Nursing Investigation Results -

Pennsylvania Department of Health
RIVERWOODS
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
RIVERWOODS
Inspection Results For:

There are  103 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.
RIVERWOODS - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey completed on October 22, 2021, it was determined that Riverwoods was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

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

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

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

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

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

Based on review of select facility policies and procedures, a resident group interview, and staff interview, it was determined that the facility failed provide all residents the opportunity to exercise their right to vote for eight of eight residents in the group interview (Residents 88, 72, 38, 67, 26, 56, 40, and 92).

Findings:

The policy entitled "Voting Opportunities for Residents," last reviewed without changes on August 17, 2021, revealed each executive director/administrator will establish procedures to help residents exercise their right to vote. Assistance for residents will be provided with completing voter registration, obtaining absentee ballots, providing transportation to voting sites, arranging for voting sites on the campus, if possible, and establish a main contact person for requests for voting information. Each community executive director/administrator will establish the procedures unique to their campus and attach it to this policy.

The surveyor conducted a resident group interview on October 20, 2021, at 10:30 AM with eight residents attending. Resident 92 stated he has resided in the facility since 2018 and has requested absentee ballots several times. Resident 92 stated that he has not been afforded the opportunity to vote since admission to the facility. The other residents in the group stated the facility did not assist them in obtaining absentee ballots or transportation to a polling place.

Interview with Employee 2 (activity director) on October 22, 2021, at 9:30 and 11:23 AM confirmed that the facility does not have a plan to ensure residents can exercise their right to vote, whether in person, by mail, absentee, or other authorized process. Employee 2 stated there was no evidence that Residents 88, 72, 38, 67, 26, 56, 40, and 92 were offered voting assistance.

The findings were reviewed and confirmed during an interview with the Nursing Home Administrator on October 22, 2021, at 11:00 AM.

28 Pa. Code 201.29(i) Resident rights


 Plan of Correction - To be completed: 12/15/2021

1.Residents #26, #40, #67, #72, #92 are verified as registered voters. Residents #38, #56, #88 have been given the option to register to vote with resident decisions pending.
2.Eligible residents will be afforded the opportunity to vote in upcoming elections.
3.Activities and social services staff will be re-educated on F-Tag 550; Residents Rights/Exercise of Rights by the NHA/designee on or before the date of compliance. The "Voting Opportunities for Residents" policy, is being reviewed and revised.
4.The NHA/Designee will audit new residents voting status x3 months.
5.Date of Compliance: December 15, 2021

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff: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.
483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:

Based on review of facility documentation and residents, responsible party, and staff interview, it was determined that the facility failed to ensure sufficient nursing staff to provide appropriate call bell response times for one of three nursing units (Evergreen; Residents 21, 37, and 107).

Findings include:

Interview with Resident 37 on October 19, 2021, at 11:33 AM revealed that she does not always get out of bed because it takes two staff to get her out of bed and sometimes it takes up to an hour for her needs to be met. The staff start at one end of the hall and work their way to her end of the hall.

Interview with Resident 107's responsible party on October 19, 2021, at 12:12 PM revealed the resident is not always able to use the call bell so the responsible party rings it. The responsible party said it sometimes takes 30 minutes for the bell to be answered.

Interview with Resident 21 on October 20, 2021, at 10:07 AM revealed that she cannot always get out of bed because there is not enough staff to use the mechanical lift and that sometimes she rings her call bell and staff do not always respond.

Review of facility documentation entitled "Device Activity Report" (a log of times when a call bell in resident rooms were activated and when the call bell was reset by facility staff) for the following Resident Rooms from September 29 through October 20, 2021, revealed the following call bell response times that were over 25 minutes:

Resident 37, Evergreen Nursing Unit:

September 30, 2021, 10:36 AM, 32 minutes, 3 seconds
September 30, 2021, 9:42 PM, 25 minutes, 42 seconds
September 30, 2021, 10:28 PM, 28 minutes, 3 seconds
October 1, 2021, 6:03 AM, 26 minutes, 30 seconds
October 2, 2021, 4:43 PM, 35 minutes, 45 seconds
October 4, 2021, 9:23 PM, 30 minutes, 33 seconds
October 6, 2021, 1:24 PM, 25 minutes, 56 seconds
October 9, 2021, 7:20 PM, 33 minutes 50 seconds
October 9, 2021, 8:57 PM, 36 minutes, 58 seconds
October 10, 2021, 6:49 PM, 74 minutes, 18 seconds
October 11, 2021, 3:37 AM, 25 minutes, 45 seconds
October 14, 2021, 4:05 PM, 46 minutes, 34 seconds
October 20, 2021, 5:56 PM, 55 minutes, 55 seconds

Resident 21, Evergreen Nursing Unit:

October 1, 2021, 8:48 AM, 29 minutes, 55 seconds
October 2, 2021, 10:12 AM, 42 minutes, 28 seconds
October 7, 2021, 3:40 PM, 32 minutes, 15 seconds
October 8, 2021, 1:45 PM, 36 minutes, 20 seconds
October 10, 2021, 10:57 AM, 27 minutes, 48 seconds
October 10, 2021, 8:33 PM, 50 minutes, 21 seconds
October 14, 2021, 7:51 PM, 37 minutes, 49 seconds
October 17, 2021, 2:04 AM, 71 minutes, 49 seconds
October 19, 2021, 1:57 AM, 36 minutes, 38 seconds
October 19, 2021, 7:41 PM, 29 minutes, 35 seconds
October 19, 2021, 9:52 PM, 31 minutes, 30 seconds
October 20, 2021, 5:05 PM, 30 minutes, 12 seconds
October 20, 2021, 7:53 PM, 34 minutes, 21 seconds

Resident 107, Evergreen Nursing Unit:

September 29, 2021, 5:40 PM, 43 minutes, 46 seconds
September 30, 2021, 9:38 AM, 27 minutes, 52 seconds
September 30, 2021, 6:31 PM, 25 minutes, 19 seconds
September 30, 2021, 7:20 PM, 55 minutes, 28 seconds
September 30, 2021, 10:26 PM, 29 minutes, 58 seconds
October 3, 2021, 2:19 AM, 30 minutes, 28 seconds
October 5, 2021, 4:33 AM, 29 minutes, 40 seconds

Interview with the Nursing Home Administrator on October 21, 2021, at 2:30 PM acknowledged the above findings.

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

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


 Plan of Correction - To be completed: 12/15/2021

1.Resident #21, #37, #107 has been assessed and all call bell needs are met.
2.Call light system has been reconfigured with updated email notifications and additional pagers have been ordered.
3.Staff will be educated on F-Tag 725, Sufficient Nursing Staff and the importance of timely responses to resident call lights by the DON/designee on or before the date of compliance.
4.Random audits will be conducted weekly x4 weeks and then monthly x 2 months to validate call bells are answered timely. Audits will be completed by the DON/Designee with trends reported through QAPI.
5.Date of Compliance: December 15, 2021

483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:

Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide showers per resident preference for two of four residents reviewed (Residents 34 and 51).

Findings include:

In an interview with Resident 34 on October 19, 2021, at 12:03 PM the resident indicated she has not received a shower since she came to the facility, and she took showers at home. Resident 34 stated the staff just wash her up in bed.

Clinical record review for Resident 34 revealed the resident was admitted to the facility on August 6, 2021. A review of Resident 34's bathing records for August 6 through October 20, 2021, revealed the resident was only documented as receiving a full bed bath on August 23, 2021, and again on October 18, 2021. There was no other documentation to indicate the resident was bathed and/or offered or refused a shower.

Review of an admission minimum data set assessment (MDS, an assessment completed a specific intervals to assess resident care needs) for Resident 34 dated August 13, 2021, indicated it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath, and the resident bathing did not occur even though the resident had been in the facility since August 6, 2021.

Review of a shower schedule for the Evergreen nursing unit where Resident 34 as resided since September 8, 2021, revealed the resident was listed to receive a shower on Mondays during the evening shift.

There was no evidence to indicate Resident 34 had received a shower per her preference since she was admitted on August 6, 2021, until Thursday evening, October 21, 2021, after the above information was reviewed with the Nursing Home Administrator and Director of Nursing on October 21, 2021, at 2:15 PM.

Clinical record review for Resident 51 revealed that she was admitted on August 19, 2021. Review of Resident 51's bathing documentation revealed that the facility completed a shower on August 25, 2021. Review of Resident 51's initial MDS dated August 26, 2021, revealed that Resident 51 believed that it was somewhat important to choose between a bed bath, shower, or a sponge bath.

Observation of Resident 51 on October 19, 2021, at 2:07 PM revealed that she was lying in bed watching TV. Interview with Resident 51 regarding why she remained in bed revealed that she wanted to get a shower today, but staff indicated to her that "it wasn't her day" (to be showered) and informed her that her shower day was tomorrow (Wednesday, October 20, 2021). Resident 51 indicted that since staff would not shower her, she chose to stay in bed. Resident 51 also revealed that she had only received one shower since admission.

Further review of Resident 51's shower documentation confirmed that the only shower (or any type of bath/shower) that she received since admission was on August 25, 2021.

The surveyor reviewed the information for Resident 51 during an interview with the Director of Nursing (DON) on October 22, 2021, at 9:51 AM and with the Nursing Home Administrator (NHA) on October 22, 2021, at 12:56 PM. The interviews with the DON and NHA revealed the facility transitioned to a new clinical record system on September 1, 2021. The resident bathing/shower task did not transfer or was not implemented correctly on the new clinical record system to inform staff of Resident bathing/showering needs; therefore, there was no documentation available indicating Resident 51 received either a bed bath or shower after September 1, 2021.

There was no evidence that Resident 51 received a shower per her request since August 25, 2021, until discussed with the NHA and DON.

28 Pa. Code 201.14(a) Responsibility of licensee

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


 Plan of Correction - To be completed: 12/15/2021

1.Resident #34's shower preferences were reviewed and updated. Resident #34 has received showers according to their preferences.
Resident #51's preferences were reviewed and updated according to their preference. Resident #51 has received a showers according to their preferences.
2.Bathing schedules will be reviewed with each resident or POA to confirm their bathing preference.
3.Nursing and activities staff will be educated on F-Tag 561; Self Determination by the DON/designee on or before the date of compliance.
4.Random audits of 10 residents bathing preferences and documentation be conducted weekly x4 weeks and then monthly x 2 months to validate interventions are implemented for residents related to their bathing preferences. Audits will be completed by the DON/Designee with trends reported through QAPI.
5.Date of Compliance: December 15, 2021

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on observation, clinical record review, review of facility documentation, and resident, responsible party, and staff interview, it was determined that the facility failed to provide personal hygiene assistance and showering for one of five residents reviewed for activities of daily living (Resident 42).

Findings include:

Observation of Resident 42 on October 19, 2021, at 11:48 AM revealed that the resident had long facial hair that extended onto his neck. Concurrent interview with Resident 42 revealed that he prefers to be shaven. Observation revealed an electric razor was plugged into the wall.

Clinical record review of Resident 42's Minimum Data Set (MDS, an assessment tool completed at specific intervals to determine care needs) dated August 17, 2021, revealed facility staff assessed the resident as requiring extensive assistance for personal hygiene, which included combing his hair, brushing his teeth, shaving, washing/drying face, and hands. Review of the bathing task revealed that Resident 42 did not have a bath/shower during the look back period of seven days from August 17, 2021. Review of Resident 42's MDS assessment dated June 15, 2021, revealed the resident required physical help with bathing/showering with the assistance of one staff member.

Observation of Resident 42 on October 20, 2021, at 12:30 PM revealed that the resident was shaven. Concurrent interview with Resident 42's responsible party revealed that she brought in a manual razor this date to shave the resident. She also revealed that she would be satisfied if the facility shaved the resident. The responsible party reported that she also brushed his teeth at times because they are not always brushed. The responsible party looked in the resident's mouth and said that his teeth were not brushed today. The responsible party reported mentioning in a care conference that his teeth needed brushed and that he missed a shower, and he was to have weekly showers.

During a meeting with the Director of Nursing and Nursing Home Administrator (NHA) on October 20, 2021, at 2:30 PM, Resident 42's unshaven condition and his responsible party's expectations were discussed.

Review of grievances since August 1, 2021, revealed three grievances (one related to Resident 42) were filed related to ADL's (Activities of Daily Living, daily care items such as feeding, bathing, dressing, and grooming including mouth care, nail care, and shaving) concerning lack of mouth care and showering. One of the above grievances dated August 31, 2021, was related to Resident 42's responsible party who voiced concerns during a care plan conference regarding the resident's lack of mouth care and that he missed a weekly shower. The grievance form indicated that Resident 42 was showered after the responsible party discussed the issue with unit staff. The facility's investigation revealed that mouth care was needed facility-wide, and education was provided to the licensed practical nurses and nurse aides.

Review of Resident 42's shower documentation from September 5 through October 19, 2021, revealed the following:

Week of September 5-11, shower provided Monday, September 6
Week of September 12-18, shower provided Saturday, September 18 (12 days since last shower)
Week of September 19-25, no shower documentation
Week of September 26-October 2, no shower documentation
Week of October 3-9, resident was hospitalized from October 4-8
Week of October 10-16, full bed bath on October 16
October 17-19, scheduled shower not provided on October 18, reason was "Chg" (indicated a change in the schedule)

Interview with the NHA on October 22, 2021, at 9:00 AM revealed there was no documentation why showers were not provided. The NHA also indicated that the facility changed its electronic medical record as of September 1, 2021, and there was a possibility that showers were provided, however, staff did not document correctly in the new system. The NHA confirmed that there was no documentation of weekly showers (for four of the seven weeks reviewed for Resident 42.

The facility failed to shave Resident 42 and document that weekly showers were provided to Resident 42.

483.24(a)(2) ADL Care Provided for Dependent Residents
Previously cited 9/25/2020

28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services


 Plan of Correction - To be completed: 12/15/2021

1.Resident #42 continues to be shaved and showered to their satisfaction.
2.Residents requiring assistance with personal hygiene and/or bathing have been identified. ADL care plans will be updated to reflect personal and bathing hygiene assistance needs.
3.Nursing staff will be educated on F-Tag 677; ADL Care Provided Dependent Residents by the DON/designee on or before the date of compliance.
4.Random audits of 10 residents will be conducted weekly x4 weeks and then monthly x2 months to validate interventions are implemented for residents with shaving and bathing preferences. Audits will be completed by the DON/Designee with trends reported through QAPI.
5.Date of Compliance: December 15, 2021

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(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 resident and staff interviews and clinical record review, it was determined that the facility failed to provide a restorative nursing range of motion program for one of two residents reviewed for limited range of motion concerns (Resident 99).

Findings include:

Interview with Resident 99 on October 19, 2021, at 11:46 AM revealed concerns that her rehabilitation was not consistent. She stated that therapy worked with her so that she could do a stand-pivot transfer onto the toilet but after she was discharged, there was no follow through, so she declines again. She indicated that she could not go back to the personal care home because she needed to be able to stand-pivot transfer.

Review of therapy documentation revealed that Resident 99's discharge from therapy was on October 6, 2021. Physical therapy discharged her with a restorative program for transfers with a rolling walker, two staff to assist and the sit to stand lift.

Interview with Employee 7, Director of Therapy, revealed that Resident 99 was not able to complete stand pivot transfers when physical therapy discharged her on October 6, 2021. She was discharged to a restorative nursing program to maintain her current transfer status with a sit to stand lift or with a rolling walker and two staff to assist. She also indicated that Resident 99 cannot consistently transfer with her walker and that the sit to stand lift is used more often.

Review of Resident 99's clinical record revealed that there was no documentation related to this program being completed in the month of October 2021.

Interview with the Nursing Home Administrator on October 22, 2021, at 11:00 AM confirmed the above noted findings for Residents 99.

The facility failed to initiate therapy recommended restorative programs for Residents 99.

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


 Plan of Correction - To be completed: 12/15/2021

1.Resident #99 has been assessed by therapy for a mobility (transfers) program with recommendations being followed.
2.Residents in the past 30 days discharged from therapy have been identified. Orders were reviewed to determine therapy recommended mobility (transfers) programs have been initiated. Programs are being established for residents requiring restorative needs.
3.Nursing and therapy staff will be educated on F-Tag 688; Increase / Prevent Decrease in ROM/Mobility by the DON/designee on or before the date of compliance. The facilities restorative program is being re-implemented to meet the needs of current residents.
4.Audits will be conducted of residents discharged from therapy weekly x4 weeks and then monthly x 2 months to validate interventions are implemented for residents with therapy recommended restorative ROM programs. Audits will be completed by the DON/Designee with trends reported through QAPI.
5.Date of Compliance: December 15, 2021

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to assess and implement interventions to ensure acceptable parameters of nutrition for one of 10 residents sampled for nutrition concerns (Resident 83).

Findings include:

The policy entitled "Weighing Residents," last reviewed without changes on August 17, 2021, revealed all residents will be provided adequate nutrition to maintain body weight. Each resident will be weighed at least monthly. Staff will provide the weights to the registered dietitian, registered nurse, or licensed practical nurse to review and assess if a re-weight will be needed. The registered dietitian, registered nurse, licensed practical nurse, and interdisciplinary team will monitor all weights and request re-weights when indicated or as needed. The registered dietitian will review monthly weights and notify the physician and nursing staff if there is a significant weight gain/loss in one month. The registered dietitian will then complete an assessment in the electronic health record and forward the appropriate dietary recommendations to the physician and/or charge nurse to act upon.

Clinical record review for Resident 83 revealed the facility admitted her on January 12, 2021, with an admission weight of 116.5 pounds. Review of weight documentation in Resident 83's electronic medical record indicated the following weights:

April 1, 2021, 111.4 pounds
May 1, 2021, 105.2 pounds (5.56 percent, 6.2-pound severe weight loss)
May 5, 2021, 105.2 pounds
June 1, 2021, 93.0 pounds (11.59 percent, 12.2-pound severe weight loss)

Documentation noted a 6.2-pound, 5.56 percent severe weight loss from April 1 to May 1, 2021. Review of Resident 83's nutrition notes dated May 28, 2021, confirmed Resident 83 had a significant weight loss and Employee 1 (registered dietician) recommended Magic Cup (frozen supplement) and Ensure plus (nutritional supplement that provides concentrated calories and protein to help patients gain or maintain healthy weight) 240 ml (milliliters) every day.

Review of Resident 83's Medication Administration Record (MAR, a form utilized to document the administration of medications) dated May 2021 revealed that Resident 83's Magic Cup and Ensure Plus were not implemented.

Further review of Resident 83's clinical record revealed documentation noting another severe weight loss of 12.2 pounds, 11.59 percent from May 1 to June 1, 2021 (totaling an 18.4 pounds and 16.51 percent severe weight loss since April 1, 2021).

Review of Resident 83's nutrition note dated June 14, 2021, revealed Employee 1 noted Resident 83 was at risk of malnutrition related to decreased meal intakes and previous weight loss. Employee 1 again recommended a new order for Magic Cup and Pudding 4 ounce every day.

Interview with Employee 1 (registered dietitian) on October 22, 2021, at 10:15 AM confirmed that her recommended interventions on May 28, 2021, were not started until after her follow up assessment on June 14, 2021. After the two week delay in treatment, Resident 83 sustained an 18.4 pound, 16.51 percent severe weight loss from April 1, 2021.

483.25(g)(1)-(3) Nutrition/Hydration Status Maintenance
Previously cited September 25, 2020

28 Pa. Code 211.6 (d) Dietary services

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


 Plan of Correction - To be completed: 12/15/2021

1.Resident #83 is receiving recommended nutritional supplements and being monitored through weekly weights.
2.Residents identified with significant weight loss in the past 30 days have been identified. Dietary recommendations will be reviewed to validate all orders have been implemented.
3.The Registered Dietician and nursing department will be educated on F-Tag 692; Nutrition / Hydration Status Maintenance by the DON/designee on or before the date of compliance. The supplementation recommendation has been reviewed and revised. The registered dietician in concurrence with the Medical Director will initiate orders for nutritional supplements as needed.
4.Random audits of 5 residents will be conducted weekly x4 weeks and then monthly x 2 months to validate supplement interventions related to weight loss are provided as ordered. Audits will be completed by the DON/Designee with trends reported through QAPI.
5.Date of Compliance: December 15, 2021

483.25(k) REQUIREMENT Pain Management: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(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 clinical record review and resident and staff interview, it was determined that the facility failed to ensure the highest practicable pain management for one of five residents reviewed (Resident 99).

Findings include:

Interview of Resident 99 on October 19, 2021, at 11:45 AM revealed that she has pain in her legs every day. She stated that the staff give her pain medication. She also indicated that on a scale of 1-10, with 10 being the worst pain, she would rate her pain between and 6-7 most of the time.

Clinical record review for Resident 99 revealed physician orders for September and October 2021, dated May 3, 2021, that included acetaminophen (a mild pain reliever) 325 milligrams (mg) 2 tablets as needed every four hours for mild pain (a pain level of 1-3 on a pain scale of 1-10). She also had a physician's order for Oxycodone (a narcotic used to treat moderate to severe pain) 5 mg as needed for a pain level of 8-10.

Review of Resident 99's medication administration record (MAR) for September and October 2021, revealed that she received Oxycodone 5 mg 66 times, as follows:

September 29, 2021, at 11:22 PM for a pain level of 4
September 4, 2021, at 11:59 PM for a pain level of 7
September 5, 2021, at 12:00 AM for a pain level of 7
September 23, 2021, at 4:30 AM for a pain level of 7
October 2, 2021, at 10:24 PM for a pain level of 7
October 13, 2021, at 6:19 AM for a pain level of 7
October 16, 2021, at 1:50 AM for a pain level of 7

Resident 99's oxycodone order was only to be administered for pain levels of 8-10.

There was no documentation in Resident 99's clinical record to indicated that the facility notified her physician of her continued daily use of her as needed oxycodone for her leg pain.

Interview with Employee 5, Registered Nurse Unit Manager, on October 21, 2021, at 11:30 AM confirmed the above noted findings related to Resident 99's pain.

The Nursing Home Administrator and the Director of Nursing were made aware of the concerns with Resident 99's pain during a meeting on October 21, 2021, at 2:30 PM.

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


 Plan of Correction - To be completed: 12/15/2021

1.Resident #99's pain medication order has been clarified with appropriate parameters.
2.Current residents utilizing PRN pain medications in the past 14 days have been identified and reviewed to determine the appropriate prescribed pain parameters are in place and monitor the PRN usage.
3.Nursing staff will be educated on F-Tag 697, Pain Management by the DON/designee on or before the date of compliance.
4.Random audits of 5 residents will be conducted weekly x4 weeks and then monthly x 2 months to validate the resident is receiving the highest practicable pain management. Audits will be completed by the DON/Designee with trends reported through QAPI.
5.Date of Compliance: December 15, 2021

201.19 LICENSURE Personnel policies and procedures.:State only Deficiency.
Personnel records shall be kept current and available for each employe and contain sufficient information to support placement in the position to which assigned.
Observations:

Based on review of employee personnel records and staff interview, it was determined that the facility failed to ensure verification of health status for four of five personnel records sampled (Employees 3, 4, 5, and 6).

Findings include:

Review of Employee 3's, licensed practical nurse, personnel record revealed that the facility hired her on July 6, 2021.

Review of Employee 4's, dietary aide, personnel record revealed that the facility hired him on August 30, 2021.

Review of Employee 5's, registered nurse, personnel record revealed that the facility hired her on August 30, 2021.

Review of Employee 6's, nurse aide, personnel record revealed that the facility hired her on September 27, 2021.

There was no indication in these personnel records that the facility verified their health status before allowing them to assume job responsibilities.

Interview with the Nursing Home Administrator on October 21, 2021, at 2:30 PM confirmed that she was unable to provide verification of Employees 3, 4, 5, and 6's health status prior to working in the facility.


 Plan of Correction - To be completed: 12/15/2021

1.Employee #3, #4, #5, #6 will have their health status verified.
2.All current employees' files will be reviewed. Any missing health status verification will be completed.
3.HR staff will be educated on F-Tag 540, Personnel Policies and Procedure by the NHA/designee on or before the date of compliance.
4.Audits of new hires will be conducted weekly x4 weeks and then monthly x 2 months to validate all new hires have their health status verified. Audits will be completed by the NHA/Designee with trends reported through QAPI.
5.Date of Compliance: December 15, 2021


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