Nursing Investigation Results -

Pennsylvania Department of Health
MOUNT CARMEL NURSING & REHABILITATION CENTER
Patient Care Inspection Results

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MOUNT CARMEL NURSING & REHABILITATION CENTER
Inspection Results For:

There are  88 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
MOUNT CARMEL NURSING & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey completed on February 6, 2020, it was determined that Mount Carmel Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on observation and staff interview, it was determined that the facility failed to store, prepare, and serve food in a manner to prevent the potential for food borne illness and maintain equipment in a clean and safe operating condition in the facility's main kitchen.

Findings include:

Initial tour of the facility's main kitchen on February 3, 2020, at 9:40 AM revealed the following:

Dried food and dirt debris were observed throughout the kitchen under tables and equipment and along wall edges.

The ice machine contained a drainage pipe connected from the machine that ran behind a utility table located beside the ice machine. The drainage pipe ended beside the doorway entrance to the kitchen along the wall and was dripping directly onto the floor. A floor drain was located approximately one foot in front of where the pipe ended. In a concurrent interview with Employee 8 (dietary manager), she stated there is another piece of the pipe that extends to the drain, and it just gets knocked off when sweeping and mopping at times. Employee 8 then located a piece of pipe from under the opposite end of the table and placed it on the pipe end by the door to extend the pipe over the drain.

The bag in box juice holder located on the bottom shelf of the utility table beside the ice machine were dusty and contained dried spills.

The walk-in cooler located closest to the dining room contained open metal wire rack shelving units. Two of the units contained bottom shelves, which were approximately four inches off the floor, less than the required six inches from the floor, with food items stored on the shelf. The cooler floor contained dried food and debris under the shelving units.

Open wire rack shelving was identified throughout the kitchen in the walk- in coolers, walk-in freezer, dry storage area, and in the production area with food and equipment (pans) stored on the bottom open wire shelves. The open wire rack shelving throughout the kitchen did not contain a barrier on the bottom shelf to prevent the potential for contamination from sweeping debris or mop water splash.

A drainage pipe was observed outside the walk-in cooler wall closest to the office area, draining directly onto the floor along the wall edge of the cooler. A floor drain was located approximately six inches from the end of the drainage pipe. Employee 8 indicated this was the drainage pipe from the cooler.

A two-shelf utility cart was in the production area with a tub of clear plastic bowls on the cart. Employee 8 indicated theses bowls were clean and going to be used for lunch. The shelves of the cart contained dried food.

A utility table contained a microwave and household toaster. The interior of the microwave was significantly soiled with dried spills and splatter. The toaster contained a dark brown buildup around the edges. The bottom shelf of the table contained three large plastic totes. The shelf and the lids to the plastic totes contained dust and dried food debris.

The steam kettle was cool, and not in use. The interior of the kettle contained dried food on the wall edges, and the outside of the kettle facing the oven contained several dried spills.

Five sheet trays were observed on a speed rack beside the stove. The sheet trays contained a thick dark brown buildup on the outer edges of the trays.

The walk-in freezer contained ice buildup on the condenser fan unit, and the back ceiling and side walls of the freezer. Ice was observed on top of two boxes of food products located on the top shelf under the condenser unit.

Food products identified by Employee 8 as two bags of French fries, one bag of potatoes, and a plastic crate containing a pork loin, half of a bag of meatballs, one pack of hot dogs, and a half bag of pork riblets were located in the freezer out of the original shipping container. There was no indication as to when the products were delivered, when they were opened, or when they expired.

At 10:00 AM, kitchen staff were observed washing dishes, which Employee 8 indicated were from breakfast. A review of the facility's dish machine temperature log for February 2020, revealed a wash and rinse temperature recorded for lunch on February 3, 2020. Employee 8 was not able to indicate why a wash and rinse temperature was recorded at 10:00 AM for lunch on that day, as the lunch meal had not occurred yet.

The flooring tile outside the exit door of the kitchen to the dining area contained several cracks and visible dirt and debris on the tile along the floor moldings.

483.60 (i) 1-3 Food Procurement, Store/Prepare/Serve-Sanitary
Previously cited 3/8/19

28 Pa. Code 211.6 (c) Dietary services
Previously cited 3/8/19


 Plan of Correction - To be completed: 03/18/2020

F812
1. The identified concerns observed in the facilities main kitchen have been cleaned and resolved.
2. Items discovered in the main kitchen have been inspected and will be cleaned routinely.
3. Dietary staff were re-educated on facility policy for Food Safety requirements. Additionally, Dietary staff were re-educated on keeping the main kitchen clean. Dietary manager/designee will inspect the main kitchen routinely to ensure cleanliness is maintained and proper food storage.
4. NHA/designee will audit the facilities main kitchen to ensure appropriate action takes place related to Food Safety requirements. Results of audits will be reported to QA Committee for review and recommendations.
5. Corrective Action Date: March 18, 2020.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 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 clinical record review, observation, and staff interview, it was determined that the facility failed to implement an infection control program to prevent the potential spread of infection on two of four nursing units (Marble and Maple; Residents 96, 33, and 28).

Findings include:

Observation on February 5, 2020, at 10:36 AM revealed Resident 96 had a sign on her door indicating to see the nurse before entering. Concurrent interview with Employee 1, licensed practical nurse, revealed Resident 96 was on contact precautions (additional infection control precautions needed for those who have certain types of infections to prevent the spread of infection) due to c-diff (clostridium difficile, a bacterial infection that causes a mild to life threatening form of diarrhea) and colitis (a serious inflammation of the colon). Employee 2, nurse aide, was in Resident 96's room making the bed. A gown and gloves that was used by Employee 2 was on the seat of a chair in the room and not in a plastic bag. Employee 1 indicated that the gown and gloves should not have been placed on the chair and that they should have been discarded properly. Employee 1 discarded the gown and gloves by applying gloves and placing the gown and gloves in a plastic bag, and then discarded them into the trash receptacle.

Interview with Employee 5, registered nurse, on February 6, 2020, at 10:00 AM revealed that Employee 2 was employed through an agency, and that she had training on infection control prevention.

Nursing documentation dated February 5, 2020, at 3:14 AM revealed that Resident 96 continues antibiotics for a c-diff infection.

The surveyor reviewed the above findings for Resident 96 during an interview with the Director of Nursing on February 6, 2020, at 11:00 AM.

Observation of Resident 33's room on February 3, 2020, at 9:30 AM revealed a sign on her door indicating that you were to see the nurse before entering. The surveyor asked Employee 4 (licensed practical nurse), who identified herself as the charge nurse, why the sign was posted. She responded that she did not know.

Clinical record review for Resident 33 revealed she is on contact precautions for Extended Spectrum Beta-Lactamases (ESBL, which causes a hard to treat urinary tract infection).

Observation of Employee 3, nurse aide, on February 3, 2020, at 9:42 AM revealed that she was handling soiled linen with ungloved hands. She placed the soiled linen on a resident's bed and then put the soiled linen in a bag.

Observation of Resident 28 on February 3, 2020, at 9:45 AM revealed a urinal full of urine hanging on the waste can. A soiled paper towel was stuck on the side of the urinal. On the other side was a large amount of what appeared to be thick blood tinged sputum. The urinal itself appeared dirty.

An interview with Resident 28 at the time of the observation revealed that staff usually wait until the urinal is full before they empty it. He also indicated that staff keep telling him that he needs a new urinal, but he never got one.

The surveyor reviewed the above findings for Residents 33 and 28 during an interview with the Nursing Home Administrator and the Director of Nursing on February 4, 2020, at 2:00 PM.

483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control
Previously cited 3/8/19

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 3/8/19

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


 Plan of Correction - To be completed: 03/18/2020

F880
1. Infection Control procedures have been reviewed relative to resident 28, 33, 96 and Marble/Maple Hall.
2. Current Infection Control practices have been reviewed to maintain an infection prevention and control program to provide a safe and sanitary environment.
3. All appropriate Staff have been re-educated on Facility Infection Control practices.
4. DON/designee will audit Compliance amongst staff with all Infection Control Practices. Results of audits will be reported to QA Committee for review and recommendations.
5. Corrective Action Date: March 18, 2020.

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

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

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

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

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

Based on clinical record review, review of facility documentation, and staff and family interview, it was determined that the facility failed to allow residents/responsible party to make choices about aspects of their life that were important to them, such as bathing/shower preference for one of one resident reviewed (Resident 55)

Findings include:

Interview with Resident 55's daughter on February 3, 2020, at 11:27 AM revealed that her mother is getting showered by the facility instead of baths. She stated that her mother would always prefer a bath over a shower. She stated that they were never asked their preference related to baths or showers.

Clinical record review for Resident 55 revealed that she was admitted to the facility on December 4, 2019. Since admission, she was given five showers and three bed baths. Further clinical record review revealed no documentation addressing Resident 55's preference related to baths or showers.

Interview with the Director of Nursing on February 5, 2020, at 2:00 PM revealed that the facility does not have a system to address resident preferences related to baths and showers.

28 Pa. Code 201.29 (j) Resident rights


 Plan of Correction - To be completed: 03/18/2020

F561
1. Resident 55 and resident's responsible party have been interviewed to offer choice of bathing preferences.
2. Current residents have been reviewed to ensure their bathing preferences are accurate based on choice.
3. Nursing and social service staff have been re-educated on the need to offer resident's/resident's responsible party a choice for bathing preference. New Admissions/Responsible parties will be asked what bathing preference is preffered.
4. DON/designee will audit residents to ensure bathing preferences have been offered and followed. Results of audits will be reported to QA Committee for review and recommendations.
5. Corrective Action Date: March 18, 2020

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations: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.
483.80(d) Influenza and pneumococcal immunizations
483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
Observations:

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to evaluate a resident for the administration of a pneumococcal vaccine for one of five residents reviewed for immunization status (Resident 90).

Findings include:

The facility policy entitled, "Standing Orders for Administering Pneumococcal Vaccine to Adults," last reviewed on January 31, 2020, revealed the facility will identify adults in need of a second and final dose of the pneumococcal vaccine if five or more years have elapsed since the previous dose of the vaccine and certain criteria are met.

Clinical record review for Resident 90's immunization history revealed that the resident received her pneumococcal vaccine or Pneumovax on December 4, 2008.

Interview with Employee 5, infection control coordinator, on February 6, 2020, at 11:00 AM revealed the resident was not evaluated for or offered the second dose of a pneumococcal vaccine.

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 3/8/19


 Plan of Correction - To be completed: 03/18/2020

F883
1. Resident 90 was evaluated for appropriate administration of a pneumococcal vaccine.
2. Current resident's in the facility will be reviewed for a 2nd and final dose of the pneumococcal vaccine.
3. Licensed Nursing Staff have been re-educated on the Pneumococcal Vaccine.
4. DON/designee will audit residents in need of a 2nd and final dose of a Pneumococcal Vaccine. Results of audits will be reported to QA Committee for review and recommendations.
5. Corrective Action Date: March 18, 2020.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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.
483.45(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of five residents reviewed (Resident 75).

Findings include:

The policy entitled "Medication Monitoring," last reviewed without changes on January 31, 2020, revealed that the consultant pharmacist works with the facility to establish a system whereby the observations and recommendations regarding residents' drug therapy are communicated to those with authority and/or responsibility to implement recommendations and responded to appropriately and timely.

The procedure indicates that the pharmacist will document potential or actual medication therapy problems and other drug regimen review findings appropriate for prescriber and/or nursing to review. The consultant pharmacist and the facility follow up on the recommendations to verify that appropriate action has been taken.

Clinical record review for Resident 75 revealed that the facility admitted her on August 3, 2018, with the diagnosis of major depressive disorder.

Resident 75's clinical record review revealed current physician orders for Effexor extended release (a medication used to treat depression) 150 milligrams (mg) daily for depression and anxiety.

A medication record review (MMR) note to the attending physician from the pharmacist dated August 5, 2019, indicated that Resident 75 has had no signs or symptoms of depression and no side effects related to the medication Effexor ER. The pharmacist suggested a trial reduction of Effexor ER to 112.5 mg. The physician marked the box "disagree" and wrote that Resident 75 "does worse without medications."

A medication record review (MMR) note to the attending physician from the pharmacist dated December 2, 2019, indicated that Resident 75 remains on Effexor ER 150 mg daily for anxiety/depression but is "not exhibiting worsening symptoms of depression or anxiety." The pharmacist suggested a trail dose reduction to Effexor ER 75 mg daily. The physician marked the box "disagree" and wrote that Resident 75 "is finally good."

A physician's progress note dated December 27, 2019, revealed that Resident 75 denied Anxiety, nervousness, depression, sadness, and frequent crying. The note also indicated that Resident 75's nerves seem to be under control, and she is not asking to go home anymore.

Interview with the Director of Nursing on February 6, 2020, at 1:00 PM revealed that there was no evidence in the clinical record that a decrease in Resident 75's Effexor ER was contraindicated or that a gradual dose reduction had been tried and failed.

483.45(c)(3)(e)(1)-(5) Free from Unnecessary Psychotropic Medications/PRN Use
Previously cited 3/08/2019

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 3/08/19


 Plan of Correction - To be completed: 03/18/2020

F758
1. Resident 75 has been reviewed by Physician, Consultant Pharmacist and IDT team to evaluate gradual dose reduction.
2. Other resident's on anti-depressants have been reviewed by the Physician, Consultant Pharmacist, and IDT team to evaluate Gradual Dose Reductions.
3. Nursing Staff have been re-educated on documenting behaviors and understanding Gradual Dose Reductions.
4. DON/designee will audit anti-depressant use and Gradual Dose Reduction recomendations. Results of audits will be reported to QA Committee for review and recommendations.
5. Corrective Action Date: March 18, 2020.

483.25(n)(1)-(4) REQUIREMENT Bedrails:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.
Observations:

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to assess for the risk of side rail entrapment, review the risk and benefits of side rail utilization with the resident or resident representative, and receive consent for the use of side rails for 11 of 11 residents reviewed (Residents 2, 35, 46, 58, 68, 75, 76, 77, 80, 93, 108,).

Findings include:

An observation of Resident 68 on February 3, 2020, at 9:53 AM revealed the resident had enabler bars up on both sides of her bed. The resident stated she uses them to move in bed and to help her get out of bed.

An observation of Resident 46 on February 3, 2020, at 10:05 AM revealed the resident in bed with enabler bars up on both side of the bed.

An observation of Resident 93 on February 3, 2020, at 12:58 PM revealed the resident in bed with enabler bars up on both sides of the bed.

An observation of Resident 58 on February 4, 2020 at 9:58 AM revealed the resident in bed with enabler bars up on both sides of the bed.

An observation of Resident 108 on February 3, 2020, at 10:45 AM revealed the resident in bed with Halo enabler bars up on both sides of the bed. The resident was not able to answer the surveyor's questions about the enabler bars.

An observation of Resident 35 on February 3, 2020, at 10:59 PM revealed the resident in bed with Halo enabler bars up on both sides of the bed. The resident stated she needs help to use them.

An observation of Resident 80's bed on February 3, 2020, at 1:49 PM revealed Halo enabler bars up on both sides of the bed. The resident stated she depends on these to help her move.

An observation of Resident 2 on February 4, 2020, at 10:10 AM revealed Halo enabler bars up on both sides of the bed. The resident was not able to answer the surveyor's questions about the enabler bars.

An observation of Resident 76 on February 4, 2020, at 10:36 AM revealed the resident in bed with Halo enabler bars up on both sides of the bed. The resident stated he needs them to help him move and get up.

An observation of Resident 75 on February 4, 2020, at 10:00 AM revealed the resident in bed with Halo enabler bars up on both sides of the bed. The resident stated she needed them to help move when in bed.

An observation of Resident 77 on February 5, 2020, at 9:41 AM revealed the resident in bed with Halo enabler bars up on both sides of the bed. The resident stated she needed them to help move around in bed.

There was no evidence to indicate that the above residents and/or responsible party(ies) were educated on the risk of entrapment with the use of the enabler bars, signed consent, or that the entrapment zones were assessed prior to the utilization of the enabler bars.

The above findings were reviewed in an interview with the Nursing Home Administrator and Director of Nursing on February 5, 2020, at 1:45 PM. They indicated the facility does not have any policy in place regarding the assessment for the use of the enabler bars, signed consent, or the measurement of entrapment zones.

28 Pa. Code 211.12 (d)(5) Nursing services
Previously cited 3/8/19


 Plan of Correction - To be completed: 03/18/2020

F700
1. Residents 2, 35, 46, 58, 68, 75, 76, 77, 80, 93, and 108, have all been assessed for the risk of side rail entrapment. In addition, the risks and benefits have been discussed with the resident and/or resident representative and consent obtained.
2. Current residents with enabler bars have been assessed for the risks of entrapment. Additionally, residents and or the resident representative have also been informed of the risk versus benefits of utilization of enabler bars and consent obtained.
3. Comprehensive Enabler Bar Policy and Forms will be reviewed and updated. Nursing and therapy staff will be educated on updated policy and forms.
4. DON/designee will audit resident's charts to ensure Enabler bar policy is being followed. Results of audits will be reported to be educated on the QA Committee for review and recommendations.
5. Corrective Action Date: March 18, 2020.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care related to pressure ulcer assessment for one of seven residents reviewed (Resident 77).

Findings include:

Clinical record review for Resident 77 revealed a skin/wound progress note dated November 21, 2019, at 9:58 AM that indicated Resident 77's right gluteal fold (the crease area between the buttocks and the back of the thigh) remained beefy red, raw in appearance. A skin/wound progress note dated November 27, 2019, at 8:15 AM revealed that MASD (moisture associated skin damage) "persist with raw skin and odor to all gluteal folds."

Review of Resident 77's treatment orders for November 2019, revealed an order dated November 20, 2019, to cleanse open area on right gluteal fold with wound cleanser, pat dry, apply Silvadene, and cover with foam adhesive every day and as needed for soilage or detachment. The treatment Kardex also indicates that this treatment was discontinued on November 27, 2019.

A skin/wound progress note dated December 3, 2019, at 9:43 AM revealed that Resident 77's skin observations follow-up from readmission on November 29, 2019, revealed that she had severe moisture associated dermatitis (skin irritation caused from the skin being moist) versus ischemic skin failure (tissue death caused by an interruption of blood supply to an area) to the right gluteal fold. Skin to her right gluteal fold "is open, red, raw, and with yellow slough" (dead tissue).

Review of Resident 77's clinical record revealed a new physician's order dated November 30, 2019, for Silvadene cream (a cream used to stop the growth of bacteria in an open wound) apply to right gluteal fold every day after washing with wound cleanser and then cover with a foam dressing.

A skin/wound progress note dated January 9, 2020, at 9:14 AM revealed that Resident 77 had an overall decline to her skin in the entire region of her buttocks area and gluteal folds. The progress note revealed that the presentation of the areas are of both pressure areas versus severe MASD versus impaired circulation. The note indicated that Resident 77 was scheduled to go to the wound clinic on January 17, 2020.

Review of Resident 77's treatment Kardex for January 2020, revealed to continue the Silvadene cream.

A skin/wound progress note dated January 13, 2020, at 9:08 AM revealed that there were no significant changes to the areas since the treatment was changed to Silvadene. Slough areas continued to the right gluteal fold.

Review of Resident 77's wound clinic progress note dated January 17, 2020, revealed that the wound clinic physician made no mention of Resident 77's right gluteal fold wound.

A skin /wound progress note dated January 20, 2020, at 8:54 AM revealed that the "moisture areas to the right butt continued."

The next skin/wound progress note dated January 30, 2020, at 9:40 AM, 10 days after the last skin/wound note, revealed that while providing incontinence care a layer of intact granulation tissue/slough to "right gluteal fold caved in and opened" causing a large open cavernous ulcer with slough and eschar (dead black tissue) base. The area measured 10 centimeters (cm) by 6 cm with a depth of 3 cm and had a foul odor. A message was sent to the physician at the wound clinic and a new treatment of Dakin's packing (gauze soaked with an antiseptic solution) was ordered.

Interview with Employee 1 (Licensed practical nurse, wound nurse) on February 6, 2020, at 10:15 AM revealed that Resident 77 went to the wound clinic on January 17, 2020, but the wound clinic did not assess the right gluteal fold because it was a MASD and not a pressure wound. She also revealed that there was no evidence that an RN (registered nurse) assessed Resident 77's right gluteal fold or that a physician was made aware of the area not improving and getting worse when identified on January 9, 2020.

Interview with Employee 6 (RN) on February 6, 2020, at 10:30 AM confirmed that Employee 1 is a licensed practical nurse and that she is not certified in wound care. She also confirmed that the expectation is that a registered nurse would verify Employee 1's findings related to wounds and that an RN would assess the wound when there was a decline noted. Employee 6 could not provide documentation that a registered nurse or a physician assessed Resident 77's wound when it declined on January 9, 2020.

The surveyor reviewed the above findings with the Director of Nursing on February 6, 2020, at 11:00 AM.

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.10(d) Resident care policies
Previously cited 3/08/2019

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 3/08/2019


 Plan of Correction - To be completed: 03/18/2020

F686
1. Resident 77 has been assessed and the wound has been staged appropriately.
2. Current residents have been reviewed and assessed to ensure proper staging of wounds.
3. All Licensed staff have been re-educated on proper assessment and staging of wounds.
4. DON/designee will audit residents to ensure proper assessments and wound staging is occurring. Results of audits will be reported to QA Committee for review and recommendations.
5. Corrective Action Date: March 18, 2020.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on clinical record review and resident and staff interview, it was determined that the facility failed to promote resident involvement with care plan development for one of two residents reviewed (Resident 105).

Findings include:

In an interview with Resident 105 on February 3, 2020, at 10:57 AM, the resident stated he "doesn't remember being invited or attending a care plan meeting since his admission" to the facility on December 3, 2019. The resident also stated he attends dialysis on Monday, Wednesday, and Friday.

Clinical record review for Resident 105 revealed an MDS (Minimum Data Set, an assessment completed at specific intervals of time to determine resident care needs) completed on January 17, 2020, which indicated the resident had a BIMS (Brief Interview of Mental Status, assessment to determine cognitive status) score of 13, indicating little or no cognitive impairment.

Further clinical record review revealed a plan of care note dated January 27, 2020, at 2:16 PM which noted a care plan meeting was held with Resident 105's son and Resident 105 had left for dialysis.

The above care plan meeting for Resident 105 was held on a Monday, and at a time the resident was scheduled to attend his dialysis treatment, inhibiting the resident's ability to attend and participate in the development of his plan of care.

The surveyor reviewed the above findings for Resident 105 during an interview with the Nursing Home Administrator and the Director of Nursing on February 5, 2020, at 2:00 PM.

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

28 Pa. Code 211.10(a) Resident care policies
Previously cited 3/8/19

28 Pa. Code 211.11(e) Resident care plan

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 3/8/19


 Plan of Correction - To be completed: 03/18/2020

F657
1. Resident 105 has been invited and has attended a care plan meeting to promote involvement with care plan development.
2. Current residents have been reviewed to ensure the facility promotes resident involvement with care plan development.
3. Nursing and social service staff have been re-educated on the need to promote resident involvement with care plan development.
4. DON/designee will audit resident's care plan meetings to ensure resident involvement is being offered with care plan meeting. Results of audits will be reported to QA Committee for review and recommendations.
5. Corrective Action Date: March 18, 2020.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:

Based on review of select facility policies and procedures, and clinical record review, it was determined that the facility failed to develop a comprehensive individualized care plan for one of 23 residents reviewed (Resident 76).

Findings include:

The facility policy entitled "Smoking Policy," last reviewed on January 31, 2020, revealed upon completion of the Safe Smoking Assessment Form, facility staff will complete the individualized care plan to reflect appropriate interventions for each resident.

Clinical record review revealed that Resident 76 did not have a care plan related to smoking and the required interventions related to the resident's safety and the safety of others in the facility, the location of smoking, the level of supervision required, the accessibility of matches, lighters, and smoking material, and any pertinent information identified in the smoking safety screen.

The surveyor reviewed the above findings with the Nursing Home Administrator during an interview on February 5, 2020, at 1:45 PM.

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 3/8/19


 Plan of Correction - To be completed: 03/18/2020

F656
1. Resident 76 has been interviewed and the comprehensive individualized care plan has been updated.
2. Current residents who smoke have been reviewed to ensure the comprehensive individualized care plan is accurate with appropriate interventions in place to ensure the safety of residents.
3. Nursing and social service staff have been re-educated on the need to update and accurately document in the Individualized Comprehensive Care Palm to reflect person centered care.
4. Social Services Director/designee will audit residents to ensure Individualized Comprehensive Smoking Care Plans are accurate and accurately documented. Results of audits will be reported to QA Committee for review and recommendations.
5. Corrective Action Date: March 18, 2020

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to implement a resident's wishes regarding an advance directive for one of three residents reviewed (Resident 28).

Findings include:

Clinical record review for Resident 28 revealed his end of life care decision dated March 25, 2014, was for full code treatment (cardiopulmonary resuscitation if he ceased to breathe).

Review of Resident 28's current physician's orders indicate that he is not to be resuscitated should he cease to breathe.

An interview with the Director of Nursing on February 5, 2020, at 2:30 PM confirmed the above findings and revealed that there was no further documentation indicating that Resident 28 had changed his wishes regarding a full code prior to the surveyor identifying the conflicting information.

28 Pa. Code 201.29(a) Resident rights


 Plan of Correction - To be completed: 03/18/2020

F578
1. Resident 28 's Advanced Directive has been changed and updated to reflect the resident's wishes.
2. Current residents have been reviewed to ensure accuracy with the resident's Advanced Directives.
3. Nursing and social service staff have been re-educated on the need to follow resident wishes and to accurately document the residents Advanced Directive.
4. Social Services Director/designee will audit the residents Advanced Directives to ensure accuracy relative to the resident's wishes. Results of audits will be reported to QA Committee for review and recommendations.
5. Corrective Action Date: March 18, 2020

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
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 81F; 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 provide a clean, comfortable environment on four of four nursing units (Marble, Maple, Victoria, and Oak; Residents 13, 84, 2, 28, 30, 95, 55, 101, 75, 112, 44, 86, 68, 105, 65, 93, and 58).

Findings include:

An observation on February 2, 2020, at 10:30 AM during the initial tour revealed the floor edges of Marble hall to have a buildup of dirt along the edges of the floor. A corner panel on the wall near the nursing station was cracked and torn away from the wall.

An observation on February 3, 2020, at 10:45 AM revealed dried gray stains and brown flecks of dirt on the floor near the entryway of Resident 13 and 84's room. There was dust and crumbs under the foot of Resident 84's bed. A strong urine smell was present in the bathroom. A brown colored stain was on the floor around the base of the toilet and a brown colored stain was inside the toilet. The stain did not flush away. A follow up visit to this room on the same day at 12:30 PM revealed the stains in the entryway on the floor to be smaller in size. A follow up visit to this room on February 4, 2020, at 9:43 AM revealed a strong urine smell in the bathroom.

An observation on February 4, 2020, at 10:13 AM of Resident 2's room revealed an overbed tray table with the edges along the sides and top of the table peeled off. Dust and crumbs, and embedded dirt was on the floor behind the door, along the wall edges, and under the folding tray table.

Observation of Resident 28's room on February 3, 2020, at 9:54 AM and February 4, 2020, at 9:40 AM revealed a strong odor of urine. During the same observations it was noted that Resident 28's overbed tray table was broken.

Observation of Resident 30's chair on February 4, 2020, at 10:30 AM revealed the cushion and under the cushion contained a large amount of dried food.

Observation of the Victoria Nursing Unit hallway on February 4, 2020, at 10:45 AM revealed a trail of white spillage.

Observations of the Victoria Nursing Unit throughout the survey revealed debris on the floors of the resident rooms and in the hallway.

Observation of Resident 95's electric wheelchair on February 3, 2020, at 10:31 AM revealed it was dirty with dust and food particles.

Observation of the Oak Nursing Unit on February 3, 2020 at 12:48 PM revealed Resident 55's room with loose dirt debris all around the baseboard and at the entrance of the room. There was dirt behind the door to her room and the bathroom door was marred.

Observation of the Oak Nursing Unit on February 4, 2020, at 9:30 AM revealed Resident 101's room was dirty around the edges of the floor with loose particles of dirt and debris and the bathroom door was noted to be marred.

Observation in the Oak Nursing Hallway on February 4, 2020 at 10:03 AM revealed Employee 7, housekeeper, mopping the rooms of Residents 55, 75, and 112. Employee 7 took her wet mop into the rooms, without sweeping or dust mopping the rooms first and she used the wet mop to brush loose debris that was on the floor and push it out into the hallway. She then picked up the loose debris with the dustpan and a hand-held broom. Concurrent interview with Employee 7, revealed that she "only sweeps the floors or dust mops them first if they are really dirty." She said then they would utilize a broom. Interview with the Nursing Home Administrator and Director of Nursing on February 4, 2020 at 1:45 PM revealed that the expectation is for the loose dirt to be cleaned up prior to mopping the floor.

Observation of the Oak Nursing Unit on February 4, 2020, at 10:08 AM revealed Resident 44's room had loose dirt debris all around the baseboard in the room. The wainscoting ledge had visible dust on it. Her oxygen concentrator was dirty and dusty, the heater in the room had visible dust in it. The wall near Resident 44's window, close to her dresser, was marred. The bathroom door as marred.

Observation of the Oak Nursing Unit Hallway on February 4, 2020, at 10:38 AM revealed Resident 75's room had loose dirt debris on the floor around the baseboard in the room. Resident 75's bathroom door was marred. There was dust on the wainscoting ledge and dirt under the wheels of the bed.

Observation of the Oak Nursing Unit on February 4, 2020, at 11:02 AM revealed Resident 112's floor to be dirty. There were dirt particles noted all the way around room along baseboard and the bathroom door was marred.

Observation of the Oak Hallway nursing unit on February 4, 2020 at 11:15 AM revealed visible loose dirt along the baseboard down both sides of the hallway.

An observation on February 3, 2020, at 10:30 AM during the initial tour revealed dust and debris throughout the Maple hall along the floor edges. The top of the chair rail trim along the walls in the hall contained a significant amount of dust. Door jams throughout the hall contained a buildup of dirt/debris.

An observation of Resident 86's room on February 3, 2020, at 10:30 AM revealed a fall mat covered in crumbs and dirt on the floor beside the resident's bed. The footboard on the bed contained unfinished edges surrounding the footboard with exposed press board. The floor throughout the room contained areas of dirt and debris under the beds, in the corners of the room, and throughout the wall edges. A wheelchair sitting in front of the resident's bed contained crumbs and dried food on the seat cushion and the frame and wheels were dusty.

An observation of Resident 68's room on February 3, 2020, at 10:37 AM revealed dirt and debris along the floor edges to the wall, the base of the resident's tray table by her bed was dusty. A piece of the cove base located to the right interior of the resident's door to her room was pulling from the wall and was full of dust.

An observation of Resident 105's room on February 3, 2020, at 11:11 AM revealed significant marring to the resident's door frame of the room. The floor contained debris buildup at the wall edges to the floor, and around the frame of the bathroom door.

An observation of Resident 65's room on February 3, 2020, at 11:15 AM revealed dirt and debris along the wall edges of the room, a wheelchair in front of the resident's bed contained a cushion with dried food on it, and the wheels and frame of the wheelchair were dirty and dusty.

An observation of Resident 93's room on February 3, 2020 at 12:22 PM revealed dirt and debris under the resident's bed, behind the bed, and along the floor against wall edges throughout the room. Dirt and debris were identified under the unoccupied bed next to the residents. The base of the resident's bedside table was dirty. A tall dresser provided by the facility located in front of the resident's bed contained several unfished edges on the drawers with exposed press board.

An observation of Resident 58's room on February 4, 2020, at 12:13 PM revealed peeling paint on the bathroom door and buildup of dirt and debris along the door jam on the door to the room, and bathroom door. Dirt and debris were observed in the corners inside the door and in front of the closet curtain.

The surveyor reviewed the above findings regarding the environment with the Nursing Home Administrator and Director of Nursing on February 4, 2020, at 1:45 PM.

483.10(i)(1)-(7) Safe/Clean/Comfortable/Homelike Environment
Previously cited 3/8/19

28 Pa. Code 201.18(b)(3) Management
Previously cited 3/8/19

28 Pa. Code 207.2(a) Administrator's responsibility
Previously cited 3/8/19


 Plan of Correction - To be completed: 03/18/2020

F584
1. Marble, Maple, Victoria, Oak Hall, and residents 13, 84, 2, 28, 30, 95, 2, 28, 30, 95, 55, 101, 75, 112, 44, 86, 68, 105, 65, 93, and 58 rooms have been cleaned.
2. Nursing units and resident rooms have been inspected and are routinely being cleaned.
3. Housekeeping and nursing staff have been re-educated on promoting a clean and orderly environment. When areas of dirtiness are revealed cleaning will be completed to eliminate the concern. Facility administration will complete routine environmental rounds to maintain a clean and orderly environment.
4. NHA/designee will audit nursing units and resident rooms to ensure a clean and orderly environment. Results of audits will be reported to QA Committee for review and recommendations.
5. Corrective Action Date: March 18, 2020.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide required notification to a resident whose payment coverage changed for one of three residents reviewed (Resident 92).

Findings include:

A review of the form "Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123," (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed.

Clinical record review for Resident 92 revealed that she was discharged from Medicare part A services on January 8, 2020. Resident 92 remained in the facility.

The facility failed to provide evidence that form CMS-10123 NOMNC was provided to Resident 92 informing her that the effective date her coverage of skilled services would end on January 8, 2020.

The surveyor reviewed the above noted findings for Resident 92 during a meeting with the Nursing Home Administrator, Director of Nursing, and Employee 6 (Assistant Director of Nursing) on February 5, 2020, at 1:45 PM.

28 Pa. Code 201.18(b)(2)(e)(1) Management

28 Pa. Code 201.29(a) Resident rights


 Plan of Correction - To be completed: 03/18/2020

F582
1. Resident 92's form CMS-10123 NOMNC was completed and discussed with resident 92.
2. Current residents that have been discharged from Medicare part A services have been reviewed with appropriate documentation completed.
3. The Medical Record Director has been re-educated on the policy regarding, "Instructions for the Notice of Medicare Non-coverage (NOMNC), to include appropriate signature, notification, and rights related to termination of service.
4. NHA/designee will audit residents discharged from Medicare A services to ensure proper documentation/notifications are complete. Results of audits will be reported to QA Committee for review and recommendations.
5. Corrective Action Date: March 18, 2020.


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