Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS FOR MEMORY CARE AT EASTON, THE
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS FOR MEMORY CARE AT EASTON, THE
Inspection Results For:

There are  86 surveys for this facility. Please select a date to view the survey results.

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GARDENS FOR MEMORY CARE AT EASTON, THE - 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 January 24, 2020, it was determined that The Gardens for Memory Care At Easton, 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 as they relate to the Health portion of the survey process.



 Plan of Correction:


483.10(g)(5)(i)(ii) REQUIREMENT Required Postings:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives:
(i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and
(ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community.
Observations:

Based on observation, resident interview, and staff interview, it was determined that the facility failed to ensure that information regarding how to contact state agencies and advocacy groups, including a statement that the resident may file a complaint with the State Survey Agency, was accessible to all residents.

Findings include:

Observations during the survey January 21, 2020, through January 24, 2020, revealed that informational posters regarding how to contact the Long-Term Care Ombudsman and State Survey Agency, including a statement that the resident may file a complaint, were not accessible to residents. Second and third floor nursing units were secured and information was not posted on either unit. Residents did not have access to posters providing this information that were located in the entryway of the facility.

During the resident council meeting on January 22, 2020, at 10:30 a.m., four of four residents (Residents 10, 12, 21, and 45) were unaware of the Ombudsman program or that a complaint could be filed with the State Survey Agency.

In an interview on January 22, 2020, at 11:30 a.m., the Director of Nursing confirmed that information was not posted on the nursing units.

28 Pa. Code 201.29(i) Resident rights.




 Plan of Correction - To be completed: 02/28/2020

1. The facility has posted the required information on how to contact state agencies/advocacy groups, including information on how the resident may file a complaint with the State Survey Agency.

2. Residents that want to contact state agencies, advocacy groups, or file a complaint with the State agency have the potential to be affected by this alleged deficient practice. These residents will have this contact information posted and accessible to them.


3. Administrative staff will be educated on ensuring information on how to contact state agencies/advocacy groups, including information on how the resident may file a complaint with the State Survey Agency is posted and accessible to residents.

4. DNS/Designee randomly audit postings to ensure that they contain current information on how to contact state agencies/advocacy groups, including information on how the resident may file a complaint with the State Survey Agency and that they are accessible to residents. These audits will be conducted weekly x4, then monthly x 2 or until substantial compliance has been achieved. Results of the audits will be presented to the QAPI committee for review and recommendations

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(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, it was determined that the facility failed to provide a safe, clean, and comfortable environment on one of two nursing units. (Third Floor)

Findings include:

Observations during the initial environmental tour of the third floor nursing unit on January 21, 2020, at 9:46 a.m., revealed the following:

Closet and entrance doors had holes and wood missing in areas of the doors in resident rooms 302, 304, 305, 312, and 314.

Baseboard and heating unit covers were observed with a build-up of dirt and with rust in resident rooms 302, 306, 307, 308, 312, 313, and 314.

Floor tiles in resident room 305 near bed 3 were cracked and lifting from the floor.

Resident room 305 contained a damaged chair with an exposed large black spring.

Resident room 312 had wall molding coming loose near the closet area.

The right side of the doorway to resident room 313 had screws protruding from the plastic molding.

A hole was observed behind the entrance door to resident room 314.

The bathroom in resident room 314 had wall tile missing.

28 Pa. Code 207.2(a) Administrator's responsibility.






 Plan of Correction - To be completed: 02/28/2020

1. Facility addressed build-up of residue in identified areas. Floor tiles were replaced in room 305. Damaged chair removed from 305. Wall molding in room 312 repaired. Protruding screws in 313 doorway repaired. Hole in wall behind door in 314 patched, and the bathroom tile replaced. Order placed to replace damaged doors on unit.
2. Housekeeping department cleaned all facility heating units. Maintenance did full resident room assessments to identify areas in need of repair and developed work orders as necessary.
3. Facility to educate staff on reporting of repair and cleaning needs to resident unit, rooms or furnishings on discovery.
4. Administrator/designee will conduct rounds on nursing units to ensure areas in need of repair or cleaning are being addressed and will facilitate correction of any discovered issue. These audits will be conducted weekly x4, then monthly x 2 or until substantial compliance has been achieved. Results of the audits will be presented to the QAPI committee for review and recommendations.


483.10(c)(2)(3) REQUIREMENT Right to Participate in Planning Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:
(i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.
(ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
(iii) The right to be informed, in advance, of changes to the plan of care.
(iv) The right to receive the services and/or items included in the plan of care.
(v) The right to see the care plan, including the right to sign after significant changes to the plan of care.

483.10(c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-
(i) Facilitate the inclusion of the resident and/or resident representative.
(ii) Include an assessment of the resident's strengths and needs.
(iii) Incorporate the resident's personal and cultural preferences in developing goals of care.
Observations:

Based on clinical record review, resident interview and staff interview, it was determined that the facility failed to ensure that residents were invited to care plan meetings for four of four residents present at the resident council interview. (Residents 10, 12, 21, 45)

Findings include:

During the resident council interview conducted on January 22, 2020, at 10:30 a.m., Residents 10, 12, 21, and 45 reported that they had never been invited to a meeting regarding their care, including establishing the expected goals and outcomes of care. The residents were not aware of the care plan meetings.

Clinical record review revealed that Resident 10's Minimum Data Set (MDS) assessment, dated November 4, 2019, indicated that the resident was oriented and usually understood others. Multidisciplinary care conference notes for meetings conducted May 21, 2019, August 20, 2019, and November 19, 2019, lacked documentation to support that the resident was invited to the care plan meetings.

Clinical record review revealed that Resident 12's MDS assessment, dated November 6, 2019, indicated that the resident was understood and able to understand others. Multidisciplinary care conference notes for meetings conducted July 1, 2019, August 20, 2019, and November 19, 2019, lacked documentation to support that the resident was invited to the care plan meetings.

Clinical record review revealed that Resident 21's MDS assessment, dated November 8, 2019, indicated that the resident was oriented and understood others. Multidisciplinary care conference notes for meetings conducted April 3, 2019, May 14, 2019, November 19, 2019, and November 26, 2019, lacked documentation to support that the resident was invited to the care plan meetings.

Clinical record review revealed that Resident 45's MDS assessment, dated November 19, 2019, indicated that the resident was oriented and understood others. Multidisciplinary care conference notes for meetings conducted May 21, 2019, July 23, 2019, August 20, 2019, November 19, 2019, and December 3, 2019, lacked documentation to support that the resident was invited to the care plan meetings.

In an interview on January 24, 2020, at 1:05 p.m., the Administrator confirmed that Residents 10, 12, 21, and 45 had not been invited to care plan meetings.

28 Pa. Code 211.11(e) Resident care plan.






 Plan of Correction - To be completed: 02/28/2020

1. All residents are now being invited to their care plan meetings.

2. Residents having a care plan meeting have the potential to be affected by this alleged deficient practice. These residents will be invited to participate in their care plan meeting.

A house wide audit was conducted of current scheduled care plan meeting to ensure that residents have been invited.

3. The interdisciplinary team will be in-serviced on ensuring all residents are invited to scheduled care plan meetings.

4. The RNAC or designee will randomly audit care plan meeting schedules to ensure that residents have been invited. These audits will be completed weekly x 4 weeks, and then monthly x 2 months or until substantial compliance has been achieved. Results of the audits will be presented to the QAPI committee for review and recommendations

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(g)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide enteral nutrition (delivery of nutrition by a feeding tube) in accordance with the dietitian's recommendation and the physician's order for one of 23 sampled residents. (Resident 93)

Findings include:

Clinical record review revealed that Resident 93 had diagnoses that included Parkinson's disease and dysphagia. The resident received nutrition through oral intake in addition to enteral nutrition via a feeding tube inserted into the stomach (gastrostomy tube).

On November 7, 2019, the dietitian recommended administering 240 milliters of supplemental feeding via a feeding tube if the resident consumed less than 50% of a meal due to variable oral intake and a history of weight loss.

A review of the Medication Administration Record (MAR) for December 26, 2019, revealed that a supplemental feeding was administered three times, at 9:00 a.m., 1:00 p.m. and at 7:00 p.m., however, a review of meal completion documentation revealed only one entry for the day where the resident consumed 26-50%, justifying the need for the supplemental feeding.

A review of the MAR for January 12, 2020, revealed that a supplemental feeding was administered twice at 1:00 p.m. and 6:00 p.m., however, a review of meal completion documentation revealed only one entry for the day where the resident consumed 0-26%, justifying the need for the supplemental feeding.

In an interview on January 24, 2020 at 9:40 a.m., the Dietitian confirmed the supplemental feeding was documented as being administered at times not consistent with the physician's order.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 2/13/19























































 Plan of Correction - To be completed: 02/28/2020

1. Dietitian reviewed and clarified order for supplemental feedings.
2. Residents receiving enteral nutrition have the potential to be affected by this alleged deficit practice. These residents will have their dietitian recommendations and MD orders followed.
A house wide audit was conducted on residents receiving enteral nutrition to ensure their dietitian recommendations and MD orders are being followed.
3. Licensed Nursing staff will be re-educated on ensuring residents receiving enteral nutrition have their dietitian recommendations and MD orders followed.
4. Dietitian/designee will randomly audit residents on enteral nutrition to ensure the dietitian recommendations and MD orders are being followed. These audits will be conducted weekly x4, then monthly x 2 or until substantial compliance has been achieved. Results of the audits will be presented to the QAPI committee for review and recommendations

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(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 clinical record review and a review of facility documentation, it was determined that the facility failed to ensure that the environment remained free of accident hazards and that residents received adequate interventions to prevent accidents for one of 23 residents. (Resident 26).

Findings include:

Clinical record review revealed that Resident 26 had a history of long term inpatient psychiatric admission and diagnoses that included unspecified dementia, anxiety disorder, suicide attempt, major depressive disorder and unspecified psychosis. The Minimum Data Set (MDS) assessment dated November 13, 2019, indicated the resident was cognitively impaired and was able to move about independently. Observation of Resident 26 on January 25, 2020, at 12:05 p.m., revealed that the residents was able to self propel in a wheelchair.

Review of nursing documentation dated November 13, 2019, at 9:32 a.m., revealed Resident 26 had grabbed a nurse's stethoscope from her hand and placed the stethoscope around his neck. Resident 26 was transferred to the hospital for evaluation and treatment of the behavior. Resident 26 had returned to the facility the same day at 8:20 p.m., pending transfer to a Behavioral Hospital. On November 14, 2019 at 1:35 a.m., it was documented that Resident 26, had attempted to tighten the ties on the hospital gown he had been wearing around his neck. On November 14, 2019, at 5:18 a.m., Resident 26 was transferred and admitted to a behavioral hospital for inpatient treatment of unsafe behaviors.

On November 19, 2019 Resident 26 returned to the facility. There was no documented evidence in clinical record that the facility assessed the resident for the need for additional safety measures or increased supervision upon return to the facility in light of the resident's two documented incidents of using objects in his environment to harm himself.


28 Pa. code 211.12 (d)(1)(5) Nursing Services
Previously cited 2/13/19

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










 Plan of Correction - To be completed: 02/28/2020

Plan of Correction:




1. Facility confirmed physician assessment from time of event Resident 26 deemed not suicidal.

2. Residents with a history of suicidal ideations have the potential to be affected by this alleged deficient practice. These residents will not have access to items in their environment to attempt to harm themselves.

House wide audit was conducted on residents with suicidal ideations to ensure their environment is free of items that could be utilized to attempt to harm themselves.

3. Staff educated on ensuring residents with a history of suicidal ideations have an environment that is free of items that could be utilized to attempt to harm themselves.

4. SS/designee will conduct random observations of residents with suicidal ideations environment to ensure it is free of items that could be utilized to harm themselves. These audits will be conducted weekly x4, then monthly x 2 or until substantial compliance has been achieved. Results of the audits will be presented to the QAPI committee for review and recommendations.


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

Based on clinical record review and observation, it was determined that the facility failed to provide nail care to residents requiring assistance with grooming and personal hygiene for three of 23 sampled residents.
(Residents 1, 2, 24)

Findings include:

Clinical record review revealed that Resident 1 had diagnoses that included dementia with behavioral disturbance and paranoid schizophrenia. The Minimum Data Set (MDS) assessment dated January 7, 2020, indicated that the resident required extensive staff assistance with personal hygiene. Review of the current care plan identified that the resident had activities of daily living self-care deficits and required staff to provide nail care weekly and as needed. Observation on January 21, 2020, at 10:15 a.m. and on January 22, 2020, at 11:00 a.m., revealed R1's fingernails were long, jagged and the nail beds were dirty.

Clinical record review revealed that Resident 2 had diagnoses that included schizophrenia, depression and Psoriasis (flaky, red or white scaly patches on your skin). The MDS assessment dated November 2, 2019, indicated that the resident required limited staff assistance with personal hygiene. Review of the current care plan identified that the resident had activities of daily living self-care deficits and required staff to "check nail length and trim and clean on bath day and as necessary". Observation on January 21, 2020, at 10:45 a.m. and on January 22, 2020, at 12:30 p.m., revealed R 2's fingernails were long, jagged and the nail beds were dirty; the resident was also observed scratching his white scaly patched elbows with his unclean fingernails.

Clinical record review revealed that Resident 24 had diagnoses that included Alzheimer's disease, depression, and diabetes. The MDS assessment dated November 12, 2019, indicated that the resident required extensive staff assistance with personal hygiene. The care plan reflected that the resident had activities of daily living self-care deficits related to cognitive deficits and directed that the resident receive nail care weekly and as needed. On January 21, 2020, at 10:06 a.m., the resident was observed with long fingernails.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 2/13/19








 Plan of Correction - To be completed: 02/28/2020

1. The facility provided nail care to identified residents.
2. Residents that require assistance with grooming and personal hygiene have the potential to be affected by this alleged deficint practice. These residents will have their nail care provided.
A house wide audit of residents nail care has been conducted to ensure it has been provided..
3. Nursing Staff will be educated on nail care policy.
4. DNS/Designee will randomly audit residents that require assistance with grooming and personal hygiene to ensure nail care compliance. These audits will be conducted weekly x4, then monthly x 2 or until substantial compliance has been achieved. Results of the audits will be presented to the QAPI committee for review and recommendations.

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 clinical record review, observation and resident interview, it was determined that the facility failed to implement a care plan and interventions for one of 23 sampled residents. (Resident 2)

Findings included:

Clinical record review revealed that Resident 2 had diagnoses that included Psoriasis (flaky, red or white scaly patches on your skin). Observation on January 21, 2020, at 10:45 a.m., and January 22, 2020, at 12:37 p.m., revealed that Resident 2 had bilateral elbow Psoriasis and the resident stated it was "itchy". There was a physician's order dated June 26, 2019, for a dermatology consultation related to Psoriasis . Review of the current care plan revealed the resident was to remain free from skin complications, to consult dermatology as ordered and to notify the physician for observed adverse reactions. There was no documentation to support that dermatology or the physician had been notified regarding the resident's current skin complications as care planned.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 2/13/19















 Plan of Correction - To be completed: 02/28/2020

1. Facility contacted dermatologist and the resident's appointment previously scheduled for February 4, 2020 was not changed. Special soap ordered by medical team and care plan updated with same.
2. Residents with a dermatology consult ordered have the potential to be affected by this alleged deficint practice. These resident will have their dermatologist or physician contacted regarding skin complications as per MD orders.
A house wide audit was completed on residents with dermatology consults to ensure their MD has been notified if there have been skin complications as per their md orders.
3. Licensed staff will be re-educate on ensuring that residents with dermatology consults have notifications completed to their MD's if they are experiencing skin complications as per MD orders.
4. DNS/Designee will conduct random audits of medical records for residents with dermatology consults to ensure to ensure their MD has been notified if there have been skin complications as per their md orders. These audits will be conducted weekly x4, then monthly x 2 or until substantial compliance has been achieved. Results of the audits will be presented to the QAPI committee for review and recommendations.


483.12(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 facility policy review, clinical record review and staff interview, it was determined that the facility failed to notify the facility administrator and report an incident of sexual abuse to officials in accordance with State law, including to the State Agency and the Adult Protective Services for one of 23 sampled residents (Resident 68)

Findings include:

A review of the facility policy entitled "Abuse Protection", dated January 1, 2020, indicated that the reporting of all alleged violations involving abuse, neglect, exploitation or mistreat including injuries of unknown origin and misappropriation of resident property were to be reported immediately to the state agency and local law enforcement entity, but no later than two hours after the allegation if the events that cause the allegation involve abuse or serious bodily injury.

Clinical record review revealed Resident 68 had a documented incident dated August 23, 2019, that staff observed Resident 68 with his mouth on an unidentified female peers right breast. There was no documentation completed by the facility to support that the State Agency or Adult Protective Services was notified of incident.

In an interview on January 24, 2019, at 11:00 a.m., the Director of Nursing indicated that there was no documentation to support that the State Agency or Adult Protective Services had been notified of the incident.

28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29(i) Resident rights













 Plan of Correction - To be completed: 02/28/2020

1. Facility failed to report the identified behavior.
2. Residents involved with alleged abuse allegations have the potential to be affected by this alleged deficient practice. These residents will have their abuse reported to the Administrator and appropriate state agencies.
House wide audit of abuse allegations from 1/1/20 to current has been conducted to ensure all appropriate notifications have been completed.
3. Administrator and DNS will be re-educated on ensuring all allegations of abuse are reported to the Administrator and appropriate state agencies.
4. DNS/Designee will randomly audit allegations of abuse to ensure that the Administrator and appropriate state agencies have been notified. These audits will be conducted weekly x4, then monthly x 2 or until substantial compliance has been achieved. Results of the audits will be presented to the QAPI committee for review and recommendations.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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 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 policy review, clinical record review, and staff interview, it was determined that the facility failed to prevent resident to resident sexual abuse and ensure that a resident was free from abuse for one of 23 sampled residents. (Resident 8)

Finding include:

A review of the facility policy entitled "Abuse Protection," dated January 1, 2020, revealed that each resident has the right to be free from abuse that included sexual abuse.

Clinical record review revealed that Resident 8 was admitted to the facility on September 9, 2016, with diagnoses that included Alzheimer's disease, psychotic disorder with delusions, major depressive disorder, and schizoaffective disorder. Review of Resident 8's Minimum Data Set (MDS) assessment completed August 6, 2019, revealed that the resident's cognition was severely impaired.

Clinical record review revealed that Resident 68 was admitted to the facility on July 5, 2019 with diagnoses that included Alzheimer's disease, anxiety disorder, and depression. Review of Resident 68's MDS assessment completed August 2, 2019, revealed that his cognition was severely impaired.

On January 1, 2020 at 2:50 p.m., staff (CNA 1) witnessed the accused, Resident 68, holding Resident 8's head down on his penis as she performed oral sex. CNA 1 stated that she observed Resident 68 sitting on the bed with his "boxers" below his knees and Resident 8 was bent over him with her mouth on top of his erect penis and her hands were on his knees. Resident 68 had one hand on top of Resident 8's head, holding her head down with his other hand braced on the bed. CNA 1 stopped and removed Resident 8 from the room and notified the supervisor.

In an interview on January 24, 2020, at 1:05 p.m., the Director of Nursing confirmed that the facility failed to ensure that Resident 8 was free from sexual abuse.

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

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 2/13/19



















 Plan of Correction - To be completed: 02/28/2020

Plan of Correction:

1. Facility immediately separated residents at time of discovery and placed both on 1:1 observation. Resident 68 was evaluated by medical doctor and medication adjusted to address behaviors.
2. All residents have the potential to be affected by this alleged deficient practice. These residents will be free from abuse.
A house wide audit was conducted on residents exhibiting inappropriate sexual behaviors and their care plans have been updated to reflect appropriate interventions.
3. Staff will be re-educated on the Abuse policy and specifically identifying residents with inappropriate sexual behaviors to ensure their care plans have been updated to reflect appropriate interventions.
4. DNS/Designee will randomly audit residents with inappropriate sexual behaviors noted to ensure their care plans have been updated to reflect appropriate interventions. These audits will be conducted weekly x4, then monthly x 2 or until substantial compliance has been achieved. Results of the audits will be presented to the QAPI committee for review and recommendations.

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483.10(g)(10)(11) REQUIREMENT Right to Survey Results/Advocate Agency Info: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(g)(10) The resident has the right to-
(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and
(ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.

483.10(g)(11) The facility must--
(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility.
(ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and
(iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.
(iv) The facility shall not make available identifying information about complainants or residents.
Observations:

Based on observation, staff interview, and resident interview, it was determined that the facility did not post Department of Health survey results with plan(s) of correction in a place readily accessible to residents and family members.

Findings include:

Observations January 21, 2020, through January 24, 2020, in both first and second floor secured nursing units revealed that survey results were not available on either unit.

During the resident council meeting on January 22, 2020, at 10:30 a.m., four of four residents (Residents 10, 12, 21, 45) reported that they were unaware of the location of Department of Health survey results.

During an interview on January 22, 2020, at 11:30 a.m., the Director of Nursing (DON) confirmed that survey results were kept in the DON's office; not readily accessible to residents and family members.

28 Pa. Code: 201.29(i) Resident rights.



















 Plan of Correction - To be completed: 02/28/2020

1. The Department of Health Survey results with plans of correction in a place have been posted in a new location and are readily accessible to residents and family members.
2. Residents that would like to review Facility Survey results with plans of correction have the potential to be affected by this alleged deficient practice. These residents will have the results readily accessible.

3. Administrative staff have been educated on the updated location of the Department of Health Survey results and ensuring they are readily accessible to residents.

4. DON/designee will audit the Department of Health Survey results postings to ensure they are readily accessible to residents and family members. These audits will be conducted weekly x4, then monthly x 2 or until substantial compliance has been achieved. Results of the audits will be presented to the QAPI committee for review and recommendations..


201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to report a hospital transfer to the Division of Nursing Care Facilities Field Office for one of 23 residents. (Resident 26).

Findings included:

Clinical record review revealed that Resident 26 had a history of long term inpatient psychiatric admission and diagnoses that included unspecified dementia, anxiety disorder, suicide attempt, major depressive disorder and unspecified psychosis. The Minimum Data Set (MDS) assessment dated November 13, 2019, indicated the resident was cognitively impaired and the able to move about independently with no physical behavioral symptoms directed towards self or others.

Review of nursing documentation dated November 13, 2019, at 9:32 a.m., revealed that Resident 26 had grabbed a nurse's stethoscope from her hand and placed it around his neck. Resident 26 was transferred to the hospital for evaluation and treatment of the behavior.

There was no documentation that the facility had notified the State Agency of the incident. In an interview on January 23, 2020 at 2:00 p.m., the Administator and Director of Nursing confirmed the facility had not informed the State Agency of the hospital transfer.




 Plan of Correction - To be completed: 02/28/2020

1. Facility failed to report the identified behavior..
2. Residents requiring a hospital transfer have the potential to be affected by this alleged deficient practice. These residents will have the transfer reported appropriately.
A house wide audit of hospital transfers from 1/1/20 to current was conducted to ensure that applicable transfers were reported as required.
3. Licensed Nursing staff will be re-educated on ensuring that residents requiring a hospital transfer are reported to the Division of Nursing Care Facilities Field Office as required.
4. DNS/Designee will randomly audit hospital transfers to ensure that they are being reported as required to Division of Nursing Care Facilities Field Office. These audits will be conducted weekly x4, then monthly x 2 or until substantial compliance has been achieved. Results of the audits will be presented to the QAPI

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