Pennsylvania Department of Health
 AVENTURA AT TERRACE VIEW
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
AVENTURA AT TERRACE VIEW
Inspection Results For:

There are  182 surveys for this facility. Please select a date to view the survey results.

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AVENTURA AT TERRACE VIEW - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Abbreviated Complaint Survey and Civil Rights Compliance Survey completed on June 14, 2024, it was determined that Aventura at Terrace View 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:


483.12(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 observation, a review of clinical records and facility documentation and staff interviews, it was determined that the facility failed to ensure that one resident (Resident 35) was free from physical abuse, which resulted in a rib fracture and failed to implement sufficient measures necessary to protect residents from abusive behavior perpetrated by one resident (Resident 72) out of 33 sampled residents.

Findings include:

Review of Resident 72's clinical record revealed admission to the facility on September 16, 2021, with diagnoses, which included Alzheimer's disease, anxiety, and major depression. The resident was significantly cognitively impaired with a BIMS (Brief Interview for Mental Status a tool to assess cognitive function) score of 3.

Review of Resident 72's care plan, initiated September 16, 2021, identified that the resident has the potential to wander with a goal for the resident to be safe in his environment, resident will not leave secured unit without staff/family, and resident will not leave building without escort x 90 days. Planned interventions directed that staff be aware of the resident's tendency to wander, apply code alert bracelet, attempt to redirect wandering behavior by initiating conversation with resident, ensure safe environment which enables free movement around unit, if wandering must place in close supervision until behavior de-escalates, involve resident in exercise program to help with excess energy, take on walks whenever possible, observe behavior and redirect to activity of choice/interest when wandering, last revised on May 3, 2024.

The resident care plan, initiated June 19, 2023, also identified that the resident has potential to exhibit verbal/physical aggression toward others and that the resident had a physical altercation with another resident on June 19, 2023. Identified goal for the resident is that resident will not exhibit any physical aggression toward others x 90 days. Planned interventions included that if exhibiting agitation/frustration then keep distant from others until calm, keep distance from residents who are exhibiting agitation or behavioral changes, maintain safe environment, and psych consult as needed, last revised June 19, 2023.

A review of Resident 35's clinical record revealed admission to the facility on November 30, 2023, with diagnoses which included dementia. Review of resident care plan, dated March 12, 2024, identified that the resident has the potential to wander and was an elopement risk with a goal for the resident to not leave the building without escort, resident will be safe in his environment, and resident will not leave secured unit without staff/family member. Planned interventions were to ensure safe environment which enables free movement around unit, all staff be aware of resident's tendency to wander, apply code alert bracelet, observe resident's whereabouts throughout the day, and observe behavior and redirect to activity of choice/interest when wandering, last revised June 13, 2024.

A review of documentation dated June 10, 2024, at 9:04 PM, indicated that the nurse heard a noise come from Resident 35's room. Upon entering, the nurse observed Resident 35 laying on the floor of his room between bed one and bed two. Resident 72 stated that Resident 35 "was trying to kill him." Resident 72 had to be escorted out of Resident 35's room and was placed on every 15-minute monitoring.

Review of an incident report dated June 10, 2024, at 8 PM revealed that Resident 35 told staff that Resident 72 had hit him "with a yellow book and it hurts." It was later determined that the Resident 72 hit Resident 35 with a plastic "wet floor" sign because he thought Resident 35 was going to "kill him."

A review of witness statement completed by Employee 2, nurse aide, dated June 10, 2024, at 8:30 PM revealed that she saw Resident 72 "holding the neck of Resident 35's gown. He pushed him down between bed 1 and bed 2. Resident 35 fell on the floor. When asked why he did that, Resident 72 told Employee 2 "he \ was trying to kill me."

Review of documentation dated June 10, 2024, at 10:37 PM indicated that Resident 35 was assisted to bed after altercation with Resident 72 and that he had refused to be assessed for injuries by the nurse. Resident 35 then complained of pain later and an x-ray was ordered.

Results of x-ray received on June 11, 2024, identified that Resident 35 had sustained a "fracture involving the lateral portion of the left 3rd rib with minimal displacement" as a result of Resident 72's physical altercation.

Observation of Resident 35 on June 13, 2024, at approximately 9:15 AM revealed that the resident was seated in a stationary chair in the hallway outside of his room. When interviewed, the resident stated that he "felt sore" when asked how he was feeling, then got up out of chair and walked into his room.

Observations of Resident 72 on June 11, 2024, at approximately 12:40PM revealed that the resident was wandering unsupervised in the halls, testing each exit door for a means of egress.

Observations of Resident 72 on June 13, 2024, at approximately 10AM again found Resident 72 wandering unsupervised in the halls, searching for an exit.

Interview with the Nursing Home Administrator and Director of Nursing on June 14, 2024, at 3 PM failed to provide evidence that the facility had implemented effective measures to prevent Resident 72, a resident with known wandering and physically and verbally abusive behavioral symptoms, from physically abusing Resident 35, which resulted in serious physical injury to Resident 35.


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

28 Pa. Code 201.29 (a) Resident Rights

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




















 Plan of Correction - To be completed: 07/28/2024

IDT to review care plan and interventions to ensure proper interventions are in place to prevent verbal and physical abuse on #72and #35.
Resident's with known wandering and physically/verbally abusive behavior symptoms; care plans will be reviewed for appropriate interventions by IDT by 7/28/24.
Social services or designee will educate staff on abuse policy and procedure by 7/28/24. Staff to complete CMS hand in hand series for nursing homes and abuse prevention in persons with dementia by 7/28/24.
DON or designee will audit 4 residents 4x a week for 4 weeks for effectiveness of interventions for physical/verbal and wandering interventions.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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.
§483.25(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 a review of clinical records and select investigation reports and staff and resident interviews, it was determined that the facility failed to provide timely and necessary supervision, and effective safety measures for a resident with known unsafe behaviors and unwitnessed falls, to prevent a fall with multiple serious injuries, shoulder and rib fractures, and a subdural hematoma, for one resident out of 33 sampled residents (Resident 121).


Findings include:

Clinical record review revealed that Resident 121 was admitted to the facility on February 16, 2024, with diagnoses of adult failure to thrive, chronic kidney disease and a history of falls.

An admission MDS (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 19, 2024, revealed that the resident was moderately cognitively impaired with a BIMS score of 9 ( a score of 8 to 12 indicates moderate cognitive impairment). The resident required staff assistance with activities of daily living and utilized a walker and wheelchair for mobility and ambulation.

A review of a current care plan initiated February 16, 2024, for at risk for falls related to the diagnosis of "at risk for falls", weakness and impaired mobility, with the noted goal of having no fall related injuries in the next 90 days. Interventions were the use of a chair seating equipment as ordered, encourage frequent rest periods, call bell in reach and answer promptly, proper fitting footwear and clothing, safety interventions as per physician order and transfer/ambulation as ordered.

A review of nursing documentation and a facility investigation report dated March 7, 2024, at 8:57 PM revealed that staff found the resident on the floor of his room. Prior to the fall, the resident had been seated in a wheelchair, and was attempting to throw garbage away and slipped out of the wheelchair. The resident's roommate witnessed the fall. Resident 121 was receiving therapy services at the time of this fall. Planned interventions to prevent future falls included the addition of a dycem (non slip material placed on the seat of the wheelchair), placed on the seat of his wheelchair.

A review of nursing documentation and facility investigation revealed that on April 3, 2024, at 7:05 AM the resident again fell from his wheelchair. He had bent over in his chair, attempting to pick up a piece of paper. The planned intervention after this fall was to provide the resident with a reacher device.

A review of nursing documentation and facility investigation report dated May 3, 2024 at 11:15 PM Resident 121 was found on the floor near his bed. He stated "I was trying to get my hat that was on the wall." A review of a witness statement (no date or time indicated) from Employee 1, a nurse aide, stated that she last saw Resident 121 "about" 10:20 PM -10:30 PM" and the resident was sleeping in bed.

Staff found the resident at the change of shift, between the off-going 3 PM to 11 PM staff and the oncoming shift on 11 PM - 7 AM. There was no documented evidence to confirm the last time staff provided care to Resident 121, including toileting, on the 3 PM to 11 PM shift on May 3, 2024, only reference was Employee 1's statement that the resident was last seen sleeping in bed between 10:20 PM and 10:30 PM, approximately 45 minutes prior to being found on the floor.

The resident was assessed for any injuries. A small skin tear was noted to his left elbow measuring 2.2. cm x 1 cm. The resident was assisted back to bed. The area was cleaned and dressed. The MD and responsible party were notified. Neurological checks started. After this third fall, the facility initiated every 15 minutes checks of the resident.

A review of nursing documentation dated May 4, 2024, at 7:12 P.M. revealed Resident 121 complained of pain to his left shoulder and left arm. The physician was contacted and an order was received for a STAT (immediate) x-ray of the left forearm, left wrist and hand.
The x-rays were completed on May 5, 2024 at 10:24 A M.

A nurses note dated May 5, 2024, at 10:33 P.M. revealed that the results of the x-ray was that Resident 121, had sustained a left arm fracture of the acromion (shoulder). The physician was contacted and ordered an orthopedic consult.

A nurses note dated May 6, 2024, at 10:23 P.M., vital signs stable, neuro checks within normal limits post fall. He was out of bed most of the shift, but resting in bed at present. Medicated at 6 PM with Tylenol 650 mg for complaints of left shoulder pain with effect.

Nursing documentation dated May 7, 2024 at 10:01 A.M. revealed that the physician called the facility and gave a new order to send the resident to the local hospital for evaluation of the left shoulder due to the resident's continued complaints of pain.

On May 7, 2024 at 1:42 PM nursing called the hospital and was informed that Resident 121 was diagnosed with a left shoulder fracture, second and third rib fractures and a left side subdural hematoma. The resident was being transferred to a different hospital as a trauma alert.

A review of hospital documentation dated May 7, 2024 at 2:45 PM revealed that the resident had a history of Left Shoulder Pain and admitted to trauma with orthopedic surgery input for left scapula abnormality. A arm sling was provided to the resident. The hospital documentation indicated that the resident was involved in unwitnessed fall at a nursing home and presents with a chief complaint of left shoulder pain. Patient fell at his nursing last night and was sent to a different hospital for evaluation. \ Reports falling backwards and striking his head. Upon further workup at the initial hospital, he was found to have a Subdural Dural Hematoma and multiple left side rib fractures so transfer to the hospital with a trauma center was arranged.

Hospital documentation dated May 7, 2024, revealed Resident 121's clinical testing and results of stable thin bilateral subdural hematomas, comminuted slightly displaced fracture deformity of the anterior left scapula and into the coracoid process, fluid seen anterior to the left scapula which could represent hematoma, nondisplaced left anterolateral 2nd rib fracture, and
left lateral fourth, fifth and sixth rib fractures.

The resident was readmitted to the facility May 10, 2024.

During an interview June 13, 2024 at 12 P.M., Resident 121 stated that his shoulder still hurts and that the doctors could not do anything for him but have him wear the arm sling. An observation at the time of the interview revealed that he was wearing the sling incorrectly, as it was not positioned correctly to maintain supportive comfort and alignment. He stated that that was the way nursing had applied it that morning.

Resident 121 had a history of unwitnessed falls occurring in his room and increased supervision, every 15 minute checks of the resident, was not initiated until after the third fall with injuries. The facility failed to demonstrate the provision of necessary staff supervision, at the level and frequency required, and the timely implementation of safety measures to prevent this fall resulting in multiple serious injuries to the resident, which was confirmed during interview with the interim DON on June 13, 2024 at 2:30 P.M.


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




































 Plan of Correction - To be completed: 07/28/2024

Resident had no negative outcome.
IDT will Identify the like residents that have unwitnessed falls since 6/14/24 and will review for effective safety measures are in place and implemented by 7/28/24.
Physical therapy to provide education to staff about proper placement of slings by 7/28/24.
DON or designee will audit that effective safety measures including timely supervision are in place and implemented and reviewed for effectiveness on 4 residents 4x week for 4 weeks and results will be brought to QAPI.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.
§483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:

Based on observation and staff interview, it was determined that the facility failed to properly contain and dispose of garbage and provide a sanitary environment on the facility grounds.

Findings include:

Observation of the dietary department's receiving dock and cardboard receptacle on June 14, 2024, at 12:07 p.m., revealed one of two outside dumpsters, used for cardboard only, was overflowing with cardboard boxes.

The area surrounding the dietary dumpster was cluttered with a large broken cart and other maintenance equipment cluttering the refuse area.

Interview with the Nursing Home Administrator (NHA) on June 14, 2023, at 1:30 p.m., confirmed that the facility's dumpsters and surrounding areas should be maintained in a sanitary manner and garbage contained.


28 Pa. Code (e)(2.1) Management






 Plan of Correction - To be completed: 07/28/2024

No Residents had ill affects from this deficiency.

Dietary review of dumpster did not indicate further violations.

Maintenace Director or designee will educate staff ensuring breakdown of boxes and dumpsters are properly maintained.

Dietary Dept will audit dumpster 4X weekly X3 months.
483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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



Based on review of select facility policies, the facility's infection control tracking log and staff interview, it was determined that the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility.

Findings include:

A review of the facility's current infection control policy dated as reviewed by the facility February 2024, revealed that it is the policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

A review of the facility's infection control data provided at the time of the survey ending June 14, 2024, revealed that the facility's infection control program failed to reflect an operational system to monitor and investigate causes of infection and manner of spread. There was no evidence of a functional system, which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner.

A review of a facility form entitled " Outbreak Case-Patient Line List" dated March 2024 revealed 6 resident cases of influenza A and 2 cases of Influenza B; April 2024 revealed 2 cases of influenza B and 6 cases of RSV, and April 16, 2024 through May 2, 2024, 27 residents with GI symptoms. There was a notation on the April line listing of residents with respiratory symptoms which stated "3 cases of employee flu, confirmed and 1 symptomatic employee, not confirmed."

There was no documentation of any staff infections in the infection control logs.

A review of facility infection control logs for June 2024, as of June 14, 2024, revealed that the facility had not yet started tracking infections for the month of June as of the time of the survey.

Threw was no documentation of any staff or resident education provided after the upper respiratory or GI outbreaks in the facility noted on the line listings. There was no documentation of any evaluation or interventions designed to prevent the spread of the infections in response to the outbreaks of flu, RSV and GI illnesses that occurred.

There was also no documented evidence that the facility tracked and trended these infections to identify the potential need for intervention with staff and residents to deter similar infections.
There was no indication that the limited data that was compiled was then evaluated to determine what could be done to prevent the spread or recurrence of infection.

Interview with the Infection Preventionist on June 13, 2024, at 11 AM confirmed that the facility infection control tracking logs were incomplete and that the facility was unable to demonstrate a fully functioning comprehensive program to monitor and prevent infections.



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

28 Pa. Code 211.10(a)(d) Resident care policies




































































 Plan of Correction - To be completed: 07/28/2024

DON or designee will educate infection preventionist on maintaining and implementing a comprehensive program to monitor and prevent infections in the facility. Including monitoring, investigating and maintaining a system that logs the causes of infection and manner of spread. Trending the data frequently to provide staff education on mitigation. Tracking and trending staff infections, documenting and providing resident education in response to outbreaks and prevention. Line listing will be up to date from 6/14/24 to current for employees and residents by 7/28/24.
DON or designee will audit line listing will be audited on staff and residents weekly x4 weeks for tracking and trending.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.
Observations:

Based on a review of the facility's abuse prohibition policy and employee personnel files and staff interviews, it was determined that the facility failed to implement their established procedures for screening four of five employees for employment (Employee 2, 3, 4, and 5).

Findings include:

A review of the facility's Resident Abuse policy last reviewed by the facility February 2024, revealed procedures for screening potential employees that included obtaining references from current/previous employers.

Review of employee personnel files revealed that Employee 2 (Nurse Aide) was hired May 14, 2024. The employee's application indicated that she had previous employers. There was no indication that the facility obtained any references for this employee's previous employers.

Review of employee personnel files revealed that Employee 3 (Registered Nurse) was hired April 2, 2024. The employee's application indicated that she had previous employers. There was no indication that the facility obtained any references from the prior employers.

Review of employee personnel files revealed that Employee 4 (Activities Aide) was hired May 14, 2024. The employee's application indicated that she had previous employers. There was no indication that the facility obtained references from any prior employers.

Review of employee personnel files revealed that Employee 5 (LPN) was hired April 4, 2024. The employee's application indicated that she had previous employers. There was no indication that the facility obtained references for this employee from any prior employers.

Interview with the Administrator on January 11, 2024, at 12:15 p.m. the NHA verified that there was no evidence that previous employers were contacted for references according to the facility's Resident Abuse policy procedures for screening employees.


28 Pa. Code 201.19 (1)(9) Personnel records










 Plan of Correction - To be completed: 07/28/2024

Employee #2, #3, #4, #5 references checked per policy by HR director by 7/28/24.
Admin or designee to educate HR department on abuse policy by 7/28/24.
HR to audit all new hires weekly for proper reference checks.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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.
§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:

Based on observations, a review of clinical records, and resident and staff interviews, it was determined that the facility failed to ensure that a resident's individualized dementia care needs are consistently met and that the facility assessed, developed, and implemented interdisciplinary care planned approaches and provided resources necessary for management of dementia related behaviors on one of two secured dementia care units (C1 Unit).

Findings include:

Interview with Employee 10, registered nurse/unit manager, on June 11, 2024, at approximately 12:40 PM revealed that the determination for residents to reside on the facility designated male dementia unit is based on cognitive status and/or behaviors. According to Employee 10, behaviors include those of a sexual nature. Employee 10 stated the staff providing care and services to residents on the C1 unit were not provided, and do not possess any additional training related to providing care and services male residents with dementia related behaviors which included verbal and physical aggression toward others and sexual behaviors.

Review of Resident 72's clinical record revealed admission to the facility on September 16, 2021, with diagnoses which included Alzheimer's disease, anxiety, and major depression and was significantly cognitively impaired with a BIMS score of 3.

Resident 72's care plan, dated September 17, 2021, identified that the resident has potential to exhibit distressed mood and behavioral symptoms as evidenced by tearfulness, territorial, anxiety, resistance to care, swearing and swinging at staff, agitated and uncooperative, pacing related to major depressive disorder and anxiety. Identified goals for the resident are to become more accepting of care, speech/questions and swearing and swinging at staff will decrease x 90 days, and the resident's agitation and uncooperativeness will decrease x 90 days (August 28, 2024). Planned interventions are to explain all routines and procedures to decrease potential tearfulness and anxiety as evidenced by repetitive speech/questions, swearing and resistance to care, if exhibiting behaviors then initiate conversation with him about his supportive wife, and children and his past occupation as housekeeper, encourage activities of choice/interest, and approach in a calm and unhurried manner.

The resident care plan, initiated June 19, 2023, also identified that the resident has potential to exhibit verbal/physical aggression toward other and that the resident had a physical altercation with another resident on June 19, 2023. Identified goal for the resident is that resident will not exhibit any physical aggression toward others x 90 days. Planned interventions included that if exhibiting agitation/frustration then keep distant from others until calm, keep distance from residents who are exhibiting agitation or behavioral changes, maintain safe environment, and psych consult as needed, last revised June 19, 2023.


A review of documentation dated June 10, 2024, at 9:04 PM, indicated the nurse heard a noise come from another resident's room. Upon entering, the nurse noticed Resident 35 laying on the floor of his room between bed one and bed two. Resident 72 stated that Resident 35 "was trying to kill him." Resident 72 had to be escorted out Resident 35's room and was placed on every 15-minute monitoring.

Review of documentation dated June 10, 2024, at 10:37 PM indicated that Resident 35 was assisted to bed after altercation with Resident 72 and that he had refused to be assessed for injuries by the nurse. Resident 35 then complained of pain and an x-ray was ordered.

Review of incident report dated June 10, 2024, at 8 PM revealed that Resident 35 told staff that Resident 72 had hit him "with a yellow book and it hurts." It was later determined that the Resident 72 had hit Resident 35 with a plastic "wet floor" sign because he thought Resident 35 was going to "kill him."

Observations of Resident 72 on June 11, 2024, at approximately 12:40PM found the resident wandering unsupervised in the halls, testing each exit door for a means of egress.

Observations of Resident 72 on June 13, 2024, at approximately 10AM again found Resident 72 wandering unsupervised in the halls, searching for an exit.

There was no indication that the facility had reviewed the effectiveness of the interventions planned to address the resident's dementia related behavioral symptoms and modified and revised the approaches that staff were to employ in response to the resident's dementia related behaviors, including intrusive wandering, and/or physical aggression, in an attempt to manage or modify the resident's behavioral symptoms, which was confirmed during interview with DON on June 13, 2024, at approximately 11:51 AM.

The Nursing Administrator confirmed during an interview on June 14, 2024, at approximately 2:30 PM that there was no additional training provided to the staff assigned to the C1 male dementia unit related to dementia related physically aggressive behaviors.

Refer F600 & F679

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





 Plan of Correction - To be completed: 07/28/2024

C1 residents will have interventions reviewed by IDT for effectiveness related to appropriate dementia related behavioral interventions by modifying and revising staff approaches in relation to dementia carev by 7/28/24.
DON or designee will educate staff on quality of care policy and procedure, CMS hand in hand series for nursing homes and abuse prevention in persons with dementia, challenging behaviors, behaviors/medications/interventions, comprehensive view of dementia, comprehensive view of Alzheimer's disease by 7/28/24.
DON or designee will visualize 4 random interventions 4x a week for 4 weeks on C1 noting staff member, behavior, intervention and effectiveness.

483.30(c)(1)-(4) REQUIREMENT Physician Visits-Frequency/Timeliness/Alt NPP: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.
§483.30(c) Frequency of physician visits
§483.30(c)(1) The residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter.

§483.30(c)(2) A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required.

§483.30(c)(3) Except as provided in paragraphs (c)(4) and (f) of this section, all required physician visits must be made by the physician personally.

§483.30(c)(4) At the option of the physician, required visits in SNFs, after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist in accordance with paragraph (e) of this section.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure timely physician visits for three of 33 sampled residents (Residents 117, 72, and 35).

Findings included:

A review of Resident 117's clinical record revealed admission to the facility on August 4, 2023. A review of physician's progress notes, conducted during the survey of June 14, 2024, indicated that the resident had not been seen by his attending physician in the last 6 months.

There was no documented evidence that Resident 117 was seen by a physician at least once at least once every 60 days.

Further review of Resident 117's clinical record revealed that on June 11, 2024, the resident's representative requested a change in the resident's attending physician which was granted.

A review of Resident 35's clinical record revealed admission to the facility on November 30, 2023. A review of physician's progress notes, conducted during the survey of June 14, 2024, indicated that the resident had not been seen by is attending physician in the last 6 months.

A review of Resident 72's clinical record revealed admission to the facility on September 16, 2021.

A review of physician's progress notes, conducted during the survey of June 14, 2024, indicated that the resident had not been seen by is attending physician in the last 6 months.

Interview with the Nursing Home Administrator on June 14, 2024, at approximately 1:00 p.m. confirmed that there was no evidence in the resident's clinical record that the physician had visited the above residents as required, and that it had been more than six months since the resident had been seen by the physician according to the clinical record.



28 Pa Code 211.2 (d)(3)(8) Medical Director



 Plan of Correction - To be completed: 07/28/2024

Residents 117, 72 and 35 had no negative outcomes, physician notified and physician will visit 117,72 and 35 by 7/28/24.

Other Residents charts will be reviewed by medical Records to ensure no visits were Missed.

DON or Designee will educate physicians of timely physician's visits.

Medical Records will audit 6 charts w week X 3 months.
483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on a review of clinical records, select facility policy and investigative reports and staff interviews it was determined that the facility failed to assess and implement individualized measures to meet the toileting needs of two residents out of four sampled with a decline in continence (Residents 119 and 129).

Findings included:

A review of a facility policy entitled "Urinary Incontinence - Clinical Protocol" that was last reviewed by the facility February 2024, indicated that for incontinent individuals that the nursing staff would identify and document circumstances related to the incontinence. As appropriate, based on assessment of the category and cause of incontinence, the staff would provide a scheduled toileting, prompted toileting, or other intervention to try to improve the individual's continence status.

A review of Resident 119's clinical revealed that the resident was admitted to the facility on August 18, 2023, with diagnoses that included cervical cancer [is a tumor that occurs in cervix, the lower part of the uterus] and hemiplegia (refers to the severe or complete loss of motor function on one side of the body) and hemiparesis [is one-sided muscle weakness that happens because of disruptions in the brain, spinal cord or the nerves that connect to the affected muscles] post cerebral infarction [also known as an ischemic stroke, is the pathologic process that results in an area of necrotic tissue in the brain (cerebral infarct)] impacting right dominant side.

A review of Resident 119's quarterly Minimum Data Set (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated April 18, 2024, indicated that the resident cognitively intact impaired with a BIMS (brief interview for mental status - a tool to assess cognitive status) of 13 and was occasionally incontinent of bladder and always continent of bowel and was not on a bladder or bowel retraining program. A significant change assessment dated May 2, 2024, indicated that Resident 119 was now always incontinent of urine and always incontinent of bowel and was not on a toileting program.

Resident 119 had a decline in bladder and bowel continence from the quarterly MDS completed on April 18, 2024, and the significant change MDS completed on May 2, 2024.

The "Schedule of Toileting" form dated May 1, 2024, through May 31, 2024, revealed that a check and change every two-hours would be implemented for the resident.

A review of a nursing progress note completed by Employee 7, Nursing Unit Manager, dated May 31, 2024, at 5:15 p.m., revealed that Resident 119's toileting schedule was evaluated and that the resident was primarily incontinent, and would be removed from a toileting schedule and placed on every two-hour check and change.

However, at the time of the survey ending June 14, 2024, the facility unable to provide evidence that every two-hour check and change program was implemented for this resident as the intervention to address the resident's decline in bowel and bladder continency.

During an interview with the Director of Nursing (DON) on June 13, 2024, at 10:45 a.m., confirmed that the facility was unable to provide evidence of the implementation of an every two-hour check and change program due to decline in bladder and bowel incontinence.

A review of Resident 129's clinical record revealed that the resident was admitted to the facility on February 16, 2024, with diagnoses that included Alzheimer's dementia and UTI (urinary tract infection).

A review of Resident 129's 5-day MDS assessment dated February 23, 2024, indicated that had sever cognitive impairment with a BIMS of 2 and was frequently incontinent of bladder and frequently incontinent of bowel and was not on a bladder or bowel retraining program.

Resident 129's clinical record failed to reveal that the facility evaluated the resident for appropriateness of a bladder and bowel retraining program or continence check and changes to prevent incontinence related conditions.

The resident was admitted to the hospital on April 10, 2024, due to a UTI and was readmitted to the facility on April 12, 2024, with antibiotic treatment for UTI.

A quarterly MDS assessment dated April 19, 2024, revealed that Resident 129 was always incontinent of bladder and always incontinent of bowel, which was a decline from the February 23, 2023, MDS assessment.

A review of Resident 129's "Bowel/Bladder Pattern Assessment" dated as completed April 13, 2024, through April 15, 2024, indicated that the resident required a check and change every two-hours.

Resident 129's clinical record failed to reveal documented evidence that check and change every two-hour was implemented.

During an interview with the Director of Nursing (DON) on June 13, 2024, at 10:47 a.m., confirmed that the facility was unable to provide documented evidence that every two-hour check and change program was implemented.


28 Pa. Code 211.10 (a)(c)(d) Resident care policies

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




 Plan of Correction - To be completed: 07/28/2024

Resident 119 and 129 ,IDT will review and verify proper interventions related to incontinence care and validate they are in place and being followed.

IDT will Identify the like residents that are incontinent since 6/14/24 to verify proper interventions related to incontinence care are in place and being followed.
DON or designee will educate nursing staff on check and change policy by 7/28/24.
DON or designee will audit check and change program on 4 residents 4x week for 4 weeks.

483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident: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.
§483.24(c) Activities.
§483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
Observations:

Based on a review of the facility's activities programming and clinical records and resident and staff interviews, it was determined that the facility failed to provide an ongoing program of activities designed to meet the needs, interests, preferences, and functional abilities of at least two residents out of 24 residents residing on the C1 male locked dementia unit (Residents 117, and 61).

Findings include:

A review of the facility census at the time of survey ending June 14, 2024, revealed a census of 134 residents. Review of the facility census of residents residing on the designated dementia units indicated that 71 residents required designated dementia care activities on secured dementia care units; 24 male residents on the facility designated male dementia unit and 47 female residents on the facility designated female dementia unit.

Interview with Employee 10, registered nurse/unit manager, on June 11, 2024, at approximately 12:40 PM revealed that the determination for residents to reside on the facility designated male dementia unit is based on cognitive status and/or behaviors, which include those behaviors of a sexual nature. Employee 10 stated that the staff providing care and services to residents on the C1 unit did not have any additional training related to providing care and services to the male residents with cognitive deficits and/or behaviors, which included verbal and physical aggression toward others and sexual behaviors.

Interview with the Nursing Home Administrator and Director of Nursing on June 11, 2024, at 2:15 PM indicated that the criteria for placement on the the facility designated male locked dementia unit (C1) is no different than a standard dementia care unit. According to both the NHA and DON, the care and services required and/or provided on the C1 unit is no different than what is provided on the facility designated female dementia unit (D Unit).

Observation of the posted Activity Posting for activities scheduled for June 11, 2024, revealed that there were activities scheduled specifically for the residents residing on the C1 male dementia unit. According to the posted schedule, at 10:15 AM on the C1 Unit there were pet visits scheduled, and at 6:30 PM an "evening busy room" was planned.

Interview with facility staff on June 11, 2024, who requested anonymity, stated that "evening busy room" activities usually consisted of word puzzles for the residents to do if they chose.

A review of Resident 117's clinical record revealed that the resident was admitted to the facility on August 4, 2023, with diagnoses of Alzheimer's disease, anxiety, and hypertension, and was significantly cognitively impaired with a BIMS [Brief Interview of Mental Status-a tool to assess cognitive function] score of 5 (a score of 0-7 indicates severe cognitive impairment). The resident resided on the male locked dementia unit.

Review of Resident 117's Individual Activity log dated May 2024, revealed that the resident participated in one-to-one visits, one-to-one discussion/reminiscence, mail delivery, spiritual visit, self-propelling/independent mobility, and pet visits on 11 of the 31 days in the month. The Individual Activity Log revealed that May 11, 2024, was the only day that the resident was provided/offered more than one activity during the day/evening.

A review of Resident 61's clinical record revealed that the resident was admitted to the facility on August 24, 2022, with diagnoses of dementia with behavioral disturbances, heart disease, and skin cancer and was significantly cognitively impaired with a BIMS score of 3. The resident resided on the male dementia unit.

Review of Resident 61's Group Activity Log dated May 2024, revealed that the resident participated in group activities on 18 of the 31 days in the month, which consisted of men's/ladies group, trivia, games, movies, exercise club, social event/party, and bingo. All of which take place off the secured men's dementia unit during the 7 AM to 3 PM hours.

Review of Resident 61's Individual Activity Log dated May 2024, revealed that the resident participated in pet visits, one-to-one visits, and self-propelling/independent mobility on 8 of the 31 days available.

There was no evidence that the above residents were provided and/or offered evening activities on or off the secured men's dementia unit.

Review of the June 2024 Activity Calendar revealed that there were 21 days out of 30 with scheduled events for the C1 men's dementia unit, all of which were scheduled for the morning hours. Further review of the activity calendar revealed that 4 of the 21 days with designated activities for the C1 unit consisted of "Independent Leisure.
Observation of the C1 unit on June 14, 2024, revealed posted activities for the day. According to the posting, the residents on the C1 unit would have activities provided on the unit at 10AM, 2:30 PM, and again at 6:30PM which consisted of "Friday Night Freestyle and Cognitive Games."

Interview with the facility's Activity Director on June 14, 2024, at approximately 9:30AM revealed that the activities department did not have an adequate number of staff to provide specialized dementia care activities to both the male and female dementia care units. The Activity Director further stated that the intention was to provide appropriate activities to an all male dementia/behavioral unit, but the lack of activity staff prevents that type of specialized dementia activities programming on the locked male unit. The Activity Director further confirmed that there were little to no activities provided on the C1 unit during the evening hours. Only select residents residing on the locked dementia units leave the unit to attend activities programming off the locked units, according to the Activity's Director, but the Director was unable to state how those residents are selected.

The facility failed to develop and implement a program of meaningful activities to residents with dementia and failed to demonstrate the provision of engaging activities to decrease distress and agitation. The facility failed to develop individualized and customized activities based on the resident's previous lifestyle, occupation, family, hobbies, preferences and comfort.



28 Pa. Code 201.29 (a) Resident rights

28 Pa. Code 201.18 (e)(1)(2)(3)(6) Management




 Plan of Correction - To be completed: 07/28/2024

Residents had no negative outcome.

Resident clinical records will be audited for activities needed.

Activity Consultant or designee will educate activity staff new activity schedule and placement. New activity/Dining schedules have changed to have increased accommodations and decrease behavioral interaction.

NHA or designee will audit activity record for appropriate activity completion. Audits will include Resident interaction decrease. Report recommendations on 4 residents 4x a week for 4 weeks. to QAPI.
483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

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

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

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

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

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

Based on review of select facility policy, and resident and staff interviews, it was determined that the facility failed to provide an environment, which promotes each resident's quality of life by failing to accommodate a cognitively intact resident's smoking for one resident out of one sampled smoking residents (Resident 71).

Findings include:

A review of Resident 71's clinical record revealed admission to the facility on August 18, 2023, with diagnoses that included cerebral infarction [also known as an ischemic stroke, is the pathologic process that results in an area of necrotic tissue in the brain (cerebral infarct) and is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia)] affecting non-dominant side, traumatic subdural hemorrhage [an abnormal collection of blood under the dura mater] without loss of consciousness, and asthma [is a chronic respiratory condition which is caused by inflammation of the airway that causes narrowing of the airway with symptoms that include cough, shortness of breath and wheeze]. The resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). At the time of the survey ending June 14, 2024, the facility identified this resident as the only smoker at the facility.

A review of facility developed contract entitled "Tobacco Products and The Use of Vape Devices and e-Cigarettes" contract between the facility and signed by Resident 71 on August 29, 2023, indicated that the smoking contract governs the regulations for the use and possession of tobacco products in any form and the use of vapor devises or e-cigarettes at the facility. For residents deemed independent per smoking assessment, they will utilize the designated smoking location to use tobacco products in any form and use the use of vapor devices or e-cigarettes.

A review of a facility's smoking policy that was last reviewed by the facility February 2024, indicated that the facility was a smoke free and that resident's "grandfathered-in" may smoke outside in the designated smoking area outside of the building. The guidelines noted that the current smoking residents would be assessed quarterly by the MDS coordinator and reviewed by the interdisciplinary team to determine appropriate and safest manner to smoke. Residents deemed safe to smoke independently, would be supervised by staff during designated smoking times: 9:30 a.m., 1:00 p.m., 4:00 p.m., and 7:30 p.m. The assigned staff need only to provide minimal supervision, from a distance at the designated smoking area.

A review of a social services progress note dated March 26, 2024, at 6:55 p.m., revealed that social worker visited with the resident to discuss and review the facility's smoking policy. Capable resident expressed understanding of same.

A review of Resident 71's smoking safety screen completed March 28, 2024, at 2:39 p.m., revealed that the resident's score was one (1) noting that the resident was safe to smoke without supervision.

A social service progress notes dated April 3, 2024, at 4:19 p.m., revealed that the social worker met with Resident 71 on April 2, 2024, to discuss and educate the resident on facility smoking policy. Worker reviewed the entire smoking policy with resident and provided him with copy of same. Resident expressed understanding.

During an interview with Resident 71 on June 12, 2024, at 11:00 a.m., the resident stated that he was upset that the facility would only allow him to smoke with staff supervision and at designated times. He expressed that he didn't understand why he needed staff to "babysit" him while he smoked because he was cognitively intact. Resident 71 stated that he went outside to the designated smoking area ad lib (as he wished) and that now he had to smoke at the times set by the facility and that it wasn't his preference to go outside during at those times. The resident stated that he was a "night owl" and liked to stay up late and didn't like to get up and out of bed early to make the 9:30 a.m. facility smoke time. Additionally, Resident 71 stated that sometimes his lunch didn't arrive to his room until 1:00 p.m. and would miss the 1:30 p.m. set smoke time because he was still eating his lunch and currently wasn't smoking because of the restricted times. Resident 71 stated that he didn't understand why the facility would complete a safe smoking screen and deeming him safe to smoke without supervision, and then suddenly require staff to "observe him from a distance" during times convenient for staff and not him Resident 71 stated that he would like to smoke independently and at times that accommodated his preferences, as he once did.

An interview with the Nursing Home Administrator (NHA) on June 13, 2024, at 2:30 p.m., confirmed that Resident 71 was the facility's only smoker and that he could only go outside to smoke with staff supervision (from a distance) and only at the times established by the facility at 9:30 a.m., 1:00 p.m., 4:00 p.m., and 7:30 p.m. The NHA did not provide the reason or explanation for no longer permitting Resident 71 to smoke as per his preference and why he required staff supervision while smoking.


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

28 Pa. Code 201.29 (a) Resident Rights.






 Plan of Correction - To be completed: 07/28/2024

 Facility admin clarified and adjusted smoking policy. Facility policy is for supervised smoking only. Resident is found safe to smoke without direct assistance with smoking paraphernalia. Grandfathered smokers assessed by licensed or registered nurse by 7/28/24.
Education provided to resident #71 on clarified/updated smoking policy. Activity, social service and nursing staff will be educated about resident rights and clarified/updated smoking policy by administrator or designee by 7/28/24.
Admin or designee will audit by interviewing smoking residents (that are interviewable) to ensure resident rights and preferences are met 4 times a week.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).
Observations:

Based on a review of clinical records and staff interview, it was determined that the facility failed to notify the resident's interested representative of a change in condition which resulted in need for diagnostic testing for one out of 33 residents sampled (Resident 117).

Findings include:

A review of Resident 117's clinical record revealed that the resident was admitted to the facility on August 4, 2023, with diagnoses to include, Alzheimer's disease, anxiety, and hypertension.

Review of documentation dated May 1, 2024, at 12:43 PM indicated that Resident 117 complained of abdominal pain and the physician ordered an abdominal x-ray.

There was no documented evidence that the resident's interested representative was notified of the change in condition and need for diagnostic testing.




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

28 Pa. Code 201.29 (a) Resident rights





 Plan of Correction - To be completed: 07/28/2024

Nurse notified resident representative of need to obtain diagnostic studies and results by 7/28/24.
Current resident's documentation will be reviewed for proper notification of change of condition since 6/14/24. All interested representatives will be notified by 7/28/24. Other Residents chart will be reviewed to ensure family notification was complete.
Education to be provided to licensed and registered nurses by DON or designee on notification of change in condition that includes timely notification and documentation by 7/28/24.
DON or designee will audit 4 charts 4x a week for 4 weeks for proper notification of change of condition .

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain a clean, safe, and orderly environment in the resident dining room area on the C1 Unit.

Findings include:

During an observation of the C1 Unit resident dining room on June 13, 2024, at 11:55 a.m., a three-compartment dirty linen cart was observed along the left side of the wall in the dining area while residents were eating their lunch.

Observation also revealed that the dining area was was cluttered with activity equipment to include a large slot machine on a dining table, portable radio, and three yellow wet floor signs propped against the wall and partially obstructing a dining room entryway. Several dining chairs were positioned in dining area in a manner that made it difficult for residents in wheelchairs to maneuver around the room.

During an interview with the Nursing Home Administrator (NHA) on June 14, 2024, at 12:30 p.m., confirmed that all dining areas should be maintained in a safe, sanitary, and orderly manner.


28 Pa. Code 201.18 (e)(2.1) Management










 Plan of Correction - To be completed: 07/28/2024

No Residents had negative outcome.

Nursing staff will check Dining Rooms before all meals to ensure clutter free homelike environment.

Housekeeping staff will be educated on clutter free homelike environment by Maintenace Director or designee.

Housekeeping supervisor/Designee will audit common areas for homelike environment 5 times weekly X3 months.
483.12 REQUIREMENT Free from Misappropriation/Exploitation: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.
§483.12
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.
Observations:


Based on a review of clinical records, select facility policy and investigative reports and staff interview, it was determined that the facility failed to implement procedures to identify and prevent potential misappropriation of resident property, medications, for one resident out of 33 sampled (Resident 121).


Findings include:

The facility policy for Abuse Protection, reviewed by the facility February 2024 revealed, it is the policy of the facility that act of physical, verbal, psychological, and financial abuse directed against residents are absolutely prohibited. Each resident has the right to be free from verbal, sexual, physical, mental abuse and misappropriation of property.

A review of the clinical record revealed Resident 121 was admitted to the facility on February 1, 2023, with diagnoses of Multiple sclerosis ( a progressive neurological disease) and attention deficit hyperactivity disorder (ADHD is a neuro developmental disorder of childhood. It may last till adulthood in some cases. Persons will have trouble paying attention, controlling impulsive behaviors or be overly active).

The resident had a current physician order dated February 1, 2024, for Adderall ER, extended release (Adderall is central nervous system stimulant that affect chemicals in the brain and nerves that contribute to hyperactivity and impulse control) 20 mg by mouth every morning and Adderall ER 10 mg by mouth in the evening (5 P.M.).

A review of a controlled drug sign-out record revealed that the pharmacy dispensed 14 Adderall (amphetamine/Dextr) ER 20 to the facility on May 20, 2023, for administration to Resident 121 (once dispensed medications are the property of the resident). The medication card containing the 14 Adderall 20 mg caps as well as the controlled drug sign-out sheet went missing on May 29, 2024, at 10 AM.

A review of a facility investigation dated May 29, 2024, at 10 AM nursing staff notified facility administration that Resident 121's Adderall 20 mg capsules (14 caps) and the controlled drug sign out sheet were missing from the medication cart and an investigation was initiated.

A witness statement dated May 30, 2024, (no time indicated) from Employee 7 (LPN) revealed that the nurse stated "When I left work on Monday May 27, 2024, there were approximately 7-8 days supply (of the Adderall) left. I worked Monday May 27, 2024, until 11 PM (I worked a double shift). I passed the medication cart keys to Employee 8 (agency LPN). The med and card count were correct at that time. I was looking at the "controlled substance shift to shift count shift" when I noticed on the sheet, on the date May 27, 2024, I reviewed another resident's narcotic medication as well as the narcotic sign out sheet and marked the count as 23 cards of meds ( in the count, there was previously 22, one received and the count increased to 23). Someone changed the form, from 23 to 22. I know the signature to be Employee 8 (agency LPN). When I returned to work on Wednesday May 29, 2024, I was asked by a supervisor about the incident and that is when I noticed my "23" was written over with the "22."

A witness statement dated June 2, 2024 at 8:32 PM from Employee 8 (agency LPN) stated "I am writing in response to allegations of narcotic misconduct. I was made aware of the concerns through my nurse staff agency. I am concerned that I was initially only told that my do not return (the facility told the agency that this employee can no longer work at the facility) stemmed from a "violation of policy." Had I been told of this serious allegation, I would have immediately reported for the drug screen. I do acknowledge having pulled a medication in error while attempting to complete the assignment on time. I also recall leaving the floor after ringing the supervisors extension and simply writing a note "assistance needed" when this supervisor was not in the office at the time or readily available to me and leaving on the desk and not following up. While I am guilty of a violation of policy, I am not guilty of misconduct."

A review of a controlled substance shift to shift count sheet revealed that on May 27, 2024, 11 PM to 7 AM shift, Employee 7 (LPN) the off going 3 P.M. to 11 P.M. nurse signer and Employee 8 (agency LPN) the oncoming 11 P.M. to 7 A.M. nurse signer, the 23 was written over to appear as 22 cards of narcotic medication in the cart.

Resident 121 did not miss any doses of medication as the resident was on Adderall 10 mg by mouth at 5 P.M. daily and had a supply of this dose until the correct was obtained from pharmacy.

The investigation conclusion dated May 30, 2024, at 5 PM revealed that the facility determined that the agency LPN in question did not respond to requests for a statement and a drug screen test. The misappropriation of property was confirmed, however the perpetrator was not verified/identified.


28 Pa. Code 201.29 (a)(c) Resident rights

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

28 Pa. Code 211.9 (a)(1)(b)(d)(k) Pharmacy services

































 Plan of Correction - To be completed: 07/28/2024

Facility purchased the misappropriated medication at facility cost. House audit of narcotic substances completed by registered nurse by 7/28/24 and no other misappropriation found. The facility implemented a new form that will itemize narcotic substances that track the addition and subtraction along with 2 nurse signatures in order to prevent future misappropriation.
DON or designee will educate licensed and registered nurses on "The controlled substance count sheet" by 7/28/24.
DON or designee will audit 4 carts 4x a week for 4 weeks for misappropriation.

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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.
§483.12(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 a review of select facility policy and clinical records and staff interviews it was determined that the facility failed to report a serious injury, a comminuted hip fracture, of unknown origin to the State Survey Agency for one (Resident 137) and the physical abuse of one resident with resultant injury (Resident 35) out of 33 residents sampled.

Findings include:

A review of facility policy entitled "Abuse" last reviewed February 2024 revealed all incidents of abuse will be reported electronically to the Scranton Field Office Pennsylvania Department of Health (the State Survey Agency). Local law enforcement is to be notified of any instances of resident abuse, mistreatment, neglect, involuntary seclusion, or misappropriation of personal property. Further review of this policy revealed, under section 4. Identification: "since the following signs and symptoms may possibly indicate the presence of abuse, attention will be given to: the resident might have bruises, burns, cuts, or more serious injuries like a broken hip or cracked rib."

A review of clinical record revealed that Resident 137 was admitted to the facility on March 13, 2024, with diagnoses which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain).

A review of clinical record revealed that Resident 137 was admitted to the facility on March 13, 2024, with diagnoses which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain).

A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) dated March 20, 2024, revealed that the resident was severely cognitively impaired.

A review of the resident's clinical record conducted during the survey ending June 14, 2024, revealed that on May 5, 2024, Resident 137 began exhibiting signs of pain at approximately 8:00 PM. On May 5, 2024, at approximately 8:30 PM staff administered Tylenol (analgesic) according to the resident's May 2024 Medication Administration Record (MAR). Nursing progress notes dated May 5, 2024 at 10:30 PM revealed that the Resident 137 continued crying and screaming, more than her normal, and staff observed increased swelling and redness in her right upper leg.

A review of a progress note dated May 5, 2024, at 10:24 p.m., indicated that Resident 137 was in severe pain. "Resident holding onto right leg and loud cry. Transferred to bed from wheelchair not able to bear weight on the right leg, area swollen and warm." Resident was transferred to the hospital at approximately 12:30 a.m., on May 6, 2024.

A review of the resident's hospital records revealed that it was determined the resident had a comminuted (comminuted fracture happens when you break a bone into three or more pieces)
intertrochanteric fracture right femur (broken hip at the points where the muscles of the thigh and hip attach). The hospital records revealed that the hospital received information that the resident was found on the floor of her room after a fall. This account of the resident's fall was noted multiple times in the resident's hospital records, along with a note from hospital physician "Patient came with fall X-ray evaluated by myself showing Acute mildly comminuted and displaced right intertrochanteric femur fracture."

During the survey ending June 14, 2024, the survey team requested evidence of the facility's follow up or investigation into the circumstances of the resident's fall and serious injury. Interviews with Nursing Home Administrator and Director of Nursing on June 12, 2024, revealed that the facility did not report or investigate any fall related to this injury or unknown origin related to Resident 137's hip fracture. The NHA and DON that they not believe the resident fell because she would not have been able to get rise from the floor unassisted, but verified that the facility had not timely investigated to rule out abuse, neglect or mistreatment or to determine whether a fall had occurred. The facility investigation did not begin until brought to their attention by surveyors during survey ending June 14, 2024.

The facility failed to report this serious injury of unknown origin requiring a transfer to the hospital to the State Survey Agency.

An interview with the Nursing Home Administrator and Director of Nursing on June 13, 2024, at approximately 1:45 PM confirmed that the facility had failed to report the injury of unknown origin requiring hospitalization of Resident 137 to the State Survey Agency, Scranton Field Office of Pennsylvania Department of Health

Review of clinical record revealed that Resident 35 was admitted to the facility on November 30, 2023, with diagnoses which included dementia and anxiety and was severely cognitively impaired with a BIMS of 7.

Review of Resident 72's clinical record revealed admission to the facility on September 16, 2021, with diagnoses which included Alzheimer's disease, anxiety, and major depression and was significantly cognitively impaired with a BIMS score of 3.

A review of documentation dated June 10, 2024, at 9:04 PM, indicated the nurse heard a noise come from Resident 35's room. Upon entering, the nurse observed Resident 35 laying on the floor of his room between bed one and bed two. Resident 72 stated that Resident 35 "was trying to kill him." Resident 72 had to be escorted out of Resident 35's room and was placed on every 15-minute monitoring.

Review of documentation dated June 10, 2024, at 10:37 PM indicated that Resident 35 was assisted to bed after altercation with Resident 72 and that he had refused to be assessed for injuries by the nurse. Resident 35 then complained of pain and an x-ray was ordered.

Review of incident report dated June 10, 2024, at 8 PM revealed that Resident 35 told staff that Resident 72 had hit him "with a yellow book and it hurts." It was later determined that the Resident 72 had hit Resident 35 with a plastic "wet floor" sign because he thought Resident 35 was going to "kill him."

Review of clinical record revealed that Resident 35 had sustained a fracture of the lateral portion of the left third rib after an altercation with Resident 72. Resident 35 did not require hospitalization for treatment.

An interview with the Nursing Home Administrator on June 13, 2024, at approximately 11:51 AM confirmed that the facility had failed to report the physical abuse which resulted in an injury to the State Survey Agency, Scranton Field Office of Pennsylvania Department of Health.




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

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

28 Pa. Code 201.29(a)(c) Resident Rights








 Plan of Correction - To be completed: 07/28/2024

 Incident was reported as of 7/14/24. Resident #35 and #72 was reported as of 7/14/24.
Admin or designee will report reportable incidents timely as indicated on Long term care provider bulletin and federal reporting required for reportable events/actions by facility.
Admin and Don educated on state and federal reporting requirements of incidents by nursing consultant By 7/28/24.
Admin or designee will educate staff on abuse policy and reportable events by 7/28/24.
Admin or designee will audit daily progress notes 4x a week for 4 weeks for any reportable events.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§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 select facility policies and staff interviews, it was determined that the facility failed to thoroughly investigate injuries of unknown origin, a broken hip, to rule out abuse, neglect or mistreatment as the potential cause for one out of 33 sampled residents (Resident 137).

Findings include:

A review of facility policy entitled "Abuse" last reviewed February 2024 revealed under section 4. Identification: "since the following signs and symptoms may possibly indicate the presence of abuse, attention will be given to: the resident might have bruises, burns, cuts, or more serious injuries like a broken hip or cracked rib." Further review revealed an injury of unknown origin should be investigated including, interviewing any witnesses, staff on all shifts having contact with the resident during period of alleged incident, and reviewing all circumstances surrounding the incident.

A review of clinical record revealed that Resident 137 was admitted to the facility on March 13, 2024, with diagnoses which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain).

A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) dated March 20, 2024, revealed that the resident was severely cognitively impaired.

A review of the resident's clinical record conducted during the survey ending June 14, 2024, revealed that on May 5, 2024, Resident 137 began exhibiting signs of pain at approximately 8:00 PM. On May 5, 2024, at approximately 8:30 PM staff administered Tylenol (analgesic) according to the resident's May 2024 Medication Administration Record (MAR). Nursing progress notes dated May 5, 2024 at 10:30 PM revealed that the Resident 137 continued crying and screaming, more than her normal, and staff observed increased swelling and redness in her right upper leg.

A review of a progress note dated May 5, 2024, at 10:24 p.m., indicated that Resident 137 was in severe pain. "Resident holding onto right leg and loud cry. Transferred to bed from wheelchair not able to bear weight on the right leg, area swollen and warm." Resident was transferred to the hospital at approximately 12:30 a.m., on May 6, 2024.

A review of the resident's hospital records revealed that it was determined the resident had a comminuted (comminuted fracture happens when you break a bone into three or more pieces)
ntertrochanteric fracture right femur (broken hip at the points where the muscles of the thigh and hip attach). The hospital records revealed that the hospital received information that the resident was found on the floor of her room after a fall. This account of the resident's fall was noted multiple times in the resident's hospital records, along with a note from hospital physician "Patient came with fall X-ray evaluated by myself showing Acute mildly comminuted and displaced right intertrochanteric femur fracture."

During the survey ending June 14, 2024, the survey team requested evidence of the facility's follow up or investigation into the circumstances of the resident's fall and serious injury. Interviews with Nursing Home Administrator and Director of Nursing on June 12, 2024, revealed that the facility did not investigate any fall surrounding this injury of unknown origin to determine the source of Resident 137's hip fracture. The NHA and DON that they not believe the resident fell because she would not have been able to get rise from the floor unassisted, but verified that the facility had not timely investigated to rule out abuse, neglect or mistreatment or to determine whether a fall had occurred. The facility investigation did not begin until brought to their attention by surveyors during survey ending June 14, 2024.

During interview with the Director of Nursing (DON) on June 14, 2024, at 12:00 PM, were unable to provide evidence that the facility investigated the resident's injury of unknown injury to rule out abuse.

At the time of the survey ending June 14, 2024, there was no documented evidence that the facility had investigated the potential origin of Resident 137's broken hip to rule out abuse, neglect or mistreatment as the potential cause of the injuries.

During an interview with the Director of Nursing (DON) on June 14, 2024, at 11:25 a.m., the DON was unable to provide evidence that the facility implemented the facility's abuse prevention policy related to investigating Resident 137's broken hip.



28 Pa. Code 201.29(a)(c)(d) Resident rights

28 Pa. Code 201.14(a) Responsibility of Licensee

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





 Plan of Correction - To be completed: 07/28/2024

Event has been reported and investigated for #137 by 7/28/24.
SSD or Designee will interview all interviewable Residents for injuries of unknown source. Licensed or registered nurse will observe non interviewable residents for injuries of unknown source. All injuries of unknown source will be reported and investigated by DON or designee as indicated by state and federal reporting guidelines.

Nurse consultant will educate DON, ADON , Admin on investigating/prevention /reporting alleged violations timely by 7/28/24.
Admin or designee will audit daily progress notes 4x a week for 4 weeks for any reportable events that need investigated.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff: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 Nursing Services
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)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:

Based on a review of clinical records and facility investigative reports and staff and family interviews it was determined the facility failed to provide nursing staff with the appropriate competencies and skills sets necessary to conduct necessary assessments of a resident's clinical status after a fall for one resident, (Resident 96), out of 33 sampled residents.

Findings include:

A review of a facility policy entitled "Neurological Assessment" that was last reviewed by the facility February 2024, indicated that neurological assessments are completed upon physician order, when following an unwitnessed fall, subsequent to a fall with a suspected head injury; or when indicated by resident condition. When assessing neurological status, always include frequent vital signs. Particular attention should be paid to widening pulse pressure (difference between systolic and diastolic pressure). This may be indicative of increasing intracranial pressure. Any change in vital sign or neurological status in a previously stable resident should be reported to the physician. Neuro checks should be completed as ordered per the falls protocol or as per physician's order.

A review of Resident 96's clinical record revealed that the resident was admitted to the facility of March 4, 2022, with diagnoses that included dementia, protein calorie malnutrition, and muscle weakness.

According to an annual Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 14, 2024, the resident had severe cognitive impairment based on a BIMS (brief interview for mental status - a tool to assess cognitive function) and was dependent on staff for all ADLs (activities of daily living such as toileting, turning and repositioning, and transferring).

A review of Resident 96's care plan dated March 22, 2024, identified that the resident was at risk for falls due to dementia, weakness, and GAIT (walking pattern) dysfunction with planned interventions for the use of a bed and chair sensor alarms, bilateral fall mats, ensure that supplies required for care were gathered prior to providing care due to the resident known to stand without assistance.

A review of an unwitnessed fall incident report completed by Employee 8, a licensed practical nurse (LPN) dated May 4, 2024, at 9:36 p.m., revealed that she was called to Resident 96's room and found the resident lying on floor, between the beds. Alert and oriented to self. VSS (vital signs): temperature 97.6-74-18 BP (blood pressure) 156/110 O2 sats (oxygen saturation) 97% on room air. Able to move all extremities without signs or symptoms of pain or discomfort. RN Supervisor aware and assessed and noted 0.5 cm by 0.3 cm skin tear noted on right forearm at end of purpura. Attending physician made aware and responsible party made aware. The incident report indicated that the resident stated, "I hit my head." Staff assisted with two persons to her wheelchair and was taken to her room and assisted with PM care and into bed. Neuro checks were within normal limits and the immediate intervention was to assist the resident to bed between 7 and 8 PM due to tired after meal.

Following the initial neurocheck conducted at the time of the resident's fall, a review of Resident 96's clinical record failed to reveal that licensed professional nursing staff continued to conduct, and document, neurological assessments of the resident after an unwitnessed fall with head strike.

Nursing progress notes completed by Employee 9, a LPN, dated May 5, 2024, at 7:52 a.m., revealed that she was called to the dining room and the resident was unresponsive but breathing. Vital signs BP (blood pressure) 81/57 L (left) arm, rechecked R (right) arm BP (blood pressure) 106/80 T (temperature) 97.9 P (pulse) 80 O2 (oxygen saturation) 97% on RA (room air) R (respiration)14 and the nursing supervisor was called to the unit to assess. After several attempts at arousing resident via sternum rub, she raised head to yell then her head dropped back down. MD notified and gave orders to transfer the resident to the hospital, but the RP declined transfer and wanted her \ to remain at the facility. MD aware, with plan to continue to observe and monitor and initiate neuro checks.

Resident 96's clinical record failed to reveal documented evidence that licensed nursing staff completed neurological checks post this second unwitnessed fall.

During an interview with the Director of Nursing (DON) on June 13, 2024, at 2:00 p.m., confirmed that licensed nursing staff failed to conduct and document neurochecks after the above falls to monitor the resident's status. .




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

28 Pa. Code 211.5 (f) Medical records







 Plan of Correction - To be completed: 07/28/2024

DON or designee will educate nursing staff on neuro check policy and complete a competency with licensed and registered nurses by 7/28/24.
DON or designee will audit neuro check completion through medical record review to ensure neurochecks have been completed 4 x wk for 4 weeks.

483.40 REQUIREMENT Behavioral Health Services: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.
§483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations:

Based on review of clinical records and staff interview it was determined that the facility failed to consistently provide necessary services to meet the behavioral health needs of one of 33 sampled residents (Resident 43).

Findings include:

Review of the clinical record revealed that Resident 43 was admitted to the facility on November 28, 2023, and had diagnoses, which included Alzheimer's disease (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life) and depression.

Resident 43's clinical record revealed the resident had a new onset of delusions on May 18, 2024. A nursing progress note dated May 18, 2024, 11:53 a.m., revealed the resident had increased confusion and told nursing "There are bats in my vagina." Further review of the clinical record revealed Resident 43 made allegations that a male resident had put his hands in her pockets and attempted to touch her pubic area on May 19, 2024, at approximately 9:30 p.m.

Review of Resident 43's care plan in place at time of survey ending June 14, 2024, revealed a focus area related to the resident's potential to exhibit distressed mood & behavioral symptoms related to diagnosis of depression. An intervention was noted for MediTeleCare (outside telehealth psychiatric services) to evaluate and treat for psychiatric and psychological services.

A review of psychiatric/psychological services documentation, dated May 24, 2024, revealed that the resident required services for treatment of depression, and Alzheimer's. Review of the documentation provided by Meditelecare dated May 24, 2024, revealed the resident was difficult to communicate with due to the resident being very hard of hearing. Resident told Meditelecare staff that she needed hearing aid batteries. There was no indication that the resident's new onset of behavioral issues and allegations of potential sexual abuse noted above were addressed or discussed with the resident during that telehealth psych visit.

There was no documented evidence that Resident 43 was provided follow-up psych services treatment thru the time of the survey ending June 14, 2024.

During an interview with the Nursing Home Administrator (NHA), on June 14, 2024, at approximately 11:00 a.m., the NHA was unable to provide evidence that Resident 43 had received psychological/psychiatric services as recommended.


28 Pa. Code 211.2 (d)(8) Medical director








 Plan of Correction - To be completed: 07/28/2024

Resident #43 will be seen by psych services by 7/28/24. Resident was ensured to have functioning hearing aid batteries.
Resident clinical records will be audited for psych service clinical follow up since 6/14/24.
DON or designee will educated nursing staff and social services on new onset of behavioral symptoms and providing necessary behavioral health needs by 7/28/24.
DON or designee will audit clinical record for new onset of behavioral symptoms and follow through of recommendations on 4 residents 4x a week for 4 weeks.

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed: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.
§483.60(c) Menus and nutritional adequacy.
Menus must-

§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

§483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

§483.60(c)(5) Be updated periodically;

§483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

§483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.
Observations:

Based on observations, review of the facility's planned written menus, menu extensions, and select facility policy, and staff interviews, it was determined that the facility failed to adhere to planned written menus for two residents out of 33 residents sampled (Residents 7 and 72).

Findings included:

A review of a facility policy entitled "Double Portion Diet Policy" last reviewed by the facility February 2024 indicated that all residents ordered/requested double entrunless requested otherwise. Special requested double portion would include but not limited to, double portion vegetable, double portion fruit, double portion starch, etc. Example: two pieces of lasagna, two slices of pizza, two 4-ounce portions of chicken, and two 8-ounce scoops of macaroni and cheese.

A review of Resident 7's clinical record revealed that he was admitted to the facility on December 5, 2019, with a diagnosis of a traumatic brain injury [A head injury causing damage to the brain by external force or mechanism and can result with long term complications or death.

A review of Resident 7's plan of care initiated on December 6, 2019, and revised on April 19, 2021, identified that the resident was nutritionally at risk due to hypertension. Planned interventions included: diet as per physician order - regular/ ground / thin, double portions per resident request, and to honor food preferences within prescribed diet.

A review of the facility's menu extension dated June 13, 2024, revealed that the standard/regular portion for the ground hot turkey was a #10 scoop (equivalent to 3.25 fluid ounces or 3/8 cup) ground meat. A double portion should consist of two #10 scoops of ground hot turkey as indicated in the facility's double portions policy.

An observation of meal service on the C1 Unit on June 13, 2024, at 12:25 p.m., revealed Resident 7's tray card/ticket menu dated June 13, 2024, lunch meal, revealed that the resident's daily items were to include 4-ounces of super pudding (higher calorie and protein pudding), 8-ounces Ensure Clear (a clear-liquid high protein nutrition supplement), cup fortified mashed potatoes (enhanced recipe to offer increased calories and protein), double portion entrsalt packet (1-each), pepper packet (1-each), 2 sugar packets, and the main menu included one #10 scoop (equivalent to 3.25 fluid ounces or 3/8 cup) ground meat - hot turkey with gravy (1-ounce), bread stuffing (4-ounces), chopped #8 scoop (1/2 cup) green beans, chilled pears (4-ounces), coffee/cream (6-ounces), and apple juice cup (4-ounces).

Further observation of Resident 7's lunch tray revealed that the resident's plate consisted of a single portion of ground hot turkey and side accompaniments and the not double portions as care planned.

An interview with Employee 6, a nurse aide, on June 13, 2024, at 12:25 p.m., confirmed that the resident did not receive a double portion of ground hot turkey as indicated on his tray card.

A review of Resident 72's clinical record revealed that the resident was admitted to the facility on September 16, 2021, with diagnoses that included Alzheimer's dementia.

A review of a physician order dated December 4, 2021, at 3:30 a.m., revealed that the resident was prescribed a no added salt (NAS - no salt packet) double portion diet regular texture with thin liquids.

A review of the facility's menu extension date June 13, 2024, revealed that the standard/regular portion for the hot turkey was 3-ounces EP (edible portion - is the amount of usable food/ingredients that can be used in food preparation after removing trimmings or waste from the original AP form). A double portion should consist of 6-ounces EP as indicated in the facility's double portions policy.

An observation of meal service on the C1 Unit on June 13, 2024, at 12:30 p.m., revealed Resident 72's tray card/ticket [is a printed document for resident meal trays to help dietary departments and their staff organize and serve foods to their residents according to their prescribed diets] menu dated June 13, 2024, lunch meal, revealed that the resident's daily items were to include 4-ounces of yogurt, double portion entrpepper packet (1-each), 2 sugar packets, and the main menu included hot turkey with gravy (3-ounces), bread stuffing (4-ounces), green beans (4-ounces), chilled pears (4-ounces), coffee/cream (6-ounces), and apple juice cup (4-ounces).

Observation of Resident 72's lunch tray revealed that the resident's plate consisted of a single portion of hot turkey and side accompaniments and not the double portions as ordered. Resident 72 stated during interview at that time that he was still hungry after consuming one hundred percent of the meal and requested another meal.

Interview with Employee 6 confirmed that Resident 72 was served only a single portion and that his tray card indicated that he should receive a double portion.

Interview with the dietary manager on June 13, 2024, at 12:45 p.m., confirmed that residents were to receive double portions as ordered by the physician or per their preference/care plan and that the facility failed to provide double portions to Residents 7 and 72.


28 Pa. Code 211.6 (a) Dietary services.







 Plan of Correction - To be completed: 07/28/2024

No Resident affected.
Resident #72 will be reviewed to ensure no ill-effect. Education was provided to dietary staff regarding double portion notation and following tray tickets.
Immediately and ongoing until September 30, 2024 all dietary staff must participate in and complete the following educations prior to returning to work: Tray Accuracy In-service and policy review training; Service Line Checklist In-service
Food Service Director to participate in tray line oversight, minimum of ten meals weekly
DM or Designee to participate in tray line oversight, concurrent with FSD, minimum of 2x weekly for 4 weeks
Audits and tracking tool will be sent to NHA weekly on Friday.
DM will compile weekly tracking tool into monthly compliance audit. Monthly tray audit accuracy percentage will be provided at QAPI meetinguntil the POC is satisfied.

483.60(d)(3) REQUIREMENT Food in Form to Meet Individual Needs: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.
§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(3) Food prepared in a form designed to meet individual needs.
Observations:

Based on observations, and review of clinical records, select facility policy and select reports and staff interview, it was determined that the facility failed to ensure that food was served in a form to meet the individual needs of one resident out of 33 sampled residents (Resident 28).

Findings include:

A review of the facility's "Chopped Diet Policy" that was last reviewed February 2024, indicated that a chopped diet consisted of foods cut into small, bite-sized pieces (approximately inch to inch) and was intended for patients with difficulty chewing and swallowing. When serving, clearly label all trays and meal components for patients on a chopped diet, verify the correct diet order before serving meals to ensure accuracy, and serve meals attractively to enhance the dining experience.

A review of Resident 28's clinical record revealed that she was admitted to the facility on February 15, 2018 and was prescribed a mechanically altered, chopped diet. .

A review of the facility's menu extension date June 13, 2024, revealed that the chopped diet was to consist of a #10 scoop (equivalent to 3.25 fluid ounces or 3/8 cup) ground meat on one piece of white bread.

A review of Resident 28's tray ticket/card [is a printed document for resident meal trays to help dietary departments and their staff organize and serve foods to their residents according to their prescribed diets] dated June 13, 2024, lunch meal, revealed that the resident's main menu was to consist of chopped #10 scoop (equivalent to 3.25 fluid ounces or 3/8 cup) hamburger on a bun (double portion).

An observation of Resident 28's served lunch on June 13, 2024, at 11:30 a.m., revealed that the resident received two hamburgers that were not chopped as indicated on her tray ticket/card and diet order.

During an interview with the Food Service Manager on June 13, 2024, at 11:33 a.m., confirmed that Resident 28's hamburger was served whole and not chopped. The manager stated, "she always gets her hamburgers that way, her brother does not want her to have chopped food." The Food Service Manager was unable however to provide documented evidence that supported that the resident could safely consume the whole foods, and meats that were not chopped.






 Plan of Correction - To be completed: 07/28/2024

Residents 28 was evaluated by Speech and diet was altered appropriately.

Immediately and ongoing until September 30, 2024 all dietary staff must participate in and complete the following educations prior to returning to work: Tray Accuracy In-service and policy review training; Service Line Checklist In-service with review of tray tickets.

Food Service Director to participate in tray line oversight, minimum of ten meals weekly
DM or Designee to participate in tray line oversight, concurrent with FSD, minimum of 2x weekly for 4 weeks

FSD will send completed tray line accuracy audits to DM.
DM will monitor results and compound audits into a single weekly tracking tool.
Audits and tracking tool will be sent to NHA weekly on Friday.
DM will compile weekly tracking tool into monthly compliance audit. Monthly tray audit accuracy percentage will be provided at monthly QAPI meeting, each month, until the POC is satisfied.

483.90(h)(1)-(4) REQUIREMENT Requirements for Dining and Activity Rooms: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.
§483.90(h) Dining and Resident Activities
The facility must provide one or more rooms designated for resident dining and activities.

These rooms must--
§483.90(h)(1) Be well lighted;

§483.90(h)(2) Be well ventilated;

§483.90(h)(3) Be adequately furnished; and

§483.90(h)(4) Have sufficient space to accommodate all activities.
Observations:

Based on observation and interview, it was determined that the facility failed to provide adequate dining/activity space one one of four occupied resident units (Resident unit, C1).

Findings include:

The current census for the C1 male only locked dementia unit at the time of the survey was 24 residents. The resident capacity for the unit is 57.

There was one dining /activity room on the locked unit. The room measured 24 feet x 24 feet, 576 square feet.

An observation of the C1 dining/activity room, June 11, 2024 at 12 P.M. revealed 9 dining tables with 4 chairs, a video game machine, a poker machine placed on a dining table, an over the bed table, and 4 stationary high back chairs. There were 6 residents seated in wheelchairs at the time of the observation. Several residents were observed having difficulty passing each other and maneuvering about in the room due to space constraints.

There room did not provide adequate space to accommodate the number of residents currently residing on this unit and the necessary dining and activity equipment/supplies.

During an interview June 12, 2024 at approximately 1 P.M. the interim Director of Nursing (DON) stated that there was only one seating for each meal and "most" of the residents eat in this dining room. She stated that it was a "tight fit" in the room during meals. She confirmed that this room is the only dining/activity on the male locked unit for residents use as these residents do not leave the unit for any meals or activities.



28 Pa Code 201.18 (e)(2.1) Management




 Plan of Correction - To be completed: 07/28/2024


No Residents had negative outcome.
Dining staff will check Dining Rooms before all meals to ensure new seating schedules are in place.

Dining staff will be educated on space and schedule division by Dining Services Director or designee.

Dining staff/Designee will audit Dining rooms areas for appropriate space 5 times weekly X3 months.
483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program: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.
§483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.
Observations:

Based on observation, a review of facility pest service records and staff interview, it was determined that the facility failed to maintain an effective pest control program.

Findings include:

A review of the facility's contracted pest management company service inspection report dated June 11, 2024, at 3:22 p.m., revealed that staff made verbal reports that mice activity was observed in resident rooms D106, D115, and D-wing dining room. The logbooks (the facility's method of communicating pests with the pest management company) were checked and no written reports of pest activity were noted in the logbooks.

The pest management service inspection report revealed that RTU (ready-to-use) pesticide and glue boards [trays that are coated with a potent adhesive that prevents the escape of any animal that touches it] were placed throughout. Treated common areas, nurse's stations, lounge rooms, dinning rooms, employee breakrooms, restrooms, and lobby for general pest control.

Observation of the D-Unit dining room on June 13, 2024, at 8:29 a.m., revealed that inside a cabinet underneath the sink there was a dead decomposing mouse stuck to a glue trap. A yellow-colored substance was smeared on the floor of the cabinet, and small black/brown speckles, that appeared to be rodent droppings, were observed on the bottom floor of the cabinet along with debris and dead bugs.

Interview with the Nursing Home Administrator (NHA) on June 13, 2024, at 8:50 a.m., reported that that pest management company "was just in on Tuesday to take care of the mice" and that they \ check the traps.

The NHA confirmed that the facility failed to perform environmental maintenance and checks to remove dead rodents from pest traps and deter unsanitary dining conditions that increase the risk of infestation.



28 Pa. Code 201.18 (e)(2.1) Management





 Plan of Correction - To be completed: 07/28/2024

No residents were affected.

Maintained had all other traps checked and replaced if needed.

Maintenace or designee will educate pest control on times to review traps and spray.

Maintenance or designee will monitor traps 5 X week X 3 months and report outcomes to QAPI.
§ 201.14(g) LICENSURE Responsibility of licensee.:State only Deficiency.
(g) A facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the resident ' s health and safety are jeopardized.

Observations:

Based on review of facility outstanding accounts payable and interview with administrative staff, it was determined that the facility failed to pay, in a timely manner, bills incurred in the operation of the facility, that are not in dispute, and are for services without which the residents' health and safety are jeopardized.

Findings include:

A review of the facility aging report (financial report which shows unpaid invoices by date ranges) conducted at the time of the survey ending June 14, 2024, revealed outstanding accounts payable balances, which required payment of goods and services within 91-120 days.

These outstanding accounts payable as of June 14, 2024, noted on the aging report were were outstanding for 91-120 days beyond terms of payment included:

HealthCare food service equipment (Aladdin Temp-Rite LLC): $1677.77

All State Pest Management: $3162.85

Medical supplies (Alpha-Med): $4244.83

Medicus Urgent Care (local urgent care medical facility):$665.00

Netsmart Technologies (internet technology services): $1513.25

NutraCo ( dietitian staffing service): $29,052.00

QRM (rehab services):$19,000.00

Rite-temp group (mechanical contractors HVAC): $3952.91

Rock Bottom Construction (local contractor): $2245.00

Star Stone Speciality insurance company (insurance company): $50,000.00

T.E.Spall and Co (local plumbing and heating contractor):$10,000.00

The Advocacy Alliance (resident guardianship services): $500.00

Total Plan Concepts (employee healthcare benefits): $5929.58

The NHA (nursing home administrator) confirmed during interview on June 14, 2024, at 3:00 PM these outstanding balances owed.















 Plan of Correction - To be completed: 07/28/2024

No resident had a negative outcome.

Bills will be audited by BOM or designee for 60 days past due. Regional BOM will discuss bills with creditors to establish acceptable terms.

BOM or designee will be educated by regional Business office to maintain or monitor compliance of billing and payment procedure.

BOM or designee will monitor billing of 4 weekly X 3months and report results to QAPI.

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