Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT STROUD, THE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS AT STROUD, THE
Inspection Results For:

There are  120 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.
GARDENS AT STROUD, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance survey completed on November 22, 2019, it was determined that The Gardens at Stroud was not in compliance with the following requirements of 42 Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.70(e)(1)-(3) REQUIREMENT Facility Assessment: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.
483.70(e) Facility assessment.
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include:

483.70(e)(1) The facility's resident population, including, but not limited to,
(i) Both the number of residents and the facility's resident capacity;
(ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population;
(iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population;
(iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and
(v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

483.70(e)(2) The facility's resources, including but not limited to,
(i) All buildings and/or other physical structures and vehicles;
(ii) Equipment (medical and non- medical);
(iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies;
(iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;
(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
(vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.
Observations:

Based on staff interviews and facility documentation it was determined that the facility failed to conduct and document a facility wide assessment annually in order to identify the specific resources necessary to care for its residents.

Findings include:

At the time of the survey ending November 22, 2019, the facility had not yet completed a facility assessment for 2019 to determine the specific and unique needs of its resident population and the available and accessible resources to meet these needs on a daily basis and during emergent situations.

Following surveyor inquiry, the facility provided a facility assessment developed in 2017. However, this document did not contain comprehensive data and information regarding the facility resources and the select needs of the current resident population.

An interview with the NHA (nursing home administrator) on November 22, 2019, at approximately 1:45 PM confirmed the facility did not conduct and document an facility wide assessment annually.


28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 8/6/19

28 Pa. Code 201.18(e)(1)(3) Management
Previously cited 12/21/18, 2/19/19, 8/6/19

28 Pa. Code 201.18(b) Management
Previously cited 2/19/19




 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

- The facility assessment will be conducted and documented to show the facility's comprehensive data and information regarding the facility resources and the select needs of the current resident population.
- The facility assessment will be updated at least annually to show the facility's comprehensive data and information regarding the facility resources and the select needs of the current resident population.
- Department managers will be educated on the process and implementation for the facility assessment.
- The facility assessment will be audited monthly x3 to ensure the facility's comprehensive data and information regarding the facility resources and the select needs of the current resident population is current. Trends will be reviewed at QAPI meeting monthly.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:

Based on observation and staff interview, it was determined that the facility failed to demonstrate systematically organized, readily accessible and secured resident medical records.

Findings include:

During an interview conducted on November 22, 2019, at approximately 9 AM, the RN supervisor stated that the facility utilized electronic medical records. She stated that forms and paper records that arrived at the facility were looked at by the nursing staff, then placed in an box at the nurses station for pick up by the medical records person several times a day. The medical records person would then scan the paper records into the into the electronic medical record. However, the RN supervisor stated that the facility had been without a medical records person "for some time" and the paper records to be scanned had "piled up" on the nursing unit.

During a tour of the second floor nursing unit on November 22, 2019, observation revealed a metal filing cabinet containing folders of resident medical records. The RN Nursing Supervisor stated that each nursing unit has a filing cabinet containing resident medical records The RN Supervisor was unable to state if all the records in the cabinet had been scanned into the applicable resident electronic medical record.

Obseravtion of the basement floor central supply area conducted on November 22, 2019, revealed a desk on which medical records had been placed. There were several cardboard boxes on the floor containing resident medical records. There was also a large paper shredder box next to the desk. Resident care supplies and over the counter stock medications were also stored in this area.

Medical records were also observed stored on the second floor a room at the end of the hallway in metal cabinets.

Medical records were stored in a filing cabinet on the third floor in which boxes of resident briefs, medical gloves and cartons of peri wash were stored.

During a a review of the closed clinical record, in paper format, for Resident 102, several pages of Resident CR1's progress notes were discovered in the closed record of Resident 102.

During an interview November 22, 2019 at approximately 11 AM, the Nursing Home Administrator confirmed that the medical records in the facility were not properly organized and stored. The NHA stated that currently there was no medical records personnel employed at the facility. He further stated that the facility employed a qualified medical records consultant to visit the facility quarterly. He stated that this person was last at the facility in September 2019 and had identified issues with the medical records department and its procedures, but the consultant's recommendations had not yet been implemented at the time of the survey.



28 Pa Code 211.5 (f)(g)(h)(i) Clinical records
previously cited 12/21/18, 2/19/19





 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

- Resident medical records are scanned an uploaded properly into the residents' electronic medical record. The boxes of medical records were removed, organized and stored in the medical record room on the 2nd floor and/or uploaded properly into the residents' medical record. The boxes of briefs, medical gloves, and peri wash was removed from the third-floor medical record storage room.
- Medical record storage room was organized and filed properly. Medical records on the floors were scanned and uploaded properly into the residents' corresponding electronic medical records.
- Department managers and Medical record staff will be educated on the proper process for uploading medical record documents into the electronic medical record system and to maintain an organized medical record system.
- Resident medical records will be audited weekly x3 then monthly x3 to ensure resident medical records are uploaded to the electronic medical record properly. The medical record storage will be audited weekly x4, then monthly x2 to ensure the medical records are organized properly. Trends will be reviewed at QAPI meeting monthly.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on observation, clinical record review and staff and resident interview, it was determined that the facility conduct meal service in a manner and environment that respected the personal dignity of two of 22 residents sampled (Resident 201 and 61).

Findings include:

A review of the clinical record revealed revealed that Resident 201 was cognitively intact. The resident was admitted to the facility on November 11, 2019, following a hospitalization, with diagnoses to include ESBL (Extended spectrum beta-lactamase (or ESBLs for short) are a type of enzyme or chemical produced by some bacteria. ESBL enzymes cause some antibiotics not to work for treating bacterial infections; most ESBL infections are spread by direct contact with an infected person ' s bodily fluids \ They can also be spread by contact with equipment or surfaces that have been contaminated with the germ. Casual contact, such as touching or hugging, doesn ' t spread ESBL) infection in the urine. The resident had an indwelling urinary foley catheter (a catheter is inserted through the urethra, this is the tube that carries urine from the bladder to the outside of the body) in place. Upon review on November 20, 2019, the resident's clinical record did not reflect the initiation and/or discontinuation of infection precautions related to the resident's ESBL infection.

An observation November 19, 2019, at approximately 12 PM and again November 20, 2019 at approximately 9:30 AM revealed Resident 201 was served her meals on disposable styrofoam containers, drinking cups and provided disposable plastic silverware.

During an interview at the time of the observation, Resident 201 stated that she did not know why she was served her meals on disposable styrofoam dishware and utensils and other residents were served meals on regular dishware. The resident stated that she did not like using the plastic utensils and eating from the styrofoam dishware at her meals.

An interview November 19, 2019, at approximately 10:15 AM, with Employee 6 (LPN) revealed that Employee 6 stated that Resident 201 "came off isolation precautions a few days ago." and was unable to state why this resident was using styrofoam and plastic products for meals.

A review of the clinical record of Resident 61 revealed admission to the facility on May 9, 2019. The resident was assessed as cognitively impaired resident with diagnoses to include altered mental status and diabetes. Resident 61 was diagnosed with Klebsiella Pneumoniae Bacteremia (among the most common gram-negative bacteria encountered by physicians worldwide. It is a common hospital-acquired pathogen, causing urinary tract infections, nosocomial pneumonia, and intraabdominal infections. K. pneumoniae is also a potential community-acquired pathogen) and placed on contact precautions November 5, 2019. Further review of clinical record revealed resident contact precautions were discontinued on November 13, 2019.

An observation November 19, 2019, at approximately 12 PM and again November 20, 2019, at approximately 9:30 AM revealed Resident 61 was served his meals on disposable styrofoam containers, drinking cups and provided plastic silverware.

An interview November 20, 2019, at approximately 9:00 a.m., with Employee 7 (LPN) revealed that Resident 61's isolation precautions ended "a few days ago" and the employee was unable to state why the resident was receiving styrofoam and plastic products for meal service.

During an interview November 21, 2019 at approximately 1 PM, the facility certified dietary manager stated that a previous administrator instructed the dietary department to serve meals to residents on contact isolation on throw away styrofoam, paper and plastic products for meals.

During an interview November 21, 2019 at approximately 1:45 PM, the Nursing Home administrator confirmed that the above residents should have receive regular dishware and flatware at their meals.


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



 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

- R201 d/c to home on 11/21/19. R61 began to receive proper dinnerware on 11/20/19 for the dinner meal.
- Residents on isolation will receive proper dinnerware unless specific isolation requirements are identified.
- Dietary and Nursing staff will be educated on the proper dinnerware to be serviced for residents on isolation precautions.
- Resident on isolation will be audited weekly x4, then monthly x2 to ensure proper dinnerware is served to residents on isolation. Trends will be reviewed at QAPI meeting monthly.

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff: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.
483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:

Based on observations, clinical record review and staff interview it was determined that the facility failed to provide and/or efficiently deploy sufficient nursing staff to timely provide meals and feeding assistance and ensure consistent quality of care, services and supervision to maintain the physical and mental well-being of the residents in the facility on two of four nursing units (Third floor AACU and ACU units).

Findings include:

A review of the facility's nurse staffing for the third floor Advanced Alzheimer's Care Unit (AACU) and Alzheimer's Care Unit (ACU) on November 19, 2019, at 9:35 AM revealed one licensed practical nurse on each unit and 3 nurse aides (one aide assigned to float between the AACU and ACU) were scheduled to care for 19 residents on the AACU and 18 residents on the ACU.

Interview with Employee 1 (nurse aide) on November 19, 2019, at 9:35 AM revealed that staffing for the day was comparable to the usual staffing level in the facility.

Review of the facility meal schedule revealed that breakfast service for the third floor was scheduled for 8:15 AM.

Observations conducted on the AACU at this time revealed residents were eating breakfast in the dining room. Observation revealed staff which included Employees 1, 2 (LPNs), and 3 (nurse aide) were assisting residents with dining. Resident 73 required feeding and was not served breakfast until 9:45 AM.

Review of Resident 73's clinical record revealed the resident was severely cognitively impaired and required extensive feeding assistance.

Interview with Employee 3 at approximately 10:15 AM confirmed that meals are delayed due to the amount of care each resident requires.

Observation at lunch on the AACU on November 19, 2019, at 12:38 PM revealed lunch was being served. Observation at this time revealed of the 19 residents that seven residents required staff feeding assistance. Employees 1, 2, and 3 were observed assisting residents with meals. Resident 73 and Resident 69 were observed seated in the dining room waiting to be served lunch. Their meals were observed uncovered on the table next to the residents. At 1:01 PM Employee 1 began to feed Residents 73 and 69.

Review of Resident 69's clinical record revealed the resident was severely cognitively impaired and required staff assistance for eating.

Observation on the ACU on November 20, 2019, at 8:54 AM revealed staff included one LPN and one nurse aide and one nurse aide who floats back and forth between the AACU and ACU.

17 residents were present in the ACU dining room. Employee 4 (nurse aide) and employee 5 (dietary aide) were present in the dining room. At 9:00 AM Employee 5 began to portion each resident's meal from the portable steamtable. At 9:11 AM, Resident 65's breakfast was placed uncovered in front of her. At 9:17 AM Employee 4 finished distributing each resident a breakfast meal. Employee 4 then passed coffee to residents as requested. At 9:30 AM Employee 4 began to feed Resident 65.

Review of Resident 65's clinical record revealed the resident was severely cognitively impaired and required extensive staff assistance for eating.

Observation at 9:20 AM revealed that Employee 5 left the ACU and arrived with the portable steamtable on the AACU to begin serving breakfast. Staffing on the AACU included one LPN, and two nurse aides. 17 residents were present in the dining room. At 9:38 AM Employee 5 finished plating a meal for each resident. Resident 73's breakfast meal was place uncovered on the table at which the resident was seated. Employee 1 began to feed Resident 73 breakfast at 10:01 AM.

Interview with the director of nursing on November 20, 2019, at approximately 2:00 PM failed to provide evidence that sufficient nursing staff were provided and/or efficiently deployed on the AACU and ACU to meet the needs of the resident to ensure timely meal service and feeding assistance.

Refer to F804

28 Pa. Code 211.12(a)(c)(d)(1)(3)(4)(5) Nursing services
Previously cited 2/21/18, 2/19/19, 8/6/19

28 Pa. Code 201.18(e)(1)(2)(3)(6) Management
Previously cited 12/21/18, 2/19/19, 8/6/19












 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

- Unable to correct the concern from 11/20/19 as it related to F-725.
- Staff will be allocated to ensure 2 LPNs and 4 CNAs are on the AACU and ACU collectively. Meal services will be reevaluated to ensure the residents and staff are ready for meal service for the scheduled time. Staff will be assigned to ensure residents requiring assistance with meals will be serviced timely.
- Dietary staff and nursing staff will be educated to ensure the staff is allocated properly and the meal services is provided timely to meet the needs of the residents on the ACU and AACU communities.
- Meal services will be audited 3x per week x4 weekly, then weekly x4 weeks, then monthly x 1 to ensure timely meal service and feeding assistance by providing and /or efficiently deploying sufficient nursing to the AACU and ACU to meet the needs of the residents. Trends will be reviewed at QAPI meeting monthly.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on observations, clinical record review and staff interview, it was determined that the facility failed to accurately monitor a fluid restriction prescribed to address a resident's clinical condition and maintain fluid balance for three residents out of 22 sampled (Resident 95, 300, and 74).

Findings include:

A review of the clinical record revealed that Resident 95 was admitted to the facility on January 5, 2017, with diagnoses that included congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues).

A current physician order, initially dated April 12, 2019, was noted for 1800 cc fluid restriction daily. Dietary allowance was breakfast 480 cc (cubic centimeter), lunch 360 cc, and dinner 240 cc. Nursing staff allowance was 240 cc on the 7 AM to 3 PM shift, 240 cc per shift 3 PM to 11 PM shift and 120 cc on the 11 PM to 7 AM shift.

An observation on November 20, 2019, at 10:04 AM of Resident 95 revealed that the resident was seated in her room drinking from a 20-fluid ounce (600 ccs) Styrofoam cup filled with ice water.

A review of the October 2019 MAR (medication administration record) indicated that Resident 95 received and consumed more than 600 ccs fluids allotted to nursing, daily, on 11 occasions.

A review of the November 2019 MAR indicated the resident received and consumed more than 600 ccs fluids allotted to nursing daily on 8 occasions.

A review of the clinical record revealed that Resident 300 was admitted to the facility on September 15, 2017, with diagnoses that included end stage renal disease (kidneys are only functioning at 10 to 15 percent of their normal capacity) and is dependent on dialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood).

A current physician order, initially dated October 1, 2019, was noted for 1200 cc fluid restriction daily. Dietary allowance was breakfast 240 ccs, lunch 240 ccs and dinner 240 ccs. Nursing staff allowance was 240 ccs on the 7 AM to 3 PM shift, 120 ccs per shift 3 PM to 11 PM shift and 120 ccs on the 11 PM to 7 AM shift.

A review of the October 2019 MAR indicated that Resident 300 received and consumed more than 480 ccs fluids allotted to nursing, daily, on 23 occasions.

A review of the November 2019 MAR indicated the resident received and consumed more than 480 ccs fluids allotted to nursing, daily, on 12 occasions.

An interview with the Director of Nursing on November 21, 2019, at 12:43 PM revealed that staff document on the MAR only the fluids that are provided by the nursing staff. The DON confirmed that the amount of fluid consumed by the above residents exceeded the physician prescribed fluid restriction.

A review of the clinical record revealed that Resident 74 was admitted to the facility on July 1, 2019, and had current diagnoses that include diabetes and end stage renal disease. The resident was receiving dialysis.

A current physician order, initially dated, September 13, 2019 was noted for 1200 cc fluid restriction daily. Dietary allowance was breakfast 240 ccs (cubic centimeter), lunch 240 ccs, and dinner 240 ccs. Nursing staff allowance was 120 ccs on the 7 AM to 3 PM shift, 120 ccs per shift 3 PM to 11 PM shift and 120 ccs on the 11 PM to 7 AM shift. The total for dietary and nursing allowances totaled 1080 ccs of the physician prescribed limit of 1200 ccs.

Observations on November 19th and 21st, 2019, at 10:00 AM of Resident 74 revealed that the resident was seated in her room drinking from a 20-fluid ounce (600 ccs) Styrofoam cup filled with ice water

An observation conducted on November 19, 2019, at approximately 12 PM, revealed Resident 74 was seated at a table in the dining room eating lunch. She had consumed a 240 ccs cup of juice, a 240 cc cup of tea and 30 ccs of milk. A review of her dietary meal tray slip dated November 19, 2019, revealed that she was she was on a 1200 cc fluid restriction and was to receive 8 fluid oz (240 cc) to drink with her lunch meal.

During an interview on November 19, 2019, at approximately 12:20 PM Employee 7 (nurse aide) confirmed that Resident 74 received the above noted amounts of fluids with her lunch meal. She also stated that the resident's allotted fluids are noted on the diet slips with their meal tray, but that Resident 74 was served fluids in amounts that exceeded the planned allotment.

A review of the September 2019 and November 2019 MAR (medication administration record) indicated that Resident 74's fluid consumption's were not totaled to include both the dietary and nursing totals. On multiple occasions, when the daily consumption was totaled, the amounts were both above and below the allotted 24 hour fluid restriction.

A review of dietary documentation for September 2019 and November 2019, however, revealed no documentation that dietary staff had identified any disparity with this residents' fluid intakes.

An interview with the Director of Nursing on November 21, 2019, at 1 PM revealed that the
documentation on the MAR are the fluids provided by the nursing staff and did not include the daily dietary fluid allotment. She further confirmed that the noted 24 hour total calculations were not consistently accurate.


28 Pa. Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services
Previously cited 12/21/18, 2/19/19, 8/6/19

28 Pa. Code 211.5(f)(g) Clinical records
Previously cited 12/21/18, 2/19/19











 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

- R95 had the 20-ounce Styrofoam cup removed from the room. Unable to correct the concern noted from October and November fluid documentation on MAR. R74 had the 20-ounce Styrofoam cup removed from the room.
- Residents on a fluid restriction will be reviewed to ensure no free fluid is kept at the bedside. Residents on a fluid restriction will have documented fluid intake reviewed daily and communicated to the physician when necessary and plan of care will be updated appropriately.
- Nursing staff and Registered Dietician will be educated on the fluid restriction process with ensuring free fluid is not maintained at bedside and daily review of intake documentation.
- Fluid restriction documentation and free fluid at bedside will be audited 3x per week x4 weeks, then monthly x2 to ensure compliance with physician orders. Trends will be reviewed at QAPI meeting monthly.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on a review of clinical records and interviews with residents and staff it was determined that the facility repeatedly failed to provide prescribed maintenance care to prevent complications related to the use of resident's urinary catheter out of 22 sampled residents (Resident 16).

Findings included:


A review of the clinical record revealed that Resident 16 was admitted to the facility on March 22, 2019, and had diagnoses that included urinary retention (inability to completely or partially empty the bladder), neuromuscular dysfunction of the bladder (dysfunction of the urinary bladder due to disease making it difficult to pass urine), and cerebral vascular accident (CVA when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel).

Current physician's orders in effect since August 9, 2019, directed staff to perform Foley catheter (thin, sterile tube inserted into the bladder to drain urine) care every shift daily.

A review of Resident 16's task documentation for bathing/bed baths for August 2019 to November 2019 revealed that catheter care was not consistently provided every shift per the physician's orders.

A review of the resident's August 2019 task record revealed that catheter care was not provided 23 times on the dayshift, 18 times on evening shift and 18 times on night shift.

A review of the resident's September 2019 task record revealed that catheter care was not provided 12 times on the dayshift, 13 times on evening shift and 8 times on night shift.

A review of the resident's October 2019 task record revealed that catheter care was not provided 10 times on the dayshift, 4 times on evening shift and 24 times on night shift.

A review of the November 2019 task record revealed that catheter care was not provided on 5 times on the dayshift, 5 times on evening shift and 17 times on night shift.

Interview with the director of nursing on November 21, 2019, at approximately 2:15 PM indicated catheter care is done with bathing/bed baths and confirmed that nursing staff failed to follow physician orders to perform Foley catheter care every shift.




28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing services
Previously Cited 12/21/18, 2/19/19, 8/6/19

28 Pa. Code 211.5(f)(h) Clinical records
Previously Cited 12/21/18, 2/19/19






 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

- R16 has a Foley catheter that is changed monthly as prescribed by the urologist. The Foley catheter care preformed is soap and water with daily hygiene according to the CDC guidelines.
- Residents with Foley catheters will be reviewed to ensure daily hygiene is in place with appropriate treatments orders and care plans as required.
- Nursing staff will be educated on Foley catheter care and accurate documentation.
- Residents with Foley catheters will be audited for proper hygiene and accurate documentation weekly x4, then monthly x2. Trends will be reviewed at QAPI meeting monthly.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(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 clinical record review and staff interview, it was determined that the facility failed to consistently provide services planned to maintain or improve range of motion of three of five residents reviewed (Resident 16, 49, 75).

Findings include:

A review of the clinical record revealed that Resident 16 was admitted to the facility on March 22, 2019. A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated August 19, 2019, indicated that the resident required the assistance of two staff member for activities of daily living (ADLS are routine activities people do every day without assistance, including eating, bathing, getting dressed, toileting, transferring) including transfers, toileting, and bathing.

A review of facility documentation for September 2019 to November 2019, revealed that the resident was to receive restorative nursing services that included, active range of motion (ROM) to both lower extremities for 10 repetitions three sets for 15 minutes daily and bathing and dressing upper extremities with stand by assistance for 15 minutes daily.

Further review of the documentation of the completion of Resident 16's restorative services program revealed that the facility had not consistently provided the planned services from September 1, 2019, to the time of the survey ending November 22, 2019.

A review of the clinical record revealed that Resident 49 was admitted to the facility on August 13, 2019. A significant change Minimum Data Set assessment dated October 11, 2019, indicated the resident required the assistance of two staff member for activities of daily living including transfers, toileting, and bathing.

A review of facility documentation for September 2019 to November 2019, revealed that the resident was to receive restorative nursing services that included, active ROM to both lower extremities 30 times each extremity to increase strength 15 minutes daily and bed mobility during ADL care with extensive assistance 15 minutes daily.

Further review of the documentation of the completion of Resident 49's restorative services program revealed that the facility had not consistently provided the planned services from September 29, 2019, to the time of the survey ending November 22, 2019.

A review of the clinical record revealed that Resident 75 was admitted to the facility on May 7, 2013. A quarterly Minimum Data Set assessment dated October 30, 2019, indicated the resident required the assistance of two staff member for activities of daily living including transfers, toileting, dressing, hygiene and bathing.

A review of facility documentation for September 2019 to November 2019, revealed that the resident was to receive restorative nursing services that included, apply elbow extension splints with morning care and remove with evening care, apply left hand palm roll at night and remove before morning care, apply palms guards to both hands with morning care and remove with evening care, and passive ROM to both upper and lower extremities for 10 repetitions three sets for 15 minutes twice a day.

Further review of the documentation of the completion of Resident 75's restorative services program revealed that the facility had not consistently provided the planned services from September 1, 2019, to the time of the survey ending November 22, 2019.

A review of the clinical record revealed that Resident 74 was admitted to the facility on July 1, 2019. A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated August 14, 2019, indicated the resident required staff assistance for activities of daily living (ADLS are routine activities people do every day without assistance, including eating, bathing, getting dressed, toileting, transferring) including transfers, toileting, and bathing.

A review of facility documentation for October 2019 to November 2019, revealed the resident was to receive restorative nursing services that included, active range of motion (ROM) to both lower extremities for 10 repetitions three sets for 15 minutes daily

Further review of the documentation of the completion of Resident 74's restorative services program revealed that the facility had not consistently provided the planned services from October 1, 2019, to the time of the survey ending November 22, 2019.

Interview with the DON (director of nursing) on November 21, 2019, at approximately 2:15 PM confirmed that the restoratives services were not consistently provided to each resident as planned.


28 Pa. Code 211.5(f) Clinical records.
Previously cited 12/21/18, 2/19/19

28 Pa Code 211.12(a)(c)(d)(5) Nursing services.
Previously cited 12/21/18, 2/19/19, 8/6/19






 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

- R16 will be provided RNP as prescribed for 15 minutes daily x6 days a week. R49 is deceased. R75 will be provided RNP as prescribed 15 minutes daily x6 days a week.
- Residents ordered RNP programs will be reviewed for need and updated as needed. Resident requiring RNP programs will be the service provided as prescribed.
- Nursing staff will be educated on the Restorative Nursing programs and the need to correctly document the resident's involvement in the medical record. RN/LPN will evaluate the RNP completion and progress weekly and document in the resident's medical record. The interdisciplinary team will meet monthly to discuss and evaluate the residents on the restorative nursing program and document the findings and outcome.
- Residents ordered RNP programs will be audited weekly x4, then monthly x2 to ensure completion consistent and accuracy. Trends will be reviewed at QAPI meeting monthly.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

483.10(f)(6) The resident has a right to participate in family groups.

483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:

Based on review of select facility policy and minutes from Resident Council meetings and resident and staff interviews it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints/grievances expressed during Resident Council Meetings including those voiced by seven of seven residents attending a group meeting (Residents 10, 59, 90, 54, 35, 63, and 33).

Findings include:

Review of the facility's Grievance policy indicated that it is the facility's policy to provide an opportunity for residents to express concerns at any time. The facility's goal is to resolve resident and family concerns in a timely basis.

Review of the minutes from the May 21, 2019, through October 29, 2019, Resident Council meetings revealed that residents in attendance at these resident group meetings voiced their concerns regarding resident care and facility services during the meetings.

During the May 21, 2019, Resident Council meeting the residents relayed concerns regarding long waits for staff to respond to their call bells. The residents complained that staff inform the residents "I will be right back" and do not return to assist them. The residents also voiced concerns that aides do not introduce themselves to the residents.


During the June 25, 2019, Resident Council meeting the residents relayed concerns regarding snacks not being offered or available in the evening.

During the September 24, 2019, Resident Council meeting the residents relayed concerns regarding snacks not being offered or available in the evening.

During the October 29, 2019, Resident Council meeting the residents relayed continued concerns regarding snacks not being offered or available in the evening.

During a group meeting held on November 20, 2019 at 10:30 a.m., with seven (7) alert and oriented residents, all residents in attendance stated that they continued to complaint that the facility does not consistently offer evening snacks and when snacks are offered, snack variety is lacking. The residents stated they continue to have concerns with the timeliness of staff response to their call bells and meeting their needs for assistance in a timely manner. The residents stated that they have repeatedly brought these particular complaints to the facility's attention without resolution to date.

The facility was unable to provide documented evidence that the facility had determined if the residents' felt that their complaints/grievances had been resolved through any efforts taken by the facility in response to the residents' expressed concerns regarding untimely staff response to call bells and delays in meeting residents' needs for assistance and consistent offering and variety of evening snacks.

During an interview with the Nursing Home Administrator (NHA) on November 21, 2019, at 2:00 p.m. the NHA was unable to provide documented evidence that the facility had followed-up with the residents' to ascertain the effectiveness of the facility's efforts in resolving their complaints regarding facility services.


28 Pa. Code 201.18(e)(1)(3)(4) Management
Previously cited 12/21/18, 2/19/19, 8/6/19

28 Pa. Code 201.29(i)(j) Resident Rights
Previously cited 12/21/18, 2/19/19, 8/6/19



 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

- HS snacks have been offered to the residents on each floor. Call bell are being answered timely. Resident council will have the concerns from resident reviewed and the concern form will be signed by the resident council president if the concerns are addressed and resolved.
- Resident council minutes and concerns will be reviewed by the NHA or designee for proper resolution. Resident council will have the concerns from resident council reviewed and the concern form will be signed by the resident council president if the concerns are addressed and resolved.
- Activity Director and the Social Service Director will be educated to review the resident council concern forms with resident council and the concern forms are to be signed by the resident council president if the concerns are addressed and resolved.
- Resident council minutes and concerns will be audited monthly x3 to ensure the concerns are being addressed properly and timely and the concern form will be signed by the resident council president if the concerns are addressed and resolved. Trends will be reviewed at QAPI meeting monthly.

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 observations, clinical record review, resident and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet the individualized needs of two residents (Resident 74 and 14 ) out of 22 sampled.

Findings include:

A review of the clinical record revealed that Resident 74 was admitted to the facility on July 1, 2019, and had current diagnoses that included diabetes and end stage renal disease. The resident was receiving hemodialysis (A medical procedure to remove fluid and waste products from the blood and to correct electrolyte imbalances. This is accomplished using a machine and a dialyzer, also referred to as an "artificial kidney).

A review of the resident's care plan, revealed a problem of hemodialysis initiated July 11, 2019 with interventions that staff will monitor AV shunt ( a type of access used for hemodialysis. An AV fistula is a connection between an artery and a vein ) for bruit and thrill (Thrill & Bruit "Thrill" is a rhythmic vibration that can be felt over your fistula, whereas "bruit" - pronounced "brew-ee" is a sound that is heard when listening to your fistula with a stethoscope) Notify the physician if absent.

A review of the resident's current care plan failed to address the emergency care and services for this dialysis access site.

Review of Resident 14's clinical record revealed admission to the facility on May 30, 2016, with diagnoses including dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).

Review of Resident 14's current care plan revealed that the facility had not developed or implemented a person-centered care plan to address the resident's dementia.

Interview with the Director of Nursing on November 21, 2019 at approximately 2:00 p.m. were unable to provide evidence a dementia care plan had been developed or implemented for Resident 14's care plan and had been developed to address emergent care of Resident 74 dialysis access site.



28 Pa. Code 211.11(d) Resident care plan


28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services
Previously cited: 12/21/18, 2/19/19, 8/6/19














 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

- R74 care plan was updated to address the emergency care and services for the dialysis access site. R14 care plan was developed to address the diagnosis of dementia.
- Care plans will be reviewed and updated if necessary to address the residents with dementia and the resident receiving dialysis services are person-centered and meet the care and needs of the residents.
- Department managers and nursing staff will be educated to ensure the care plans for residents with diagnosis of dementia and residents receiving dialysis services are person-centered and address the care and needs of the residents.
- Care plans will be audited weekly x4, then monthly x2 to ensure the residents with dementia and the resident receiving dialysis services are person-centered and meet the care and needs of the residents. Trends will be reviewed in QAPI meeting monthly.

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 staff interview, it was determined that the facility failed to revise a comprehensive plan in response to behavior changes for one resident out of 22 reviewed (Resident 3).

Findings include:

A review of the clinical record revealed that Resident 3 had diagnoses, which included dementia (group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning).

A review of the resident's comprehensive plan of care, initially dated, November 20, 2018, revealed that the resident has a behavior problem related to disease process. The goal was to have no evidence of behavior problems. Interventions included to anticipate and meet the resident's needs and to provide a program of activities that is of interest and accommodates the resident's status.

A nurses note dated November 14, 2019, at 3:25 AM indicated that the resident "was awake with usual insomnia." The entry noted that the resident "Wanders in and out of other rooms, sometimes taking water pitchers and other various items from dressers including her own. STOP sign placed in doorway of frequently entered room of a resident with behaviors when Resident 3 enters. Staff continues to redirect and provide activities."

The resident's current care plan failed to identify and address the resident's specific behaviors. There was no documented evidence that the facility revised the comprehensive care plan to reflect interventions specific to intrusive wandering.

Interview with the director of nursing on November 22, 2019, at approximately 10:30 AM confirmed the resident's care plan had not been revised in response to the resident's intrusive wandering.



28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing Services.
Previously cited 12/21/18, 2/19/19, 8/6/19

28 Pa. Code 211.11(d)(e) Resident Care Plan.











 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

- R3 care plan was updated to be person-centered and include behaviors of intrusive wandering.
- Residents with behaviors will have the care plans reviewed to ensure individualized care plans are developed to address the needs of the resident with behaviors.
- Department managers and nursing staff will be educated to ensure the care plans for residents with behaviors are individualized to address the needs of the resident with behaviors.
- Care plans will be audited weekly x4, then monthly x2 to ensure the residents with behaviors are individualized and address the needs of the resident with behaviors. Trends will be reviewed in QAPI meeting monthly.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

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

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

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

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

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

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


Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the presence of adequate medical justification and/or attempt a gradual dose reduction of an antipsychotic medication for one of five residents reviewed for unnecessary medications (Resident 95).

Findings included:

A review of Resident 95's clinical record revealed that the resident was admitted to the facility on September 27, 2017, with diagnoses that included psychotic disorder (mental disorders that cause abnormal thinking and perceptions) with delusions (a belief that is clearly false and that indicates an abnormality in the affected person's content of thought) and major depressive disorder (a persistently depressed mood and long-term loss of pleasure or interest in life).

A review of current physician's orders revealed the resident was prescribed Zyprexa 5mg (milligram) one tablet daily.

A review of a pharmacy noted dated December 27, 2018, at 1:28 PM revealed the pharmacist recommended a gradual dose reduction of the physician prescribed medication Zyprexa.

No physician response was documented to include resident specific details regarding the risk vs. benefit analysis and how the medication, and its current dose, improved the resident's quality of life.

An interview with the nursing home administrator (NHA) and director of nursing (DON) on November 22, 2019, at approximately 1: 45 PM confirmed no attempts at gradually reducing the dose of Zyprexa had been made and the physician did not respond to the pharmacy's recommendation.


28 Pa. Code 211.2(a) Physician services.
Previously cited 12/21/18, 2/19/19

28 Pa. Code 211.5(f)(g)(h) Clinical records.
Previously cited 12/21/18, 2/19/19

28 Pa. Code 211.9(a)(1)(k) Pharmacy Services.

28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing Services.
Previously cited 12/21/18, 2/19/19, 8/6/19




 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

- R95 had Gradual Dose Reduction of the Zyprexa from 5mg to 2.5mg at 6pm.
- Residents ordered antipsychotic, antianxiety, and hypnotic medications will be reviewed to ensure medication reduction is attempted or proper documentation is in place by the physician.
- Nursing staff and attending physicians will be educated timely gradual dose reductions of antipsychotic, antianxiety, and hypnotic mediations and the proper documentation necessary if a dose reduction is contraindicated.
- Antipsychotic, antianxiety, and hypnotic medications will be audited monthly x3 to ensure gradual dose reductions are attempted properly or proper documentation is in place indicating a dose reduction is contraindicated. Trends will be reviewed at QAPI meeting monthly.

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 of medication storage and staff interview it was determined that the facility failed to adhere to medication/pharmaceuticals expiration dates.

Findings included:


A tour of the facility's central supply area conducted on November 22, 2019, at approximately 10:30 AM, revealed a stock medication storage cabinet containing 4 bottles of Niacin 500 mg with an expiration date of September 2019; 1 bottle of vitamin D -400, dietary supplement with an expiration date of September 2019 and a bottle of Vitamin E-dietary supplement with an expiration date of August 2018.

This observation of expired vitamin supplements, remaining in storage and available for administration to residents, was confirmed at the time of the observation by the Nursing Home Administrator.


28 Pa Code 211.9 (a)(1)(k) Pharmacy services


 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

- Expired stock medication was immediately discarded.
- All stock medications were checked for expiration dates and discarded if necessary.
- Nursing staff and central supply staff will be educated to ensure no expired stock medications are stored in the facility.
- Stock medication will be audited monthly x3 to ensure no expired stock medication are stored in the facility. Trends will be reviewed at QAPI meeting monthly.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

483.55(b) Nursing Facilities.
The facility-

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

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

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

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

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

Based on observation, review of clinical records and payor source data and staff interview, it was determined that the facility failed to promptly refer a resident with a need for lower dentures for dental services for one Medicaid payor source residents (Resident 80) out of one resident sampled for dental services.

Findings include:

A review of the clinical record revealed that Resident 80 (Medicaid payor source) had diagnoses, which included dementia (group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning).

Observation of Resident 80 on November 19, 2019, at approximately 11:00 AM revealed that the resident had upper dentures in place, but no lower dentures.

A social services note dated October 9, 2019, indicated that the resident was on the list to see the dentist to address a lower denture issue.

Further review of the clinical record, conducted at the time of the survey ending November 22, 2019, revealed no documented evidence that the resident had been scheduled for an appointment to see the dentist to address the resident's issue with lower dentures.

Interview with the Nursing Home Administrator on November 22, 2019, at approximately 9:30 AM failed to provide evidence that the facility timely attempted to refer Resident 80 for dental services for lower dentures.




28 Pa Code 211.12 (a)(c)(d)(3)(5) Nursing services
Previously cited 12/21/18, 2/19/19, 8/6/19

28 Pa. Code 211.15(a) Dental services.

28 Pa. Code 211.16(a) Social Services









 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

- R80 was scheduled to be seen by the dentist on the next scheduled visit, January 20, 2020, to address the lower dentures.
- Residents will be reviewed for dental needs and scheduled for follow up with the dentist if necessary.
- Nursing staff and Social Service Director will be educated on dental services for the residents.
- Residents will be audited monthly x3 for dental needs and scheduled with the dentist as needed. Trends will be reviewed at QAPI meeting monthly.

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 observations, review of test tray results and staff interview, it was determined that the facility failed to serve foods at safe and palatable temperatures.

Findings include:

According to the federal regulation 483.60(i)-(2) Food safety requirements - the definition of "Danger Zone", found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness.

Review of the facility Food Trucks Delivery Schedule revealed that the scheduled breakfast time for the third floor nursing unit was 8:15 AM.

Observation of the breakfast meal on November 20, 2019, at 9:20 AM on the Third floor AACU (advanced Alzheimer's Care Unit) revealed that Employee 5 (dietary aide) began serving breakfast from the portable steamtable. Seventeen residents were observed present in the dining room. A meal was plated for each resident. The last meal was plated at 9:38 AM. A test meal was requested at this time.

Resident 73's meal was placed uncovered on the dining room table at which the resident was seated. Resident 73 was the last resident to be assisted with the breakfast meal. Employee 1 (nurse aide) began to feed the resident at 10:01 AM (twenty-three minutes after the meal was placed uncovered on the table).

The temperatures of the test meal revealed the following unpalatable food temperatures:

Puree eggs - 85 degrees Fahrenheit (cool to taste)
Cream of Rice hot cereal - 124 degrees Fahrenheit (cool to taste)
Puree English muffin - 89 degrees Fahrenheit (cool to taste)

Interview with the administrator on November 21, 2019, at approximately 10:00 AM confirmed that residents' meals were to be served in a timely manner to ensure palatable temperatures for residents.

Refer to F725

28 Pa. Code 201.29(j) Resident rights.
Previously cited 2/19/19

28 Pa. Code 211.6(c) Dietary services.
Previously cited 12/21/18

28 Pa. Code 211.12 (a)(c)(d)(1)(3)(4)(5) Nursing services
Previously cited 12/21/18, 2/19/19, 8/6/19









 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

- Unable to correct the concern from 11/20/19 as it related to F-804.
- Meal services will be reevaluated to ensure the residents and staff are ready for meal service for the scheduled time. Staff will be assigned to ensure residents requiring assistance with meals will be serviced timely in the ACU and AACU communities.
- Dietary staff and nursing staff will be educated to ensure the meal services is provided timely to meet the needs of the residents on the ACU and AACU communities.
- Meal services will be audited 3x per week x4 weekly, then weekly x4 weeks, then monthly x 1 to ensure timely meal service to ensure palatable temperatures for the residents. Trends will be reviewed at QAPI meeting monthly.

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 observation and staff interview it was determined that the facility failed to adhere to infection control practices for the storage of resident care and medical equipment.

Findings include:


Observations during a tour of the second floor clean linen room November 22, 2019 at 10:30 AM , revealed adult briefs on the floor and the plastic bag (for the briefs) on the floor. There was a large cardboard box containing individual boxes of tissues, a box of vinyl exam gloves and a cardboard box containing oxygen concentrator humidifier bottles with water in them directly on the floor. The floor was observed to be soiled with dirt and debris. There were multiple unbagged briefs observed on the shelves of the metal storage cart in the room. These observations were confirmed at that time by Employee 8 (nurse aide).

A tour of the facility central supply room on November 22, 2019, located in the basement of the facility revealed multiple boxes of resident medical records on the floor and opened on the desk located in the room. On the shelves of the multi-tiered metal shelving unit located in this same room were clean medical supplies. There was an unbagged suction machine, 10, oxygen concentrators, 4 tube feeding pumps and 4 nebulizer machines (unbagged). There was a tube feed bag, observed to be removed from the manufacturer packaging observed in the box with other packaged tube feeding bags.

During an interview November 22, 2019 at approximately 10:45 AM, the Director of Nursing stated that the above resident equipment is to be cleaned by housekeeping after use, rebagged in plastic and then stored in the clean central supply. The observation of the unbagged resident care and medical equipment was confirmed by the NHA at this time.



28 Pa. Code 211.10(d) Resident care policies

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



 Plan of Correction - To be completed: 01/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

- Briefs were removed from the floor. Tissues were removed from the floor. Gloves were removed from the floor. Oxygen concentrator humidifier bottles were removed from the floor. The floor was cleaned, stripped and waxed. The "unbagged" briefs were discarded. The medical records were removed from the central supply room and stored in the medical records closet and/or uploaded into the appropriate electronic medical record. the suction machine, oxygen concentrators, tube feeding pumps and nebulizer machines were cleaned and bagged. The tube feed bag was discarded.
- Supplies in the central supply room are stored off the floor on clean shelving. Resident equipment will be cleaned and bagged by housekeeping and stored in the central supply room. Medical records will no longer be stored in the central supply room, but stored in the medical record closet.
- Nursing staff and central supply staff will be educated on proper storage of nursing supplies and equipment.
- Central supply room will be audited weekly x4, then monthly x2 to ensure nursing supplies and equipment are stored properly. Trends will be reviewed at QAPI meeting monthly.


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