comprehensive MDS assessments completion within the required time frame.

Audits will be completed by the RNAC or designee weekly for 4 weeks and monthly for 2 months to assure that comprehensive MDS assessments are completed within the required time frame. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee.

483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months: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.
483.20(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.
Observations:


Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for one of 36 residents reviewed (Resident 16).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to have a completion date (Section Z0500B) that was no later than the ARD plus 14 calendar days.

A quarterly MDS assessment for Resident 16 had an ARD of February 24, 2024, but it was not completed (Section Z0500B) until March 11, 2024, which was two days late.

An interview with Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on March 18, 2024, at 1:35 p.m. confirmed that the above referenced quarterly MDS assessment was completed late.

28 Pa. Code 211.5(f) Clinical Records.




 Plan of Correction - To be completed: 05/03/2024

The facility is unable to retroactively correct the observations for Resident 16, as it is a past event.

An audit of the quarterly Minimum Data Set (MDS) MDS assessment schedule from April 4, 2024 forward will be completed to assure timely completion of quarterly MDS assessments.

The Registered Nurse Assessment Coordinator (RNAC) will receive education by the Nursing Home Administrator or designee regarding timely completion of quarterly MDS assessments. The RNAC will utilize the MDS tracking log in the electronic medical record to assure that assessments are completed within the required time frame.

Audits will be completed by the RNAC or designee weekly for 4 weeks and monthly for 2 months to assure timely completion of quarterly MDS assessments. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee.

211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:


Based on review of nursing schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide per 20 residents on the overnight shifts for one of 21 days (24-hour periods) reviewed.

Findings Include:

Review of facility census data indicated that on March 9, 2024, the facility census was 78, which required 3.90 (78 residents divided by 20) nurse aides during the night shift. Review of the nursing time schedules revealed 3.57 nurse aides provided care on the night shift on March 9, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Interview with the Nursing Home Administrator on March 21, 2024, at 1:00 p.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the days listed above.



 Plan of Correction - To be completed: 05/03/2024

The facility is unable to retroactively correct the observations regarding the nurse aide to resident ratio, as this is a past event.

An audit of current nurse aide staffing ratios will be completed by the Scheduling Coordinator or designee to assure that the facility maintained the required nurse aide staffing ratios for each shift.

The Scheduling Coordinator will receive education by the Director of Nursing or designee regarding the required nurse aide staffing ratios on each shift. The Scheduling Coordinator will notify the Director of Nursing or designee if an instance occurs that the ratio is projected to be below requirements, and measures will be taken to secure additional staffing to assure the ratio is met.

Random audits will be completed by the Director of Nursing or designee weekly for 4 weeks and monthly for 2 months to assure that the required nurse aide staffing ratios are met on each shift. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee.

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


Based on review of nursing schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift for five of 21 days reviewed.

Findings Include:

Review of facility census data indicated that on March 4, 2024, the facility census was 75, which required 3.00 LPN's during the day shift. Review of the nursing time schedules revealed 2.93 LPN's worked on the day shift on March 4, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 8, 2024, the facility census was 79, which required 3.16 LPN's during the day shift. Review of the nursing time schedules revealed 3.03 LPN's worked on the day shift on March 8, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 9, 2024, the facility census was 78, which required 3.12 LPN's during the day shift. Review of the nursing time schedules revealed 3.00 LPN's worked on the day shift on March 9, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 10, 2024, the facility census was 78, which required 3.12 LPN's during the day shift. Review of the nursing time schedules revealed 3.00 LPN's worked on the day shift on March 10, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 11, 2024, the facility census was 76, which required 3.04 LPN's during the day shift. Review of the nursing time schedules revealed 3.03 LPN's worked on the day shift on March 11, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Interview with the Nursing Home Administrator on March 21, 2024, at 1:00 p.m. confirmed that the facility did not meet the required nurse LPN-to-resident staffing ratios for the days listed above.



 Plan of Correction - To be completed: 05/03/2024

The facility is unable to retroactively correct the observations regarding the licensed practical nurse (LPN) to resident ratios, as these are past events.

An audit of current LPN staffing ratios will be completed by the Scheduling Coordinator or designee to assure that the facility maintained the required LPN staffing ratios for each shift.

The Scheduling Coordinator will receive education by the Director of Nursing or designee regarding the required LPN staffing ratios on each shift. The Scheduling Coordinator will notify the Director of Nursing or designee if an instance occurs that the ratio is projected to be below requirements, and measures will be taken to secure additional staffing to assure the ratio is met.

Random audits will be completed by the Director of Nursing or designee weekly for 4 weeks and monthly for 2 months to assure that the required LPN staffing ratios are met on each shift. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee.


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