Nursing Investigation Results -

Pennsylvania Department of Health
SILVER STREAM NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SILVER STREAM NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  106 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.
SILVER STREAM NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey and an Abbreviated survey in response to two complaints, completed on June 13, 2022, it was determined that Silver Stream Nursing and Rehabilitation Center was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.



 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 clinical record review and interviews with staff, it was determined that the facility failed to supervise and monitor a resident with a known history of self-harm when he cut himself with a razor blade which caused harm to a resident (Resident R59) and the facility failed to supervise a resident with a history of wandering for one of thirty-three sampled residents (Resident R232).

Findings include:

A review of Resident R59's clinical record revealed the resident was admitted to the facility on June 25, 2019, with diagnosis that included Bipolar (manic depression), Impulsive disorder (inability to control urges), Major Depressive disorder (persistent feelings of sadness), Schizophrenia (hallucinations, delusions and disorganized thoughts), Schizoaffective disorder (combination of symptoms of schizophrenia and mood disorder), Suicidal ideation, borderline personality disorder (unstable moods and thoughts) and PICA (eating disorder in which a person eats things not usually considered food).

A review of Resident R59's clinical record revealed a nurse progress note dated October 15, 2021, at 3:44 PM, which revealed: at approximately 2PM nurse entered room to give Bolus feed via G tube and found resident had cut up his G tube so he could then eat by mouth.

A review of Resident R59's clinical record revealed on November 9, 2021, at 5:19 PM, during a Risk Meeting documentation revealed resident noted with three small foreign objects in his ear, found during an audiology appointment.

A review of Resident R59's clinical record progress note dated April 17, 2022, at 8:31 a.m. revealed: At 12:55 AM [Resident R59] came to nurses with his shirt lifted and visible bleeding from a superficial cut on the abdominal area, when he was asked what happened [Resident R59] stated that "I cut myself with a razor", the nurse asked why did you cut yourself, and he responded "I have no reason to live, I want to die., I am only 62 years old and I have no future, I am just here day after day doing nothing, I just want to die". [Resident R59] was asked where he got razor, he stated I just took it, the blades from the disposable razor were removed.

A review of a clinical progress note dated April 17, 2022, at 3:51 p.m. revealed: Resident risk meeting held with behavioral IDT team which revealed "Resident does have history of suicidal ideations, self-harm and behavioral problems, all contributory factors to resident self-infliction for injury." Intervention identified in IDT meeting, Resident sent out 911 and admitted to Behavioral health unit for intention to harm self, DOH reportable to be submitted.

A review of Resident R59's Care Plan revealed documented under Psychotropic medications, Behavior management, Potential for injury to self or others. History of suicidal ideation and self-harm (cutting). Further review revealed Interventions: revised date on intervention revealed April 17, 2022, transfer to Behavior Unit. Last revised intervention dated March 27, 2020, revealed interventions listed; Take all suicidal ideation seriously, resident on behavior management, offer emotional support.
Further review of the resident's Care Plan dated March 20, 2022, under Behavior problem, Resident R59, has a behavior problem surrounding making false accusations, swallowing small items - batteries, potential to barricade himself in his room and to harm himself. PICA, resident is also monitored for severe recalcitrant, aggressive and explosive behaviors. Interventions documented reveal, s/p incident April 17, 2022, date-initiated April 18, 2022. Support care to follow; toiletries will not be left in room.

During an interview June 10, 2022, 1:30 p.m., discussed with Administrator and DON Incident on Resident R59's suicidal attempt on April 17, 2022. Administrator verified in statement it was not reported to DOH. Discussion on monitoring room and resident for hazards revealed there were no interventions to monitor and assess resident for self-harm aside from only allowing resident to have plastic wear for dining.

Facility failed to adequately supervise and provide an environment free of accident hazards to a resident with a history of self harm which caused harm to Resident R59 on April 17, 2022, when he used a razor to cut himself on the abdomen.

Review of the "Elopements and Wandering Residents" policy with a date implemented of June 2021 stated that the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Further review of the policy stated that the facility is equipped with door locks/alarms to help avoid elopements, and that alarms are not a replacement for necessary supervision, and that staff are to be vigilant in responding to alarms in a timely manner.

Review of the resident's clinical record indicated that the resident was admitted into the facility on May 19, 2021.

Review of the January 2022 physician orders for Resident R232 included the following diagnosis: cognitive communication deficit (problems with communication), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), dysphasia (difficulty with swallowing), and difficulty in walking.

Review of the resident's physician orders for the resident also revealed a physician order for a wander guard bracelet (an electronic monitoring device tis secured on a resident's wrist of ankle and will sound an alarm when a resident wearing one is in the vicinity of exit areas) with a start date of August 31, 2021.

Review of the resident's person-centered plan of care indicated initiated on September 7, 2021, that
Resident R232 was an elopement risk and wandered, related to attempts to leave the facility unattended. The care plan also indicated that the resident had impaired safety awareness, and that he wandered aimlessly.

Review of the resident's Quarterly Minimum Data Set (MDS is an assessment of resident's care needs) dated August 23, 2021, revealed the resident was severerly cognitive impaired.

Review of the resident's interdisciplinary notes indicated that on September 5, 2021, Resident R232 eloped from the facility. Review of the facility investigation indicated that the resident was last seen in the facility at 3:40 p.m. Employee E11, Nursing Assistant, alerted the facility at approximately 4:00 p.m. that the resident was across the street from the facility at approximately 4:00 p.m.

During a discussion with the Nursing Home Administrator (NHA), on June 10, 20221 at approximately 1:54 p.m. it was discussed that the resident exited out of the first-floor door with a vendor who was in the building. The first-floor alarm door that was equipped with a wander guard alarm, which did sound an alarm to indicate that a resident with a wander guard was near the vicinity of the door. The NHA reported that the staff heard the alarm but did not go check to see if anyone exited the premises.

28 Pa. Code 201.29(c) Resident rights

28 Pa. Code 211.10(d) Resident care policies







 Plan of Correction - To be completed: 07/26/2022

Disclaimer: Facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal Regulations relating to long term care. This should not be construed as either a waiver of the Facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or any admission of any wrongdoing or an admission of past or ongoing violations of State and Federal Regulations.

Resident R232 is no longer residing at the facility.
Resident R59 is still residing at the facility with no adverse reactions from this deficient practice and safety precautions are in place.
Residents with a history of self-harm and wandering have the potential to be affected by this deficient practice.
A facility wide audit will be completed to identify residents with history of wandering and self-harm to ensure safety measures are in place.
Education will be done with all nursing staff to ensure and be mindful of the safety precautions necessary for R59 and other residents who may have a history of self-harm.
Education will be done with all staff on how to prevent elopements and to ensure that alarms are responded to in a timely manner, and that residents are accounted for in the event that an alarm is sounding with an unknown cause.
Safety checks on R59 will be done by nursing every 2 hours x 2 weeks, then every 4 hours x 4 weeks, then every 6 hours x 12 months to ensure resident safety.
Administration/designee will conduct random audits daily x 2 weeks, then weekly x 6, then monthly x 6 on R59's room to ensure safety and no sharp objects are present.
Resident list will be reviewed monthly x 12 to ensure all wandering residents have safety precautions in place.
DON/designee will conduct an audit weekly x4 and monthly x3 to ensure all safety measures are in place and being followed.
Audit findings will be reported to the QA Committee monthly x 6 for further recommendations

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i) Food safety requirements.
The facility must -

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

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

Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Findings include:

An initial tour of the Food Service Department conducted on June 8, 2022, at 10:15 a.m. with Employee E3, Food Service Director (FSD), revealed the following:

Observation in the receiving area revealed a green dumpster with the sliding side door left open exposing the bags of trash inside. There was paper, condiment packets, plastic spoons and forks, cardboard and other trash scattered around the dumpster area.

Observation in the dry storage room revealed a dirty and dusty floor especially under the shelving and along the walls and dark, wet stains on the floor in several places.

Observation in the freezer revealed open cardboard boxes of sliced carrots and green peas with the plastic inner bag left open to the air and a stack of four cases of frozen vegetables stacked outside the freezer.

Observation in the walk-in cooler revealed a dirty, wet floor with dark substance in the grout and along the baseboards and dirt and onion skins under the shelving units.

Observation of the kitchen equipment revealed dirt and dust on the surfaces and dust and crumbs on the shelves under the tables and the galvanized shelves are starting to show rust.

Observation in the dish room area revealed dirty ceiling tiles along the side wall near the duct work which is dirty and dusty and the wall above the ductwork has dark spots.

Interview on June 8, 2022, at 10:30 a.m. with the Food Service Director confirmed the above findings.

The facility failed to store, prepare and serve food in accordance with professional standards for food service safety.


28 PA Code: 201.14(a) Responsibility of licensee.

28 PA Code: 201.18(e)(1) Management.

28 Pa. Code 201.18(b)(3) Management



 Plan of Correction - To be completed: 07/26/2022

Disclaimer: Facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal Regulations relating to long term care. This should not be construed as either a waiver of the Facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or any admission of any wrongdoing or an admission of past or ongoing violations of State and Federal Regulations.

Dry storage room, walk in fridge, dumpster area, kitchen equipment and shelves were cleaned.
A thorough kitchen inspection will be completed by FSD/designee to identify other areas potentially affected with the deficient practice and corrected as needed.
Dietary staff were educated on proper cleanliness and sanitation of dry storage room, walk in fridge, dumpster area, and kitchen areas.
FSD/designee will conduct an audit weekly x 4, then monthly x 4 to ensure proper cleanliness and sanitation of equipment, dry storage room, walk in fridge, and dumpster area.
Audit findings will be reported to the QA Committee monthly x 6 for further recommendations

483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

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

Based on clinical record review, policy and procedure review and interviews with staff, it was determined that the facility failed to report an injury related to a suicide attempt to the proper authorities in accordance with State law within the required timeframes for one of 33 records reviewed. (Resident R59).

Finding include:

Review of Resident R59's clinical record revealed diagnosis that includes, Bipolar, Impulse disorder, Schizophrenia, Major Depression and Schizoaffective disorder.

Review of Resident R59's progress note dated April 17, 2022, at 12:55 a.m. revealed, that Resident R59 came out to nurses' station with his shirt lifted and visible bleeding from his abdomen. When Resident R59 was questioned what had occurred, Resident R59 stated, "I cut myself, I have no reason to live, I want to die".

Further, review of the Resident's record revealed a progress note dated April 18, 2022, at 3:15 p.m. by the Risk management team, "Resident does have a history of suicidal ideation(s) self-harm and behavioral problems - all contributory factors to resident self-infliction for injury."

An interview with the Nursing Home Administrator and Director of Nursing on June 10, 2022, at 1:30 PM, confirmed that the facility failed to report the suicidal attempt resulting in injury to the State office as required.


28 Pa. Code 201.14(a) Responsibility of Licensee

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

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



 Plan of Correction - To be completed: 07/26/2022

Disclaimer: Facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal Regulations relating to long term care. This should not be construed as either a waiver of the Facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or any admission of any wrongdoing or an admission of past or ongoing violations of State and Federal Regulations.

Incident related to Resident R59 was submitted to the PA DOH electronically.

Facility will review all incidents and accidents for the last 3 months to ensure all reportable events were reported appropriately. If any missed, a new event report will be submitted.

Administrator and DON will be educated on the reporting requirements under Federal and state regulations by an outside consultant.

Administrator will conduct weekly audits x 4 and then monthly x3 for all incidents and accidents to ensure all events required to be reported have been reported correctly.

Audit findings will be reported to the QA Committee monthly x 6 for further recommendations


483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(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 clinical record review, a review of facility policy and documentation and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for one of three closed records reviewed (Residents R46).

Findings include:

A review of the Transfer and Discharge policy revealed that a copy of the discharge notice shall be provided to a representative of the Office of the State Long-Term Care Ombudsman.

Clinical record review for Resident R46 revealed that resident was admitted to the facility on May 3, 2022, with diagnoses including liver cell carcinoma (cancer that starts in the liver) and chronic viral hepatitis C (a viral infection that causes inflammation of liver).

Continued record review for Resident R46 revealed progress notes, dated May 31, 2022, at 2:26 p.m., indicating that the resident's sister was adamant that the resident be sent to the hospital and that the nurse practitioner agreed to send resident out to the hospital to be checked out. Resident left via stretcher with two ambulance attendants. A copy of bed hold policy was faxed to the hospital. All personal belongings remain safe and secure in resident room, and the medication disposition was completed.

An interview on June 13, 2022, at approximately 2:00 p.m. with the Administrator, Employee E1, confirmed that according to the Social Worker, Employee E10, the Long-Term Care Ombudsman was not informed of the transfers and discharges for the past few months.

The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges.

CFRNotice before transfer.

28 Pa. Code 201.14(a) Responsibility of licensee




 Plan of Correction - To be completed: 07/26/2022

Disclaimer: Facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal Regulations relating to long term care. This should not be construed as either a waiver of the Facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or any admission of any wrongdoing or an admission of past or ongoing violations of State and Federal Regulations.

Facility initiated emergency transfer and discharge for Resident R46 will be reported to the Office of the Long-Term Care Ombudsman
All emergency transfers and discharges for the last 3 months will be reviewed and reported to the Office of the Long-Term Care Ombudsman
Education was provided to the social services department on communicating with the Office of the Long-Term Care Ombudsman of all facility initiated emergency transfers and discharges.

Social Worker/designee will audit monthly x 6 to ensure all facility initiated emergency transfers and discharges have been communicated with the Office of the Long-Term Care Ombudsman.

Audit findings will be reported to the QA Committee monthly x 6 for further recommendations


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, a review of facility policy and staff interview, it was determined the facility failed to complete a comprehensive assessment after a significant change in condition for one of thirty-three residents reviewed (Resident R66).

Findings include:

A review of Care Plan Revisions Upon Status Change, dated June 2021, revealed that the MDS Coordinator will determine whether a Significant Change in Status Assessment is warranted. If so, the assessment will be completed according to established procedures.

Review of Resident R66's clinical record revealed diagnoses of cerebral infarction (also called ischemic stroke, a cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and vascular dementia (condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain, causing problems with reasoning, planning, judgment, and memory).

Review of the Resident R66's Hospice Certification and Plan of Care revealed that Hospice care was started on January 12, 2022.

Review of Resident 66's clinical record revealed that a Minimum Data Set (MDS, an assessment tool) was done for admission on November 12, 2021 and a Quarterly MDS was done on February 6, 2022, and that a Significant Change MDS was not done as required after the resident was put on hospice.

Interview on June 13, 2022, at approximately 11:00 a.m. with the Social Worker, Employee E10, revealed that the MDS Coordinator was not at the facility, and that it was her understanding that when someone went on hospice a Significant Change MDS was required.

An interview on June 13, 2022, at approximately 1:45 p.m. with the Administrator, Employee E1, confirmed that
the Significant Change MDS should have been completed within the 14-day period after the change in Resident 21's status.

The facility failed to complete a comprehensive assessment after a significant change in condition for one resident who was placed on hospice services.


28 Pa Code 211.12(d)(1)(5) Nursing services




 Plan of Correction - To be completed: 07/26/2022

Disclaimer: Facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal Regulations relating to long term care. This should not be construed as either a waiver of the Facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or any admission of any wrongdoing or an admission of past or ongoing violations of State and Federal Regulations.

A significant change MDS was completed for Resident R66
A facility wide audit will be completed to identify any other residents affected by this deficient practice and corrected appropriately.
Education was done with the MDS Coordinator on ensuring that all residents receive a significant change MDS when they have a significant change in condition.
MDS Coordinator/designee will audit all residents monthly x 6 to ensure anyone requiring a sig change MDS has one completed.

Audit findings will be reported to the QA Committee monthly x 6 for further recommendations

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on observations, review of facility documents and interviews with resident's and staff it was determined that the facility failed to clarify physician orders for CPAP settings, and failed to develop a person centered plan of care for CPAP care and usage for one out of 33 residents reviewed (Resident R233).

Findings include:

Review of the June 2022 physician orders indicated that Resident R233 was admitted into the facility on May 23, 2022 after a fall at home, which resulted in surgery and both of the resident's legs being in casts. The resident diagnosis included sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and obesity.

During an observation on June 8, 2022 at approximately 9:30 a.m. indicated that the resident had a CPAP machine (a device utilized by individuals with a diagnosis of sleep apnea) that was on his dresser in his room.

Review of the resident's June 2022 physician orders indicated a physician's order dated May 24, 2022, with instructions to apply the residents CPAP at bedtime, and remove the CPAP in the morning.

Review of a physician's note dated May 25, 2022 indicated that the resident had sleep apnea and that he utilized a CPAP. Review of the physician orders did not include instructions to include settings for the resident's CPAP machine.

During a visit to the resident's room with the Employee E9, licensed nursing staff, on June 10, 2022 at approximately 1:30 p.m. Employee E9 asked the resident what his setting he used on his CPAP, and the resident stated that the setting was "13." The resident also asked if the nurse could clean the device.

Review of the resident's person-centered plan of care did not include a plan of care for the CPAP machine's usage or care.

28 Pa. Code 211.11(d) Resident care plan

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services






 Plan of Correction - To be completed: 07/26/2022

Disclaimer: Facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal Regulations relating to long term care. This should not be construed as either a waiver of the Facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or any admission of any wrongdoing or an admission of past or ongoing violations of State and Federal Regulations.

CPAP order for Resident R233 was clarified with the physician and care planned.
A facility wide audit will be conducted to ensure all residents receiving CPAP treatment have appropriate orders and physician clarification will be completed as needed.
Education will be done with all licensed nursing staff to review new admission orders to ensure all ordered CPAP will have proper settings in place and care planned.
DON/designee will audit weekly x 4, then monthly x 3 to ensure CPAP settings are in place and care planned as ordered.

Audit findings will be reported to the QA Committee monthly x 6 for further recommendations

483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to maintain ongoing communication between the facility and a dialysis provider for one of 30 residents reviewed (Resident R35).

Findings include:

A review of the Dialysis Policy dated June 2021, revealed that a communication book will be sent with the resident to dialysis. Upon return from dialysis, the charge nurse will review and take note of any recommendations.

Review of Resident R35's clinical record revealed that the resident was admitted on June 22, 2020, with diagnoses that included end stage renal disease (condition where the kidney reaches advanced state of loss of function).

Further review of Resident R35's clinical record revealed that the resident has dialysis treatments three times per week on Tuesdays, Thursdays, Saturdays with a Pick-up Time of 5:30 a.m., for a 6:15 a.m. chair time at Lansdale Dialysis Center.

Continued review of Resident R35's clinical record revealed that all 12 of the dialysis communication forms located in his dialysis binder were incomplete, missing the top part (including Covid19 status and vital signs) which was to be completed by the facility prior to Resident R35 going to dialysis.

An interview on June 13, 2022, at approximately 2:00 p.m. with the Administrator, Employee E1, confirmed the above findings, acknowledging that the log sheets should be completed each time the resident goes to dialysis.

The facility failed to maintain ongoing communication between the facility and a dialysis provider.


28 Pa. Code: 211.10(c) Resident care policies

28 Pa Code 211.5(f) Clinical records

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services



 Plan of Correction - To be completed: 07/26/2022

Disclaimer: Facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal Regulations relating to long term care. This should not be construed as either a waiver of the Facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or any admission of any wrongdoing or an admission of past or ongoing violations of State and Federal Regulations.

Dialysis communication form is being completed properly for R35.
A facility wide audit will be completed for all residents receiving dialysis to ensure proper communication is being followed.
Education will be completed with all licensed nursing staff on proper completion of dialysis communication.
DON/designee will audit dialysis communication books weekly x 4, then monthly x 6 to ensure proper completion.

Audit findings will be reported to the QA Committee monthly x 6 for further recommendations


483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e)

This includes:
483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who-
(i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is:
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.
Observations:

Based on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employees E3).

Findings include:

An interview on June 8, 2022, at approximately 10:30 a.m. with Employee E3, Food Service Director (FSD), revealed that her responsibilities included oversight of ordering, receiving, storing, preparation and service of food. Further interview with the FSD confirmed that she was not a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; or had an associate's or higher degree in food service management or hospitality from an accredited institution; and that she had not received frequently scheduled consultations from a qualified dietitian.

A review of Employee E3's credentials revealed that Employee E3 did not meet the statutory qualifications of a director of food and nutrition services.

An interview on June 13, 2022, at approximately 1:45 p.m. with the Administrator, Employee E1, confirmed that the registered dietitian is part-time, working Tuesday and Thursday's, or two days a week, and therefore does not meet the full-time requirement for a qualified dietitian. During further discussion, the Administrator acknowledged that the FSD did not possess the regulatory required qualifications to provide operational oversight of the dietary department in the absence of a full-time Registered Dietitian.

The Nursing Home Administrator was unable to provide evidence that the FSD was receiving frequently scheduled consultation from a qualified dietitian to ensure that adequate guidance was provided to the FSD of the dietary department.


28 Pa. Code 211.6(c)(d) Dietary services

28 Pa Code 201.18(e)(1)(6) Management



 Plan of Correction - To be completed: 07/26/2022

Disclaimer: Facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal Regulations relating to long term care. This should not be construed as either a waiver of the Facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or any admission of any wrongdoing or an admission of past or ongoing violations of State and Federal Regulations.

Food Service Director will be enrolled in a CDM program.
RD will be available for consultation as needed.
483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(d) Food and drink
Each resident receives and the facility provides-

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

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

Based on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature for two of 36 residents reviewed (Residents R49 and R8).

Findings include:

Interview with Resident R49 on June 8, 2022, at approximately 10:30 a.m. revealed that the resident felt that the food tasted like crap, was always late, and usually cold when served.

Interview with Resident R8 on June 8, 2022, at approximately 10:40 a.m. revealed that the resident felt that food served at all three meals each day is cold.

Observations on June 9, 2022, at approximately 12:20 p.m. with Employee E4, Assistant Food Service Director (AFSD), during a test tray evaluation done on the first floor revealed that the temperature of the Chicken was 121 degrees, the broccoli was 101 degrees, the cranberry juice was 49 degrees and the fruit crisp was 65 degrees. A review of the facilities Test Tray Evaluation Form revealed that the acceptable point of service temperature for hot food was listed as 130 degrees and cold food was listed as 45 degrees. All food items listed above were outside the acceptable point of service temperatures.

An interview with the AFSD on June 9, 2022, at approximately 12:30 p.m. confirmed that the chicken and broccoli were below the acceptable temperature and therefore too cold to be palatable and the cranberry juice and fruit crisp were above the acceptable temperature and was too warm to be palatable.

The facility failed to provide food and drink that was palatable and at a safe temperature that was appetizing to the residents.


28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(3) Management

28 Pa. Code 201.29(j) Resident rights

28 Pa. Code 211.6(f) Dietary services



 Plan of Correction - To be completed: 07/26/2022

Disclaimer: Facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal Regulations relating to long term care. This should not be construed as either a waiver of the Facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or any admission of any wrongdoing or an admission of past or ongoing violations of State and Federal Regulations.

FSD/designee will meet with R8 and R49 for them to update their food preferences and the list of alternatives will be provided.
Food choices will be discussed in the next resident council meeting and menu planning will be updated as needed.

Cooks were educated on palatability. All dietary staff have been educated on proper food temperatures
Facility will continue to educate and in-service the dietary staff on palatability and proper food temperatures.
FSD/designee will audit test trays daily x 2 weeks, then weekly x 4, then monthly x 4 to ensure palatability and temperatures.
FSD/designee will conduct interviews with randomly selected residents weekly x 8 to get feedback.
The results of these audits will be shared with the QA committee monthly, which will make recommendations based on the results for these audits.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:

Based on observations and interviews with staff it was determined that the facility failed to ensure that garbage and refuse was disposed of properly in the Food Service Department's receiving area.

Finding include:

A tour of the Food Service Department conducted on June 8, 2022, at 10:15 a.m. with Employee E3, Food Service Director (FSD), revealed the following:

Observation in the receiving area revealed a green dumpster with the sliding side door left open exposing the bags of trash inside. There was paper, condiment packets, plastic spoons and forks, cardboard and other trash scattered around the dumpster area.

Interview on June 8, 2022, at 10:30 a.m. with the FSD, confirmed the above findings.

The facility failed to maintain the outside dumpster area in a safe and sanitary condition.


28 Pa. Code 201.18(b)(3) Management

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




 Plan of Correction - To be completed: 07/26/2022

Disclaimer: Facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal Regulations relating to long term care. This should not be construed as either a waiver of the Facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or any admission of any wrongdoing or an admission of past or ongoing violations of State and Federal Regulations.

Door to dumpster was closed. Dumpster area was cleaned.
FSD/designee will check dumpster area daily x 2 weeks, then weekly x 4 months to ensure door is closed, not overflowing and surround area clean.
All dietary and housekeeping staff were educated on proper sanitation of dumpster area.
FSD/designee will conduct an audit weekly x 4 then monthly x 4 to ensure proper sanitation of dumpster area.

Audit findings will be reported to the QA Committee monthly x 6 for further recommendations


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