Nursing Investigation Results -

Pennsylvania Department of Health
RIVER'S EDGE REHABILITATION & HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
RIVER'S EDGE REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

There are  75 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.
RIVER'S EDGE REHABILITATION & HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to one complaint, completed on September 3, 2019, it was determined that River's Edge Rehabilitation and Healthcare Center, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.















 Plan of Correction:


483.60 REQUIREMENT Provided Diet Meets Needs of Each Resident:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60 Food and nutrition services.
The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.
Observations:

Based on interviews with residents, observations and reviews of facility menus, it was determined that the facility failed to plan and serve satisfying foods taking in consideration residents preferences for eight of 49 residents reviewed. Residents (R60, R71, R27, R100, R104, R24, R61 and R13)


Findings include:

A review of the food committee minutes for June 27, 2019 and July 25, 2019 revealed that the residents participating in these meetings were unsatisfied with many of the foods being served and wanted the menus to be adjusted to reflect foods that they enjoyed eating and drinking. The food committee meetings were held with Employee E8, food service supervisor. The residents reported that the were interested in a certain brand of iced tea that they were accustomed to on the menu. Employee E8, reported that the facility could not get this brand; however there was no resolution offered or documented to this resident concern. The residents reported that they liked the "cheerios" brand of cold cereal for the breakfast menu. The residents were told that the facility had decided to use a less expensive cold cereal. The residents said that the menu deli meats (ham and turkey) were too salty. The food service supervisor failed to respond to the residents concerns about the deli meats. The residents were requesting that Hebrew national hot dogs be added to the menu. The food service supervisor did not respond to the residents concerns. The residents requested that chipped beef be added to the menus, because this was a popular food item that the residents enjoyed. The food service supervisor responded to the residents that the vender the facility uses does not carry this menu item. Residents requested that stuffed peppers, baked potatoes, baked sweet potatoes potato cakes and corn fritters be added to the menus. There was no response from the food service supervisor related to the menu suggestions made by the residents. The residents asked to have home-made chocolate brownies and blue berry muffins added to the menus. There was no documented response from the food service supervisor related to the residents request.

Interview with seven residents (R100, R61, R13, R60, R71, R24, and R27) at the group meeting held on August 28, 2019 at 10:00 a.m., revealed that the residents were not satisfied with the facility's menus and food preparation. The residents indicated that they felt the dietitian should change the menu to reflect their food preferences. Residents reported that they have not been consistently getting ice cream or flavors that they liked. The residents stated that they rarely get fresh fruit although it was listed on the menus every day. The residents reported that they would prefer waffles for breakfast more often. Additionally, the residents indicated that they wanted more breakfast meats and that they preferred (bacon and scrapple). The residents further reported that the iced tea that they wanted had been removed from the menus.

Interview with Resident R60 on August 27, 2019 at 1:10 p.m., revealed that residents receive the same foods over and over and that are quite bland tasting. The resident reported that the facility "really should know what foods I like and don't like by now." The resident also had one request, for a steak and mashed potatoes once a year.

Review of the clinical record for Resident R60 revealed that the resident was alert and oriented. According to the physician's orders for August, 2019, Resident R60 was ordered a Regular diet with thin liquids.

Resident R104 reported during an individual interview on August 27, 2019 that the resident receives foods from her family member; because she can't get the food and nutrition department to make regular jello and rice pudding. Review of physician's orders for Resident R104 dated August, 2019 revealed that the resident was ordered a regular diet with chopped meats and thin liquids. Further review of the clinical record indicated that Resident R104 was alert and oriented.

Resident R24 reported during an individual interview on August 27, 2019 that the facility does not serve gravy with foods. The resident reported requesting gravy over and over again. The resident said it was useless reporting food preferences "no one listens." The resident also has requested to have cold cereal for breakfast. Resident R24 said that the cold cereal requested was rice crispies not corn flakes. The resident reported that it was a constant kitchen mistake serving corn flakes or hot cereal instead of the cereal preferred by the resident. According to the physician's orders for August, 2019, Resident R24 was ordered a dental soft diet with thin liquids. Clinical record review indicated that Resident R24 was alert and oriented.

Interview with the food service supervisor, Employee E8 and the dietitian, Employee E9 at 2:00 p.m., on August 28, 2019 confirmed that the resident's food preferences for the menus had not been added to the facility's menus.

The facility failed to serve food in accordance with residents preferences.

28 Pa. Code: 211.6(b)(d) Dietary services

28 Pa. Code: 201.29(a)(j) Resident rights















 Plan of Correction - To be completed: 10/25/2019

Residents R60, R71,R27, R100, R104, R24, R61, R13 were surveyed to discuss preferences and concerns.

All residents will be given the opportunity by the monthly Food Committee meeting to discuss their personal preferences.
The Food Service Director will respond to all resident concerns and the response will be detailed in the Food committee minutes.
The Dietitian or designee will conduct random audits to ensure residents satisfaction with the meals accommodating their personal preferences. This will be done weekly for the first 4 weeks and then monthly for the next 3 months.
Results of audits will be shared with the monthly Qapi meeting and then reviewed by the quarterly Quality Assurance Committee which will make recommendations based on the outcome of the audits.The administrator will monitor performance to ensure sustainable solutions for ongoing compliance.

483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions: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) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.
Observations:

Based on a review of clinical records and resident and staff interviews, it was determined that the facility failed to ensure that residents were informed of changes in their treatment for one of 49 resident records reviewed (Resident R61).

Findings include:

A review of the facility's policy "Resident/Patient Bill of Rights," undated, stated that the resident has the right to be fully informed in advance about the care and treatment received and be fully informed in advance of any changes in treatment.

Interview with Resident R61 on August 28, 2018 at approximately 10:30 p.m. revealed that her stomach medication (Protonix) was taken away and no one told her until she became sick.

Review of Resident R61's July 2019 physician's orders revealed that the medication Pantoprazole (Protonix) 40 milligrams (mg) to be taken daily was discontinued and the dosage decreased to 20 mg on July 11, 2019.

Further review of Resident R61's clinical record revealed no documented evidence that the resident had been notified of the change in her medication dosage.

Interview with the Director of Nursing on August 29, 2019 at approximately 2:00 p m., confirmed that the facility failed to ensure that the resident's right to be informed of changes in her treatment plan was honored.


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







 Plan of Correction - To be completed: 10/25/2019

R61 was fully informed of the risk/benefit of the change in her Protonix dose on 7/19/19.
A review was immediately completed of all residents that received treatment changes in the past 30 days. Per this review, all residents/resident representatives were informed of changes in their treatments. Resident/Patient Rights has been reviewed and updated.
All Nursing staff will be re-educated regarding the policy and procedure requiring all resident/resident representatives to be informed in advance of a change in treatment plan and required documentation. treatments. The Director of Nursing or designee will perform 5 random audits of new or changed resident treatment orders confirming that residents were informed.
This will be done weekly for the first 4 weeks and then monthly for the next 3 months.
Results of audits will be shared with the monthly Qapi meeting and then reviewed by the quarterly Quality Assurance Committee which will make recommendations based on the outcome of the audits.The administrator will monitor performance to ensure sustainable solutions for ongoing compliance.
483.10(j)(1)-(4) REQUIREMENT Grievances:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

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

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

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

Based upon observation and interviews with residents and staff, it was determined that the facility failed to establish a grievance policy, failed to display in a prominent locations the residents' right to voice a grievance, how to file a grievance and the contact information of the facility's grievance official with six of forty-nine residents interviewed, (Resident R13, R27, R60, R61, R71 and R100).

Findings include:

A review of facility policy "Resident/Patient Bill of Rights," undated, stated that the resident has the right to object to any treatment or care which has been furnished as well as that which has not been furnished with the assurance that there will be no reprisals or voicing a grievance.

Observation of the facility throughout all the days of the survey, revealed that the facility failed to prominently post throughout the facility the residents' rights related to filing a grievance, including instructions on how to file a grievance as well as the facility's grievance official's contact information.

A group interview conducted with six residents (Resident R13, R27, R60, R61, R71 and R100) on August 28, 2019, at approximately 10:00 a.m. revealed that all six residents indicated that they did not know how to file a grievance if they chose to do so.

Interview with the Nursing Home Administrator on August 29, 2019 at approximately 1:30 p.m. revealed that the facility had not developed a grievance policy. Further interview with the administrator confirmed that the facility failed to place the grievance postings throughout the facility as required.

The facility failed to establish a grievance policy and failed to post information related to the residents' right to file a grievance.

28 Pa. Code: 201.29(a)(b)(c)(i)(j) Resident rights




 Plan of Correction - To be completed: 10/25/2019

The facility established a grievance policy.
Residents R13 ,R27, R60 ,R61, R71 and R100 were informed of this policy and their right to voice a grievance and the process to file a grievance as well as the contact information of the facilities grievance official.
Signs were posted in prominent locations throughout the facility detailing residents right to voice a grievance as well as the process needed to file a grievance.

Residents will be educated on the process of filing a grievance upon admission and by quarterly care conferences as well as during monthly Resident Council meetings.

The Social Service Director or designee will interview random residents to ensure they are aware of the grievance process.
This will be done weekly for the first 4 weeks and then monthly for the next 3 months.
Results of audits will be shared with the monthly Qapi meeting and then reviewed by the quarterly Quality Assurance Committee which will make recommendations based on the outcome of the audits.The administrator will monitor performance to ensure sustainable solutions for ongoing compliance.

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, review of facility policy and procedure and interview with staff, if was determined the facility failed to develop a comprehensive person-centered care plan for two of 49 residents reviewed (Resident R263 and Resident R61).

Findings include:

Review of Resident R263's August 2019 physician's orders revealed an admission date of August 12, 2019 with diagnoses of Stage IV lung cancer, Chronic Obstructive Pulmonary (COPD - progressive lung disorder characterized by increasing breathlessness) an order for continuous oxygen and the use of the an antibiotic medication Levofloxacin 500 milligrams (mg) taken daily for 21 days for an upper respiratory disease.

Review of Resident R263's care plan revealed the facility failed to develop a comprehensive care plan related to the resident's diagnoses of Lung Cancer, COPD, and the treatments for his respiratory needs.

Further review of Resident R263's physician's orders revealed a diagnosis of depression. The resident was ordered on August 23, 2019 the antidepressant medication Mirtazapine 7.5 mg, 15 mg daily daily for 7 days. Review of the resident's current care plan revealed that there was no care plan developed to address Resident R263's depression.

Interview with the Director of Nursing confirmed on August 29, 2019 at approximately 2:00 p.m., confirmed that the facility failed to develop a comprehensive person-centered care plan to meet Resident R263's needs.

A review of facility policy, "Mood and Behavioral Policy and Procedure" dated 3/2019, stated that the facility promotes and supports a resident centered approach to care regarding mood and behavioral health services to attain of maintain the highest practicable wellbeing in accordance with the comprehensive assessment and plan of care. It encompasses a resident's whole emotional and mental well-being, therefore an individualized approach to care is essential. The policy defines behavior as symptoms that may potentially be harmful to a resident.

Review of Resident R1's clinical record revealed that the resident was admitted to the facility on October 27, 2018 with diagnoses that included depression and anxiety. A review of the resident's nursing note dated November 1, 2018 revealed that prior to admission, the resident attempted suicide three times that year and had two inpatient stays at a psychiatric hospital.

Review of Resident R61's care plan for depression and/or anxiety did not include any information related to the resident's previous suicide attempts and/or any interventions developed related to the need to monitor the resident for for signs and symptoms of suicidal idealizations.

Interview with the Director of Nursing confirmed on August 29, 2019 at approximately 2:00 p.m. confirmed that the facility failed to develop a comprehensive person-centered care plan to address Resident R263's suicidal ideation.

The facility failed to develop a comprehensive care plan for Resident R61 related to the resident's history of suicide attempts.

28 Pa. Code 211.11(a)(b)(c)(d) Resident care plan
Previously cited 12/20/2018

28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing services
Previously cited 12/20/2018












 Plan of Correction - To be completed: 10/25/2019

R263 has been discharged from the facility
R61's comprehensive person-centered care plan has been updated to address the past hx of suicide attempts and interventions that include assessments for signs and symptoms of suicidal ideation.
All residents have had a review of their comprehensive care plan and updated to include person centered care services and care needs.The policy and procedure: Care plans have been reviewed and updated. All Interdisciplinary Team staff will be re-educated on the policy and procedure: Development and Implementation of the resident's person-centered comprehensive care plan based upon the resident's comprehensive assessment.
The Director of Nursing or designee will audit 5 random resident comprehensive care plans to ensure they are comprehensive and patient centered. Any missing elements of the comprehensive care plan will be corrected at that time of the audit. This will be done weekly for the first 4 weeks and then monthly for the next 3 months.
Results of audits will be shared with the monthly Qapi meeting and then reviewed by the quarterly Quality Assurance Committee which will make recommendations based on the outcome of the audits.The administrator will monitor performance to ensure sustainable solutions for ongoing compliance.
483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary: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(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of 483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
Observations:

Based on review of clinical records, facility documentation, and interviews with staff, it was determined that the facility failed to complete a discharge summary for one of four residents reviewed. (Residents R156).

Findings include:

Clinical record review for Resident R156 revealed that the resident was admitted to the facility on June 26, 2019 and discharged from the facility on June 26, 2019.

Review of nursing progress note for R156 dated June 26, 2019 at 11:25 p.m., indicated "The resident was admitted this evening by EMT and family present. Charge nurse attempted to monitor vital signs and do skin assessment. The resident became combative with staff and unable to redirect." The progress note continued to state that Resident
R156 had a fall out of the bed. The physcian ordered that the resident be send to the hospital emergency room for treatment and evaluation.

Review of the physician discharge summary for Resident R156 revealed that, in the discharge summary dated June 30, 2019, the lines for Admission Date, Discharge Date, Reason for Admission, Patient Clinical and Laboratory Findings, Course and Treatment in Facility, Condition on Discharge, Instructions, Final Diagnosis, Rehabilitation Potential, and Prognosis were left blank; except for a note which read " Patient returned to hospital before attendee was able to examine her."

Interview with the Director of Nursing, Employee E2, at approximately 3:00 p.m., on August 30, 2019, confirmed that the facility failed to complete R156's Physician Discharge Summary for the closed record review concluded on August 30, 2019.

The facility failed to complete a discharge summary for one of four residents' records reviewed.

28 Pa. Code: 211.5(d) Clinical records















 Plan of Correction - To be completed: 10/25/2019

R156 has been discharged from the facility. All residents discharged from the facility require a discharge summary.
Discharge Summary/Physician has been reviewed and updated. Attending physicians will be re-educated on the Clinical Record Discharge Summary requirement.
The Medical Records Director will audit all resident discharge records for the completion of a physician discharge summary. Any missing physician discharge summaries will be reported to the Medical Director for corrective action.
Results of audits will be shared with the monthly Qapi meeting and then reviewed by the quarterly Quality Assurance Committee which will make recommendations based on the outcome of the audits.The administrator will monitor performance to ensure sustainable solutions for ongoing compliance.
483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities: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) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

483.24(b)(2) Mobility-transfer and ambulation, including walking,

483.24(b)(3) Elimination-toileting,

483.24(b)(4) Dining-eating, including meals and snacks,

483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
Observations:

Based on clinical record review and interviews with staff, it was determined that the facility failed to ensure that one of 49 residents reviewed received the appropriate treatment and services to maintain and/or improve mobility related to ambulation (Resident R36).

Findings include:

Review of the comprehensive Minimum Data Set (MDS- resident assessment of care needs) dated January 11, 2019 indicated that Resident R36 required the physical assistance of one person to walk in the corridor.

Review of the physical therapy assessment for Resident R36 dated January 3, 2019 through February 1, 2019 indicated that Resident R36 received skilled physical therapy to assess the resident's ambulation ability. The physical therapist developed a restorative nursing program for the ambulation needs of Resident R36. The physical therapist indicated that Resident R36 was able to walk a distance of 10 to 49 feet with partial/moderate assistance from staff.

Continued review of Resident R36's clinical record revealed no documented evidence that a restorative ambulation program had been initiated to meet the resident's ambulation needs (walking).

Interview with Employee E10, licensed nurse on August 29, 2019. at 9:30 a.m. confirmed that a restorative ambulation program had not been provided to Resident R36 for February, March, April, May, June, July and August, 2019

The facility failed to ensure that one resident received the necessary care and services to maintain and improve their abilities for activities of daily living related to mobility.


28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
Previously cited 12/20/2018

28 Pa. Code 211.11(a)(b) Resident care plan
Previously cited 12/20/2018








 Plan of Correction - To be completed: 10/25/2019

R36 is currently on a restorative program for ambulation and Active Range of Motion and participates consistent with her choices. All refusal of treatment will be documented.
A review was completed of all residents that have orders for a restorative program are being treated and care planned.
Restorative Nursing Program has been reviewed and updated. All nursing staff will be re-educated on the policy/procedure and required documentation.Weekly, the rehabilitation director or designee will submit all new restorative nursing referrals to the Director of Nursing or the designee for tracking residents on program. Monthly for 90 days, the DON/or nurse designee will audit and complete a Restorative progress tracking report to ensure the facility is providing necessary care and services to restore/maintain each resident's ADL.
Results of audits will be shared with the monthly Qapi meeting and then reviewed by the quarterly Quality Assurance Committee which will make recommendations based on the outcome of the audits.The administrator will monitor performance to ensure sustainable solutions for ongoing compliance
483.25 REQUIREMENT Quality of 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.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on observation, review of clinical records, review of hospital records, and review of facility policies and interviews with staff, it was determined that the facility failed to ensure that one resident was transferred to the hospital in a timely manner (Resident R155). Additionally, the facility failed to follow and/or clarify physician's orders for three of forty-nine residents reviewed (Residents R36, R263, R265).

Findings include:

Review of facility policy "Neurological Observation," dated February 21, 2013, revealed that neurological observations were "... a systematic organized assessment of neurological status following head trauma ...." The policy further indicated that "... Elevated blood pressure may indicate increased intracranial pressure and may indicate an emergency situation. Note any deviation from baseline blood pressure. ... and "notify MD (physician) of significant changes or abnormalities."

A review of an article "Vital Signs' by the Cleveland Clinic, dated reviewed January 23, 2019, revealed "Blood pressure is the measurement of the pressure or force of blood against the wall of the arteries. ... Healthy blood pressure for an adult , relaxed at rest, is considered to be a reading of less 120/80 mm Hg (millimeters of Mercury). ... Hypertension (high blood pressure) is considered to be a reading of 140/90 mm Hg or higher. Blood pressure that remains high for an extended period of time can result in such health problems as atherosclerosis (hardening of the arteries), heart failure and stroke."

Review of the clinical record for Resident R155 revealed a quarterly Minimum Data Set (MDS- assessment of resident care needs) dated May 2, 2019 which revealed a BIMS score of 15; indicating that the resident was alert and oriented and independent with cognitive function. Further review of the clinical record revealed that the resident had been readmitted into the facility on May 16, 2019, at approximately 3:15 p.m. following an inpatient hospital stay. Review of facility documentation revealed that at approximately 5:30 p.m. Resident R155 was found on the floor by her bed. Further review of the progress notes indicated that the resident reported to staff that she had hit her forehead when she fell.

Interview with Employee E6, registered nurse, on September 3, 2019, at 9:00 a.m., confirmed that Resident R155 was found directly on the the floor, following her fall on May 16, 2019, and that the floor was not padded.

Review of Resident R155's progress note dated May 16, 2019 revealed a blood pressure reading of 194/113 (normal blood pressure 120/80) for the resident immediately following her fall on May 16, 2019. Continued review of the Neurological Observation Record for Resident R155 revealed the following abnormal blood pressure recordings following the resident's fall on May 16, 2019: at 5:15 p.m.-150/108, at 5:30 p.m.- 154/109, at 5:45 p.m.- 162/106, at 6:00 p.m..

Review of progress notes dated May 16, 2019 at 6:17 p.m. revealed that the resident's physician was notified of the resident's fall and ordered an xray of the hip and vital signs in a half hour from the time of the phone call.

Review of the "Neurological Observation Record", dated May 16, 2019 revealed at 7:00 p.m. the resident's blood pressure was 176/84, at 7:30 p.m. the resident's blood pressure was 182/78 and at 8:00 p.m. the resident's blood pressure was 186/74. Review of progress notes revealed that the physician was not notified of the resident's continued blood pressure elevations until 9:45 p.m.. At this time the resident's blood pressure was 151/104. The physician's response to the nurse on May 16, 2016 was "administer pain meds."

At 10:00 p.m., on May 16, 2019 the resident's blood pressure was 180/100 which continued to be elevated for the resident. There was no evidence that the physician was informed of the elevated blood pressure and pulse readings until 11:01 p.m.; one hour after the blood pressure was obtained.

Further review of Resident R155's progress notes revealed that nursing staff had called the resident's physician at approximately 1:07 a.m. to notify him of the resident's xray results. Review of the progress notes revealed no documented evidence that the physician returned the staff's phone call.

Review of a hospital transfer time tracker form indicated that staff had contact Resident R155's physician at 8:25 a.m. and ordered the resident be transferred to the hospital via an ambulance.

Review of progress notes dated May 17, 2019, at 3:44 p.m. confirmed that staff had contacted Resident R155's physician regarding resident symptoms including: increased confusion, diaphoretic (sweating) complaints of abdominal pain and elevated blood pressure of 180/120.

Review of hospital records revealed that Resident R155 arrived at the hospital on May 17, 2019 at 10:00 a.m.,. The hospital admission record indicated that the resident was admitted into the Intensive care Unit (ICU) with a primary diagnosis of subarachnoid hemorrhage (bleeding from a damaged artery at the surface of the brain).

Interview with Employee E6, registered nurse, on September 3, 2019 at 9:00 a.m., reported that due to Resident R155's abnormal neurological status noted on May 16, 2019, the resident required immediate emergency care at the hospital.

The facility failed to ensure that one resident with abnormal blood pressure readings following a fall with a reported head injury was transferred to the hospital in a timely manner.

A review of Resident R263 physician orders dated 8/28/2019 related to Advance Directives (a document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves) revealed that the orders stated both, Do not Resuscitate ( indicates that a person does not want to receive cardiopulmonary resuscitation (CPR) if that person's heart stops beating) and Full Code (is when all possible measures are taken to revive a person and sustain life).

Interview with the Director of Nursing confirmed on August 29, 2019 at approximately 2:00 p.m., that the facility failed to clarify the advanced directive order with the physician.

A review of Resident R265 physician orders dated August 26, 2019 revealed a diagnosis of diabetes and stated to monitor the blood sugars four times a day and call the physician if the blood sugar dropped below 70 (under 70 maybe critical).

A review of Resident R265's nursing notes revealed on August 28, 2019 the resident's blood sugar was noted at 61. Further review of Resident R265's nursing notes did not reveal any documentation that the physician had been notified.

An interview with the Director of Nursing confirmed on August 29, 2019 at approximately 2:00 p.m., that the facility failed to notify the physician of Resident R265's low blood sugar on August 28, 2019, as ordered by the physician.

Review of Resident R36's Minimum Data Set (MDS-an assessment of resident care needs) dated January 11, 2019 indicated that the resident had a diagnosis of Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment).

Review of August 2019 physician's orders revealed an order to obtain a blood glucose reading using a a blood glucose monitoring/testing device. The physician's order indicated that Resident R6 was to be tested twice a day at 6:30 a.m., and at 4:30 p.m.. The order also stipulated that if the blood glucose reading obtained was below 70 or above 400; that the physician was to be notified. On August 6, 2019 at 3:51 p.m. nursing staff obtained a blood glucose reading of 66. There was no documented evidence that the physician was notified of the blood glucose that was below 70.

Interview with Employee E10, licensed nurse, on August 29, 2019 at 10:00 a.m. confirmed that nursing staff did not notify the physician of Resident R36's low blood glucose (reading of 66) on August 6, 2019, as ordered.

The facility failed to follow and clarify physician's orders for the care and treatment of residents.

28 Pa. Code 201.18(a)(1)(d)(e)(1)(3) Management
28 Pa. Code 201.18(a)(d)(1) Management
Previously cited 12/20/2018

28 Pa. Code 201.18(b)(3) Management
Previously cited 09/28/2018
28 Pa. Code 211.10(a)(b)(c) Resident care policies
28 Pa. Code 211.12(c)(d)(1)(3)(5)(e) Nursing services
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
Previously cited 12/20/2018











 Plan of Correction - To be completed: 10/25/2019

R155 is no longer at the facility
R36 has had a physician review of blood glucose levels in August, 2019
R265 has had a physician review of blood glucose levels in August, 2019
R 263 is no longer at the facility
All residents with a change in condition, have specific orders that require communication of clinical information to the physician, or have orders that conflict, have the potential to be affected by the deficient practice. For the past 30 days, the Nursing 24 hour shift report was reviewed to identify cases of resident change in condition, Blood glucose results for those residents that have specific parameters were reviewed, and new orders were checked and appropriate and timely physician notifications were made.
Nursing staff will be re-educated on the facility policy and procedure: Change in Condition and physician notification and the professional standard of practice requiring the nurse to follow and/or clarify physician orders as applicable. Nurses will document on the 24 hr Nursing Report all residents that have had a change in condition, transfer to a higher level of care, or abnormal laboratory results in order to communicate changes to other nurses, managers, and nurse leaders to monitor that physicians are notified timely as well as orders are followed and/or clarified.The DON/designee will review the daily nursing shift report to identify residents that have had a change in condition, vital sign/lab result abnormality, or order conflict and review each case for documentation and action of timely physician notification. Any variances related to the policy will be addressed immediately. This will be done weekly for the first 4 weeks and then monthly for the next 3 months.
Results of audits will be shared with the monthly Qapi meeting and then reviewed by the quarterly Quality Assurance Committee which will make recommendations based on the outcome of the audits.The administrator will monitor performance to ensure sustainable solutions for ongoing compliance.
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 review of clinical records and facility documentation, it was determined that the facility failed to supervise two of 49 resident records reviewed (Resident R1 and R156).

Findings include:

Review of Resident R1's admission Minimum Data Set (MDS- periodic assessment of resident care needs) dated April 11, 2019, indicated the resident was diagnosed with dementia and had difficulties focusing, was easily distracted and known to be restless. The MDS further indicated that Resident R1 needed extensive physical assistance of two persons with bed mobility and transfers.

A review of Resident R1's fall risk assessment dated, July 9, 2019 revealed that the resident was disoriented at all times, had one or two falls in the past three months and had three or more predisposing diseases to increase his chance of falling. The resident's fall assessment scored was 17. A total score of 10 or above represented a high risk for falls.

A review of Resident R1's care plan for falls indicated that the resident had sustained three falls on 4/30/19, 5/1/19 and 5/2/19. Continued review of the care plan revealed interventions that included, keeping a bedside mat on the right and left side of the bed.

A review of the documentation dated July 9, 2019 received by the facility stated that Resident R1 was presented with increased confusion and edema (swelling) in his lower extremities. A Doppler (that shows how much blood is flowing through your arteries and veins) was ordered for his lower extremities. A contracted technician arrived at the facility to perform the Doppler study. At 5:00 p.m. the staff assisted the resident back into the bed and left the technician with the resident to finish the procedure. At 5:50 p.m. the documentation stated that the resident became agitated and fell out of bed. At the time of the fall, the technologist stated that the floor where the resident fell did not have any padding. The resident sustained bleeding and a small laceration to the right eye and first aid with steri-strips were applied. The documention further stated "The resident was unable to explain the accident due to confusion." The investigation continued to state the nurse informed the technician that the resident was a fall risk but there was no documented evidence that the technician was informed of Resident R1's cognitive or physical limitations.

Interview with the Nursing Home Administrator on August 29, 2019 at approximately 1:30 p.m., confirmed that the facility is responsible for the overall safety of the residents and that the facility should have not left the resident unsupervised.

Review of facility documentation revealed that Resident R156 was admitted to the facility on June 26, 2019 at approximately 6:00 p.m.. The resident was admitted from the hospital with a diagnoses of left femur (bone in the thigh) fracture and moderate intellectual disabilities.

Further review of Resident R156's progress notes revealed that "family came in with TV along with movies. Stated she is able to change her movies, do not touch her movie. Upon leaving the family spoke with charge nurse and was advised that the bed will be placed in a low position. Family stated to charge nurse leave bed in the position that it was in so that the resident may access the TV and movies."

Further review of information submitted by the facility for Resident R156's dated August 26, 2019, confirmed that staff advised the family regarding the position of the resident's bed at 8;00 p.m.. At 8:20 p.m., the staff found the "resident sitting on the floor mat, back against the bed, and head bleeding." Resident R156 sustained a two centimeter (CM) laceration to the back of the head, was transferred to the hospital and received four staples to the back of her head.

The facility failed to adequately supervise two residents.

F689 Free of Accident Hazards/Supervision/Devices
CFR 483.25(d)(1)(2)
Previously cited 12/20/2018

28 Pa. Code 211.11(a)(b)(c)(d) Resident care plan
Previously cited 12/20/2018

28 Pa. Code 211.12(c)(d)(1)(5) Nursing services
Previously cited 12/20/2018





 Plan of Correction - To be completed: 10/25/2019

R1 and R156 are not at the facility.
All residents assessed to be at risk for falls have the potential to be affected by the deficient practice. These residents plan of care has been reviewed to ensure interventions are present that address supervision by staff.
Fall Prevention has been reviewed and updated. All direct care staff will be re-educated on the facility Fall Prevention policy and procedure and required supervision of residents' person-centered plan of care.The DON/designee will audit x 90 days all post-fall investigation reports to ensure the person-centered plan of care has been followed and appropriate supervision was provided.
Results of audits will be shared with the monthly Qapi meeting and then reviewed by the quarterly Quality Assurance Committee which will make recommendations based on the outcome of the audits.The administrator will monitor performance to ensure sustainable solutions for ongoing compliance.
483.40(b)(1) REQUIREMENT Treatment/Srvcs Mental/Psychoscial Concerns:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.40(b) Based on the comprehensive assessment of a resident, the facility must ensure that-
483.40(b)(1)
A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being;
Observations:

Based on review of clinical records, review of facility policies and interviews with staff, it was determined that the facility failed to provide the appropriate psychosocial services to attain the highest mental well-being for one of 49 residents reviewed. (Resident R61)

Findings include:

A review of facility policy " Mood and Behavioral Policy and Procedure," dated 3/2019, stated that the facility promotes and supports a resident centered approach to care regarding mood and behavioral health services to attain of maintain the highest practicable wellbeing. The facility's policy further indicated that each resident must receive and the facility must provide the necessary behavioral health care and services.

During a group meeting with six residents on August 28, 2019 at approximately, 10:30 a.m. Residents R13, R27, R61 and R71 voiced concerns that they had a psychiatric doctor to talk with but he left in April 2019 and was never replaced. Additionally, Resident R61 indicated, "Just because I don't walk around depressed doesn't mean I don't want to talk to someone. Before I came to this facility, I had intensive psychiatric therapy three times a week. I saw the nurse practioner last Thursday and told her I needed to speak with her. She said she'd see me tomorrow, but she never showed. She only comes every three months."

Review of Resident R61's clinical record revealed she was admitted to the facility on October 27, 2018 with diagnoses that included depression (major loss of interest in pleasurable activities) and anxiety. Review of the resident's nursing note dated November 1, 2018 revealed that prior to admission, the resident had attempted suicide three times that year and had two inpatient stays at a psychiatric hospital. Further review of this note revealed that the resident's psychiatrist who worked with the resident in the community confirmed that the resident had attempted suicide in the past and had previous psychiatic hospitalization.

Interview with the Nursing Home Administrator on August 28, 2019 at approximately 2:30 p.m. confirmed they have not had a psychologist since April 2019 and have not replaced the psychologist.

The facility failed to provide one resident with the appropriate services to attain her highest mental and psychosocial well-being.

28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing services
Previously cited 12/20/2018









 Plan of Correction - To be completed: 10/25/2019

Resident R61 was seen by a Psychologist.
Psychology services is now available on a steady basis for all residents.

Residents will be educated upon admission and by quarterly care conference as well as by Resident Council meetings of the availability of Psychology services in the facility. An Interdisciplinary team will constantly assess residents if they are in need of being seen and then ensure an order for psychology services will then be obtained from the attending physicians.

Social Services Director or designee will conduct random audits of residents to ensure they are aware of this service. This will be done weekly for the first 4 weeks and then monthly for the next 3 months.

Results of audits will be shared with the monthly Qapi meeting and then reviewed by the quarterly Quality Assurance Committee which will make recommendations based on the outcome of the audits.The administrator will monitor performance to ensure sustainable solutions for ongoing compliance.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs: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.
483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

483.55(b) Nursing Facilities.
The facility-

483.55(b)(1) Must provide or obtain from an outside resource, in accordance with 483.70(g) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.
Observations:

Based on clinical record review and interviews with residents and staff, it was determined that the facility failed to provide timely dental services for two of 49 residents reviewed (Residents R104 and R24).

Findings include:

Review of Resident 104's comprehensive Minimum Data Set (MDS -an assessment of care needs) dated August 16, 2019 indicated that Resident R104 was cognitively intact (alert and oriented to person, place and time).

Interview with Resident R104 on August 27, 2019 at 11:00 a.m., revealed that the resident had mouth and/ or facial pain and discomfort and difficulty chewing on the left side of the mouth. The resident reported being in need of dental services.

Review of the clinical record for Resident R104 revealed that on July 17, 2019 the resident was evaluated by a dentist. At the time of the evaluation, the dentist recommended that the facility make arrangements for Resident R104 to return to the dental office for further dental care. The dentist had documented that this resident required fillings in the teeth, on the left side of the oral cavity.

Continued review of Resident R104's clinical record revealed no documentation that the facility had arranged the needed dental services for Resident R104.

Interview with Employee E3, social worker, on August 28, 2019 at 10:00 a.m. confirmed that Resident R104 had not received the needed dental services. Continued interview with the social worker revealed that Resident R104 needed transportation to and from the dental office and that the arrangements had not been obtained; therefore the needed dental services had not been scheduled for Resident R104.

Interview with Resident R24 on August 27, 2019 at 1:00 p.m., revealed that the resident had a broken and/or loosely fitting partial denture.

Review of Resident R24's clinical record revealed a comprehensive Minimum Data Set (MDS- assessment of resident needs) completed May 10, 2019 which indicated that Resident R24 was independent with decision making.
Continued review of the clinical record for Resident R24 revealed that the resident had a bottom denture that was out for repair since May 3, 2019. Further review of Resident R24's clinical record revealed no documentation of the status of the resident's denture and/or the necessary repair.

Interview with Employee E3, social worker, on August 28, 2019 at 11:30 a.m. confirmed that the facility had not obtained the necessary dental services for Resident R24.

The facility failed to assist each resident in obtaining timely and as needed dental care.

28 Pa. Code 211.15(a)(b) Dental services








 Plan of Correction - To be completed: 10/25/2019

Both R104 and R24 have had follow up dental services.
All residents with dental concerns were reviewed to ensure appropriate timely dental appointments have been made.
Dental Services has been reviewed and updated. Nursing staff will be re-educated on the facility policy and procedure to assist residents in obtaining timely dental care.
Nurse managers will meet with Unit Secretaries and Social Service staff weekly to ensure residents receive timely assistance with dental appointments.
Social service director or designee will complete a monthly audit of resident dental appointments made to identify and track the timeliness of this assistance.
Results of audits will be shared with the monthly Qapi meeting and then reviewed by the quarterly Quality Assurance Committee which will make recommendations based on the outcome of the audits.The administrator will monitor performance to ensure sustainable solutions for ongoing compliance.
483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:

Based on a review of the facility documentation, observation and reviews of the facility menus, it was determined that the facility failed to served palatable, attractive and appetizing foods that the residents found satisfying to eat for eight of 49 residents reviewed (R60, R71, R104, R27, R100, R61, R13, and R24).

Findings include:

According to the 2011 Symposium called Cultural Change: Enriching Lives in Nursing Homes, it was revealed that, "liberalized diets" should include the older adult's right to choose weather or not to follow a restrictive diet. Reviews of the facility's menus and diets with the registered dietitian, Employee E9, confirmed that the facility had not planned menus and diets that implemented culture change and empowered residents to choose foods that they found satisfying and nutritious. The facility's menus and diets included a 2 gram sodium diet and a low fat low cholesterol diet, which were not liberalized.


Residents R60, R71, R104, R27, R100, R61, R13, and R24 interviewed individually and assembled in a group had concerns about the menus and foods being served at the facility. The residents reported on August 27 and August 28, 2019 that they were unsatisfied with the taste, appearance and flavor of the foods they were being served at the facility. The residents reported that they were making suggestions for menu item changes; however there suggestions were not being implemented.

Reviews of the menus and observations of the noon meal service on August 27 and 28, 2019 revealed that the residents were served canned fruit instead of fresh fruit. The corn on the cob served was water saturated and unappealing. The three bean salad was left uneaten by a majority of the residents. Chilli with beans over rice was served on August 28, 2019. Residents were observed having difficulty trying to get the food onto their utensils (spoons). The entree was not cohesive the white rice was widely dispersed on the plate. The beans were also separate and uniform with the rice or meat. The meat resembled the ground beef from the previous days lunch entree. The cooked ground beef was placed on top the unjelled white rice.


28 Pa. Code: 211.6(b)(d) Dietary services

28 Pa. Code: 201.29(a)(j) Resident rights












 Plan of Correction - To be completed: 10/25/2019

The facilities menu has been changed to reflect residents desire to choose foods they desire to be satisfied with such as increasing the availability of fresh fruit and accommodating their menu selections.
Dietary staff were in-serviced regarding food quality and preparation techniques.
Food Service Director or designee will audit a test tray weekly for the first 4 weeks and then monthly for the next 3 months.

Results of audits will be shared with the monthly Qapi meeting and then reviewed by the quarterly Quality Assurance Committee which will make recommendations based on the outcome of the audits.The administrator will monitor performance to ensure sustainable solutions for ongoing compliance.
205.72 LICENSURE Furniture.:State only Deficiency.
A resident shall be provided with a drawer or cabinet in the resident's room that can be locked.
Observations:

Based on observation, review of facility policies and staff and resident interviews, it was determined that the facility failed to provide eighteen of forty-nine residents reviewed, a means to secure their personal belongings (valuables), upon admission as required (Residents: R19, R13, R54, R29, R22, R87, R50, R58, R61, R356, R25, R44, R90, R38, R4, R32, R30 and R20).

Findings include:

Review of facility policy "Locked Drawer Availability," undated, stated that "If a resident, family member or resident representative would like to have a lock added to a drawer in a resident's room, they can speak with any staff member, who will submit a request to maintenance to have a lock added to the drawer of their choice."

Observations of resident rooms on the second floor on August 29, 2019 at 10:32 a.m. revealed that residents R19, R13, R54, R29, R22, R87, R50, R58, R61, R356, R25, R44, R90, R38, R4, R32, R30 and R20) did not have a locked cabinet to secure their valuables:

Review of Resident R19's comprehensive assessment Minimum Data Set (MDS-an assessment of care needs) dated June 10, 2019 revealed that Resident R19 was cognitively intact. Interview with Resident R19 at 1:00 p.m. on August 27, 2019 revealed that she was missing $30.00 dollars during the month of January, 2019. The facility was aware of her missing money as evidenced by the facility reported misappropriation of property report to the Department dated January 17, 2019. Observations of Resident R19 and her room on August 27, 2019 revealed that this resident had no access to a locked cabinet to secure her belongings. The resident reported that would be nice, if she had a way to secure her belongings.

Interview with Employee E1, Nursing Home Administrator, on August 29, 2019 at 1:00 p.m., revealed that residents in rooms: 216, 215, 206, 212, 211, 210, 207, 202, 217, 201, 222, 227 and 225 were not offered a locked cabinet to secure their valuables upon admission and throughout their stay. The administrator reported that the residents had to request a place to secure personal belongings.

The facility failed to offer a locked cabinet or other means to safe guard residents personal belongings .

28 Pa. Code: 205.72 Furniture

28 Pa. Code: 201.29 (k) Resident rights














 Plan of Correction - To be completed: 10/25/2019

Residents R19, R13, R54, R29, R22, R50, R58, R61, R356, R25, R44, R90, R38, R4, R32, R30, and R20 were offered the option of having a locked compartment. Resident R87 discharged from the facility.
All residents will be offered a locked compartment upon admission and during quarterly care conferences as well as by the monthly resident council meeting.
Admission Director will conduct audits of residents to ensure they are aware of the availability of a locked compartment. This will be done weekly for the first 4 weeks and then monthly for the next 3 months.
Results of audits will be shared with the monthly Qapi meeting and then reviewed by the quarterly Quality Assurance Committee which will make recommendations based on the outcome of the audits.The administrator will monitor performance to ensure sustainable solutions for ongoing compliance.


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