Nursing Investigation Results -

Pennsylvania Department of Health
SAYRE HEALTH CARE CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SAYRE HEALTH CARE CENTER
Inspection Results For:

There are  74 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.
SAYRE HEALTH CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, Civil Rights Compliance Survey, and Abbreviated Survey to review a Complaint completed on September 27, 2019, it was determined that Sayre Health Care Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate and implement interventions to prevent resident accidents for one of six residents reviewed for falls (Resident 29) and failed to implement interventions to prevent an accident with serious injury resulting in harm for one of six residents reviewed for falls who sustained a subarachnoid hemorrhage (Resident 51).

Findings include:

The facility policy entitled, "Incident/Accident-Reporting, Investigating, and Implementing Corrective Actions," last reviewed without changes on June 24, 2019, revealed that it is the policy of the facility to promptly report and investigate an incident or accident and initiate measures to prevent a recurrence. The non-licensed person (e.g. nurse aide) will report the occurrence to the charge nurse and complete a written summary of what was observed or discovered on the facility's incident/accident form via a witness statement. The licensed nurse will report the occurrence to the registered nurse supervisor and initiate the facility incident/accident form. Investigation of the occurrence will be initiated with a statement from staff, residents, and visitors if possible. Immediate interventions will be initiated to prevent recurrence of the incident and ensure resident safety. The event and interventions will be added to the resident's plan of care. The Administrator or designee will be responsible for reporting the incident or accident to the appropriate agencies or authorities, according to local, state, and federal regulations and statutes. The charge nurse and/or the nursing supervisor will initiate any plan of care change that is professionally warranted to ensure resident welfare and safety prior to the end of the shift. The Director of Nursing or designee will check the incident/accident form for completeness, report the incident/accident as necessary to comply with local, state, and federal regulations, and ensure that immediate corrective action/intervention, as warranted, has been initiated and entered into the plan of care.

Clinical record review for Resident 29 revealed quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessments dated August 13, 2019, and May 13, 2019, that assessed Resident 29 as needing the extensive physical assistance of two staff for bed mobility and transferring between two surfaces (to or from bed, chair, wheelchair).

Nursing documentation dated June 3, 2019, at 8:49 AM indicated that the writer was called to the nursing unit to see the resident. The documentation indicated that staff were transferring Resident 29 with a Hoyer (mechanical device used to lift and transfer a resident with minimum physical effort) when it slipped and hit him in the left cheek bone. Staff assessed a bruise and applied ice.

Review of the facility's investigation into this incident dated June 3, 2019, at 8:35 AM noted that while using the Hoyer lift with Resident 29, "legs" caught on the wheelchair and the top bracket came forward and hit Resident 29 in his left cheek resulting in an injury measuring 2 centimeters (cm) on his left cheek bone. The investigation listed only one witness (despite Resident 29 requiring the physical assistance of two staff for all transfers).

Review of the facility's investigation into an incident dated June 24, 2019, at 1:45 PM, revealed that nurse aides reported that Resident 29 sustained a skin tear while providing his care; the injury occurred while staff was turning Resident 29. The form noted the measurements of the skin tear as 2 cm by 0.5 cm to his left outer arm. The investigation identified only one witness (despite Resident 29 requiring the physical assistance of two staff for bed mobility).

Nursing documentation dated August 4, 2019, at 4:20 PM revealed that staff called the writer to Resident 29's room where he was found with the upper part of his body in the bed and his legs were out of bed on a mat.

Review of the facility's investigation dated August 4, 2019, at 4:20 PM, revealed that the facility did not implement any new interventions to prevent fall recurrence; the only intervention listed was a mat (already in place at the time of the fall per the nursing documentation).

Nursing documentation dated September 9, 2019, at 5:00 AM indicated that staff heard Resident 29 screaming, "help." Staff went to Resident 29's room and found him to have the lower half of his body out of bed (he was on his knees).

Review of the incident report dated September 9, 2019, revealed that the facility had no new interventions added after the fall to prevent recurrence.

Interview with Employee 3 (certified dietary manager) on September 27, 2019, at 12:31 PM confirmed that Resident 29 had two falls from his bed without a new intervention to prevent recurrence. The interview also confirmed that investigations regarding injuries sustained during care failed to obtain a witness statement from all staff with pertinent information regarding the incidents. Although Resident 29 required the physical assistance of two staff, the facility failed to identify, and obtain information from, the two staff present for care.

Clinical record review for Resident 51 revealed nursing documentation dated February 10, 2019, at 1:00 AM indicating that the registered nurse, the licensed practical nurse, and two nurse aides were charting in the nurse's station when staff heard a very faint call for help from a female resident. Upon checking a camera monitor, staff noticed Resident 51 lying on the floor in the hallway, on her left side, with her head resting on the floor. The initial assessment revealed that Resident 51 continuously stated, "...my leg, my leg, it hurts. I can't move my leg;" and pointed to her left leg. Resident 51 stated, "The pain in my leg is going all the way down my leg and up into my back." Upon light palpation, the resident stated the pain was located directly at the hip joint. Resident 51 stated, "The pain hurts so bad. I think I might pass out." The registered nurse identified that Resident 51 presented with a large, raised, hematoma (collection of blood under the skin that presents as a raised, bruised, area) located on the back left side of Resident 51's head that was tender on palpation. Emergency medical personnel arrived at the facility and transported Resident 51 to the emergency department for further evaluation of hip and head injuries.

Clinical record review for Resident 51 revealed nursing documentation dated February 10, 2019, at 5:00 AM that the nursing staff contacted the emergency department to obtain a status report of Resident 51. The emergency department staff informed the facility staff that Resident 51 had sustained multiple pubic rami (bones that make up the front of the pelvis) fractures. The documentation indicated that the facility staff contacted Resident 51's daughter to inform her that Resident 51 could be found in the intensive care unit and that she had sustained hip fractures during her fall.

Review of the facility's investigation dated February 10, 2019, at 1:00 AM confirmed that Resident 51 sustained an unwitnessed fall; and that the facility implemented chair and bed alarms as a new intervention to prevent fall recurrence.

Review of a plan of care developed by the facility on February 10, 2019, to address Resident 51's risk for falls characterized by her history of falls and injury listed interventions that included the facility initiated bed and chair alarms on February 14, 2019.

Nursing documentation dated March 20, 2019, at 9:25 AM revealed that the writer was working on a computer when the writer heard a nurse aide yell, "...oh my God!" The writer noted that staff saw Resident 51 on the floor, on her abdomen. Staff summoned the registered nurse to the unit. Staff noted blood coming from Resident 51's forehead. Resident 51 left the facility enroute to the emergency room at 9:40 AM.

Nursing documentation dated March 20, 2019, at 9:30 AM revealed that Resident 51 fell on the floor in the dining room. Staff found Resident 51 on the floor, face down, with a "cut" on her head measuring one inch and bleeding. Staff called an ambulance service to take Resident 51 to the emergency room for evaluation.

Nursing documentation dated March 20, 2019, at 4:07 PM revealed the writer contacted the emergency room regarding Resident 51's status. The emergency room informed the writer that Resident 51 was admitted to the hospital with a small subarachnoid hemorrhage (bleeding from a damaged artery between the skull and the surface of the brain increasing the pressure surrounding the brain; a type of stroke that can cause permanent brain damage).

Review of the facility's investigation dated March 20, 2019, at 9:15 AM confirmed that because staff heard the nurse aide yell, staff responded to the dining room to find Resident 51 had fallen out of her chair onto the floor. The incident investigation stipulated that "Resident (51) had no alarm." The witness statement from the nurse aide identified as the witness who found the resident attested that Resident 51 did not have an alarm on. Witness statements from a second nurse aide and a licensed practical nurse both stipulated no chair alarm was present.

Review of an electronic adverse event report dated March 20, 2019, provided the local field office information that Resident 51 sustained a fall, was transferred to the emergency room, and was diagnosed with a subarachnoid hemorrhage. The event report stipulated that, "Prior to event, care plan interventions were in place and included the following: safety mats on floor bilaterally next to bed, non-skid socks while in bed, and proper foot wear when OOB (out of bed), verifying frequently utilized articles were within resident's reach, environment was free of clutter, bed alarm in place, call bell within reach, and bed maintained in low position. Neglect was ruled out in course of investigation."

The event report failed to list a chair alarm as a care plan intervention in place prior to the event. The event failed to report that the plan of care included a chair alarm; and that it was not in place at the time of Resident 51's fall. The event indicated that the facility ruled out neglect; however, failed to thoroughly investigate the potential failure of staff to implement the necessary intervention.

The facility's investigation of Resident 51's fall on March 20, 2019, failed to thoroughly investigate the absence of the necessary care plan intervention (chair alarm), identify the staff member who potentially failed to implement the necessary intervention (potential neglect), and failed to notify the local Department of Health of the potential neglect.

The surveyor reviewed the above findings during an interview with Employee 3 (certified dietary manager) and the Nursing Home Administrator on September 27, 2019, at 11:10 AM. The interview confirmed that Resident 51 fell on February 10, 2019, and the facility implemented the new intervention of bed and chair alarms to prevent future falls. There was no indication that staff implemented the chair alarm before her fall on March 20, 2019, when Resident 51 fell from her chair, struck her head on the floor, and sustained a brain hemorrhage. The interview confirmed that this information was not fully disclosed to the local field office of the Department of Health via the electronic event report.

483.25(d) Free of Accident Hazards/Supervision/Devices
Previously cited deficiency 9/4/19

28 Pa. Code 211.11(d) Resident care plan
Previously cited 10/5/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 9/4/19, 11/27/18, and 10/5/18


 Plan of Correction - To be completed: 10/21/2019

F 689

Resident 29 shall have a review completed of their care plan by the DON/designee and safety interventions shall be placed as per care plan.

The DON/designee shall be responsible to complete random daily audits of the adl sheets to verify bed mobility was completed as per the care plan.

The Occupational therapist completed an in service for direct care staff on proper bed mobility according to the resident care plan, this was completed by Oct 3, 2019.

The NHA/designee shall educate the IDT on the process of completing a complete review of all accident/incident reports to verify new interventions are added as needed for each new incident and to obtain all witness statements as part of a thorough investigation.

The DON/designee shall be responsible to complete random daily audits of the adl sheets to verify bed mobility was completed as per the care plan.
All staff were in serviced by an approved Department of Health Care educator regarding accidents and incidents and follow up on accidents and incidents. This was completed on 10/1 and 10/2/2019.

All incidents will be recorded on an incident report form by the nurse whom the incident has been reported. The incident will be reported immediately to the supervisor on duty and they will begin the incident investigation immediately.

The care plan will be updated by the nurse to prevent further accidents from occurring. Nursing administration will review the incident report and verify that the investigation of the incident is completed. The incident report shall be reviewed by the management team during the morning meeting. Required staff training will be implemented immediately by the nursing administration to address prevention of recurrence of the accident and ensure all employees are trained.

Random weekly audits shall be completed by the designated nursing person to verify compliance with the regulation.
The audits shall be sent to the QAA monthly for a review.

Resident 51 will have a review of their care plan by the designated nursing person and it will be updated as needed to reflect their safety interventions.

The facility shall review the last two weeks of fall incidents to verify interventions are on the care plan to verify compliance with the process.
The NHA/designee shall educate the IDT on the process of completing a complete review of all accident/incident reports to verify new interventions are added as needed for each new incident and to obtain all witness statements as part of a thorough investigation.

All staff were in serviced by an approved Department of Health Care educator regarding accidents and incidents and follow up on accidents and incidents. This was completed on 10/1 and 10/2/2019.

The DON/designee shall be responsible to complete random weekly audit of the care plans to verify safety interventions were completed as per the care plan.

Audits will be sent to the QAA monthly for a review of issues.


483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr: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.
483.15(d) Notice of bed-hold policy and return-

483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility bed hold policy at the time of transfer for four of eight residents reviewed for hospitalizations (Residents 24, 26, 34 and 51).

Findings include:

The facility policy entitled, "Discharge/Transfer Notice," last reviewed without changes on June 24, 2019, revealed that it is the facility's policy to make sure that all residents and family members are aware of discharge or transfer from the facility, the option to have their bed held while they are out of the facility, and the possible fees associated with holding a bed in the resident's absence. When notifying family members of the transfer, the facility must also make them aware they have the right to hold the bed. The registered nurse is to check mark the choice for the bed hold. All three pages of the Notice must be signed by the resident and family at the time of transfer. If the resident is unable to sign the forms, staff write, "Unable to Sign," in the resident signature spot. If family is not present to sign the Notice, staff contact them and ask them to come to the facility to sign the papers at their earliest convenience. If family members are from out of the area, these forms can be mailed to them for signature. Any Notices that require mailing should be given to the Unit Clerk for proper management. The Unit Clerk is responsible to give them to the receptionist for mailing.

Clinical record review for Resident 24 revealed that she was transferred to the hospital on December 22, 2018, May 1, 2019, and July 15, 2019, after she had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or the resident's responsible party upon transfer out to the hospital.

Clinical record review for Resident 26 revealed that she was transferred to the hospital on December 17, 2018, January 18, 2019, February 15, 2019, and July 21, 2019, after she had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or the resident's responsible party upon transfer out to the hospital.

The surveyor reviewed the above information for Residents 24 and 26 during an interview with the Nursing Home Administrator on September 27, 2019, at 8:40 AM.

Clinical record review for Resident 51 revealed discharge MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessments dated August 12, 2019, and May 23, 2019, indicating that the facility transferred Resident 51 to the hospital.

The surveyor requested evidence of a written notice of the facility's bed hold policy provided to Resident 51 and/or her responsible party in response to her hospitalizations in May and August 2019 during an interview with the Nursing Home Administrator and Employee 1 (executive director of nursing) on September 25, 2019, at 2:00 PM.

A Discharge/Transfer Notice provided by the facility on September 26, 2019, for Resident 51's transfer to the hospital on May 23, 2019, did not include any signatures from either the resident or the resident's responsible party.

The facility failed to provide a Discharge/Transfer Notice for Resident 51's transfer to the hospital on August 12, 2019.

Interview with the Director of Nursing on September 27, 2019, at 9:30 AM confirmed that the facility had no further evidence of providing Resident 51 or her responsible party the appropriate written notice of the facility's bed hold policy in response to her hospitalizations as noted above.

Clinical record review for Resident 34 revealed MDS discharge assessments dated May 13, 2019, June 25, 2019, and August 12, 2019, indicating that the facility transferred Resident 34 to the hospital.

The surveyor requested evidence of a written notice of the facility's bed hold policy provided to Resident 34 and/or her responsible party in response to her hospitalizations in May, June, and August 2019 during an interview with the Nursing Home Administrator and Employee 1 on September 25, 2019, at 2:00 PM.

A Discharge/Transfer Notice provided by the facility on September 26, 2019, for Resident 34's transfer to the hospital on June 25, 2019, did not include any signatures from either the resident or the resident's responsible party.

The facility failed to provide a Discharge/Transfer Notice for Resident 34's transfers to the hospital on May 13, 2019, and August 12, 2019.

Interview with the Director of Nursing on September 27, 2019, at 9:30 AM confirmed that the facility had no further evidence of providing Resident 34 or her responsible party the appropriate written notice of the facility's bed hold policy in response to her hospitalizations as noted above.

483.15(d)(1)(2) Notice of Bed Hold Policy Before/Upon Transfer
Previously cite 10/5/18

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/5/18

28 Pa. Code 201.29(f) Resident rights
Previously cited 10/5/18


 Plan of Correction - To be completed: 10/21/2019

F 0625
The Social Service Director/designee shall notify residents 24,26,51 ,34, or their designated family of the facility bed hold policy, and that should their family member be transferred out of the facility in the future they will be given the bed hold notice as per regulation. The conversation shall be completed verbally and documented in the resident record.

The Licensed Nursing staff shall be educated by the DON/designee of the Bed Hold Policy .

When a resident is transferred out of the facility a bed hold letter will be given to the resident and or the resident's responsible party as per the regulation. Signatures shall be obtained to verify compliance by the resident or designated family member.

The DON/designee shall review Resident letters sent out within the last week to verify information was correct and have the appropriate signatures.

The facility shall keep a copy of the bed hold letters given to the resident or family member allowing the facility proof that the letter has been sent.

An audit tool shall be utilized and reviewed weekly verifying the notice of the bed hold letter was given. The DON/designee shall be responsible to verify completion.

The audits shall be reviewed at the QA meeting. The weekly review shall continue for 3 months, or longer if issues are identified.

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

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

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

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

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to assess and receive consent for the use of side rails for five of five residents reviewed (Residents 25, 29, 31, 48, and 69).

Findings include:

Observation of Resident 48 on September 24, 2019, at 12:43 PM revealed that her bed had bilateral enabler bars in the raised position.

A physician's order dated September 26, 2019, indicated that Resident 48 was to have bilateral assist bars to assist with bed mobility and positioning. Resident 48 and her family were informed and in acceptance. A side rail assessment and consent were completed September 25, 2019, after requested by the surveyor. There was no side rail order, assessment, or consent for Resident 48's side rails prior to identification by the surveyor.

Observation of Resident 25 on September 24, 2019, at 12:40 PM revealed that the resident's bed had bilateral assist rails.

Observation of Resident 31 on September 24, 2019, at 3:11 PM revealed that the resident's bed had bilateral enabler bars.

Observation of Resident 69 on September 25, 2109, at 10:55 AM revealed that the resident's bed had bilateral quarter rails.

Siderail assessments and consent forms were not completed for Residents, 25, 31, and 69 until September 25, 2019, after requested by the surveyor.

The surveyor reviewed the above information for Residents 25, 31, 48, and 69 during an interview with the Nursing Home Administrator on September 26, 2019, at 3:42 PM.

Nursing documentation dated July 24, 2019, at 10:34 PM revealed that the licensed practical nurse notified the writer that Resident 29 hit the left side of his head on the side rail while being rolled over; and now has an abrasion/bruise on his left outer eyebrow.

Review of the facility's investigation dated July 24, 2019, at 9:15 PM confirmed that while the nurse aide was assisting the licensed practical nurse to turn the resident for a treatment, Resident 29 bumped his head on the side rail. Resident 29 sustained an abrasion/bruise on his left outer eye brow measuring 0.5 centimeters (cm) by 0.3 cm.

Observation of Resident 29 on September 26, 2019, at 2:28 PM revealed that he was in bed, equipped with an air mattress, with bilateral upper siderails. Resident 29 wore a brace to his left upper extremity.

Interview with the Director of Nursing on September 27, 2019, at 9:30 AM revealed that the facility could not provide an assessment (to include Resident 29's ability to utilize a side rail while wearing his left upper extremity brace) or consent before installation of Resident 29's side rails.

28 Pa. Code 211.12 (d)(5) Nursing services
Previously cited 9/4/19, 11/27/18, and 10/5/18


 Plan of Correction - To be completed: 10/21/2019

F 0700
Resident 25,31,48 and 69 shall have an assessment of their bed rails completed by the Director of the therapy department.
The Director of therapy shall obtain consent for the use of the bed rails and obtain an order for their use.
Resident 29 shall have an assessment (to assess their ability to utilize the bed rail while wearing their left upper extremity brace) and consent form completed for the use of the side rail, along with an MD order for the use of the rail.

Residents utilizing bed rails shall have an assessment and consent form obtained by the designated therapy member, along with an order for the use of the side rail.

A weekly audit shall be completed by the DON/designee to verify compliance with the regulation as it relates to bed rails.

Licensed nursing staff shall be educated by the DON/designee on the bed rail policy.

The audits shall be sent to the QAA monthly meeting for a review of compliance. This will continue for three months or longer if issues are noted with compliance.


483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25 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 review of select facility policies, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician orders for two of 18 residents reviewed (Residents 26 and 41).

Findings include:

The facility policy entitled "Resident's Weights/Heights," last reviewed without changes on June 24, 2019, revealed that the facility will weigh each patient on a regular basis, as their medical conditions, and other circumstances dictate.

The facility policy entitled, "Physician Orders," last reviewed without changes on June 24, 2019, revealed that the facility will ensure that staff carries through and changes all orders accordingly. The nurse reviews all computerized physician orders.

Clinical record review for Resident 26 revealed a current physician's order indicating that staff was to weight her daily.

Review of Resident 26's weight documentation revealed that there was no documentation indicating that staff completed Resident 26's weight on the following dates:

August 2, 2019
August 3, 2019
August 4, 2019
August 13, 2019
August 15, 2019
August 17, 2019
August 19, 2019

The surveyor reviewed the above information for Resident 26 during an interview with the Nursing Home Administrator on September 26, 2019, at 2:00 PM.

Clinical record review for Resident 41 revealed a current physician's order indicating that staff was to take her blood pressure twice daily on day and evening shift.

Review of Resident 41's blood pressure documentation revealed that there was no documentation indicating that staff completed Resident 41's blood pressures on the following dates:

July 15, 2019, evening shift
July 16, 2019, evening shift
July 20, 2019, evening shift
July 27, 2019, day and evening shift

August 2, 2019, evening shift
August 3-12, 2019, day and evening shift
August 13, 2019, day shift
August 14- 29, 2019, day and evening shift
August 30, 2019, evening shift
August 31, 2019, day and evening shift

September 1-2, 2019, day and evening shift
September 3, 2019, evening shift
September 4-5, 2019, day and evening shift
September 6, 2019, day shift
September 7, 2019, day and evening shift
September 8-9, 2019, evening shift
September 10-12, 2019, day and evening shift
September 13, 2019, day shift
September 14- 22, 2019, day and evening shift
September 23, 2019, evening shift
September 24, 2019, day and evening shift
September 25, 2019, day shift

The surveyor reviewed the above information for Resident 41 during an interview with the Nursing Home Administrator on September 26, 2019, at 2:00 PM.

483.25 Quality of Care
Previously cited 10/5/18

28 Pa. Code 211.10(a)(c)(d) Resident care policies
Previously cited 10/5/18

28 Pa. Code 211.12(c) Nursing services
Previously cited 9/4/19 and 10/5/18

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 9/4/19, 11/27/18, and 10/5/18


 Plan of Correction - To be completed: 10/21/2019

F0684 weight
Resident 26 shall have her orders reviewed by nursing and their weights shall be obtained and documented per MD order.

Resident 41 shall have their orders reviewed by nursing and their blood pressure shall be obtained and documented as per MD order.

A review of resident's with orders for bp's and weights shall be completed by the designated nursing staff to verify no other issues are noted.

The Licensed nursing staff shall be educated by the Don/designee on the need to follow the MD orders and document such in the medical record.

A weekly random audit shall be completed to verify weights and B/P's were obtained and documented as ordered.

The audits shall be sent to the QAA monthly meeting for a review of compliance with the regulation.

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

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

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

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

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

Based on review of select facility policies and procedures, clinical record review, and staff and family interview, it was determined that the facility failed to promote self-determination regarding choice of activities on facility property (smoking policy, Resident 6) and of health care decisions for one of 18 residents reviewed (Resident 34).

Findings include:

Clinical record review for Resident 34 revealed nursing documentation dated August 4, 2019, at 1:49 PM indicating that the psychiatrist consulted with Resident 34 and provided a new physician's order to begin the mood stabilizing medication, Depakote sprinkles, 125 milligrams (mg), twice daily. When staff contacted Resident 34's daughter regarding the new medication, Resident 34's daughter stated that she did not want the new medication started.

Nursing documentation dated August 9, 2019, at 9:26 AM reiterated that the psychiatrist evaluated Resident 34 on August 4, 2019, and recommended the use of Depakote sprinkles. The documentation repeated that Resident 34's daughter was informed of the plan; however, did not want to start the medication as her mother was taking antibiotics for a urinary tract infection. The documentation noted that, "This was previously discussed with the assistant administrator in a previous care plan meeting."

Interview with Resident 34's daughter on September 25, 2019, at 12:40 PM revealed that the facility started the Depakote sprinkles medication without her consent. Resident 34's daughter indicated that she is her mother's responsible party as her mother is incapable of making health care decisions due to her cognitive deficits. Resident 34's daughter stated that she only became aware that the medication started because she received a bill to pay for the medication.

Review of Resident 34's medication administration record dated August 2019 revealed that staff administered Depakote sprinkles 125 mg by mouth twice a day for mood stabilization on 27 occasions from September 6 - 20, 2019.

Nursing documentation dated September 21, 2019, at 12:32 AM revealed that Resident 34's daughter called this writer at midnight as she had received a medication bill for the Depakote sprinkles. Resident 34's daughter wanted to know when her mother started taking the medication as she was not informed that Resident 34 was taking them. The writer informed Resident 34's daughter that Resident 34 had started taking the medication on September 7, 2019. Resident 34's daughter stated that she had not been informed of the medication and had not given permission for her mother to take them. The writer placed the medication on hold at the time of the conversation.

Nursing documentation dated September 23, 2019, at 11:29 AM confirmed that Resident 34's daughter continued to refuse the administration of Depakote to Resident 34.

Interview with the Nursing Home Administrator, Employee 1 (executive director of nursing), and Employee 2 (regional nursing and administrator consultant) on September 25, 2019, at 2:00 PM confirmed that the facility initially placed the Depakote medication on hold for Resident 34; however, began administration of the medication without notifying Resident 34's daughter or obtaining her consent. The interview confirmed that Resident 34 was incapable of making health care decisions; and that Resident 34's daughter is her responsible party.

The policy entitled "Nursing Policy and Procedure (Resident)," last reviewed by the facility on June 24, 2019 revealed that the facility will provide a safe, smoke free environment for all residents. Residents will be informed upon admission that the facility is a "smoke free" environment and it will be strictly enforced. If a resident does not adhere to this policy, they will be discharged. Residents admitted to the facility who do smoke will be offered "smoke free" medication, patches, etc. for the duration of their stay.

Interview with the Nursing Home Administrator on September 24, 2019, at 10:00 AM confirmed that the facility is non-smoking.

Observation of the door leading to the laundry building on September 24, 2019, at 11:42 AM revealed a sign noting, "no smoking, go to designated area."

During an interview with Employee 4, housekeeping, on September 24, 2019, at 12:00 PM it was noted that she smelled strongly of smoke.

Interview with Resident 6's wife on September 25, 2019, at 10:50 AM revealed that she did not believe that the facility was smoke-free as she witnesses staff go to the picnic table in the rear of the building by the laundry department door to smoke. Resident 6's wife also stated that staff (to include "higher ups") smoke right outside the front door and leave cigarette butts. Resident 6's wife stated that there was a female resident's family who come and take their family member outside to smoke. Resident 6's wife stated that there is a flower pot outside the rear entrance door that has become a receptacle for cigarette butts; she stated that she discussed this issue with the activities staff.

During an interview with the Director of Nursing on September 27, 2019, at 9:10 AM it was noted that she smelled strongly of smoke.

Observation on September 27, 2019, at 10:00 AM revealed that there was a picnic table and umbrella with a smoke butt receptacle near the parking lot by the laundry building.

28 Pa. Code 211.10(d) Resident care policies
Previously cited 10/5/19

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 9/4/19, 11/27/18, and 10/5/18


 Plan of Correction - To be completed: 10/21/2019

F0561 self determination
Resident # 6's wife shall be updated on the facility plans to review the facility smoking policy
with the staff . The Smoking Policy for the facility shall be followed by staff, residents and families.

Resident # 34 will have the medications reviewed with their family member. Nursing staff shall inform the MD of any identified medications that the resident or family wishes the resident not to take.

The Smoking Policy shall be reviewed during the resident council meeting as a reminder to residents that the policy is for staff, residents and visitors.

The Smoking policy shall be reviewed with staff during the POC education that will be scheduled. This shall include that this applies to all staff as well as residents.

The RN/LPN staff shall be re educated to verify that new medications that are ordered are reviewed with the family prior to starting them.

A random monthly audit shall be completed by Social Service/designee to verify residents are aware of the policy, and staff are not smoking on the premises.
A random weekly audit shall be completed by the DON/designee to verify family are made aware of the new medication.
Audits shall continue for three months and sent to the QAA monthly for a review of trends.



483.90(d)(3) REQUIREMENT Resident Bed:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.90(d)(3) Conduct Regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment. When bed rails and mattresses are used and purchased separately from the bed frame, the facility must ensure that the bed rails, mattress, and bed frame are compatible.
Observations:

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to perform an assessment for possible entrapment after installation of enabler bars for one of five residents reviewed (Residents 48).

Findings include:

Observation of Resident 48 on September 24, 2019, at 12:43 PM revealed that she was in bed with bilateral enabler bars in the raised position.

There was no documentation indicating that the facility assessed and/or measured Resident 48's bed to ensure that there was no possibility of entrapment, nor was there documentation indicating that the side rails placed on Resident 48's bed were compatible with the bed frame utilized.

The surveyor reviewed the above information for Resident 48 during an interview with the Nursing Home Administrator, on September 26, 2019, at 3:42 PM.

28 Pa Code 211.12(d)(3)(5) Nursing services
Previously cited 9/4/19, 11/27/18, and 10/5/18




 Plan of Correction - To be completed: 10/21/2019

F 0909
Resident 48 shall have their enabler bars assessed by the Director of therapy for entrapment.

Residents utilizing enabler bars shall have an assessment completed to identify zones of entrapment.

The Licensed nursing staff shall be educated by the Director of therapy on the need to ensure the use of enabler bars are assessed for entrapment.

A random weekly audit shall be completed by the Therapy Dir/designee to verify compliance with the enabler bars per regulation.

The audits shall be sent to the QAA monthly meeting for a review of issues/trends. This shall continue for three months or longer if issues are noted.


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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

Based on review of select facility policies and procedures, clinical record review, observation, and family and staff interview, it was determined that the facility failed to implement appropriate isolation precaution procedures for one of two residents reviewed for infection control concerns (Resident 34).

Findings include:

The facility policy entitled, "Contact Precautions," last reviewed without changes on June 24, 2019, revealed that the purpose of the policy is to establish a protocol to prevent the spread of germs by direct and indirect contact with residents or their environments. Staff must wear a gown and gloves when entering resident rooms and remove them when leaving the room. Notify visitors of contact precautions; place a sign on the door that reads, "Please see nurse before entering room." Educate the resident and visitors about the type of germ that is causing the infection and the reasons these precautions are required. Also, educate the resident and visitor on proper contact precautions.

Observation of Resident 34's room on September 24, 2019, at 10:34 AM revealed a yellow dividing organizer hanging from her door with personal protective equipment (e.g. gowns and gloves); however, there was no sign on the door to alert visitors to see the nurse regarding any special precautions.

Interview with Employee 10 (nurse aide) on September 24, 2019, at 10:35 AM confirmed that Resident 34's door area should have had a sign to alert visitors to see the nurse before entering because Resident 34 was on isolation precautions for a C-Diff infection (Clostridium difficile, contagious bacterial infection affecting the colon that causes severe diarrhea).

Observation of Resident 34's doorway on September 24, 2019, at 11:07 AM (after the interview with Employee 10), revealed a sign on the door to see the nurse before entering the room.

Clinical record review for Resident 34 revealed nursing documentation dated September 13, 2019, at 5:27 PM that indicated a stool specimen sent to the laboratory was positive for C-Diff.

Nursing documentation dated September 16, 2019, at 3:56 PM revealed that the physician ordered Fidaxomicin (medication used to treat diarrhea caused by the C-Diff bacterial infection) 200 milligrams by mouth two times a day for C-Diff colitis (inflammation of the bowel) for 10 days.

Observation of Resident 34's room on September 25, 2019, at 12:38 PM revealed her daughter sitting next to her, with her arm around her mother, feeding her lunch. Resident 34's daughter was not wearing any gloves or gown. Interview with Resident 34's daughter at the time of the observation revealed that she was told by her mother's infectious disease doctor to be sure to wash her hands; however, Resident 34's daughter denied any education provided by the facility staff regarding special precautions necessary due to her mother's C-Diff diagnosis.

Interview with the Nursing Home Administrator and Employee 1 (executive director of nursing) on September 25, 2019, at 2:00 PM revealed that the facility had no evidence of education regarding isolation precautions for Resident 34's daughter.

483.80(a)(1)(2)(i)-(iv)(A)(B)(v)(vi) Infection Prevention and Control
Previously cited 11/27/18 and 10/5/18

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 9/4/19, 11/27/18, and 10/5/18


 Plan of Correction - To be completed: 10/21/2019

F0880
An infection control sign has been placed on resident 34's door asking staff to see the nurse at the nursing station before entering the room

A review of resident in isolation shall be completed by the designated nursing staff to verify they have the appropriate sign placed on the door also.

The daughter of Resident shall be provided with education by the LPN charge nurse, related to the importance of following isolation precautions. Documentation shall be placed in the resident record verifying that the education has been completed with the family about the isolation precautions.

The nursing staff shall be educated on the need to verify signs are placed for isolation rooms, and the need to educate families on the infection status and the personal protective equipment that they need to use.

Random weekly audits shall be completed by the DON/designee to verify compliance with the regulation.
Audits

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:

Based on observation, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to secure medications on one of two nursing units and for one of three discharged residents reviewed (Unit 1 and Resident 76).

Findings include:

On September 25, 2019, at 8:45 AM the surveyor asked Employee 7, unit clerk, for residents' medical records. Employee 7 obtained a key from the desk at the nursing station and opened the medication room where the resident medical records were located. Employee 6, licensed practical nurse, came to the medication room to assist the surveyor. Concurrent observation of the medication room revealed one unlocked cupboard containing over the counter medication, one unlocked refrigerator containing prescription and over the counter medication, and two medication carts were present and locked.

Concurrent interview with Employee 6 revealed the key to the medication room is at the desk so that the doctor has access to the charts and the medication carts are always locked.

The surveyor reviewed the above findings about unauthorized employees having access to a key to unlock the medication room on September 25, 2019, at 2:00 PM with the Nursing Home Administrator.

The facility policy entitled, "Disposition of Medications Upon Discharge," last reviewed without changes on June 24, 2019, revealed that disposition of medications upon discharge will vary depending on the discharge destination or if they are a bed hold. When discharged to the hospital without a bed hold or upon expiration, the facility returns the medications to the pharmacy and destroys controlled substances per the facility policy.

Closed clinical record review for Resident 76 revealed the facility discharged him to the hospital on August 19, 2019, where he expired on August 20, 2019.

Review of Resident 76's medication administration record dated August 2019 revealed that staff administered the following medications prior to being transferred to the hospital:

Fentanyl patch (narcotic analgesic, a controlled substance) 12 micrograms (mcg)/hour, changed every three days
Novolin 70/30 insulin (injectable medication used to treat high blood sugar)
Pravastatin Sodium 20 milligrams (mg) (medication used to lower cholesterol)
Terazosin HCL 10 mg (medication used to treat high blood pressure)
Trazodone HCL 50 mg (antidepressant medication)
Flomax 0.4 mg (medication used to treat an enlarged prostate making it easier to urinate)
Lopressor 50 mg (medication used to lower blood pressure)
Protonix 20 mg (medication used to decrease stomach acid)
Pyridium 100 mg (medication used to relieve urinary tract pain and frequency)

A controlled substance accounting form used to monitor the supply of Resident 76's Fentanyl patches revealed that one nurse signed for the destruction of the remaining three patches. Resident 76's closed clinical record contained no evidence of the disposition (to include the quantity and method of disposal) of Resident 76's other routine medications noted above.

Interview with Employee 3 (certified dietary manager) and the Nursing Home Administrator on September 27, 2019, at 11:20 AM confirmed that it is the facility's policy to have two licensed nurses attest via signature to the destruction of controlled substances (such as Fentanyl patches) due to the potential for abuse. The interview confirmed that there was no evidence in Resident 76's closed clinical record regarding the disposition of the non-controlled medication substances.

28 Pa. Code 211.9(j)(k) Pharmacy services

28 Pa. Code 211.12 (c) Nursing services
Previously cited 9/4/19 and 10/5/19

28 Pa. Code 211.12 (d)(1)(5) Nursing services
Previously cited 9/4/19, 11/27/19, and 10/5/19


 Plan of Correction - To be completed: 10/21/2019

F0761
The keys for the medication room are being held by the RN supervisor and or LPN charge nurse.

Licensed nursing staff will be educated by the DON/designee on the need to secure medications at all times.

A random weekly audit shall be completed by the DON/designee on the need to verify only appropriate licensed staff hold the med room keys.

Audits shall be sent to the QAA monthly meeting for a review.

Resident # 76 no longer resides in the facility.

Residents being discharged from the facility shall have the proper documentation of the disposition of their medications. This shall include quantity and method of disposal.

Licensed nursing staff shall be educated by the DON/designee to document proper disposal of medications, to include the quantity and method of disposal, which is to include having two licensed nurses sign for the destruction of controlled substances.

A random weekly audit shall be completed by the DON/designee to verify compliance with the regulation.

The audits shall be sent to the QAA monthly meeting to monitor comp

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions to treat limited range of motion for one of four residents reviewed for range of motion concerns (Resident 12).

Findings include:

The facility's policy entitled, "Restorative Nursing Program," last reviewed without changes on June 24, 2019, defined a restorative nursing program as a specific approach that is organized, planned, documented, monitored, and evaluated. The criteria for a program includes that it be provided for at least 15 minutes during a 24-hour period, there be measurable objectives and interventions documented in the care plan and medical record, that there is a periodic evaluation documented by a licensed nurse, that nurse aides are trained in the restorative interventions, and that the programs are carried out and supervised by nursing staff. The monthly documentation by the licensed nurse should summarize the overall status of the resident's progress toward the goals in the program.

Clinical record review for Resident 12 revealed quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessments dated January 15, 2019, and April 15, 2019, that assessed Resident 12 as having impairment of functional range of motion on one side of her upper extremities.

Nursing documentation dated May 18, 2019, at 9:11 AM revealed that Resident 12 was to have passive range of motion exercises with a hand roll in her left hand per her restorative nursing plan of care.

The documentation did not summarize Resident 12's tolerance of the program, the frequency at which staff implemented the program, or Resident 12's progress towards any goals within the program.

A quarterly MDS dated July 15, 2019, assessed a decline in Resident 12 to now having impairment of the functional range of motion in both of her upper extremities (to include hands).

Nursing documentation dated August 27, 2019, at 11:31 AM continued to note that Resident 12 received passive range of motion of her left upper extremity with instructions to place a hand roll in her left hand as she tolerated.

The documentation did not summarize Resident 12's tolerance of the program, the frequency at which staff implemented the program, or Resident 12's progress towards any goals within the program.

Review of available plans of care developed by the facility to address Resident 12's care needs revealed no plan of care that indicated Resident 12 received a restorative nursing program for range of motion.

Observation of Resident 12 on September 25, 2019, at 1:20 PM revealed no hand roll present in her left hand.

Observation of Resident 12 on September 26, 2019, at 11:43 AM revealed no hand roll present in her left hand.

Interview with the Director of Nursing on September 27, 2019, at 9:30 AM, confirmed that the facility had no evidence that staff implemented Resident 12's range of motion restorative nursing program (to include the use of the hand roll) consistently. The interview confirmed that the facility had no method to evaluate Resident 12's tolerance to the program, frequency of refusals, number of days staff performed the program, or the total minutes of program administration per day.

28 Pa. Code 211.11(d) Resident care plan
Previously cited 10/5/19

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 9/4/19, 11/27/19, and 10/5/19


 Plan of Correction - To be completed: 10/21/2019

F 0688
Resident 12 shall have their Restorative Nursing plan reviewed by the Director of Therapy/designee and approved by the MD. Their plan shall be updated to show the tolerance of the program, frequency which staff will implement the program total minutes for the program per day and progress towards the resident goals for the program. The POC shall also be updated to reflect the current range of motion restorative program including the ordered left hand roll.

Residents on a restorative nursing program shall have their program reviewed and revised as needed by Therapy team and ordered by the MD to provide compliance with the regulation.

The nursing staff shall be educated by the nursing designee on the restorative process, including the documentation sheets to show the program ordered, tolerance and frequency for the implementation of the program and to include any assistive devices as ordered by the MD.

Weekly random audits shall be completed by the Nursing designee to verify compliance with the program.

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

Based on observation, review of select facility policies and procedures, clinical record review, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care to prevent and promote pressure ulcer healing for two of four residents reviewed for pressure ulcer concerns (Residents 25 and 73).

Findings include:

The facility policy entitled, "Skin Care/Prevention of Pressure Ulcers," last reviewed on June 24, 2019, revealed the facility will prevent pressure ulcers through the identification of those at risk. A measure implemented was to avoid pressure over bony prominences. Once staff identifies a skin issue, they need to document the following on a weekly basis: the type of ulcer, characteristics. An immobilized resident and a resident over the age of 70, are clinical conditions identified as a primary risk factor for developing pressure sores.

Interview with Resident 25 on September 24, 2019, at 11:53 AM revealed the resident reported having pressure ulcers on the right foot caused by a cast.

Clinical record review of Resident 25's orthopedic (branch of medicine concerned with the bones) consultation dated August 29, 2019, revealed Resident 25 had very thin atrophic (thinning of) skin over the right lower leg with poor turgor (the degree of elasticity). Staff removed the cast and identified a decubitus ulcer (a skin ulcer caused by pressure) with black eschar (dead skin tissue) at the heel and lateral (side) edge of foot. Daily wound checks and dressing changes were recommended with extensive padding of the removable cast.

Record review of Resident 25's nursing progress notes dated August 30, 2019, revealed that the dressing to the right heel and bottom right foot was completed as ordered. The top of the right foot had three dark colored areas. The right heel had a grey area. The right bottom foot had a grey area under the pinky toe. The resident denied pain during the dressing change. Staff applied a soft cast padding, then an ace wrap with the boot was put in place. A pillow was placed under the right calf and the right heel and foot was left floating off the surface of the bed.

Nursing documentation dated September 16, 2019, revealed the nurse changed the dressing on Resident 25's right foot. The top of the right foot had a large purple area and the outside of the large purple area started to open. The pressure area on the bottom of the foot below the pinky toe continued with a purple area and began to open around the pressure area. Staff notified the registered nurse supervisor and assessed the wounds. Orthopedics was called and the resident's appointment was moved up to September 18, 2019. New orders were obtained for Medihoney (a treatment to promote wound healing) to the open areas on top of the right foot and bottom of the right foot below the pinky toe and to cover them with Telfa (a nonstick dressing), gauze padding, and to continue with a padded wrap and ace wrap. Staff were to change the dressings daily. A verbal order was obtained from the nurse practitioner to consult with the wound clinic. An appointment was made at the wound clinic for September 25, 2019.

Clinical record review of Resident 25's wound care evaluation flowsheets revealed the following pressure ulcer documentation about the unstageable (not stageable due to coverage of wound by slough and/or eschar) wounds:

September 19, 2019:

Right heel, 4 cm (centimeters) length x 3 cm width, no depth, black wound bed, pink skin around wound
Top of right foot, 4.2 cm length x 3 cm width, no depth, black wound bed, pink skin around wound
Right fifth digit (toe), 2 cm length x 2 cm width, no depth, black wound bed, pink skin around wound
Top lower right foot, 0.8 cm length x 0.1 cm width, no depth, black wound bed, pink

September 26, 2019:

Right heel, 4 cm length x 3 cm width, no depth, black wound bed, dry scaly skin around wound
Top of right foot, 4.2 cm length x 2.7 cm width, no depth, black wound bed, pink skin around wound
Right fifth digit (toe), 4 cm length x 2.1 cm width, no depth, black wound bed, pink skin around wound
Top lower right foot, 1.3 cm length x 1 cm width, no depth, black wound bed, pink skin around wound

There was no documented evidence that the pressure ulcers were fully assessed for the type of ulcer, characteristics and staging on a weekly basis until September 19, 2019, after being identified on August 29, 2019.

The surveyor reviewed the above findings with the Nursing Home Administrator on September 27, 2019, at 11:30 AM.

Clinical record review for Resident 73 revealed that he is 78 years old. The facility admitted him on August 19, 2019, with a left leg/knee immobilizer due to a left hip fracture with repair.

Review of Resident 73's current care plan revealed that he was at risk for alteration in skin integrity due to immobility and a brace. Review of Resident 73's Wound Evaluation Flowsheet (a sheet to document wounds) dated September 6, 2019, revealed that staff identified that the back of Resident 73's left calf had a Stage II (broken skin) open area, measuring 3 cm by 2 cm by 0.1 cm, that was due to the brace rubbing on Resident 73's leg. There was no physician's order for Resident 73's left leg/knee immobilizer from admission until September 13, 2019, when the physician discontinued it. There was no order or direction on how staff was to assess and/or monitor Resident 73's left leg and/or remove Resident 73's left leg immobilizer while it was ordered.

Observation of Resident 73's left leg immobilizer on September 27, 2019, at 12:30 PM with Employee 5, Director of Therapy, revealed that there was a malleable (bendable) metal stay in the back of the immobilizer, which was in the proximity of where Resident 73's left calf Stage II open area was located. Employee 5 acknowledged that the metal stay had the potential to cause Resident 73's open area.

Review of Resident 73's Wound Evaluation Flowsheet dated August 27, 2019, revealed that his left heel developed a Stage II pressure ulcer, measuring 4 cm by 4 by less than 0.1 cm depth. Resident 73's physician ordered that staff cleanse the wound with normal saline, apply medihoney (a wound healing agent) and a dry dressing daily. On September 19, 2019, staff identified Resident 73's left heel as now unstageable with a black wound bed and yellow drainage.

Observation of Resident 73's dressing change on September 26, 2019, at 3:25 PM with Employee 8, Registered Nurse, and Employee 9, Registered Nurse, revealed that Resident 73's left calf wound now measured 1.5 cm by 1 cm. Employee 8 applied medihoney and a dry dressing as ordered. Resident 73's left heel wound now measured 5 cm by 5 cm and continued to be unstageable with a black wound base and black and yellow drainage noted. Employee 8 applied medihoney and a dry dressing as ordered, however, the dressing did not fully cover Resident 73's left heel wound. Employee 8 adhered the adhesive tape directly onto Resident 73's left heel wound.

The surveyor reviewed the above information for Resident 73 during an interview with the Director of Nursing (DON) and Employee 1, Registered Nurse, Executive Director of Nursing, on September 26, 2019, at 3:42 PM, and during an interview with the Nursing Home Administrator on September 27, 2019, at 12:22 PM.

Interview with the DON and Employee 1 on September 27, 2019, at 9:10 AM revealed that they checked Resident 73's left heel wound after the above noted conversation with the surveyor. They confirmed that staff had placed the adhesive tape directly on Resident 73's left heel wound and changed Resident 73's dressing to cover the wound completely.

483.25(b)(i)(1) (2) Treatment/Services to Prevent/Heal Pressure Ulcer
Previously cited 10/5/18

28 Pa. Code 211.5(h) Clinical records

28 Pa. Code 211.10(d) Resident care policies
Previously cited 9/4/19, 10/5/18

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 9/4/19, 11/27/18, and 10/5/18


 Plan of Correction - To be completed: 10/21/2019

F686
Resident 25 shall have their pressure ulcer assessed by licensed nursing. This will include the type of ulcer, characteristics and staging of the wound.
Resident 73 no longer resides in the facility.

Residents with identified Pressure ulcers shall have their wounds assessed by the Licensed nursing staff to identify any skin concerns.

The licensed nursing staff shall be educated by the DON/designee on the Policy and Procedure for skin care prevention of pressure. This will also include proper dressing changes and the need to obtain a MD order for any device that is utilized. Also reviewed will be the need to show how staff will assess and monitor the area to prevent breakdown.

A weekly random audit shall be completed by the designated nursing staff member to review residents with pressure ulcers .

The audits shall be sent to the QAA monthly for a review of issues.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:
Based on review of clinical records and interview with facility staff, it was determined that the facility failed to revise a comprehensive care plan in response to the development of pressure sores for one of 18 residents reviewed (Resident 25).

Findings include:

A review of Resident 25's comprehensive plan of care, last revised by the facility on July 9, 2019, revealed the facility identified the resident to be at risk for impairment of skin integrity related to immobility. Interventions at the time included weight monitoring, position changes, routine skin care during personal hygiene, monitor food intakes, and weekly skin assessments.

Clinical record review of Resident 25's orthopedic (branch of medicine concerned with the bones) consultation dated August 29, 2019, revealed Resident 25 had very thin atrophic (thinning of) skin over the right lower leg with poor turgor (the degree of elasticity). A cast was removed, and staff noted a decubitus ulcer (a skin ulcer caused by pressure) with black eschar (dead skin tissue) at the heel and lateral (side) edge of foot. Daily wound checks and dressing changes were recommended with extensive padding of the removable cast.

There was no information regarding the development of pressure ulcers and treatment interventions of the decubitus ulcers in Resident 25's care plan until September 24, 2019.

The surveyor reviewed the above findings with the Director of Nursing on September 27, 2019, at 11:30 AM.

28 Pa. Code 211.11(d) Resident care plan


 Plan of Correction - To be completed: 10/21/2019

F 657 cp
Resident 25 shall have their care plan reviewed and revised by the IDT as necessary to address the development and treatment of pressure ulcers.

Residents with identified pressure ulcers shall have their care plans reviewed and revised by the IDT as needed in relation to pressure ulcers.

The licensed nursing staff shall be educated by the DON/designee on updating the resident care plan with any identified Pressure Ulcers.

A random weekly audit shall be completed by the DON/designee to verify care plans have been updated as needed with resident changes.

The audits shall be sent to the monthly QAA for a review for three months or longer if issues are identified.

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

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to maintain the highest practicable well-being for two of 18 residents reviewed (Residents 59 and 12).

Findings Include:

Clinical record review of Resident 59's diagnostic summary revealed the resident was admitted on May 29, 2019. Resident 59 has a diagnosis of aphasia (the loss of ability to understand or to express speech, caused by brain damage).

Interview with Resident 59 on September 25, 2019, at 9:14 AM revealed the resident did not speak. The resident made vocalizations and nodded her head to questions pertaining to her homelike belongings in her room and if the care provided to her was good.

Clinical record review of Resident 59's Speech Therapy Progress and Discharge Summary dated June 25, 2019, revealed the resident was able to accurately answer yes/no questions and use gestures to get her point across. The resident benefited from "wh-questions" (who, what, where, when, why, how, whose, which, how many/long/much/often) in order to get her point across. The resident was instructed on a communication aid; however, the resident showed no interest in using it.

Interview with Employee 5, director of therapy, on September 26, 2019, at 8:45 AM revealed there was no comprehensive person-centered care plan for Resident 59 addressing communication.

The surveyor reviewed the above findings for Resident 59 with the Nursing Home Administrator on September 25, 2109, at5 2:00 PM.

The facility's policy entitled, "Restorative Nursing Program," last reviewed without changes on June 24, 2019, defined a restorative nursing program as a specific approach that is organized, planned, documented, monitored, and evaluated. The criteria for a program includes that it be documented in the care plan and medical record.

Clinical record review for Resident 12 revealed quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessments dated January 15, 2019, and April 15, 2019, that assessed Resident 12 as having impairment of functional range of motion on one side of her upper extremities.

Nursing documentation dated May 18, 2019, at 9:11 AM revealed that Resident 12 was to have passive range of motion exercises with a hand roll in her left hand per her restorative nursing plan of care.

A quarterly MDS dated July 15, 2019, assessed a decline in Resident 12 to now having impairment of the functional range of motion in both of her upper extremities (to include hands).

Nursing documentation dated August 27, 2019, at 11:31 AM continued to note that Resident 12 received passive range of motion of her left upper extremity with instructions to place a hand roll in her left hand as she tolerated.

Review of available plans of care developed by the facility to address Resident 12's care needs revealed no plan of care that indicated Resident 12 received a restorative nursing program for range of motion.

Interview with the Director of Nursing on September 27, 2019, at 9:30 AM confirmed that the facility had no evidence that staff developed a plan of care to address Resident 12's range of motion deficits that included the specifications of a restorative nursing program.

483.21(b)(1) Develop/Implement Comprehensive Care Plan
Previously cited 10/5/18

28 Pa. Code 211.11 (d) Resident care plan
Previously cited 10/5/18


 Plan of Correction - To be completed: 10/21/2019


F 0656
Resident 59 shall have their care plan updated by the IDT to address their communication need.

Resident 12's care plan shall be updated by the IDT to reflect their range of motion deficits that include specifications of a restorative nursing program.

The IDT shall review care plans for other residents with communication needs. Their care plans shall be reviewed and revised as needed to address their communication needs.

Residents on a restorative program shall have their care plans reviewed by the IDT to verify their care plans are person centered to maintain their highest practicable well- being.

The IDT shall be educated by the NHA/designee to verify care plans address the resident issues/needs as they relate to communication and restorative needs.

A weekly random audit shall be completed by the DON/designee to verify care plans meet the requirements of the regulation.

The audits shall be sent to the monthly QAA meeting for a review for three months

483.20(g) REQUIREMENT Accuracy of Assessments: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.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on clinical record review and staff interview it was determined that the facility failed to ensure the accuracy of assessments for two of 18 residents reviewed (Residents 7 and 34).

Findings include:

Clinical record review for Resident 7 revealed quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessments dated April 11, 2019 and July 11, 2019, that assessed her as receiving an antipsychotic medication.

Review of Resident 7's medication administration orders revealed no evidence that Resident 7 received an antipsychotic medication during the lookback periods pertinent to the April and July 2019 MDS assessments. The physician orders available noted that Resident 7 received the following psychotropic medication:

Aricept (brain chemical inhibitor medication used to slow the effects of Alzheimer's dementia, disease of the brain that affects memory, behavior, and cognition)
Depakote (anticonvulsant used to treat seizure disorders and stabilize mood disorders)
Remeron (antidepressant) 15 mg orally at bedtime for appetite stimulation
Namenda (miscellaneous central nervous system agent used to treat Alzheimer's dementia)

Interview with the Nursing Home Administrator and Employee 1 (executive director of nursing) on September 26, 2019, at 1:45 PM, revealed that the staff completing the MDS assessments errantly viewed Resident 7's use of Depakote as an antipsychotic.

Clinical record review of current physician orders for Resident 34 included a discontinuation of hospice services effective February 8, 2019.

Available MDS assessments for Resident 34 following the discontinuation of hospice services were quarterly MDS assessments dated April 19, 2019, and July 19, 2019, that both assessed Resident 34 as receiving hospice services.

Interview with the Nursing Home Administrator and Employee 1 on September 25, 2019, at 2:49 PM confirmed that the quarterly MDS assessments for Resident 34 completed in April and July 2019 inaccurately assessed her as receiving hospice services.

483.20(g) Accuracy of Assessments
Previously cited deficiency 10/5/18

28 Pa. Code 211.5(f) Clinical records
Previously cited 10/5/18

28 Pa. Code 211.12(d)(3)(5) Nursing services
Previously cited 9/4/19, 11/27/18, and 10/5/18


 Plan of Correction - To be completed: 10/21/2019

0641 MDS
The MDS for resident 7 shall be amended by the RNAC as it refers to the Depakote as an antipsychotic.

The MDS for resident 34 shall be amended by the RNAC to reflect their hospice status for the April and July assessment.

The MDS coordinator shall be educated by the NHA/designee on the need to address classifications of medications and current hospice status.

A random weekly audit shall be completed by the nursing designee to verify accuracy of the MDS.

The audits shall be sent to the QAA monthly for a review of issues.


483.20(b)(2)(ii) REQUIREMENT Comprehensive Assessment After Signifcant Chg: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.
483.20(b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)
Observations:

Based on clinical record review and staff interview it was determined that the facility failed to complete a significant change assessment following a change in hospice services for one of two residents reviewed for hospice services (Resident 34).

Findings include:

Clinical record review for Resident 34 revealed a significant change MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated January 21, 2019, that assessed Resident 34 as receiving hospice services.

Current physician orders for Resident 34 included a discontinuation of hospice services effective February 8, 2019.

Available MDS assessments for Resident 34 following the discontinuation of hospice services were quarterly MDS assessments dated April 19, 2019, and July 19, 2019.

Interview with the Nursing Home Administrator and Employee 1 (executive director of nursing) on September 25, 2019, at 2:49 PM confirmed that the facility failed to complete a significant change MDS assessment following the discontinuation of hospice services for Resident 34.

28 Pa. Code 211.12(d)(3)(5) Nursing services
Previously cited 9/4/19, 11/27/18, and 10/5/18


 Plan of Correction - To be completed: 10/21/2019

F0637 assessments hospice

A significant change assessment will be completed for resident # 34 due to a change to hospice care.

The RNAC shall complete a significant change assessment for residents that have changed to hospice care during the Month of September.

Education has been provided to the DON/designee on the need to verify that Significant change assessments are completed for residents changing to Hospice care.

Weekly audits shall be completed by the RNAC and verified by the NHA that significant change assessments are completed when residents are changing to hospice care.

Audits shall be sent monthly for three months to the QA for a review

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

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

Based on observation and staff interview, it was determined that the facility failed to provide housekeeping services to ensure a clean and orderly environment on one of three dining rooms (dining room across from Resident Room 502).

Findings include:

Observation of a facility dining room across from Resident Room 502 on September 24, 2019, at 11:45 AM and 12:21 PM revealed a strong urine smell on the left and right sides of the dining room.

Interview and concurrent observation on September 24, 2019, at 12:00 PM with Employee 3, certified dietary manager, confirmed the strong urine smell on the left side of the dining room.

Interview and concurrent observation on September 24, 2019, at 12:21 PM with Employee 4, housekeeping, confirmed the strong urine smell on the right side of the dining room.

The surveyor reviewed the above information during an interview with the Nursing Home Administrator on September 25, 2019, at 2:00 PM.

28 Pa. Code 201.18(b)(3) Management
Previously cited 9/4/19

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


 Plan of Correction - To be completed: 10/21/2019

F 584 Environment

The source of the odor has been removed from the dining room area by housekeeping.

The Director of Environmental service shall complete a tour of the facility in order to identify any other areas of concern. Items shall be removed as identified.

The Housekeeping Director shall be educated to complete rounds to ensure a clean and orderly environment in all areas.
The Housekeeping Director/designee shall complete a weekly random audit to verify no other issues exist.

The audits shall be sent to the QAA monthly meeting for a review of trends/issues.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

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

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

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to identify, thoroughly investigate, and report to the appropriate agencies an incident of potential resident neglect for one of six residents reviewed for fall concerns (Resident 51).

Findings include:

The facility policy entitled, "Abuse Prohibition Policy," last reviewed without changes on June 24, 2019, revealed that all incidents involving suspected abuse or neglect will be thoroughly investigated and reported to the Pennsylvania Department of Health (field office) and other agencies as directed by law. The definition of neglect included the absence of minimal services or resources to meet basic needs. Prevention of abuse/neglect included to assure that the staff assigned have knowledge of the individual resident's care needs. The facility identifies events and trends that may constitute abuse/neglect by investigating incidents. The facility thoroughly investigates all alleged or suspected instances of abuse by identifying the staff member(s) responsible for the initial reporting, investigation of alleged violations, reporting results to the proper authorities, obtaining witness and alleged abuser statements, interview employees, and reviewing staffing records and assignment sheets. The facility will notify the local Department of Health field office through the electronic adverse event reporting system within 24 hours and include the nature of the allegation.

Clinical record review for Resident 51 revealed nursing documentation dated February 10, 2019, at 1:00 AM indicating that the registered nurse, the licensed practical nurse, and two nurse aides were charting in the nurse's station when staff heard a very faint call for help from a female resident. Upon checking a camera monitor, staff noticed Resident 51 lying on the floor in the hallway, on her left side, with her head resting on the floor. Upon initial assessment, Resident 51 continuously stated, "...my leg, my leg, it hurts. I can't move my leg;" and pointed to her left leg. Resident 51 stated, "The pain in my leg is going all the way down my leg and up into my back." Upon light palpation, the resident stated the pain was located directly at the hip joint. Resident 51 stated, "The pain hurts so bad. I think I might pass out." Emergency medical personnel arrived at the facility and transported Resident 51 to the emergency department for further evaluation of hip and head injuries.

Clinical record review for Resident 51 revealed nursing documentation dated February 10, 2019, at 5:00 AM that the nursing staff contacted the emergency department to obtain a status report of Resident 51. The emergency department staff informed the facility staff that Resident 51 had sustained multiple pubic rami (bones that make up the front of the pelvis) fractures. The documentation indicated that the facility staff contacted Resident 51's (daughter) to inform her that Resident 51 could be found in the intensive care unit and that she had sustained hip fractures during her fall.

Review of the facility's investigation dated February 10, 2019, at 1:00 AM confirmed that Resident 51 sustained an unwitnessed fall; and that the facility implemented chair and bed alarms as a new intervention to prevent fall recurrence.

Review of a plan of care developed by the facility on February 10, 2019, to address Resident 51's risk for falls characterized by her history of falls and injury listed interventions that included the facility initiated bed and chair alarms on February 14, 2019.

Nursing documentation dated March 20, 2019, at 9:25 AM revealed that the writer was working on a computer when the writer heard a nurse aide yell, "...oh my God!" The writer noted that staff saw Resident 51 on the floor, on her abdomen. Staff summoned the registered nurse to the unit. Staff noted blood coming from Resident 51's forehead. Resident 51 left the facility enroute to the emergency room at 9:40 AM.

Nursing documentation dated March 20, 2019, at 9:30 AM revealed that Resident 51 fell on the floor in the dining room. Staff found Resident 51 on the floor, face down, with a "cut" on her head measuring one inch and bleeding. Staff called an ambulance service to take Resident 51 to the emergency room for evaluation.

Nursing documentation dated March 20, 2019, at 4:07 PM revealed the writer contacted the emergency room regarding Resident 51's status. The emergency room informed the writer that Resident 51 was admitted to the hospital with a small subarachnoid hemorrhage (bleeding from a damaged artery between the skull and the surface of the brain increasing the pressure surrounding the brain; a type of stroke that can cause permanent brain damage).

Review of the facility's investigation dated March 20, 2019, at 9:15 AM confirmed that because staff heard the nurse aide yell, staff responded to the dining room to find Resident 51 had fallen out of her chair onto the floor. The incident investigation stipulated that "Resident (51) had no alarm." The witness statement from the nurse aide identified as the witness who found the resident attested that Resident 51 did not have an alarm on. Witness statements from a second nurse aide and a licensed practical nurse both stipulated no chair alarm was present.

Review of an electronic adverse event report dated March 20, 2019, provided the local field office information that Resident 51 sustained a fall, was transferred to the emergency room, and was diagnosed with a subarachnoid hemorrhage. The event report stipulated that, "Prior to event, care plan interventions were in place and included the following: safety mats on floor bilaterally next to bed, non-skid socks while in bed, and proper foot wear when OOB (out of bed), verifying frequently utilized articles were within resident's reach, environment was free of clutter, bed alarm in place, call bell within reach, bed maintained in low position. Neglect was ruled out in course of investigation."

The event report failed to list a chair alarm as a care plan intervention in place prior to the event. The event failed to report that the plan of care included a chair alarm; and that it was not in place at the time of Resident 51's fall. The event indicated that the facility ruled out neglect; however, failed to thoroughly investigate the potential failure of staff to implement the necessary intervention.

The facility's investigation of Resident 51's fall on March 20, 2019, failed to thoroughly investigate the absence of the necessary care plan intervention (chair alarm), identify the staff member who potentially failed to implement the necessary intervention (potential neglect), and failed to notify the local Department of Health of the potential neglect.

The surveyor reviewed the above findings during an interview with Employee 3 (certified dietary manager) and the Nursing Home Administrator on September 27, 2019, at 11:10 AM. The interview confirmed that Resident 51 fell on February 10, 2019, the facility implemented the new intervention of bed and chair alarms to prevent future falls, there was no indication that staff implemented the chair alarm before her fall on March 20, 2019, when Resident 51 fell from her chair, struck her head on the floor, and sustained a brain hemorrhage. The interview confirmed that this information was not fully disclosed to the local field office of the Department of Health via the electronic event report.

28 Pa. Code 201.18(e)(1) Management
Previously cited 9/4/19

28 Pa. Code 201.29(a) Resident rights
Previously cited 10/5/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 9/4/19, 11/27/18, and 10/5/18


 Plan of Correction - To be completed: 10/21/2019

F 610 I&R

Resident # 51 shall have their care plan reviewed and nursing staff made aware of the resident interventions.

Resident incidents relating to falls shall be reviewed by the DON/designee for the past two weeks to verify that all interventions are being utilized as identified on the incident report.

The DON/designee shall review the incident reports during the morning meeting to identify, investigate, and report to the appropriate agencies any incidents of potential resident neglect.
The management team shall be educated by the NHA/designee on the need to complete a thorough review of the incident report during the morning meeting to identify potential neglect issues. The education shall also include the importance of disclosing all information relating to the event.

Any trends or issues noted with the incident report review shall be sent to the monthly QAA for a review.
This review shall continue for three months or longer if issues continue.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to notify a resident and/or their responsible party in writing of a transfer to the hospital for four of eight residents reviewed (Residents 24, 26, 34 and 51).

Findings include:

The facility policy entitled, "Discharge/Transfer Notice," last reviewed without changes on June 24, 2019, revealed that it is the facility's policy to make sure that all residents and family members are aware of discharge or transfer from the facility, the option to have their bed held while they are out of the facility, and the possible fees associated with holding a bed in the resident's absence. The transfer notice must give a brief summary of short or long term goals (e.g. send to emergency room for evaluation and possible treatment for respiratory distress). All three pages of the Notice must be signed by the resident and family at the time of transfer. If the resident is unable to sign the forms, staff write, "Unable to Sign," in the resident signature spot. If family is not present to sign the Notice, staff contact them and ask them to come to the facility to sign the papers at their earliest convenience. If family members are from out of the area, these forms can be mailed to them for signature. Any Notices that require mailing should be given to the Unit Clerk for proper management. The Unit Clerk is responsible to give them to the receptionist for mailing.

Clinical record review for Resident 24 revealed that she was transferred to the hospital on December 22, 2018, May 1, 2019, and July 15, 2019, after she had changes in her condition. There was no documentation that the facility provided written notification to Resident 24 or their responsible party regarding the transfers that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred, contact and address information for the Office of the State Long-Term Care Ombudsman, and information for the agency responsible for the protection and advocacy of individuals with developmental disabilities.

Clinical record review for Resident 26 revealed that she was transferred to the hospital on December 17, 2018, January 18, 2019, February 15, 2019, and July 21, 2019, after she had changes in her condition. There was no documentation that the facility provided written notification to Resident 26 or their responsible party regarding the transfers that included the required contents as listed above.

The surveyor reviewed the above information for Residents 24 and 26 during an interview with the Nursing Home Administrator on September 27, 2019, at 8:40 AM.

Clinical record review for Resident 51 revealed discharge MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessments dated August 12, 2019, and May 23, 2019, indicating that the facility transferred Resident 51 to the hospital.

The surveyor requested evidence of a transfer notice provided to Resident 51 and/or her responsible party in response to her hospitalizations in May and August 2019 during an interview with the Nursing Home Administrator and Employee 1 (executive director of nursing) on September 25, 2019, at 2:00 PM.

A Discharge/Transfer Notice provided by the facility on September 26, 2019, for Resident 51's transfer to the hospital on May 23, 2019, did not include any signatures from either the resident or the resident's responsible party. The transfer notice did not include any short or long term goals to suggest the reason for the transfer (e.g. treatment for altered mental status or urinary tract infection).

The facility failed to provide a Discharge/Transfer Notice for Resident 51's transfer to the hospital on August 12, 2019.

Clinical record review for Resident 34 revealed MDS discharge assessments dated May 13, 2019, June 25, 2019, and August 12, 2019, indicating that the facility transferred Resident 34 to the hospital.

The surveyor requested evidence of a transfer notice provided to Resident 34 and/or her responsible party in response to her hospitalizations in May, June, and August 2019 during an interview with the Nursing Home Administrator and Employee 1 on September 25, 2019, at 2:00 PM.

A Discharge/Transfer Notice provided by the facility on September 26, 2019, for Resident 34's transfer to the hospital on June 25, 2019, did not include any signatures from either the resident or the resident's responsible party. The transfer notice did not include any short or long term goals to suggest the reason for the transfer.

The facility failed to provide a Discharge/Transfer Notice for Resident 34's transfers to the hospital on May 13, 2019, and August 12, 2019.

Interview with the Director of Nursing on September 27, 2019, at 9:30 AM confirmed that the facility had no further evidence of providing Residents 51, 34, or their responsible party the appropriate transfer notices in response to the hospitalizations as noted above.

483.15(c)(3)-(6)(8) Notice Requirements Before Transfer/discharge
Previously cited 10/5/18

28 Pa. Code 201.14 (a) Responsibility of license
Previously cited 10/5/18

28 Pa. Code 201.29(a) Resident rights
Previously cited 10/5/18


 Plan of Correction - To be completed: 10/21/2019



F 0623
The Social Service Director/designee shall notify residents 24,26,51 ,34, or their designated family of the facility transfer policy, and that should their family member be transferred out of the facility in the future they will be given the transfer letter as per regulation. The conversation shall be completed verbally and documented in the resident record.

When a resident is transferred out of the facility a transfer letter shall be given which will include the reason for the transfer, date of the transfer, location where resident was transferred , contact information for the Office of the State Long-Term Care Ombudsman, and information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. The form shall be signed by the resident or their responsible party and have short or long term goals to identify the reason for the transfer.

The Licensed Nursing staff shall be educated by the DON/designee of the Transfer Policy/Procedure.

The DON/designee shall review Resident letters sent out within the last week to verify information was correct and have the appropriate signatures.

The facility shall keep a copy of the transfer letters to the family allowing the facility proof that the letter has been sent.
An audit tool shall be utilized and reviewed weekly verifying the notice of transfer was sent. The DON/designee shall be responsible to verify completion.
The audits shall be reviewed at the QA meeting. The weekly review shall continue for 3 months, or longer if issues are identified.



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