Pennsylvania Department of Health
TOWNE MANOR EAST
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

TOWNE MANOR EAST
Inspection Results For:

There are 169 surveys for this facility. Please select a date to view the survey results.

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TOWNE MANOR EAST - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to two complaints completed on July 30, 2024, it was determined that Towne Manor East 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 related to the health portion of the survey process.

Plan of Correction:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based on review of clinical records, staff and resident interviews, and review of facility documentation, it was determined that the facility failed to ensure that a resident was free of neglect resulting in actual harm to Resident R1 who fell out of bed, required transfer to the hospital via emergency medical services and sustained five sutures to the forehead for one of four resident reviewed. (Resident R1).

Findings include:

Review of Resident R1's clinical record revealed that the resident was admitted to the facility on April 25, 2024, with the diagnoses of cerebral infarction (stroke) affecting left sided weakness, deep vein thrombosis (blood clot), high blood pressure, lack of coordination, anxiety disorder, bipolar disorder (mental health condition marked by intense mood changes), morbidly obesity and weakness.

Review of Resident R1's admission Minimum Data Set (MDS-an assessment of resident's needs) dated May 2, 2024, indicated that the resident was cognitively intact. The resident was assessed with one sided upper and both sides lower body impairment. Continued review of the MDS revealed that the resident required substantial/maximum assistance to roll left and right. The resident was assessed as dependent (helper does all the effort) when lying to sitting on the side of the bed.

Review of Resident R1's care plan dated May 8, 2024 revealed that a care plan was developed due to the resident's left sided weakness and limited mobility. The resident's care plan inidcated that the resident required the total assistant of one staff member for personal hygiene, and dressing and the use a mechanical aid requiring two staff members for transfers.

Resident R1's nursing note dated July 12, 2024 revealed that the resident fell from his bed during care by staff (Nursing Assistant, Employee E3). The resident was observed laying on the floor and bleeding from his forehead. The resident was sent 911 (Emergency Medical Services) to the hospital for further evaluation. The resident received five sutures on his forehead.

Interview with Resident R1 on July 29, 2024, at 3:00 p.m. stated, "I fell out of my bed onto the floor when I was being washed. The aide just rolled me, and I had nothing to hold onto and fell. I got 5 stitches (pointing to his forehead) and cuts and bruising. My body is still sore and I have had headaches ever since my fall.

During an interview on July 30, 2024, at 4:00 p.m. with Nurse aide, Employee E3 confirmed that while providing Resident R1 with morning care, she went to roll him onto his side to wash him, and he rolled off the bed, adding that the bed was also in the highest position. The NA stated she was re-educated and in-serviced because of the way she rolled him. The NA explained, "I rolled Resident R1 away from me, not towards me, like I was taught to do."

Interview with the Director of Nursing and the Assistant Director of Nursing confirmed Nurse aide, Employee E3 was re-educated for using the incorrect technique while giving care to Resident R1.

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

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

Plan of Correction - To be completed: 08/30/2024

1.Resident R1 was immediately sent to the emergency room for further evaluation after falling out of bed and receiving five sutures to his forehead. Employee E3 was immediately re-educated and showed return demonstration on rolling resident R1 properly in bed.
2.An initial audit was conducted by the DON/designee for all staff who cared for residents to confirm if they were properly positioning residents while in bed during care.
3.Re-education will be provided to nursing staff on appropriate turning and repositioning of residents in bed.
4.DON/ADON/Educator will conduct weekly audits x 4 weeks, on 7 residents, then monthly x 2 months, then quarterly for 2 quarters to assure that staff have completed education and competency related to turning and repositioning patients. The results of the audit will be presented to the Quality Assurance committee monthly for review and further evaluation. The date of compliance will be August 30, 2024.

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

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

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

Observations:

Based on review of clinical records, resident and staff interviews, and review of facility documentation, it was determined that the facility failed to ensure that Resident R1 received adequate assistance during bed mobility which resulted in actual harm to Resident R1 who fell out of bed, required transfer to the hospital via emergency medical services and sustained five sutures on the forehead. (Resident R1)

Findings include:

Review of Resident R1's clinical record revealed that the resident was admitted to the facility on April 25, 2024, with the diagnoses of cerebral infarction (stroke) affecting left sided weakness, deep vein thrombosis (blood clot), high blood pressure, lack of coordination, anxiety disorder, bipolar disorder (mental health condition marked by intense mood changes), morbidly obesity and weakness.

Review of Resident R1's admission Minimum Data Set (MDS-an assessment of resident's needs) dated May 2, 2024, indicated that the resident was cognitively intact. The resident was assessed with one sided upper and both sides lower body impairment. Continued review of the MDS revealed that the resident required substantial/maximum assistance to roll left and right. The resident was assessed as dependent (helper does all the effort) when lying to sitting on the side of the bed.

Review of Resident R1's care plan dated May 8, 2024 revealed that a care plan was developed related to activities of daily living (adl)/self care, performance deficient due to hemiplegia and limited mobility. An intervention developed on May 23, 2024, stated that the resident needed pair care and assist of 2 people for all care related to bed mobility.

Resident R1's nursing note dated July 12, 2024, revealed that the resident fell from his bed during care by staff (Nursing assistant, Employee E3). The resident was observed laying on the floor and bleeding from his forehead. The resident was sent 911 (Emergency Medical Services) to the hospital for further evaluation. The resident received five sutures on his forehead.

Interview with Resident R1 on July 29, 2024, at 3:00 p.m. stated, "I fell out of my bed onto the floor when I was being washed. The aide just rolled me, and I had nothing to hold onto and fell. I got 5 stitches (pointing to his forehead) and cuts and bruising. My body is still sore and I have had headaches ever since my fall.

During an interview on July 30, 2024, at 4:00 p.m. with Nurse aide, Employee E3 confirmed that while providing Resident R1 with morning care, she went to roll him onto his side to wash him, and he rolled off the bed, adding that the bed was also in the highest position.

The facility failed to ensure that Resident R1 was assisted by two staff members during adl care which resulted in actual harm to Resident R1 who fell out of bed and sustained a laceration on the forehead requiring five sutures.

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

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

Plan of Correction - To be completed: 08/30/2024

1.Resident R1 has been added to the list of residents who require paired care and placed in the assignment book for each shift to refer on each unit.
2.An initial audit was done by the DON to confirm which residents needed to be on "Pair care" and that their Kardex and comprehensive plan of care was updated.
3.Nursing staff were re-educated on the importance of reviewing a resident Kardex and following the plan of care as it relates to "Pair care".
4.DON/designee will conduct weekly audits x 4 weeks on 6 residents, then monthly x 2 months, then quarterly for two quarters to assure that residents who require paired care are being implemented by nursing staff. The results of the audit will be presented to the Quality Assurance committee monthly for review and further evaluation. The date of compliance will be August 30, 2024.

483.10(j)(1)-(4) REQUIREMENT Grievances:

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(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

Observations:

Based on interviews with resident and staff, review of facility policy and grievances, it was determined that the facility failed to make prompt efforts to resolve resident's grievances for one of four resident records reviewed (Resident R2).

Findings include:

Review of the facility's policy titled, Grievance/Concern Management, effective February 2021 states, "The residents have a right to present concerns, recommend changes in policies and services. These rights include the right to prompt efforts by the facility to resolve residents' concerns. The same policy states that the Nursing Home Administrator (NHA) is responsible for oversight of the concern process. In addition, the Social Services Director in collaboration with the NHA will be the Grievance Officer at the facility."

Review of Resident R2's clinical record revealed that the resident was admitted to the facility on October 28, 2019, with the diagnoses of Chronic Obstructive Pulmonary disease (respiratory disease), high blood pressure, and major depression (severe sadness).

Review of facility grievances/concern reports revealed on May 29, 2024, revealed that Resident R2 submitted a grievance regarding a missing pair of dark brown boots and a pair of brown pumps.

On May 31, 2024 the facility followed up stating the articles were not found on Resident R2's inventory sheet and the resident was made aware.

An interview was conducted with the Nursing Home Administrator (NHA) and the Grievance Officer on July 29, 2024. The grievance officer (GO) stated two weeks ago she received receipts of the two pairs of shoes and the receipts have been sitting on the GO's desk. Review of these receipts revealed both shoes were purchased online in 2021 and both purchases were mailed to the facility's address. The NHA then stated I told Resident R2 "I needed the money in the petty cash to reimburse her and I don't have the money to pay her."

28 Pa. Code 201.14 (a) Responsibility of licensee

28 Pa. Code 201.29 (a) Resident Rights

Plan of Correction - To be completed: 08/30/2024

1.Resident R2 grievance from May 29, 2024, regarding missing a pair of dark brown boots and a pair of brown pumps with a dollar value of $95 was immediately reimbursed to the resident on July 30, 2024.
2.An initial audit was conducted by the NHA/designee on all residents who filed a grievance within the last 90 days.
3.Re-education will be provided to the Nursing Home administrator (NHA) and Grievance Officer regarding the facility policy grievances/concerns being resolved promptly/timely.
4.NHA/ designee will conduct weekly audits x 4 weeks on 6 residents who filed grievances, then monthly x2 months, then quarterly for 2 quarters to assure that grievances/concerns have been reviewed and resolved per facility policy. The results of the audit will be presented to the Quality Assurance Committee Meeting monthly for review. The date of anticipated compliance will be August 30, 2024.

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:

Based on review of clinical records and interview with staff, it was determined that the facility failed to report a serious injury sustained by a resident for one of four clinical records reviewed (Resident R1).

Findings include:

Review of Resident R1's clinical record revealed that the resident was admitted to the facility on April 25, 2024, with the diagnoses of cerebral infarction (stroke) affecting left sided weakness.

Review of Resident R1's admission Minimum Data Set (MDS-an assessment of resident's needs) dated May 2, 2024, assessed the resident with one sided upper and both sides lower body impairment. Continued review of the MDS revealed that the resident required substantial/maximum assistance to roll left and right. The resident was assessed as dependent (helper does all the effort) when lying to sitting on the side of the bed.

Resident R1's nursing note dated July 12, 2024, revealed that the resident fell from his bed, placed in the highest position during care by staff (Nursing Assistant, (NA) Employee E3). The resident was observed laying on the floor and bleeding from his forehead. The resident was sent 911 (Emergency Medical Services) to the hospital for further evaluation and received five sutures on his forehead.

During an interview on July 30, 2024, at 4:00 p.m. with NA, Employee E3 stated that while providing Resident R1 with morning care, with bed at the highest position, she went to roll him onto his side to wash him, and he rolled off the bed. The NA explained, "I rolled Resident R1 away from me, not towards me, like I was taught to do."

Interview with the Nursing Home Administrator on July 29, 2024, confirmed the facility failed to report this violations of neglect and report the results of this investigation to the State Survey Agency within prescribed time frame.

28 Pa. Code 201.14(a) Responsibility of licensee

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

Plan of Correction - To be completed: 08/30/2024

F0609 Reporting of Alleged Violation
1.Resident R1 fell from his bed on July 12, 2024, resulting in injury to his head, Survey Agency came out on 07/29/24 to investigate this fall and was provided all necessary documents and investigation for fall by the NHA.

2.An initial Audit will be conducted by the NHA to assure that residents who have had a potential for neglect within the last 30 days have been reported to the Department of Health.
3.Re-education will be provided to the NHA by the VP of operations / Designee to ensure that violation of potential neglect is reported to the State Survey Agency timely.

4.NHA/Designee will conduct weekly audits x 4 weeks on 4 residents, then monthly x 2 months, then quarterly for 2 quarters to assure that staff have completed education and competency related to turning and repositioning patients. The results of the audit will be presented to the Quality Assurance committee monthly for review and further evaluation. The date of compliance will be August 30, 2024.

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

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

Observations:

Based on a review of clinical records, and interviews with staff, it was determined that the facility failed to develop and implement comprehensive person-centered plans of care in a timely manner for one of four resident records reviewed (Resident R1).

Findings include:

Review of Resident R1's clinical record revealed that the resident was admitted to the facility on April 25, 2024, with the diagnoses of cerebral infarction (stroke) affecting left sided weakness, deep vein thrombosis (blood clot), high blood pressure, lack of coordination, anxiety disorder, bipolar ( mental health condition marked by intense mood changes), morbidly obese and weakness.

Review of Resident R1's admission MDS (an assessment of resident's needs) dated May 2, 2024, indicated the resident was cognitively intact. The resident was assessed with one sided upper and both sides lower body impairment. The reisdent needed substantial maximum assistant (helper does more than half the effort) of one staff member for toileting, showering/bathing, dressing and personal hygiene.

Review of Resident R1's care plan dated May 8, 2024 revealed that a care plan was developed related to activities of daily living (adl)/self care, performance deficient due to hemiplegia and limited mobility. An intervention developed on May 23, 2024, stated that the resident needed pair care and assist of 2 people for all care related to bed mobility

Interview on July 29, 2024, with the Therapy Director, Employee E4 stated at discharge we had placed an enabler bar on his bed in the short-term unit to assist and increase his independence with bed mobility. It was later determined the resident was to be placed in long term care. When the resident was moved to long-term care on the second floor the enabler bar should have been placed on the resident's bed.

This was confirmed with the Director of Nursing (DON) on July 29, 2024, at 2:30 p.m. that the facility failed to develop a plan of care, using an enabler as an intervention, to assist Resident R1 with bed mobility.

Further review of Resident R1's clinical record revealed on July 12, 2024 the resident fell from his bed during care by staff (Nursing assistant, Employee E3). The resident was observed laying on the floor and bleeding from his forehead. The resident was sent 911 (Emergency Medical Services) to the hospital for further evaluation. The resident received five sutures on his forehead.

On July 29, 2024 at 2:30 p.m. the DON confirmed the resident's plan of care for paired care was not implemented during the time of the fall.

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

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

Plan of Correction - To be completed: 08/30/2024

1.Resident R1 comprehensive person -center plan of care was updated to include an enabler bar on his bed to help increase his independence with bed mobility for long term care.
2.An initial audit was conducted on all residents who required an enabler by the DON to ensure that their plan of care was comprehensive person-center usage.
3.Nursing staff was re-educated by the DON/designee regarding updating the residents plan of care to make sure that it is comprehensive person-centered timely.
4.DON/designee will conduct random weekly audits x 4 weeks on 7 residents, then monthly x 2 , then quarterly for 2 quarters to assure that staff understands and can demonstrate turning and repositioning patients. The results of the audit will be presented to the Quality Assurance committee monthly for review and further evaluation. The date of compliance will be August 30, 2024.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§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 the observations, review of clinical records, facility policies, and interview with staff, it was determined that the facility failed to ensure that a resident received necessary equipment to aide with mobility for one of 4 residents reviewed. (Resident R1).

Findings include:

Review of Resident R1 clinical record revealed an admission date of April 25, 2024, diagnosed with a cerebral infarction (stroke) affecting left sided weakness, deep vein thrombosis (blood clot), high blood pressure, lack of coordination, anxiety disorder, bipolar ( mental health condition marked by intense mood changes), morbidly obese and weakness.

Review of Resident R1 Admission MDS (an assessment of resident's needs) dated May 2, 2024, indicated the resident was cognitively intact, one sided upper and both sides lower, body impairment, and needed substantial maximum assistant (helper does more than half the effort) of one staff member for toileting, showering/bathing, dressing and personal hygiene.

Review of Resident R1's clinical record revealed a plan of care was developed due to the residents left sided weakness and limited mobility requiring total assistants for personal hygiene, dressing and used a mechanical aid requiring two staff members for transfers, created May 2024.

Interview on July 29, 2024, with the Therapy Director, Employee E4 stated at discharge we had placed an enabler bar on his bed in the short-term unit to assist and increase his independence with bed mobility. It was later determined the resident was to be placed in long term care. When the resident was moved to long-term care on the second floor the enabler bar should have been placed on the resident's bed.

This was confirmed with the Director of Nursing on July 29, 2024, at 2:30 p.m. the enabler was not placed on Resident R1's bed to assist with bed mobility.

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

28 Pa. Code: 201.18 (b)(2) Management

Plan of Correction - To be completed: 08/30/2024

1.Resident R1 was provided the enabler (necessary equipment) to his bed on July 30, 2024, to help increase his independence and aid with bed mobility.
2.An initial audit was conducted on all residents who required an enabler by the DON/Therapy Director to ensure that the resident received the necessary equipment.
3.Nursing staff were re-educated on the usage of ensuring that an enabler is being used by the resident when needed.

4.DON/designee will conduct weekly audits x 4 weeks on 6 residents, then monthly x 2 months, then quarterly for 2 quarters to assure that residents who require necessary equipment of an enabler to aide with mobility have been implemented. The results of the audit will be presented to the Quality Assurance committee monthly for review and further evaluation. The date of compliance will be August 30, 2024.

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