Nursing Investigation Results -

Pennsylvania Department of Health
MANOR AT ST. LUKE VILLAGE, THE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MANOR AT ST. LUKE VILLAGE, THE
Inspection Results For:

There are  87 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.
MANOR AT ST. LUKE VILLAGE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and Revisit survey completed on May 20, 2022, it was determined that The Manor at St Luke Village corrected the federal deficiencies cited during the survey of April 12, 2022, but continued to be out of 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:


483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,
Observations:
Based on a review of employee personnel files and staff interviews, it was determined that the facility failed to implement procedures screening procedures prior to the employment of four employees out of five sampled to ensure that they were eligible for employment in a long term care nursing facility (Employees 1, 2, 3, 4)

Findings include:

A review of employee personnel files revealed that the facility was unable to provide evidence of attempts to obtain information from previous employers and/or current employers for the following employees:

Employee 1 (Temporary Nurse Aide) was hired February 22, 2022. On the employee's application for employment she indicated that she had one previous employer.

Employee 2 (LPN) was hired April 5, 2022, and on the employee's application for employment she indicated that she had three previous employers.

Employee 3 (Nurse Aide) was hired March 8, 2022, and on the employee's application for employment she indicated that she had one previous employer.

Employee 4 (Dietary Aide) was hired May 2, 2022, and on the employees application for employment she indicated that she had one previous employer.

Interview with the Administrator on May 20, 2022 at 10:15 a.m. verified that the facility was unable to show evidence that the facility had contacted any previous employers prior to hiring Employees 1, 2, 3, and 4 to screen the potential employees for a history of abuse, neglect, exploitation or misappropriation of resident property.



28 Pa Code 201.18 (e)(1) Management

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




 Plan of Correction - To be completed: 06/16/2022

1. Prior employer reference checks were obtained for Employees 2,3, & 4. Employee 1 no longer works at the facility.
2. Employee personnel files for those hired in the last 30 days will be reviewed to ensure inclusion of proper reference checks were completed. Follow up will be completed based on findings.
3. Re-Education was provided to the human resource coordinator will be completed by the NHA related to screening of potential employees, to include references from previous or current employers.
4. Monthly reviews of newly hired personnel files will be completed by the NHA or designee to ensure proper reference checks are completed. Findings to be reviewed via Quality Assurance Performance Improvement (QAPI) Committee Meeting and updated as indicated. QI schedule modified based on findings.

483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
Observations:


Based on review of the facility's monthly incident /accident logs and fall tracking it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to identify quality issues related to increased numbers of multiple resident falls and to ensure that plans were designed and implemented to improve the delivery of care and services and promote resident safety were in place to deter additional falls and future quality deficiencies.

Findings include:

A review of monthly facility incident/accident logs and analysis dated December 2021 through May 2022 revealed that in December 2021- 10 resident falls had occurred in the facility; duing January 2022 - 15 resident falls occurred; during February 2022 12 resident falls had occurred; during March 2022 - 13 falls occurred and during April 2022 21 resident falls had occurred and as of May 13, 2022, 8 resident falls had occurred.

Interview with the NHA during the survey ending May 20, 2022, revealed that the administrator was unable to provide evidence to show that the facility had identified this quality issue and determined the risk to resident safety, health, and well-being, and prioritized the issue of high volume of falls (occur with frequency).

E-mail communication with the Nursing Home Administrator, on May 23, 2022 at 8 AM revealed that the NHA relayed stated that during the complaint survey of April 12, 2022, falls were identified as a concern for QAPI. However, the noted QAPI issue dated March 22, 2022 was related to accurately coding the task of bathing on the kardex in relating only to a fall with injury for one resident. Repeated, increasing resident falls was not identified at that time.

The facility's quality assurance plan failed to identify this ongoing quality issue of increased number of resident falls occurring the facility.

Continued large numbers of resident falls noted from December 2021 through May 2022 was not identified and addressed by the facility's QAPI committee and no attempts made to identify any trends and develop and implement plans to address the quality issue of multiple resident falls to promote resident safety and prevent quality deficiencies. The facility failed to explore the potential causes for the increased falls and show the actions taken to correct the issue.

Refer F689

28 Pa. Code 211.12(c) Nursing services

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








 Plan of Correction - To be completed: 06/16/2022

1. Residents will be reviewed by DON/Designee to ensure appropriate interventions related to falls are in place. Follow up will be completed based on findings.2. The facility's QAPI plan was reviewed by the IDT. Follow up will be completed based on findings.
3. Re Education to the IDT related to the facility's QAPI plan will be completed by the NHA.
4. Quality reviews of the facility's QAPI plan will be reviewed by the QAPI team monthly to ensure that facility's QAPI plan identifies ongoing quality issues. Findings to be reviewed via Quality Assurance Performance Improvement (QAPI) Committee Meeting and updated as indicated. QI schedule modified based on findings.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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.
§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:


Based on a review of clinical records, select facility policy and controlled drug reconciliation sheets, and staff interview, it was determined that the facility failed to implement procedures to promote accurate accounting of controlled medications for one of 18 residents sampled for medication reconciliation (Resident 72).

Findings include:

The facility policy for "Administering Medications" dated as reviewed May 2, 2022 revealed;

As required or indicated for a medication, the individual administering the medication records in the resident ' s medical record:
a. The date and time the medication was administered;
b. The dosage;
c. The route of administration;
d. The injection site (if applicable);
e. Any complaints or symptoms for which the drug was administered;
f. Any results achieved and when those results were observed; and
g. The signature and title of the person administering the drug.
A review of the clinical record revealed that Resident 72 had a physician order dated April 15, 2022, for Oxycodone (a narcotic opioid pain medication ) 10 mg tablet, every 4 hours, as needed for moderate pain, 4-6 (on a pain scale, 1 indicating no pain to 10 indicating most severe pain) or 7-10, severe pain.

A review of the facility's controlled substance record accounting for the above controlled medication revealed that on April 20, 2022 at 5 PM, April 28, 2022 at 3:40 PM, April 29, 2022 at 12 PM, May 2, 2022 at 6:30 PM, May 12, 2022 at 6:55 PM, May 15, 2022 at 4 AM and May 17, 2022 at 10:30 AM, nursing staff signed out a dose of the resident's supply of Oxycodone 10 mg for administration to the resident.

However, the administration of the controlled drug to the resident was not recorded on the resident's April 2022 and May 2022 Medication Administration Records on those dates and times.

During an interview, May 18, 2022 at approximately 11 AM the Director of Nursing confirmed the inconsistencies in the accounting and administration of the opioid pain medications for the above resident.



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

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

28 Pa Code 211.5(f)(g)(h) Clinical records

















 Plan of Correction - To be completed: 06/16/2022

1. R72 discharged from the facility on 5/17/22.
2. Residents that have as needed controlled pain medication will have their MARs reviewed for accuracy in accounting and administration of as needed controlled pain medication. Follow up will be completed based on findings.
3. Re- Education will be provided to the licensed nursing staff related to accuracy in accounting and administration of as needed controlled pain medication.
4. Quality reviews of the MAR and the facility's controlled substance record accounting forms will be reviewed by the DON/designee 5x's/week for 8 weeks to ensure accurate accounting and administration of as needed controlled substances. Findings to be reviewed via Quality Assurance Performance Improvement (QAPI) Committee Meeting and updated as indicated. QI schedule modified based on findings.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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.
§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:


Based on a review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address the dementia-related behavioral symptoms displayed by two residents out of 19 residents sampled (Residents 74 and Resident 87).

Findings include:


A review of the facility policy for "Dementia Care" reviewed May 2, 2022, revealed that the main focus for the care of the resident with dementia and or related disorders is on functioning, not etiology or pathology. We provide care with dignity, understanding and acceptance.

A review of the clinical record revealed that Resident 74 had diagnoses, which included dementia (group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning) with behavioral disturbance.

A admission Minimum Data Set assessment (a federally mandated standardized assessment completed periodically to plan resident care) dated March 22, 2022, indicated that the resident was severely, cognitively impaired and required staff assistance with activities of daily living and was at high risk for falls.

A admission fall risk assessment conducted on March 18, 2022, indicated the resident was at high risk (with a score of 75) for falls and that the resident had a fall in the hospital prior to his admission to the facility.

A review of an incident/accident report, dated April 5, 2022, at 8:20 PM, revealed that staff observed Resident 74 in the dining room seated in a wheelchair. The resident's chair alarm was sounding as staff observed the resident lifting himself from the wheelchair, leaning over the side of the chair, falling and landing on the floor. A staff witness statement stated "Resident was restless at times and kept setting off the alarm. I did observe him trying to move off the chair and left my chair at the nurses station to report him. As I walked in front of the nurses station, I observed him going over the arm and landing on the floor-hitting his head." The intervention planned to prevent future falls was to offer the resident earlier bed time when he becomes restless.

The report indicated that the resident was prescribed new medications in the last seven days to include, Ativan 0.5 mg twice daily, on March 27, 2022, for anxiety/agitation, Depakote 250 mg daily, on April 4, 2022, for unspecified personality and behavior disorder and Risperdal 1 mg twice a day, on March 28, 2022 for psychotic disorder with hallucinations.

There was no documented evidence that the facility had reviewed the resident psychoactive drug regimen to evaluate the resident for potential side effects that may be a potential contributing factor to the resident's fall and fall risk. According to the report, causative factors for the resident's fall was confusion and other (explain), but no explanation was documented on the incident report.

A review of an incident/accident report, dated April 29, 2022, at 8:30 AM, revealed that Resident 74's alarm was sounding. When staff entered the resident's room, the resident was found on the floor, kneeling on his right knee in front of the chair. The causative factors were identified as gait instability, confusion and agitation.

An employee statement indicated that the resident got himself out of bed, attempted to walk, resulting in a fall. The statement noted that the resident is noncompliant with transfers and ambulation due to his dementia. The intervention planned to prevent future falls was to offer the resident an earlier rise time.

A review of an incident/accident report dated April 29, 2022, at 2:45 PM, revealed that the resident was seated in a geri chair at the nurses station, when staff witnessed the resident get up from his chair and fall on the side of the chair. The causative factor identified was documented as confusion. The new intervention planned to prevent future falls was to offer the resident to go back to bed after lunch.

A review of the resident's care plan for the problem of impaired cognition function/dementia or impaired thought processes related to dementia, dated April 22, 2022, revealed the resident's goal was that he will be able to communicate basic needs on a daily basis. This care plan did not address the relationship between the resident's impaired cognition/function/dementia to the resident's poor safety awareness, confusion and risk to the resident's safety.

There was no evidence at the time of the survey ending May 20, 2022, that the facility had developed and implemented person-centered individualized plans to manage Resident 74's dementia related behaviors, including safety awareness, confusion, transfers and self rising without assistance in an attempt to maintain the safety of the resident.

Following the resident's falls noted above, which the facility attributed to dementia and confusion, the facility failed to review and revise the resident's dementia related care plan to assure that the facility developed and implemented necessary interventions, including staff supervision, to maintain the resident's safety.

The facility failed to implement individualized interventions, as well as revise the care plan accordingly, to address the resident's dementia care needs, after the resident incurred falls, which the facility attributed to the resident's cognitive impairment, dementia and confusion.

Interview with the Nursing Home Administrator on May 20, 2022, at 10:10 AM revealed that the facility does not specific programs geared towards the 41 residents residing in the facility with dementia.

The facility was unable to provide documented evidence the facility had developed and implemented individualized, resident-centered interventions in response to the resident's behavioral symptoms to attain and/or maintain the resident's highest practicable physical, mental, and psychosocial well being of dementia residents.

A review of the clinical record of Resident 87 revealed admission to the facility on May 4, 2022 at 2 PM with a diagnosis to include Alzheimers dementia with behavioral disturbance and a history of falls at home.

A review of an admission Minimum Data Set assessment (MDS -a federally mandated standardized assessment completed at specific intervals to define resident care needs) dated May 8, 2022, revealed that Resident 87 was severely cognitively impaired with a BIMS score of 3 ( Brief Interview for Mental Status. It is a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur. BIMS is a mandatory interviewing tool for skilled nursing centers ) and required assistance with activities of daily living, was frequently incontinent of urine and required maximum assistance with activities of daily living.

A review of a facility incident investigation report dated May 4, 2022 at 5 PM Resident 87 was found on the floor next to his bed. He had previously had been lying in bed. He was attempting to get out of bed without staff assistance.

A review of a facility incident investigation report dated May 5, 2022, at 2:47 PM revealed Resident 87 was witnessed to roll himself off the left side of his bed onto the floor.

A review of a facility investigation report dated May 5, 2022 at 5 PM revealed that Resident 87 was observed lying on the fall mat on the floor next to his bed. The report stated that the resident was attempting to get out of bed without staff assistance.

Physician orders and the resident's May 2022 medication administration record (MAR) revealed an order dated May 5, 2022, for Ativan 0.5 mg (antianxiety medication) by mouth every 8 hours as needed for anxiety/aggression was ordered. A review of the May MAR revealed that on May 5, 2022, at 11:30 PM and on May 6, 2022 at 1:30 PM.

On May 6, 2022, Ativan 0.5 mg by mouth every 8 hours as needed was discontinued and Ativan 0.25 mg by mouth as needed for anxiety/agitation and Ativan 0.25 mg by mouth, every 8 hours (straight dose) was ordered.

A review of a facility investigation report dated May 16, 2022 at 3 :15 PM revealed that Resident 87 was found lying on the floor mat on the left side of his bed, alarm sounding.

A review of the May 2022 MAR revealed that along with the straight order for every 8 hour dosing of the Ativan 0.25 mg, 14 doses of the prn Ativan 0.25 mg pills were administered to the resident from May 7, 2022, through May 20, 2022.

Multiple nursing progress notes dated from the time of resident's admission to the end of the survey on May 20, 2022, indicated that Resident 87 was restless and agitated and made multiple attempts to get up from bed without staff assistance.

The facility noted that the root cause of the resident's falls were noted as"Resident 87 has Alzheimers disease with behavioral disturbance, becomes restless and rolls/crawls out of the bed and has poor safety awareness."

There was no documented evidence at the time of the survey that the facility had developed and implemented individualized person centered approaches to address the resident's anxious and agitated behavior, which was known to staff and provided necessary supervision due to the resident's multiple attempts at getting out of bed without staff assistance.

The facility identified the resident's diagnosis of Alzheimer's disease as the root cause of the resident's fall but failed to develop and implement a person-centered dementia care plan to address the resident's dementia related behavioral symptoms and promote the resident's physical well-being and safety.

At the time of the survey ending May 20, 2022, there was no documented evidence of dementia care plan or mood and behavior care plan.

A review of the resident's care plan for falls, initiated May 5, 2022, revealed that it failed to address the relationship to the resident's Alzheimer's dementia and associated behaviors.
A noted intervention dated May 4, 2022 revealed that "the resident needs activities that minimizes the potential for falls while providing diversion and distraction."

A review of a monthly resident Activity calendar dated May 2022, revealed there were no specific resident activities planned to meet the needs, functional and cognitive abilities of residents with dementia.

A review of the current resident census at the time of the survey indicated that there were 86 residents residing in the facility and 41 had a diagnosis of dementia.

During an interview May 20, 2022 at approximately 10:30 AM the Nursing Home Administrator confirmed that there was no "dementia" program currently in the facility. She also confirmed that there were no "dementia" specific resident activities currently at the facility.

There was no indication that the facility had developed and implemented person-centered non-pharmacological care approaches, to address the resident's unsafe behavioral symptoms.

The facility failed to demonstrate the implementation of person-centered care approaches designed to meet the individual safety needs of this resident with Alzheimer's disease

Refer F689


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

28 Pa Code 211.11(d) Resident care plan

































 Plan of Correction - To be completed: 06/16/2022

1. R74 & R87 had their care plans reviewed to reflect person-centered, non –pharmacological care approaches related to activities.
2. Residents with a dementia diagnosis will have their activity care plan reviewed to ensure that person-centered, non-pharmacological approaches are implemented. Follow up will be completed based on findings.
3. Re- Education will be provided to the activity staff related to person-centered, non-pharmacological approaches are care planned for residents with a dementia diagnosis.
4. Quality reviews of residents with a dementia diagnosis will reviewed weekly x's 8 weeks by the NHA to ensure implementation of person-centered activity care approaches. Findings to be reviewed via Quality Assurance Performance Improvement (QAPI) Committee Meeting and updated as indicated. QI schedule modified based on findings.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Based on review of clinical records and select resident incident/accident reports and staff interviews, it was determined that the facility failed to provide necessary staff supervision and planned safety interventions to maintain the safety of resident at risk for falls for two of 18 residents sampled (Residents 74 and 87).

Findings include:

A review of Resident 74's clinical record revealed that the resident was admitted to the facility on March 18, 2022, with diagnoses to include unsteadiness on his feet, cerebral Infraction and unspecified dementia with disturbances.

A review of Resident 74's admission MDS Assessment (Minimum Data Set assessment - a federally mandated standardized assessment completed at specific intervals to plan resident care) dated March 22, 2022, revealed that the resident's cognition was severely impaired and the resident required staff assistance with all activities of daily living. The resident required extensive assistance of one staff member for locomotion in and out of the room and was noted to be unsteady, only able to stabilize with staff assistance with; surface to surface transfers (transfers between bed and chair or wheelchair). Section J1700 fall history on admission/entry or reentry indicated that the resident had a fall in the last 2-6 months prior to the admission.

A admission fall risk assessment conducted on March 18, 2022, indicated that the resident was at high risk (with a score of 75) and that the resident had a fall in the hospital prior to his admission to the facility.

A review of an incident/accident report, dated April 5, 2022, at 8:20 PM, revealed that Resident 74 was in the dining room in his wheelchair. An alarm was sounding as staff observed the resident lifting himself from the chair. The resident was leaning over the side of the chair and fell out of the chair and landed on the floor. A witness statement from a staff member noted "Resident was restless at times and kept setting off the alarm. I did observe him trying to move off the chair and left my chair at the nurses station to repo him. As I walked in front of the nurses station, I observed him going over the arm and landing on the floor-hitting his head." After this fall, the intervention planned to prevent future falls was to offer the resident an earlier bed time when he becomes restless.

The incident report noted that the resident was prescribed new medications in the last seven days to include, Ativan 0.5 mg twice daily, dated March 27, 2022, for anxiety/agitation, Depakote 250 mg daily, dated April 4, 2022, for unspecified personality and behavior disorder and Risperdal 1 mg twice a day, dated March 28, 2022 for psychotic disorder with hallucinations.

There was no documented evidence that the facility had reviewed the resident's psychoactive medications to determine if the medications were a potential contributing factor to the resident's fall due to the potential side effects of these psychoactive drugs. The facility noted the causative factors documented on the report as confusion and other (explain), no explanation was documented for the other causative factor.

A review of an incident/accident report, dated April 29, 2022, at 8:30 AM, revealed that Resident 74's alarm was sounding. When staff entered the room the resident was found on the floor kneeling on his right knee in front of the chair. The causative factors for this fall were identified as gait instability, confusion and agitation.

A staff witness statement indicated that the resident got himself out of bed, attempted to walk, resulting in a fall. The statement noted that the resident was noncompliant with transfers and ambulation due to his dementia. The intervention planned to prevent future falls was to offer the resident an earlier rise time.

A review of an incident/accident report dated April 29, 2022, at 2:45 PM, revealed that Resident 74 was seated in a geri chair at the nurses station when staff observed the resident get up from his chair and fall on the side of the chair. The causative factor documented was confusion. The new intervention planned to prevent future falls was to offer the resident to go back to bed after lunch.

During an interview with the DON (Director of Nursing) on May 19, 2022, at 11:10 AM, the DON stated that the resident is a "frequent faller and there is nothing we can do about it." However, the DON was unable to provide evidence that staff provided sufficient supervision and monitoring of the resident, at the level and frequency required to maintain his safety and as intervention to prevent future falls. There was also no documented evidence as of the time of the survey ending May 20, 2022, that the facility had evaluated the resident's multiple psychoactive medications to determine if the potential side effects of the medications could be a possible causative factors to the resident's falls.

Clinical record review revealed that Resident 87 was admitted to the facility on May 4, 2022, at 2 PM with diagnoses to include Alzheimer's dementia with behavioral disturbance and a history of falls at home prior to admission.

A review of an admission Minimum Data Set assessment dated May 8, 2022, revealed that Resident 87 was severely cognitively impaired with a BIMS score of 3 ( Brief Interview for Mental Status. It is a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur. BIMS is a mandatory interviewing tool for skilled nursing centers ) and required staff assistance with activities of daily living, was frequently incontinent of urine and required maximum staff assistance with activities of daily living.

A review of a facility investigation report dated May 4, 2022 at 5 PM, approximately 3 hours after the resident's admission to the facility, staff found Resident 87 on the floor next to his bed. According to the report, prior to the fall he had previously had been lying in bed. He was wearing gripper socks and he was attempting to get out of bed unassisted. There was no indication of his bladder/bowel continence or toileting needs status at the time of the fall noted on the facility investigation report.

New interventions planned following this fall were to apply hip protectors, bed and chair alarms, bed in the lowest position and bilateral fall mats to the sides of the bed.

A review of a facility incident investigation report dated May 5, 2022, at 2:47 PM the day after the resident's admission to the facility, revealed that staff observed Resident 87 "roll himself off the left side of his bed onto the floor. " The resident's bed alarm was sounding. The incident was witnessed by Employee 5, a nurse aide.

A review of Employee 5's witness statement dated May 5, 2022, (no time indicated) revealed, Employee 5 stated that "I was watching Resident 87, he kept sliding down in the bed, wouldn't stop trying to get out of the bed. I kept trying to keep his feet from dangling. He turned and rolled out of the bed."

A review of an employee witness statement dated May 5, 2022 (no time indicated) revealed, Employee 6, LPN stated that Employee 5 came to the nurses station and asked for help from other nurse aides to reposition Resident 87 in bed. Employee 6 stated that "he was close to the edge of the bed. They (the nurse aides) went to Resident 87's room to reposition him, and then they were calling me that he was on the floor. When I got to the room, Resident 87 was laying on the floor mat on the left side of the bed."

Interventions in place at the time of this fall were fall mats, hipsters, bed and chair alarms and bed in the lowest position. New interventions added to the resident's care plan included to offer to get the resident out of bed after lunch, if not already out of bed and to increase his antianxiety medication Ativan. The root cause of the fall was noted as,"Resident 87 has Alzheimers disease with behavioral disturbance, becomes restless and rolls/crawls out of the bed and has poor safety awareness."

The facility did not plan to provide increased supervision or monitoring of the newly admitted resident as a fall prevention approach.

A review of a facility investigation report dated May 5, 2022 at 5 PM revealed Resident 87 was found lying on the fall mat (on the floor) next to his bed. The report stated that the resident was attempting to get out of bed. All prior interventions were in place. The report noted that Resident 87 was agitated and confused. A scoop mattress ( a mattress with raised defined edges to aide in fall prevention from bed) was added to the bed as a new intervention.

A review of physician orders and a May 2022 medication administration record (MAR) revealed that on May 5, 2022, Ativan 0.5 mg (antianxiety medication) by mouth every 8 hours as needed for anxiety/aggression was ordered.

A review of the May MAR revealed that the resident received the prn antianxiety drug, Ativan on May 5, 2022, at 11:30 PM and on May 6, 2022 at 1:30 PM.

A physician order dated May 6, 2022 noted that Ativan 0.5 mg by mouth every 8 hours as needed was discontinued and Ativan 0.25 mg by mouth as needed for anxiety/agitation and Ativan 0.25 mg by mouth, every 8 hours (straight dose) was ordered.

A review of the May 2022 MAR revealed that along with the straight dose of Ativan every 8 hour, the resident received 14 doses of the prn Ativan 0.25 mg, 14 from May 7, 2022, through May 20, 2022.

A review of a facility investigation report dated May 16, 2022, at 3:15 PM revealed that Resident 87 was found lying on the floor mat on the left side of his bed. The resident's alarm sounding.

The corresponding investigation report noted that the reason for the resident's fall was that the resident had Alzheimers disease and attempts to get out of bed unassisted despite attempts to redirect the resident. The new intervention after fall to prevent future falls is to get the resident out of bed before dinner (if in bed).

According to nursing progress notes from the time of the resident's admission through the end of the survey on May 20, 2022, the resident displayed restlessness, agitation and made multiple attempts to get up from bed unassisted.

A review of bladder continency documentation indicated that this resident was both continent and incontinent of urine during this time. His continence status was not documented on any of the incident reports to ascertain if toileting needs were a potential causative factor.

Each of the resident's four falls had occurred at approximately around the same time of the day, between 2:45 PM and 5 PM. There was no documented evidence that the facility had identified and addressed this pattern when developing new interventions to prevent future falls.

A review of the resident's care plan for "at risk for falls" initiated May 5, 2022 revealed the above noted interventions, but did not include increased staff supervision and monitoring of the resident.

A review of activity of daily living (ADL) documentation for May 2022 revealed that every 15 minute safety checks, initiated May 5, 2022. However, the documentation of the checks was signed by staff as completed once a shift and there was no means to determine if the checks were conducted as planned and the times they were conducted.

During an interview May 20, 2022 at 11 AM, the DON stated that the reason for the frequent falls for Resident 87 was his Alzheimers diagnosis. The DON stated that "he was going to fall and we could not prevent it."

The facility failed to demonstrate that this newly admitted resident, at risk for falls and in a new environment and surroundings, was adequately monitored and supervised by staff to promote this resident's safety and prevent repeated falls. The facility failed to evaluate and analyze the resident's risk factors and implement interventions, including adequate supervision to reduce the risk of falls.


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

















 Plan of Correction - To be completed: 06/16/2022

1. R74's psychoactive medication were reviewed. R87's bladder/bowel continence and toileting need were reviewed. Both R74 and R87 have had their fall interventions reviewed to ensure appropriateness of intervention.
2. Residents will be reviewed by DON/Designee to ensure appropriate interventions related to falls are in place. Follow up will be completed based on findings.
3. Re-education will be provided to the nursing staff related to ensuring appropriate fall interventions are in place.
4. Quality reviews of residents at risk for falls will be completed by DON/designee 5x's/week for 8 weeks to ensure appropriateness of resident fall interventions. Findings to be reviewed via Quality Assurance Performance Improvement (QAPI) Committee Meeting and updated as indicated. QI schedule modified based on findings.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:

Based on review of facility documentation and staff interview, it was determined the facility failed to provide a copy of the Skilled Nursing Facility Advance Beneficiary Notice Form in a timely manner to one of three residents reviewed(Resident 9).

Findings include:

The Skilled Nursing Facility Advance Beneficiary Notice Form 10055 (SNFABN-notification in advance of discontinuation of covered services) is a form that the Center for Medicare/Medicaid Services (CMS) requires for the purpose of assisting residents/beneficiaries with the decision regarding their wishes to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility for these services.

During a review of Skilled Nursing Facility Protection Notification Review Form (a form used to determine that Nursing Care Facilities are in compliance with notifying residents/families of charges for services) it was noted that Resident 9's Medicare Part A coverage was to be terminated on February 14, 2022.

The notification form was submitted to the resident's representative on February 16, 2022, two days after the skilled services were discontinued.

During interviews on May 18, 2022, at 10:23 AM, the Nursing Home Administrator confirmed that the facility social worker is responsible for sending the timely notification of termination letters to the resident's representative and that it had not been provided timely in the above noted instance.




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

28 Pa Code 201.29 (a)(e) Resident rights






 Plan of Correction - To be completed: 06/16/2022

R9 continues to remain in the facility. Notification was submitted to the resident's representative on 2/16/22. They did not wish to appeal this decision.
2. The last 30 days of Medicare A skilled coverage termination letters were reviewed to ensure timely notification was made as required.
3. Re-Education has been given by the Nursing Home Administrator to social service staff re: timely notification of Medicare A skilled coverage termination letters.
4. Quality reviews of Medicare A skilled coverage termination letters will be reviewed by the NHA on a weekly basis to ensure timely notification is noted. Findings to be reviewed via Quality Assurance Performance Improvement (QAPI) Committee Meeting and updated as indicated. QI schedule modified based on findings.

483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements: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) Transfer and discharge-
§483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i) Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the necessary resident information was communicated to the receiving health care provider for two out of 19 sampled residents who were transferred to the hospital (Residents 74 and 36).

The findings include:

A review of the Resident 74's clinical record revealed that the resident was transferred from the facility and admitted to the hospital on April 6, 2022. The resident returned to the facility on April 11, 2022. The resident was transferred from the facility again on April 25, 2022, and returned to the facility on April 28, 2022.

A review of Resident 36's clinical record revealed the resident was transferred from the facility and admitted to the hospital on March 13, 2022. The resident returned to the facility on March 14, 2022. The resident was transferred from the facility to the hospital again on March 17, 2022, and returned to the facility on March 21, 2022.

There was no documented evidence that the facility had provided the necessary resident information to the receiving health care facility regarding these residents (If the resident is being transferred, and return is expected, the following information must be conveyed to the receiving provider: Contact information of the practitioner who was responsible for the care of the resident; Resident representative information, including contact information; Advance directive information; Special instructions and/or precautions for ongoing care, as appropriate, resident's comprehensive care plan goals; and all information necessary to meet the resident's needs. this information must be conveyed as close as possible to the actual time of transfer).

Interview conducted on May 19, 2022, at 10:40 AM with the Director of Nursing (DON) stated the information communicated to the receiving health care facility upon transfer or discharge from the facility is documented in a progress note, however, the documentation could not be found at the time of the survey ending May 20, 2022



28 Pa. Code 201.29(f) Resident rights








 Plan of Correction - To be completed: 06/16/2022

1. R36 returned from the hospital on 3/21/22 and R74 returned from the hospital on 4/28/22.
2. Residents that were transferred from the facility to the hospital in the last 30 days will be reviewed to ensure that the receiving health care facility has received the required documentation related to the resident. Follow up will be completed based on findings
3. Re-Education was provided to the licensed staff related to documentation of information communicated to the receiving health care facility upon transfer or discharge from the facility.
4. Quality review of nursing documentation will be completed by the DON or designee to ensure documentation related to information communicated to the receiving health care facility upon transfer or discharge from the facility is documented in the medical record and will occur 5x/week for 8 weeks. Findings to be reviewed via Quality Assurance Performance Improvement (QAPI) Committee Meeting and updated as indicated. QI schedule modified based on findings.

483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on a review of clinical records and the Resident Assessment Instrument and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 19 sampled (Resident 66).

Findings include:

A review of Resident 66's clinical record revealed the resident was admitted to the facility on September 15, 2016.

A review of Resident 66's quarterly MDS Assessment dated April 19, 2022, indicated in Section C0100, Should Brief Interview for Mental Status be Conducted? that the resident is rarely/never understood, and to skip to and complete the Staff Assessment for Mental Status. However, Section C0600, Should the Staff Assessment for Mental Status be Conducted? was not completed and the Staff Assessment for Mental Status, Section C0700, Short-term Memory and Section C0800, Long-term Memory were not answered.

Interview with the RNAC on May 19, 2022 at 1:15 p.m. she confirmed the MDS error for Resident 66.


28 Pa. Code 211.5(g)(h) Clinical records

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




 Plan of Correction - To be completed: 06/16/2022

1. R66's MDS was corrected.
2. MDS assessments completed in the last 30 days will have Section C0600 reviewed by RNAC/designee to ensure that this section is completed accurately. Follow up will be completed based on findings
3. Re-Education was provided to the Social Service staff by the RNAC related to accuracy in completion of section C0600 of the MDS.
4. Quality review of MDS section C0600 will be completed by RNAC weekly x's 8 weeks to ensure accuracy of section. Findings to be reviewed via Quality Assurance Performance Improvement (QAPI) Committee Meeting and updated as indicated. QI schedule modified based on findings.

483.25(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of opioid pain medications prescribed on an as needed basis for two residents out of 19 residents reviewed (Resident 36 and 78).

Findings include:

A review of Resident 36's clinical record revealed a physician's order, initially dated March 1, 2022, and discontinued on March 21, 2022, for Oxycodone HCL Tablet 5 MG give 2.5 mg by mouth every 6 hours as needed for Severe Pain (7-10). Further it was noted a physician's order initially dated March 21, 2022, for Oxycodone HCL Tablet 5 MG give 1 tablet by mouth every 6 hours as needed for moderate pain (4-6).

A review of the resident's March 2022 Medication Administration Record (MAR) revealed that staff administered doses of the prn oxycodone HCL pain medication 28 times during the month of March 2022. Of the 28 doses given, all were administered with no non-pharmacological interventions attempted prior to administration.

A review of the resident's April 2022 MAR revealed that staff administered the prn opioid pain medication twice during the month of April 2022. Of the two doses given, both were administered without first attempting non-pharmacological interventions to reduce the resident's pain.

A review of the resident's May 2022 MAR revealed that as of the date of the survey ending May 20, 2022, staff administered the prn opioid pain medication once during the month of May 2022, without first attempting non-pharmacological interventions to reduce the resident's pain.

A review of Resident 78's clinical record revealed a physician's order, initially dated April 30, 2022, for Ultram Tablet 50 MG give 50 mg by mouth every 8
hours as needed for pain 4-6.

A review of the resident's May 2022 MAR revealed that staff administered the pain medication 13 times during the month of May. Of the 13 doses given, all were administered with no non-pharmacological interventions attempted prior to giving the pain medication.


Interview with the Director of Nursing on May 20, 2022, at approximately 1:45 PM confirmed that there was no evidence that non-pharmacological interventions were consistently attempted and proved ineffective prior to administration of a as needed pain medication.



28 Pa. Code 211.5(f)(g) Clinical records

28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing Services




 Plan of Correction - To be completed: 06/16/2022

1. R36 and R78 were assessed for pain by a RN & findings were reviewed with the physician.
2. Residents with physician's orders for as needed pain medication were reviewed to ensure non-pharmacological interventions were attempted prior to administered as needed pain medication. Follow up will be completed based on findings.
3. Licensed nursing staff will be re-educated on the facility's pain management policy including the use of non-pharmacological interventions prior to as needed pain medication.
4. Quality reviews of residents receiving as needed pain medication will be reviewed by the DON/Designee 5x's week for 8 weeks to ensure non-pharmacological interventions are attempted prior to as needed pain medication administration. Findings to be reviewed via Quality Assurance Performance Improvement (QAPI) Committee Meeting and updated as indicated. QI schedule modified based on findings.

§ 201.19 LICENSURE Personnel policies and procedures.:State only Deficiency.
Personnel records shall be kept current and available for each employe and contain sufficient information to support placement in the position to which assigned.
Observations:

Based on review of the personnel records of newly hired employees since the last standard survey, and staff interviews, it was determined that the facility failed to timely verify employee health status prior to reporting to their assigned department and having resident contact (Employees 1 and 3).

Findings include:

Review of employee personnel files revealed that Employee 1 (Temporary Nurse Aide) was hired February 22, 2022, and Employee 3 (Nurse Aide) was hired March 8, 2022.

Further review of revealed that the employees' physicals were completed on April 18, 2022, after the employees had begun working and having contact with residents and other staff.

Interview with the Administrator on May 20, 2022 at 10:15 a.m. verified that the employees' health status was not verified until April 18, 2022, when they were seen by a physician and cleared to work in the facility, and after they had began working and had contact with residents.



 Plan of Correction - To be completed: 06/16/2022

1. Employee 1 no longer works in the facility. Employee 3 had their health status verified and were cleared to work.
2. Employee personnel files for those hired in the last 30 days will be reviewed to ensure employee health statuses were completed prior to their start date. Follow up will be completed based on findings.
3. Re-Education was provided to the human resource coordinator will be completed by the NHA related to ensuring employee health statuses were completed prior to their start date
4. Monthly reviews of newly hired personnel files will be completed by the NHA or designee to ensure health statuses are verified prior to new employee start dates. Findings to be reviewed via Quality Assurance Performance Improvement (QAPI) Committee Meeting and updated as indicated. QI schedule modified based on findings

§ 211.9(j) LICENSURE Pharmacy services.:State only Deficiency.
(j) Disposition of discontinued and unused medications and medications of discharged or deceased residents shall be handled by facility policy which shall be developed in cooperation with the consultant pharmacist. The method of disposition and quantity of the drugs shall be documented on the respective resident's chart. The disposition procedures shall be done at least quarterly under Commonwealth and Federal statutes.
Observations:

Based on a review of three closed clinical records, and staff interview it was determined that the facility failed to document the quantity and disposition of medications upon discharge from the facility for two residents out of three reviewed (Residents 88, and 89).

Findings include:

A review of the clinical record revealed that Resident 88 was admitted to the facility on January 19, 2022, and was discharged to home on February 24, 2022. At the time of the survey ending May 20, 2022, there was no documented evidence available for review of the quantity and disposition of the resident's remaining medications on the clinical record.

A review of Resident 89's clinical record revealed that she was admitted to the facility on February 16, 2022 and was discharged to the hospital on March 1, 2022. At the time of the survey ending May 20, 2022, there was no documented evidence available for review of the quantity and disposition of the resident's remaining medications on the clinical record.

Interview with the Director of Nursing on May 20, 2022, at approximately 12:30 p.m., she confirmed that the quantity and disposition of medications upon residents' discharge from the facility were not documented on the residents' records for Residents 88 and 89.





 Plan of Correction - To be completed: 06/16/2022

1. R88 and R89 were discharged
2. Residents that were discharged from the facility in the last 30 days will be reviewed by the DON/Designee to related to completion of the resident's disposition of medication. Follow up will be completed based on findings.
3. Education to the licensed nursing staff will be completed by the DON/Designee related to completion of resident medication disposition upon discharge.
4. Quality reviews of discharged resident medication disposition sheets will be reviewed weekly x's 8 weeks to ensure completion of same. Findings to be reviewed via Quality Assurance Performance Improvement (QAPI) Committee Meeting and updated as indicated. QI schedule modified based on findings


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