Nursing Investigation Results -

Pennsylvania Department of Health
GROVE AT NEW CASTLE, THE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GROVE AT NEW CASTLE, THE
Inspection Results For:

There are  131 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.
GROVE AT NEW CASTLE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint completed on December 2, 2021, it was determined that The Grove at New Castle 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(b)(1) 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.
Observations:

Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to develop a comprehensive, individualized discharge care plan for three of three closed record residents discharged to the community (Residents CR1, CR2 and CR3).

Findings include:

Review of the facility policy entitled "MDS (Minimum Data Set - periodic assessment of resident care needs)/RAI (Resident Assessment Instrument - guidelines for completion of the MDS)/Care Planning" dated 11/20/21, revealed that a written, individualized plan of care would be developed for every resident which identifies through an assessment process his/her strengths and needs.

Review of Resident CR1's clinical record revealed an admission date of 9/13/20, and diagnoses that included chronic obstructive pulmonary disease (COPD - a respiratory disease characterized by obstructed airways and shortness of breath), low back pain and a history of drug abuse.

Review of Resident CR1's clinical record revealed that upon admission, Resident CR1 planned to remain in the facility for long term care. August 2021, Social Service (SS) Notes revealed efforts, per Resident CR1's request, to be transferred to another facility. October 2021, SS Notes indicated arrangements to obtain a primary care physician, pain clinic and apartment in Resident CR1's prior community. November 2021, SS Notes revealed a consult for home health, physical and occupational therapy services, which Resident CR1 declined; testing for oxygen use at home; and discharge arrangements for an apartment in Resident CR1's prior community and discharge on 11/10/21.

Resident CR1's clinical record lacked an individualized, comprehensive discharge care plan with a goal, interventions taken/planned by the facility to arrange for Resident CR1's discharge to the community and updates/changes to the discharge goal from long term placement to discharge to the community.


Review of Resident CR2 's clinical record revealed an admission date of 9/14/21, and diagnoses that included fractured right femur (bone extending from the pelvis to the knee) and pelvis, COPD, and depression.

Review of October 2021, SS Notes indicated that on admission Resident CR2's case worker requested involvement in care plan meetings and the discharge planning process and that Resident CR2's group home was in contact with the facility related to the discharge plan. An 11/23/21, SS Note indicated that Resident CR2 was discharged to a group home with a follow-up physician appointment and Nursing, Physical Therapy and Occupational Therapy consults in place.

Resident CR2's clinical record lacked an individualized, comprehensive discharge care plan with a goal and interventions to reflect the steps taken/planned by the facility to arrange for Resident CR2's discharge to the community.


Review of Resident CR3's clinical record revealed an admission date of 11/05/21, and diagnoses that included exploration of a left hip prosthesis (artificial part), depression and diabetes.

Review of SS Notes, dated 11/15/21, indicated that Resident CR3's discharge plan was for a short term stay. SS Notes, dated 11/16/21, and 11/17/21, revealed arrangements for physical therapy, occupational therapy and nursing services following discharge, and a physician follow-up appointment scheduled on 11/22/21. SS notes reflected Resident CR3 was discharged home with family on 11/18/21.

Resident CR3's clinical record lacked an individualized, comprehensive discharge care plan with a goal and interventions to reflect the steps taken/planned by the facility to arrange for Resident CR3's discharge to the community.

During an interview on 12/02/21, at 1:15 p.m. the Director of Nursing confirmed that all residents should have an individualized plan of care related to discharge that reflects the resident's discharge goal and interventions to meet that goal.

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.11(d) Resident care plan

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








 Plan of Correction - To be completed: 12/23/2021

"The Facility submits this Plan of Correction under procedures established by the Department of
Health in order to comply with the Department's directive to change conditions which the
Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of
Correction should not be construed as either a waiver of the facility's right to appeal or challenge the
accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or
Federal regulatory requirements."
F656
1. The facility cannot correct that residents CR1, CR2 and CR3 did not have a comprehensive,
individualized discharge care plan. Resident CR1, CR2 and CR3 are no longer in the facility.
2. The Social Service Director/designee will review current resident care plans to ensure there is a
comprehensive, individualized discharge care plan developed.
3. The Social Service Director will be re-educated by the Regional Social Services Consultant on the
facility policy for MDS/RAI/Care Planning with emphasis on discharge planning.
4. The MDS nurse/designee will audit five resident care plans weekly for four weeks and monthly for
three months to ensure residents have a comprehensive, individualized discharge care plan. Outcomes
will be reported to the Quality Assurance Performance Improvement Committee for review and
recommendations.
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 clinical records and facility policies and staff interviews, it was determined that the facility failed to administer medications per physician's order for one of three closed record residents discharged to the community (Resident CR1).

Findings include:

Review of the facility policy entitled "Medication Administration" dated 11/20/21, indicated that medications are administered in accordance with physician's orders and within 60 minutes before or after the scheduled times. The policy also indicated that medication times may be changed in response to resident preference, or to enhance compliance, unless therapeutically contraindicated.

Review of Resident CR1's clinical record revealed an admission date of 9/13/20, and diagnoses that included chronic obstructive pulmonary disease (COPD - a respiratory disease characterized by obstructed airways and shortness of breath), low back pain and a history of an irregular heart rhythm and drug abuse. The clinical record revealed that Resident CR1 was scheduled to be discharged from the facility to a private apartment, a four hour trip from the facility, on 11/10/21 at 7:00 a.m., with medications and personal belongings. Documentation further revealed that Resident CR1 didn't leave the facility until 10:30 a.m.

Resident CR1's physician ordered medications, current at the time of discharge, included the following medications to be administered in the morning: Atorvastatin (a medication to lower fat levels in the blood) 10 milligrams (mg) daily at 8 a.m.; Claritin (an allergy medication) 10 mg daily at 8 a.m.; Colace (a stool softener) 100 mg daily at 9:00 a.m.; Diltiazem Extended Release (ER - a medication for high blood pressure or irregular heart rhythm) 120 mg daily at 9:00 a.m.; Spiriva (relieves wheezing and shortness of breath) Handihaler 18 microgram (mcg) capsule, two separate inhalations, daily at 9:00 a.m.; Apixaban (slows blood clotting) 5 mg twice daily, first dose at 8:00 a.m.; Budesonide (an allergy medication) Aerosol Powder Breath Activated, 180 mcg per activation, 1 puff twice daily, first dose at 8:00 a.m.; Baclofen (for muscle spasms) 10 mg twice daily, first dose at 9:00 a.m.; Flomax (for urinary retention) 0.4 mg, twice daily, first dose at 9:00 a.m.; Mucinex ER (thins respiratory secretions) 600 mg twice daily, first dose at 9:00 a.m.; Prilosec (for gastric reflux) 20 mg twice daily, first dose at 8:00 a.m.; Gabapentin (for seizures and neurological pain) 900 mg three times daily, first dose at 9:00 a.m.; and Azelastine (for nasal allergies) 137 mcg, two sprays each nostril twice daily, first dose at 8:00 a.m.

Resident CR1's November 2021 Medication Administration Record revealed Resident CR1 did not receive medications ordered for 8:00 a.m. and 9:00 a.m. on 11/10/21 (morning of discharge), with documentation of "3" for each medication, the "3" coded as the resident on a "leave of absence."

During an interview on 11/30/21, at 11:30 a.m. Social Worker (SW) Employee E1 revealed that Resident CR1 was scheduled for discharge on 11/10/21, at 7:00 a.m., via transportation arranged by a Nursing Home Transition Coordinator associated with Resident CR1's insurance provider. SW Employee E1 indicated the transport was delayed and did not arrive until 10:30 a.m.

During an interview on 11/30/21 at 11:50 a.m. the Director of Nursing confirmed that Resident CR1 was prepared and awaiting transport for a four hour transport to his/her new home on 11/10/21, at 7:00 a.m.; that arrangements were not made for administration of Resident CR1's morning medications (due to be given while in transport) prior to discharge; or that the morning medications were administered when it was identified that Resident CR1 was not going to leave the facility until after the medications' scheduled administration times.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(e)(1)(6) Management

28 Pa. Code 211.10(c) Resident care policies

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











 Plan of Correction - To be completed: 12/23/2021

F684
1. The facility cannot correct that resident CR1 was not administered medications per physician orders. Resident CR1 is no longer in the facility.
2. Residents will be administered medications per physician orders.
3. The licensed nurses will be re-educated by the Director of Nursing/designee on the facility policy for medication administration.
4. DON/Designee will review and monitor all resident discharges to ensure medications are administered per physician orders
4. The Director of Nursing/designee will complete medication audits on five residents weekly for four weeks and monthly for three months to ensure medications are administered per physician orders. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port