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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MANOR AT ST. LUKE VILLAGE, THE
Inspection Results For:

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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 Abbreviated Complaint Survey completed on May 31, 2024, it was determined that The Manor at St Luke Village was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff:

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.

§483.35(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.

Plan of Correction - To be completed: 07/10/2024

1. Resident 199 received a shower.
Resident 88 offered out of bed earlier.
Resident 298 discharged 6/13/2024.

2. To identify other residents who have the potential to be affected, NHA to conduct a resident council meeting 6/25/24. Negative findings to be addressed.

To identify this from recurring, the IDT team quality reviewed each nursing wing per facility floor plan to ensure staffing meets resident acuity. Negative findings addressed.

3. To prevent this from recurring, the Staff Educator to educate nursing staff on answering call bells within a timely manner.

To prevent this from recurring, the Staff educator to educate nursing staff on the facility's shower policy, restorative nursing policy, and resident rights policy.

4. To monitor and maintain compliance, the NHA/designee to conduct resident council meetings 1x weekly x 4 weeks then 2x monthly x 2 months.

5. Findings will be submitted to the QAPI committee for further recommendations.

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 a review of grievances filed with the facility and minutes from resident group meetings, and resident, family, and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by two out of the 23 residents sampled (Residents 88 and 298) and three out of 10 residents interviewed during a group interview (Residents 23, 30, and 64).

Findings include:

A review of grievances filed with the facility revealed a grievance dated March 9, 2024, indicating that Resident 199 was not offered a shower because facility staff told her that they were too short \ to give her a shower.

Resident Council Meeting minutes dated April 9, 2024, revealed that the Director of Nursing (DON) explained to residents in attendance that they are trying to find workers to hire. Residents in attendance indicated that they had concerns about needing more help in the facility to provide their care.

Resident Council Meeting minutes dated May 7, 2024, revealed that the DON explained to residents that there will be a nurse aide class beginning next month and that three new nurse aides were hired to increase facility staffing.

During an interview on May 28, 2024, at 12:10 PM, Resident 88 stated that she sometimes waits 30 minutes for staff to respond when she rings her call bell for staff assistance. The resident explained that the wait time is longer on the weekends. Resident 88 stated that she ends up soiling herself when staff are not able to respond promptly. Resident 88 further explained that the facility staff are nice and work hard, but when there is only one person assigned to her hall, then that person can't help everyone.

During an interview on May 28, 2024, at 12:15 PM, Resident 88's family member explained that he is upset that there is not enough staff working in the facility to properly care for his family member. The family member stated that until hospice services began for Resident 88 on March 25, 2024, the facility staff would often leave her in bed until 11:00 AM or later. He explained that she was in bed until 2:00 PM on a few occasions. The family member explained that now that staff from the hospice agency are coming daily Monday through Friday, the hospice staff get her out of bed each morning. He stated that the lack of care is likely because of the low nurse staffing in the facility. The family member stated that he believes his mother developed a pressure injury because of the lack of care by the facility. He explained that she never had bed sores in the past, but she had been "lying in bed for hours" at the facility.

During an interview on May 28, 2024, at 12:30 PM, Resident 298 stated that she had been in the facility for only a few days. She explained that sometimes she is in pain and needs the staff's assistance. Resident 298 stated that she has stopped ringing the call bell because it takes at least 20 minutes for staff to respond to her request for assistance.

During a resident group interview with alert and oriented residents, on May 29, 2024, at 10:00 AM, all residents in attendance indicated that the facility doesn't have enough staff to take care of the residents and meet their needs timely. The residents explained that when the facility is short on staff, residents experience long waits for care and assistance. The residents stated that this has been discussed at resident group meetings with no resolution to date.

During a resident group interview on May 29, 2024, at 10:00 AM, Resident 23 stated that there is often only one nurse aide working on her hall. She explained that she had recently waited over an hour for staff to provide her care after she rings her call bell. She explained that she is frustrated and angry that no one in the facility addresses this issue.

During a resident group interview on May 29, 2024, at 10:00 AM, Resident 30 stated that she has recently waited one hour for staff assistance and has waited as long as two hours within the last two weeks. She explained that sometimes there is only one staff member assigned to her hall, causing long waits for care. Resident 30 explained that she and her husband are both dependent on staff for their care. She indicated that she attempts to help her husband because she does not like to see him waiting for assistance, even though she knows it is not safe for her to do so.

During the resident group interview on May 29, 2024, at 10:00 AM, Resident 64 stated that he has soiled himself because the staff response is longer than his body is able to wait.

During an interview on May 31, 2024, at approximately 11:30 AM, the Nursing Home Administrator (NHA) and DON verified that all residents at the facility should be treated with dignity and respect, including timely staff responses to residents' requests for assistance.

Refer F686 and F725

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

28 Pa. Code 201.29 (a) Resident Rights

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

Plan of Correction - To be completed: 07/10/2024

1. The facility cannot retroactively correct unanswered call bells

2. The facility to answer call bells within a timely manner.

3. To prevent this from recurring, the Staff Educator to in-service nursing staff on resident rights and responding timely to call bells.

4. To monitor and maintain compliance, the DON/designee to quality monitor call bell response time q shift weekly x 5 x 4 weeks then q shift 1x weekly x 4 weeks.

To monitor and maintain compliance, the NHA/designee to conduct resident council meetings 1x weekly x 4 weeks then 2x monthly x 2 months.

5. Findings will be submitted to the QAPI committee for further recommendations.

483.25(l) REQUIREMENT Dialysis:

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

Observations:

Based on observations, clinical record review and staff interview it was determined that the facility failed to ensure consistent communication between the facility and dialysis center were completed, including weights and vital signs, and failed to monitor fluid intake for residents prescribed on fluid restrictions for two residents out of 23 residents sampled (Residents 76 and 54).

Findings include:

A review of a facility policy entitled "Coordination of Hemodialysis Services" that was last reviewed by the facility on January 25, 2024, indicated that residents requiring an outside End Stage Renal Disease [(ESRD) is a condition where the kidney reaches advanced state of loss of function. This causes changes in urination, fatigue, swelling of feet, high blood pressure, and loss of appetite] facility would have services coordinated by the facility and that there would be communication between the facility and ESRD facility regarding the resident. The Dialysis Communication form would be initiated by the facility for any resident going to an ESRD center for hemodialysis [a procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean blood]. Nursing will collect and complete the information regarding the resident and send to the ESRD Center. Upon the resident's return to the facility, nursing would review the Dialysis Communication form and communicate with the resident's physician and other ancillary department as needed and implement interventions as appropriate. Nursing will complete the post dialysis information on the Dialysis Communication form and file the completed form in the resident's clinical record.

The facility policy entitled "Fluid Restrictions" that was last reviewed by the facility on January 25, 2024, indicated that the Care Planning Team will discuss the restrictions, and would be included in the care plan. The dietitian documents the allowed fluids in the medical record and provide a written breakdown of fluids to nursing staff. The attending physician will be notified of resident choice not to adhere to restrictions.

A review of Resident 76's clinical record revealed that the resident was admitted to the facility on May 23, 2022, with diagnoses that included ESRD and required hemodialysis treatments three times per week.

A physician's order was dated November 26, 2023, for dialysis treatments three times per week on Monday, Wednesday, and Friday and an order for a 1,000 cc's fluid restriction [limits the amount of daily fluid consumption to help avoid fluid overload (build-up of fluid] per day.

A review of Resident 76's plan of care that was last revised on April 15, 2024, indicated that the resident required dialysis related to renal failure and would not have any signs or symptoms of complications from dialysis. Planned interventions included to communicate with dialysis facility as needed, monitor resident treatment records from dialysis center, 1,000 ml per 24-hour fluid restriction, and 600 cc's from dietary and 400 cc's from nursing.

Review of Resident 76's Medication Administration Record dated January 2024 through May 31, 2024, revealed that the facility was not monitoring the total amount of fluids that the resident was consuming from meals and medications.

The resident's Survey Documentation Report [an electronic record that summarizes planned resident centered tasks and care completed by nurse aides] dated January 2024 through May 31, 2024, revealed that fluid consumption was not consistently recorded.

Resident 76's clinical record failed to reveal that staff were consistently and accurately recording and monitoring the physician's prescribed fluid restriction and unable to determine the actual amount of fluids consumed. The resident's plan of care failed to indicate the amount of fluids that would be provided at meals and snacks.

A review of Resident 76's Dialysis Communication forms April 2024 through May 31, 2024, revealed that there were no post dialysis weights recorded.

The facility failed to provide documented evidence that post dialysis/dry weights were obtained to ensure that Resident 76 medical status was monitored for potential complications post treatments.

A review of Resident 54's clinical record revealed that the resident was readmitted to the facility was on January 2, 2024, with diagnoses that ESRD and receiving hemodialysis, and dementia [is the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities].

A physician's order dated January 3, 2024, was noted for dialysis treatments three times per week on Monday, Wednesday, and Friday and an order for a 1,500 cc's fluid restriction [limits the amount of daily fluid consumption to help avoid fluid overload (build-up of fluid] per day.

Resident 54's plan of care that was last revised on April 23, 2024, indicated that the resident required dialysis related to renal failure and would not have any signs or symptoms of complications from dialysis. Planned interventions included to communicate with dialysis facility as needed, monitor resident treatment records from dialysis center, 1,500 ml per 24-hour fluid restriction, 260 cc's from nursing every shift.

Review of Resident 54's Medication Administration Record dated January 2024 through May 31, 2024, revealed that the facility was not monitoring the total amount of fluids that the resident was consuming from meals and medications. The Survey Documentation Report dated January 2024 through May 31, 2024, revealed that fluid consumption was not consistently recorded.

Resident 54's clinical record failed to reveal that staff were consistently and accurately recording and monitoring the physician's prescribed fluid restriction and unable to determine the actual amount of fluids consumed. The resident's plan of care failed to indicate the amount of fluids that would be provided at meals and snacks.

A review of Resident 54's Dialysis Communication forms April 2024 through May 31, 2024, revealed that there were no post dialysis weights recorded.

The facility failed to provide documented evidence that post dialysis/dry weights were obtained to ensure that Resident 54's medical status was monitored for potential complications post treatments.

During an interview with Employee 1, Registered Nurse Supervisor, on May 29, 2024, at 10:35 a.m., revealed that each dialysis resident had a Dialysis Communication form that should have a recorded pre and post dialysis weight. Employee 1 reported that post weights for dialysis residents were not being consistently obtained at the dialysis treatment center and that facility staff didn't follow-up with the center to ensure a weight was collected and entered into the resident's clinical record for post dialysis monitoring.

The facility was unable to provide documented evidence that the facility ensured that Resident 76's and Resident 54's physician prescribed fluid restriction or fluid intakes were accurately recorded or monitored.

Interview with the Director of Nursing (DON) on May 31, 2024, at 10:30 a.m., confirmed that the facility failed to accurately document fluid intakes for residents ordered on fluid restrictions and failed to provide documented evidence post dialysis weights were obtained, recorded, and monitored for Residents 76 and 54.

28 Pa. Code 211.12 (d)(3)(5) Nursing Services

28 Pa. Code 211.10 (a)(c)(d) Resident care policies

Plan of Correction - To be completed: 07/10/2024

1. Facility cannot retroactively correct missing information.

2. To identify other residents who have the potential to be affected, DON/designee completed quality review residents on hemodialysis to ensure communication forms between the hemodialysis center and the facility are completed to include weights and other relative information. Negative findings addressed.

To identify other residents who have the potential to be affected, Dietician/ designee completed quality review post dialysis weights to ensure completion and accuracy. Negative findings addressed.

To identify other residents who have the potential to be affected, DON/designee completed quality review hemodialysis residents for fluid restrictions. Negative findings addressed.

3. To prevent this from recurring, DON/designee educated nursing staff on the completion of the communication form.

To prevent this from recurring, Staff Educator/designee educated the licensed nursing staff on completion of post dialysis weights.

To prevent this from recurring, the Dietician/designee educated nursing staff on monitoring and documentation of fluid restrictions for hemodialysis residents.

4. To monitor and maintain compliance, DON/designee to quality monitor hemodialysis communication forms to ensure completion and accuracy 5x weekly x 4 then 1x weekly x 4 weeks.

To monitor and maintain compliance, the Dietician/ designee to quality monitor post dialysis weights 5x weekly x 4 weeks then 1 x weekly x 4 weeks.

To monitor and maintain compliance, DON/designee to quality monitor residents on fluid restrictions 5x weekly x 4 weeks then 1x weekly x 4 weeks to ensure compliance with fluid restrictions.

5. Findings will be submitted to the QAPI committee for further recommendations.

483.10(e)(4)-(6) REQUIREMENT Choose/Be Notified of Room/Roommate Change:

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(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

§483.10(e)(5) The right to share a room with his or her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement.

§483.10(e)(6) The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.

Observations:

Based on clinical record review, resident and staff interview, it was determined the facility failed to ensure that in preparation for a room change each resident/resident representative received written notice, including the reason for the change before the resident's room was changed for one out of 23 sampled (Resident 89).

Findings include:

Federal regulatory guidance under notes that moving to a new room or changing roommates is challenging for residents. A resident's preferences should be taken into account when considering such changes. When a resident is being moved at the request of facility staff, the resident, family, and/or resident representative must receive an explanation in writing of why the move is required. The resident should be provided the opportunity to see the new location, meet the new roommate, and ask questions about the move.

A review of Resident 89's clinical record revealed admission to the facility on April 8, 2024, with diagnoses including gastro-esophageal reflux disease (GERD), diabetes, and heart failure.

A review of Resident 89's clinical record, profile, revealed a responsible party (RP), emergency contact # 1, and next of kin, a brother. Emergency contact # 2, substitute decision maker was identified as relationship as other, and Resident 89, self, as no contact type assigned.

During interview with alert and oriented Resident 89 on May 30, 2024, at approximately 9:05 AM, the resident stated that some time ago, he had an incident that while lying in bed he was experiencing knee pain. While waiting for the nurse to get him Tylenol, his roommate (Resident 13) came over, without permission, and inappropriately began rubbing - massaging his knee. According to Resident 89, his roommate (Resident 13), then began moving his hands up his leg towards his groin area, making him feel uncomfortable, uneasy. Upon further questioning, Resident 89 stated he did not tell the staff about the incident. However, he further stated that a staff member approached him, and stated that they will be moving his room "because the police are going to arrest" his roommate (Resident 13).

A review of the resident's clinical record revealed that Resident 89's room was changed April 30, 2024.

A review of a nursing progress note dated April 30, 2024, at 9:30 AM, indicated interdisciplinary care plan team met to review the resident's plan of care and to continue current plan.

A SPN/skilled note dated May 1, 2024, at 1357 (1:57 PM), included a brief statement that the resident is adjusting well to new room.

During interview with the Director of Social Services on May 30, 2024, at approximately 11:35 AM, she stated that earlier that morning (April 30, 2024) Resident 89 had told her that he awoke and found his roommate (Resident 13), sitting next to his bed, in a chair, staring at him. Resident 89 further stated that made him feel uncomfortable, uneasy. According to the Director of Social Services, there is no documentation regarding this interaction with Resident 89, and regarding the reason for the room change.

During interview with the Nursing Home Administrator (NHA) on May 30, 2024, at approximately 1:55 PM the NHA confirmed there is no additional information regarding the room change, and that the facility did not provide any written explanation of the reasons for this move to the resident and/their representative.

Refer F 657, F 745

28 Pa Code 201.29 (a) Resident Rights

Plan of Correction - To be completed: 07/10/2024

1. The resident was notified of the room change and note was put in.

2. To identify other residents who have the potential to be affected, the Social Service Director/designee completed a quality review on room changes that have occurred since 6/3/24. No issues noted.

3. To prevent this from recurring, the Staff Educator in-serviced nursing staff and social services on facility's resident rights policy

To prevent his from recurring, the NHA educated Social Services Department on documenting notifications of room changes in the resident's chart.

4. To monitor and maintain compliance, the Social Service Director/designee to complete quality monitoring on room changes to ensure resident/responsible party notification documented 5 x weekly x 2 weeks then 1 x weekly x 4 weeks.

5. Findings will be submitted to the QAPI committee for further recommendations.

483.40(d) REQUIREMENT Provision of Medically Related Social Service:

§483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.

Observations:

Based on review of clinical records, and resident and staff interviews, it was revealed that the facility failed to provide therapeutic social services to promote the mental and psychosocial well-being of one resident out of 23 sampled (Resident 89).

Findings include:

According to regulatory guidance under Medically-related social services means services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health, which include providing or arranging for needed mental and psychosocial counseling services and identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident.

A review of Resident 89's clinical record indicated admission to the facility on April 8, 2024, with diagnosis including gastro-esophageal reflux disease (GERD), diabetes, and heart failure.

During interview with alert and oriented Resident 89 on May 30, 2024, at approximately 9:05 AM, the resident stated that some time ago, he had an incident that occurred while he was lying in bed. He was experiencing knee pain and while waiting for the nurse to get him Tylenol, his roommate (Resident 13) came over, without request or permission, and began rubbing - massaging his knee. According to Resident 89, his roommate (Resident 13), then began moving his hands up his leg towards his groin area, making him feel uncomfortable, uneasy. Upon further questioning, Resident 89 stated he did not tell the staff about the incident. However, he further stated that a staff member approached him, and stated that they will be moving his room because the police are going to arrest his then roommate (Resident 13).

Resident 89's clinical record revealed that the resident's room was changed on April 30, 2024.

A nursing progress note dated April 30, 2024, at 9:30 AM, indicated that the interdisciplinary care plan team met to review plan of care. Continue current plan.

A SPN/skilled note dated May 1, 2024, at 1357 (1:57 PM), noted that the resident was adjusting well to new room.

During interview with the Director of Social Services on May 30, 2024, at approximately 11:35 AM, she stated that earlier on the morning of April 30, 2024, Resident 89 had told her that he awoke and found his roommate (Resident 13), sitting next to his bed, in a chair, staring at him. Resident 89 further stated that made him feel uncomfortable, uneasy. According to the Director of Social Services, there is no documentation regarding her conversation with Resident 89, or regarding the room change. She was unable to provide documented evidence that she had followed up, or talked with Resident 89 regarding this incident of awakening and finding his roommate (Resident 13), sitting next to his bed, in a chair, staring at him, which caused him to feel uncomfortable, uneasy, causing the facility to change his room.

During interview with the Director of Nursing (DON) on May 30, 2024, at approximately 2:10 PM the DON confirmed there is no documentation regarding the reason for Resident 89's room change, and that there was no documented evidence of the provision of therapeutic social services provided to Resident 89 following his statement of being made uncomfortable, uneasy, by his roommate's inappropriate touching.

Refer F 559, F 657

28 Pa. Code 201.29 (a) Resident rights.

28 Pa. Code 211.5(f) Medical records

28 Pa. Code 211.16 (a) Social Services

Plan of Correction - To be completed: 07/10/2024

1. Social Service's met with resident 89 and provided emotional support.

2. To identify other residents who have the potential to be affected, Social Service Director completed quality review on Incident Reports to 6/3/24 to ensure Social Service Support Notes completed. Negative findings addressed.

3. To prevent this from recurring, the NHA/designee educated the Social Service Department on completing follow up support visits post resident incidents.

4. To monitor and maintain compliance, Social Service Director/designee to quality monitor resident incident reports to ensure follow up support visit initiated and documented 5x weekly x4weeks then 1x weekly x 4 weeks.

5. Findings will be submitted to the QAPI committee for further recommendations.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia:

§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 clinical records and select investigation reports, and staff interview, it was determined that the facility failed to develop and/or implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms to promote resident safety and highest practicable physical and mental well-being for one out of 23 residents reviewed (Resident 42).

Findings include:

A review of Resident 42's clinical record revealed the resident was admitted to the facility on September 27, 2023, with diagnoses to include dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), overactive bladder, and myasthenia gravis (a disorder that causes weakness of the skeletal muscles).

A review of Resident 42's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 15, 2023, revealed the resident was severely cognitively impaired. The resident displayed multiple behavioral symptoms including physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually); Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others); Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming. Section E, impact on resident, indicated that these behaviors significantly impacted the resident negatively and potentially impacted other residents negatively. Under section E Wandering, it was noted that the resident had wandering behavior 1-3 days during the 7 day look back period.

A review of progress notes in the resident's clinical record dated from December 1, 2023, to May 30, 2024, revealed that the resident exhibited behaviors of standing unassisted, falling, wandering, being nasty, argumentative, combative, yelling, smacking/hitting staff, cursing, undressing in public, urinating on floor.

A review of facility investigation report entitled fall, dated December 1, 2023, at 1710 hours (5:10 PM), indicated that the resident's chair alarm activated. The resident was found in dining room on floor on her left side. Resident stating "she was trying to make it to the bathroom.

A review of facility investigation report entitled fall, dated December 30, 2023, at 1932 hours (7:32 PM), indicated that the resident is non-compliant, and ambulates unassisted. Staff found the resident sitting on the floor in the doorway of another resident's room. Resident stated she was looking for a thing from the garden.

A review of facility investigation report entitled fall, dated April 20, 2024, at 11:40 AM, revealed that the resident stood up from her wheelchair unassisted. The alarm was sounding, and the resident attempted to walk and fell. Resident stated "I had to go to the bathroom."

A review of facility investigation report entitled fall, dated May 4, 2024, at 1415 hours (2:15 PM), revealed that staff observed the laying on the floor in front of the closed bathroom door with a garbage can under her buttocks, and dry brief down at her knees. Resident stated "I had to go o the bathroom."

Review of Resident 42's current care plan in effect at the time of the survey ending May 31, 2024, revealed a focus area of the resident's behavioral concerns including disrobing, restless, yelling/cursing at staff related to anxiety, and metabolic encephalopathy, date revised April 22, 2024. The interventions planned included to administer medications, anticipate needs, provide positive interaction, attention, intervene as necessary, monitor behavior and attempt to determine cause, and praise in progress, date-initiated October 4, 2023.

A review of the resident care plan also revealed a focus area regarding wandering related to attempts to leave the facility unattended date revised April 22, 2024. The interventions planned included to document wandering behavior and attempted diversional intervention, distract resident, change wander guard per protocol, check placement every shift and function daily, identify patterns, provide structured activities, date-revised November 16, 2023.

A continued review of resident 42's care plan at the time the survey ending May 31, 2024, failed to identify the resident combative behavior of smacking/hitting staff and the interventions designed for staff to employ to address these physically combative behaviors.

There was no documented evidence at the time the survey ending May 31, 2024, to demonstrate that facility had updated the resident's care plan with respect to the interventions/tasks for staff to implement in response to the dementia related behaviors, in an effort to deter, modify or safely manage the behaviors displayed.

Interview with the Director of Nursing (DON) on May 30, 2024, at approximately 2:05 PM confirmed the facility failed to identify the resident combative behavior of smacking/hitting staff and or the interventions designed for staff to employ to address these behaviors, and that the facility had not updated the resident's care plan for behaviors from November 2023, to present, with respect to the interventions/tasks, in an effort to deter, modify or safely manage the behaviors displayed, to address the resident's known dementia related behaviors to include standing unassisted, falling, wandering, being nasty, argumentative, combative, yelling, smacking/hitting staff, cursing, undressing in public, urinating on floor.

There was no evidence that the facility had developed an interdisciplinary approach to the resident's dementia care and ensured that staff demonstrated the necessary competencies and skills to provide appropriate services to the resident, to include individualized approaches to the resident's care, including direct care and activities. There was no evidence that the facility had attempted to provide meaningful activities, which promote resident engagement based on the resident's customary routines, interests, preferences, to enhance the resident's mental health and well-being.

An interview with the Nursing Home Administrator (NHA) on May 30, 2024, at approximately 2:11 PM, confirmed the facility was unable to provide evidence of the development and implementation of an individualized person-centered plan to address the resident's dementia-related behaviors.

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

Plan of Correction - To be completed: 07/10/2024

1. Resident 42's care plan has been updated.

2. To identify other residents who have the potential to be affected, the Social Service Director/ designee completed quality review on resident behavior care plans house-wide to ensure new onset behaviors have been noted and interventions in place. Negative findings addressed.

3. To prevent this from recurring, the NHA educated the Social Service Department and IDT team on updating behavior care plans with resident specific interventions following relatable events.

To prevent this recurring, the Staff Educator educated nursing staff on communicating new onset behaviors to Social Services.

4. To monitor and maintain compliance, the Social Service Director/designee to quality monitor behavior care plans in relation to new incident reports to ensure accuracy and interventions are in place 5x weekly x 4 weeks then 1x weekly x4 weeks.

5. Findings will be submitted to the QAPI committee for further recommendations.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§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 resident, and staff interview, it was determined that the facility failed to provide restorative nursing services planned to maintain mobility and functional abilities of one of four residents sampled (Resident 75).

Findings included:

A review of the clinical record of Resident 75 revealed admission to the facility on June 30, 2022, with diagnoses to include reduced mobility, muscle wasting, muscle weakness, and unsteadiness on feet.

A physician's order dated was March 22, 2024, for the resident to receive RNP ambulation.

During interview with the alert and oriented Resident 75, on May 28, 2024, at approximately 12:45 PM, the resident stated staff are not walking her. Resident 75 further stated she kept track and in the past 29 days she was walked once. The resident further stated she had told staff that she is not being ambulated as ordered and "nothing was done about it."

A review of Resident 75's Physical Therapy Discharge Summary dated April 29, 2024, indicated that the resident was receiving services from March 12, 2024, to April 24, 2024, and that the discharge recommendations were to receive Restorative Nursing Program (RNP, with no indication of the specifics of the restorative nursing program.

A review of a facility provided document entitled "Rehab Services Restorative Nursing/Functional Maintenance Referral" form dated April 24, 2024, indicated that the resident was to receive ambulation, to preserve functional mobility skills. Instructions indicated RNP with a restorative nursing assistant (RNA) for ambulation with a wheeled walker (WW) for up to 300 feet contact guard (CG) assist with close wheelchair (WC) follow.

A physician orders dated May 23, 2024, was noted for physical therapy (PT) 5X/week for 30 days for gait training, therapeutic exercises, therapeutic activities, neuromuscular re-education.

During an interview on May 29, 2024, at approximately 11:45 AM, with the Director of Therapy Services, confirmed Resident 75 should have received RNP, with a restorative nursing assistant for ambulation, from April 24, 2024, through May 23, 2024.

A review of the Documentation Survey Report v2 for April 2024, and May 2024, revealed that Resident 75's RNP for ambulation was not implemented, as recommended by in the PT discharge summary, Rehab Services Restorative Nursing/Functional Maintenance Referral, and as prescribed by the physician.

Interview with the Director of Nursing (DON) on May 29, 2024, at 12:45 PM failed to provide documented evidence that Resident 75 was provided with the physician prescribed RNP program.

28 Pa. Code: 211.5(f) Clinical records

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

Plan of Correction - To be completed: 07/10/2024

1. Resident 75 was walked.

2. To identify other residents who have the potential to be affected, DON/designee completed quality review of residents on RNP to ensure RNP programs are in place and completed. Negative findings addressed.

3. To prevent this from recurring, DON/designee educated nursing administration regarding writing orders for RNP programs.

To prevent this from recurring, the Staff Educator/designee educated nursing staff on the implementation of RNP programs.

4. To monitor and maintain compliance, DON/designee to quality monitor RNP programs documentation to ensure completion and accuracy 5x weekly x 4 weeks then 1x weekly x 4 weeks.

To monitor and maintain compliance, the NHA/designee to conduct resident council meetings 1x weekly x 4 weeks then 2x monthly x 2 months.

5. Findings will be submitted to the QAPI committee for further recommendations.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Plan of Correction - To be completed: 07/10/2024

1. Resident placed on turn and repositioning.

2. To identify other residents who have the potential to be affected, facility completed Braden's on residents who are bed bound, negative findings addressed.

To identify other residents who have the potential to be affected, DON/designee completed quality review residents on turn and repositioning. Negative findings addressed.

3. To prevent this from recurring, Staff Educator/ designee to educate nursing staff on the Braden assessment to identify residents who may have a greater potential for skin break down.

To prevent this from recurring, Staff Educator/designee to educate nursing staff on establishing interventions in conjunction with the Braden Assessment.

4. To monitor and maintain compliance, the DON/Designee to quality monitor new admissions to ensure Braden assessments are completed and turn and repo are initiated as needed based on Braden score 5x weekly x 4 weeks then 1x weekly x 4 weeks.

5. Findings will be submitted to the QAPI committee for further recommendations.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§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 care plan in response to potential inappropriate behavior displayed by one resident out of 23 reviewed (Resident 13).

Findings include:

Review of the clinical record of Resident 13 revealed initial admission to the facility on December 15, 2021, with diagnoses to include chronic obstructive pulmonary disease (COPD), and diabetes.

A Social Service Progress note dated March 25, 2024, at 1537 hours (3:37 PM), revealed that the social service staff member spoke with Resident 13 along with the Nursing Home Administrator (NHA), regarding another his roommate's (Resident 49) account that this resident (Resident 13) touched his (Resident 49) leg when he did not want him to. Resident 13, verbalized understanding of appropriate versus inappropriate touch and he denied that he touched anyone in this way. Resident 13 stated he feels safe here and has no concern. "Will continue to monitor"

A review of information dated March 25, 2024, submitted by the facility revealed that Resident 49 alleged his roommate (resident 13) touches him inappropriately while he sleeps. Responsible party (RP), MD, AAA, police notified, Act 13 sent.

A review of Resident 13's current care plan revealed a focused area of mood problems related to depression, tearful/sad, related to partner and housing situation, insomnia, date revised April 22, 2024. Interventions included to administer medications as ordered and monitor for side effects, see physician orders, medication administration records (MARs) date revised March 21, 2023, assist resident in developing/providing program of activities, identify strengths, positive coping skills, behavioral health consults as needed, educate on expectations of treatment and side effects, monitor for risk for harm to self, monitor mood, and report to MD mood patterns, acute episode feelings or sadness, depression, risk of harming others, and encourage need to express feelings, date initiated February 24, 2023.

There was no documented evidence that Resident 13's care plan had been reviewed and revised related to his roommate's allegation unwelcome touching and need for continued monitoring for this potential behavior as noted in the Social Service Progress note dated March 25, 2024, which was confirmed during interview with the .
the Director of Nursing (DON) on May 30, 2024, at approximately 2:10 PM.

Refer F 559, F 745

28 Pa. Code 211.12 (d)(3)(5) Nursing Services.

Plan of Correction - To be completed: 07/10/2024

1. Resident 13's care plan has been updated.

2. To identify other residents who have the potential to be affected, the Social Service Director/ designee completed quality review of resident behavior care plans house-wide to ensure new onset behaviors have been noted and interventions in place. Negative findings addressed.

3. To prevent this from recurring, the NHA educated the Social Service Department on updating behavior care plans with resident specific interventions following relatable events.
To prevent this recurring, the Staff Educator educated nursing staff on communicating new onset behaviors to Social Services.

4. To monitor and maintain compliance, the Social Service Director/designee to quality monitor behavior care plans in relation to new incident reports to ensure accuracy and interventions are in place 5x weekly x 4 weeks then 1x weekly x4 weeks.

5. Findings will be submitted to the QAPI committee for further recommendations.

483.20(g) REQUIREMENT Accuracy of Assessments:

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

Observations:

Based on review of clinical records, the Resident Assessment Instrument, and staff interview, it was determined that the facility failed to ensure 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 the 23 sampled (Resident 21).

Findings include:

A review of Resident 21's quarterly MDS Assessment dated May 8, 2024 revealed in Section I Active Diagnoses that Resident 21 has a Multidrug Resident Organism (MDRO- an organism that is resistant to one or more antimicrobial drugs).

However, a clinical record review revealed no evidence that Resident 21 had an acute or colonized MDRO.

During an interview on May 30, 2024, at approximately 10:30 AM, the Director of Nursing (DON) confirmed that Resident 21 did not have an acute or colonized MDRO. The DON indicated that the MDS entry was an error.

Plan of Correction - To be completed: 07/10/2024

1. Resident 21's MDS has been corrected.

2. To identify other residents who have the potential to be affected, the RNAC/designee completed a quality review of MDS Section I1700 to I2500 to ensure completion and accuracy. Negative findings addressed.

3. To prevent this from recurring, Regional MDS educated facility MDS team on accuracy of MDS Section I1700 to I2500.

4. To monitor and maintain and compliance, MDS RNAC/designee to quality monitor Section I1700 to I2500 to ensure completion and accuracy 5x weekly x 4 weeks then 1x weekly x 4 weeks.

5. Findings will be submitted to the QAPI committee for further recommendations.

483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements:

§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 a 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 one resident out of 23 residents sampled with facility-initiated transfers (Residents 21).

The findings include:

A review of Resident 21's clinical record revealed that the resident was transferred to the hospital on December 13, 2023.

There was no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, including contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, advance directive information, all special instructions or precautions for ongoing care, as appropriate, and any other documentation, as applicable, to ensure a safe and effective transition of care.

A review of Resident 21's clinical record revealed that the resident was transferred to the hospital on March 15, 2024.

There was no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, including contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, advance directive information, all special instructions or precautions for ongoing care, as appropriate, comprehensive care plan goals, and any other documentation, as applicable, to ensure a safe and effective transition of care.

During an interview on May 31, 2024, at approximately 11:30 AM, the Director of Nursing (DON) confirmed that there was no evidence that the necessary information was communicated to the receiving health care institution or provider for Resident 21's facility-initiated transfers on December 13, 2023 or March 15, 2024.

28 Pa. Code 201.29 (a)(c.3)(2) Resident rights

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

Plan of Correction - To be completed: 07/10/2024

1. The facility cannot go back and provide paperwork that was missed.

2. To identify other residents who have the potential to be affected, the Social Service Director/designee completed quality monitoring on transfers to the hospital dating back to 6/3/24 to ensure transfer notifications were completed and sent. Negative findings addressed.

3. To prevent this from recurring, the Staff Educator educated the Social Service Director and nursing staff on Admission, Transfer and Discharge policy.

To prevent this from recurring, the Staff Educator educated nursing staff on proper transfer and discharge documentation.

4. To monitor and maintain compliance, the Social Service Director/designee to quality monitor transfer paperwork to ensure completion and retainment 5x weekly x 4 weeks then 1x weekly x 4weeks.

To monitor and maintain compliance, the DON/designee to complete quality monitoring documentation regarding residents who transfer out or discharge to the hospital 5x weekly x4 weeks then 1x weekly x 4 weeks.

5. Findings will be submitted to the QAPI committee for further recommendations.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

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

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

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

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

Observations:

Based on review of clinical records and transfer notices, and staff interviews, it was determined that the facility failed to provide written notices of facility-initiated transfers to the resident and the resident's representative as soon as practicable for one out of the 23 residents reviewed (Residents 21).

Findings include:

A review of the clinical record of Resident 21 revealed the resident was transferred to a community hospital on December 11, 2023.

A clinical record review revealed no documented evidence that a notice of transfer or discharge letter was provided to Resident 21 or her resident representative regarding her transfer to the hospital on December 11, 2023.

A review of the clinical record of Resident 21 revealed the resident was transferred to the hospital on March 15, 2024.

A clinical record review revealed no documented evidence that a notice of transfer or discharge letter was provided to Resident 21 or her resident representative regarding her transfer to the hospital on March 15, 2024.

During an interview on May 31, 2024, at approximately 11:30 AM, the Nursing Home Administrator and Director of Nursing confirmed that the facility had no documented evidence that Resident 21 or her resident representative were provided written notices for the facility-initiated transfers on December 11, 2023, or March 15, 2024.

28 Pa. Code 201.29 (a)(c.3)(2) Resident rights

Plan of Correction - To be completed: 07/10/2024

1. The facility cannot go back and provide paperwork that was missed.

2. To identify other residents who have the potential to be affected, the Social Service Director/designee completed a quality review of transfers to the hospital dating back to 6/3/24 to ensure transfer notifications were completed and sent. Negative findings addressed.

3. To prevent this from recurring, the Staff Educator educated the Social Service Director and nursing staff on Admission, Transfer and Discharge policy.

To prevent this from recurring, the Staff Educator educated nursing staff on proper transfer and discharge documentation.

4. To monitor and maintain compliance, the Social Service Director/designee to complete quality monitoring of transfer paperwork to ensure completion and retainment 5x weekly x 4 weeks then 1x weekly x 4weeks.

To monitor and maintain compliance, the DON/designee to quality monitor documentation regarding residents who transfer out or discharge to the hospital 5x weekly x4 weeks then 1x weekly x 4 weeks.

5. Findings will be submitted to the QAPI committee for further recommendations

§ 201.18(b)(2) LICENSURE Management.:

(2) Protection of personal and property rights of the residents, while in the facility, and upon discharge or after death, including the return of any personal property remaining at the facility within 30 days after discharge or death.

Observations:

Based on the review of clinical records and staff interview it was determined that the facility failed to maintain a complete and accurate record of a residents' personal possessions upon admission and discharge for one resident out of three sampled (Resident 95)

Findings included:

Clinical record review revealed that Resident 95 was admitted to the facility on March 4, 2024, and discharged to the hospital March 8, 2024.

There was no documented evidence of a written record of Resident 95's personal belongings completed upon admission or discharge from the facility.

Interview with the Director of Nursing (DON) on May 31, 2024, at approximately 10:55 A.M., confirmed that the facility was unable to provide an complete and accurate record of a residents' personal possessions of Resident 95's personal belongings upon admission and discharge.

Plan of Correction - To be completed: 07/10/2024

1. Facility cannot retroactively create an inventory sheet for a discharged resident.

2. To identify other residents who have the potential to be affected, Social Service Director/designee completed a quality review on new admissions since 6/3/24 to ensure inventory sheets have been established. Negative findings addressed.

To identify other residents who have the potential to be affected, Social Service Director/designee completed a quality review on discharges since 6/3/24 to ensure inventory sheets have been reviewed on discharge. Negative findings addressed.

3. To prevent this from recurring, Staff Educator/designee educated Social Services, Admissions, Laundry, and Nursing staff on creation and implementation of inventory sheets on admission.
To prevent this from recurring, Staff Educator/designee educated Nursing Staff and Social Services on reviewing inventory sheets prior to discharge.

4. To monitor and maintain compliance, Social Services/designee to quality monitor new admissions and discharges to ensure completion and accuracy of inventory sheets 5x weekly x 4 weeks then 1x weekly x 4 weeks.

5. Findings will be submitted to the QAPI committee for further recommendations.

§ 201.19(1) LICENSURE Personnel policies and procedures.:

(1) The employee's job description, educational background and employment history.

Observations:

Based on employee personnel file review and staff interview it was determined the facility failed to verify employment histories for two out of the five employee files sampled (Employees 10 and 11).

Findings Include:

A review of personnel files for newly hired employees revealed that the facility failed to verify the employment histories of Employee 10, Licensed Practical Nurse, and Employee 11, Nurse Aide.

During an interview on May 31, 2024, at approximately 11:30 AM, the Nursing Home Administrator (NHA) was unable to provide documented evidence that the facility attempted to verify the employment history for Employee 10 or Employee 11.

Plan of Correction - To be completed: 07/10/2024

1. Human Resources corrected the missing employment verifications.

2. To identify other potential areas of concern, Human Resources audited new hires since 5/19/24 to ensure employment verifications have been completed. Negative findings addressed.

3. To prevent this from recurring, the NHA educated Human Resources on completing employment verifications prior to start date.

4. To monitor and maintain compliance, Human Resources/designee to quality review new hires to ensure employment verifications are completed. 5x weekly x4 weeks then 1 x weekly x 4 weeks.

5. Findings will be submitted to the QAPI committee for further recommendations.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Plan of Correction - To be completed: 07/10/2024

1. The facility cannot retroactively correct the nurse aide ratios.

2. The facility is focusing on retention of existing nurse aides and recruitment of new nurse aides through efforts of the Staffing Committee.

3. To prevent this from recurring, The Scheduler and Nursing Supervisors re-educated by DON/Designee regarding the ratio requirements for nurse aides.

To prevent this from recurring, the facility to include census management to coincide with staffing levels.

To prevent this from recurring, the facility to hire CNAs to meet CNA ratio requirement.

4. To monitor and maintain compliance, the DON/designee will hold staffing meetings to review calculations of the nurse aide ratios for accuracy weekly x5 x 4 weeks then weekly x2.

5. Findings will be submitted to the QAPI committee for further recommendations.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Plan of Correction - To be completed: 07/10/2024

1. The facility cannot retroactively correct the LPN ratios.

2. The facility is focusing on retention of existing nurse aides and recruitment of LPNs through efforts of the Staffing Committee.

3. To prevent this from recurring, The Scheduler and Nursing Supervisors re-educated by DON/Designee regarding the new ratio requirements for LPNs.

To prevent this from recurring, the facility to include census management to coincide with staffing levels.

To prevent this from recurring, the facility to hire LPNs to meet LPNs ratio requirement.

4. To monitor and maintain compliance, the DON/designee will hold staffing meetings to review calculations of the LPN ratios for accuracy weekly x5 x 4 weeks then weekly x2.

5. Findings will be submitted to the QAPI committee for further recommendations.

§ 211.12(i)(1) LICENSURE Nursing services.:

(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Plan of Correction - To be completed: 07/10/2024

1. The facility cannot retroactively correct the minimum direct resident care hours on the one identified date.

2. The facility is focusing on retention and recruitment of direct care staff through efforts of the Staffing Committee.

3. To prevent this from recurring, the NHA/Designee educated the Scheduler, DON, and Human Resource Director regarding the direct resident care hours requirement.

To prevent this from recurring, the facility to include census management to coincide with staffing levels.

To prevent this from recurring, the facility to hire nursing staff to meet overall PPD requirement.

4. To monitor and maintain compliance, the DON/designee will hold staffing meetings to review calculations of direct care workers hours 5x weekly x4 weeks then weekly x2.

5. Findings will be submitted to the QAPI committee for further recommendations.

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