Pennsylvania Department of Health
GLEN BROOK REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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GLEN BROOK REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are  132 surveys for this facility. Please select a date to view the survey results.

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GLEN BROOK REHABILITATION AND HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a revisit survey and an abbreviated complaint survey completed on March 28, 2024, it was determined that Glen Brook Rehabilitation and Healthcare Center failed to correct the deficiencies cited during the surveys of December 8, 2023, February 6, 2024, and February 28, 2024, and continued to be out of compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.





 Plan of Correction:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:

Based on review of clinical records, select facility policy and investigative reports resident and staff interview, it was determined that the facility failed to ensure that one resident was free from physical abuse out of 9 sampled residents (Resident C1).

Findings including

A review of the current facility policy titled "Abuse, Neglect and Exploitation", last reviewed by the facility February 7, 2024, revealed that it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. "Physical Abuse" includes, but is not limited to hitting, slapping, punching, biting, and kicking.

A review of Resident C1's clinical record revealed admission to the facility on July 15, 2022, with diagnoses, of Alzheimer's dementia [chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning], cognitive communication disorder [(CCD)are a group of disorders that affect a person's ability to communicate and can cause difficulty with understanding or producing language, as well as with nonverbal communication skills such as gestures and facial expressions. CCDs can be caused by a variety of factors, including brain injury, stroke, dementia, and developmental disabilities], and anxiety.

A quarterly Minimum Data Set (MDS) assessment dated February 12, 2024, indicated that the resident had severe cognitive impaired with a BIMS (brief interview for mental status - a tool to assess cognitive status) of 5.

Resident C2's clinical record revealed admission to the facility on November 30, 2023, with diagnoses, of Alzheimer's dementia, metabolic encephalopathy [is a condition in which diffuse disease affects brain function and/or structure], and depression. A quarterly Minimum Data Set (MDS) assessment dated March 4, 2024, indicated that the resident had severe cognitive impairment with a BIMS score of 6.

Nursing progress notes dated March 8, 2024, at 4:04 p.m., in Resident C2's clinical record revealed that the resident had increased agitation while out of his room by the nurse's station times and was redirected by staff. On March 17, 2024, at 10:06 p.m., Resident C2 continued on 1:1 supervision and was yelling out in the dining room. Progress notes dated March 18, 2024, at 7:55 a.m., revealed that Resident C2 was on a 1:1; charting reviewed and the resident had minimal episodes of yelling out with no attempts to get out of chair noted. No aggressive actions toward others noted and the resident's level of supervision was changed from 1:1 to every fifteen-minute checks.

Progress notes indicated that March 21, 2024, at 9:26 a.m., Resident C2 displayed behaviors of yelling and agitation in response to another resident yelling out and required staff redirection.

A facility incident investigation completed by Employee 3, a registered nurse (RN), dated March 22, 2024, at 7:50 p.m., revealed that Resident CR2 hit Resident C1 in the chest. The residents were in the hallway and Resident C2 rolled over to Resident C1 and struck him in the chest. Resident C1 did not swing back. Resident C2 denied that he struck another resident, stating "I did not hit anyone." The residents were immediately separated, and residents were assessed with no injuries or redness, or bruising noted. Predisposing physiological factors included impaired memory and confusion. Immediate interventions included re-instating 1:1 supervision of Resident C2 for safety.

Employee 4's, RN, witness statement dated March 22, 2024, at 8:00 p.m., revealed that "while giving meds down the hallway, I heard arguing between \ and another resident When approaching he hit another resident \ in the chest with his closed fists. Both residents were separated and Resident C2 went down the hallway to his room and the other resident \ was assessed without injuries.

A review of Resident C3's clinical record revealed that the resident was admitted to the facility on March 3, 2022, with diagnoses that included neurocognitive disorder with Lewy bodies [is a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function. Its features may include spontaneous changes in attention and alertness, recurrent visual hallucinations, REM sleep behavior disorder, and slow movement, tremors, or rigidity], dysphagia (difficulty swallowing), and cognitive communication deficit. A quarterly Minimum Data Set (MDS) assessment dated February 9, 2024, indicated that the resident had severe cognitive impaired with a BIMS of 3.

A review of Resident C3's behavior plan of care that was initiated on December 26, 2023, revealed that the resident had behavior problems at times related to increased confusion, combative with care, wandering behaviors, and physically aggressive with peers with a goal for the resident to have fewer episodes of behaviors. Planned interventions were to meet and anticipate the needs of the resident and praise any indication of the resident's progress/improvement in behavior.

A facility incident investigation report completed by Employee 5, a RN, dated March 24, 2024, at 6:30 p.m., revealed that she was called to the unit due to Resident C3 striking another resident \ on the right upper arm with his closed hand twice. Both residents were sitting in the hallway in front of North's nursing station. Resident C3 stated, "that other resident \ would not stop saying things to him, so I hit him." Both residents were immediately separated by staff members and Resident C3 returned to his unit and safety measures were initiated. Resident C1 was assessed with no injuries observed and no complaints of pain.

A review of a witness statement completed by Employee 6, a Licensed Practical Nurse (LPN), dated March 24, 2024, at 6:30 p.m., revealed that while at the nurse's desk in the North hallway, she observed resident Resident C3 slap Resident C1 and separated them for safety.

The facility failed to protect Resident C1's from physical abuse perpetrated by other residents with histories of physical aggression.

During an interview with the Nursing Home Administrator (NHA) on March 28, 2024, at 1:15 p.m., the NHA confirmed that Resident C1 was not protected from physical abuse.



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

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




 Plan of Correction - To be completed: 04/19/2024

F0600
1. Resident C1 has had no injuries related to the incidents. Residents C2, and C3 have had their care plans reviewed and revised as needed in relation to behavior interventions.
2. The facility has determined that all residents have the potential to be affected. The DON/Designee shall review the Incident Reports from the past two weeks in order to identify any resident behaviors that need to be reviewed
3. The staff development coordinator / Designee will educate the IDT on identification of behaviors and implementation of appropriate interventions to assist in preventing further incidents. IDT shall continue to review the 24 hour reports during the morning meeting in an effort to identify behavioral concerns, and update care plans accordingly.
4. The DON /Designee will complete random audits of incidents due to behaviors to assure abuse has been ruled out, identified behaviors have been reviewed and interventions are put into place. Audits will be conducted weekly for four weeks, then monthly for two months or until compliance is sustained. The DON/Designee shall review any concerns during the monthly QAPI meeting.
5. Date of compliance 4.19.2024

483.75(c)(d)(e)(g)(2)(i)(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(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at 483.70(e) and including how such information will be used to develop and monitor performance indicators.

483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

483.75(d) Program systematic analysis and systemic action.

483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

483.75(e) Program activities.

483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at 483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

483.75(g) Quality assessment and assurance.

483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.
Observations:


Based on observations, review of the statement of deficiencies from the surveys ending February 6, 2024, and February 28, 2024, and the activities of facility's quality assurance committee and staff interviews it was determined that the facility failed to implement effective plans to correct quality deficiencies in pharmacy services, timely obtaining resident medications, and accurate clinical records to ensure that corrective action plans designed to improve the delivery of care and services were consistently implemented to correct and deter future quality deficiencies.

Findings included:

During the survey ending February 28, 2024, quality deficiencies were cited under the requirements for pharmacy services due to the facility's failure to timely obtain resident medications and clinical records for failing to maintain accurate and complete medical records reflecting the resident's experience in the facility. In response to these deficiencies, the facility developed a plan of correction to correct these deficient practices that included quality assurance monitoring plans to assure solutions were sustained. These corrective plans were to be completed and functioning by March 15, 2024.

However, during this revisit survey completed on March 28, 2024, continued deficiencies were identified under these same requirements.

In response to the deficiency cited under pharmacy services the facility has determined that residents have the potential to be affected.

Staff Educator / designee educated the licensed nursing staff on the facility pharmacy procedures for ordering/reordering routine prescribed medications.

Licensed nursing staffwill order medications when there are 8 doses available. The nurse will management team will review and address pharmacy order alerts in PCC.

Director of nursing / designee will review resident clinical records to assure that prescribed medications are available for administration Audits will be completed daily x 7 days, then weekly for 4 weeks, then monthly for 2 months or until compliance is sustained.

However, at the time of the survey ending March 28, 2024, it was found through a review of clinical records and select facility policy and resident and staff interview that the facility failed to provide pharmacy services to assure consistent availability of routine prescribed pharmaceuticals and medications for four of nine residents reviewed (Residents B3, B4, B5, and C4).

During an interview with the acting Director of Nursing (DON) on March 28, 2024, at 1 PM she confirmed that when there are three doses of the medications remaining, staff should reorder medications through PCC (Point Click Care - electronic healthcare software provider). She confirmed that facility staff failed to follow this policy for reordering medications, failing to ensure consistent availability of a prescribed medications. The facility's plan of correction, however, indicated that Licensed nursing staffwill order medications when there are 8 doses available. The nurse will management team will review and address pharmacy order alerts in PCC.

Deficient facility practice was cited during the February 28, 2024, survey for failing to maintain accurate and complete clinical records according to professional standards of practice.

The facility's plan of correction indicated that the DON/designee will provide in-service education to Licensed nursing staff on the documentation standards of the American Nurses Association Principles for Nursing Documentation.

The DON/designee will complete audits of resident records related to incidents of falls to ensure licensed staff are thoroughly and accurately documenting according to professional standards of practice. Audits will be done weekly for four weeks, then monthly for two months or until compliance is achieved. Results will be presented in QAPI committee meeting.

However, at the time of this revisit survey a facility incident report dated March 24, 2024, revealed that the resident had accused a staff member of verbal abuse, which reported to nursing staff on March 26, 2024.

A review of the resident's clinical record revealed no documentation in the resident's clinical record regarding the resident's allegation of verbal abuse.

An interview with the Nursing Home Administrator on March 28, 2024, at approximately 2:45 PM confirmed that there was no documented evidence that the resident's allegation of verbal abuse was documented in the resident's clinical record.

The facility's QAPI committee failed to identify that the facility's corrective action plans were not developed and/or implemented in a manner consistent with the regulatory guidelines for these deficiencies cited, to ensure that solutions to the problems were sustained.


Refer F755, F842

28 Pa. Code 211.12 (c) Nursing services

28 Pa. Code 201.18 (e)(1)(3) Management.











 Plan of Correction - To be completed: 04/19/2024

F 0867 QA

1. The deficient practice related to unavailable medications and clinical records has been corrected.
2. The QAPI committee shall ensure accurate clinical records are maintained, and that corrective action plans are designed to improve the delivery of care and services, and that they are consistently implemented to correct and deter future quality deficiencies.
3. The QAPI committee will be educated by the governing body/designee on implementing the plan of correction in a consistent and timely manner for areas cited as deficient practice.
4. The NHA /designee will review the plan of correction for areas cited with the governing body to ensure that measures to maintain compliance are maintained. The weekly audits for unavailable medications and clinical records shall be reviewed during the monthly QA meetings for compliance. The audits shall be reviewed monthly for three months or longer if issues arise.
5. Date of compliance 4.19.2024

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 review of clinical records and select facility policy and resident and staff interview it was determined that the facility failed to provide pharmacy services to assure consistent availability of routine prescribed pharmaceuticals and medications for four of nine residents reviewed (Residents B3, B4, B5, and C4).

Findings include:

A review of the facility's policy titled "Ordering and Receiving Non-Controlled Medications" provided by facility during the survey of March 28, 2024, and dated as last reviewed by the facility August 2020, indicated that repeat medications (refills) are written on a medication reorder form or by peeling the reorder tab from the prescription label and placing it in the appropriate area on the medication reorder form provided by the pharmacy, or requested via the facility's EHR (Electronic Health Record) system.

A review of the clinical record revealed that Resident B3, was admitted to the facility on September 16, 2023, with diagnosis to include diabetes. Current physician orders for Resident B3 dated September 16, 2023, revealed, Alpha-Lipoic Acid Oral Capsule 600 mg, Give 600 mg by mouth two times a day for diabetic neuropathy

A review of the resident's March 2024 Medication Administration Record (MAR) revealed that on March 17, 2024, at 5 PM and March 18, 2024, at 8 AM the Alpha-Lipoic Acid was not available in the facility for administration to the resident.

A review of the clinical record of Resident B4, revealed admission to the facility on August 26, 2023, with diagnoses of flaccid hemiplegia and peripheral vascular disease..

The resident had a current physician order dated March 21, 2024, revealed to Cleanse a sacral wound with Normal Saline Solution. Apply Santyl (a topical debridement agent), nickel thick, to wound bed. Cover with a foam dressing. Change daily, every day shift

A review of a March 2024 MAR revealed that on March 23, 2024, day shift the Santyl debridement agent was not available in the facility for administration of the resident's wound treatment.

A review of a nurses note dated March 23, 2024 at 10:26 AM revealed that "This nurse went to do treatment and unable to locate Santyl. Supervisor aware. Cleansed wound and dressed with Dry Sterile Dressing until further notice."

A review of Resident B5's clinical record revealed admission on September 26, 2023, with diagnoses to include HEPATIC ENCEPHALOPATHY (A loss of brain function as a result of failure in the removal of toxins from the blood due to liver damage) and PORTAL HYPERTENSION (Portal hypertension is a serious condition that affects the blood flow from the digestive organs to the liver ).

Current physician orders for Resident B5 dated November 6, 2023, Lactulose Oral Solution 10 GM/15 ML, Give 45 ml by mouth four times a day related to HEPATIC ENCEPHALOPATHY and r/t increased Ammonia Level.

A nurses note dated March 23, 2024 at 4:03 PM revealed, Lactulose Oral Solution 10 GM/15 ML Give 45 ml by mouth four times a day related to HEPATIC ENCEPHALOPATHY
was "on order." The medication was not available in the facility for administration to this resident.

A nursing note dated March 25, 2024 at 07:02 AM revealed that the medication was on order. The resident, who is his own responsible party, was made aware, along with the physician with no new orders at this time.

The resident's March 2024 MAR revealed that on March 23, 2024, at 5 PM dose of Lactulose was not available in the facility for administration to the resident. However, nursing staff signed the resident's MAR as administered to the resident as ordered from March 23, 24 and 25, 2024.

During an interview with the acting Director of Nursing (DON) March 28, 2024, at approximately 1 PM the DON stated that the routine medication Lactulose was not available in the facility for administration from March 23, 2024, through March 25, 2024, as noted in the nursing documentation in the resident's clinical record. She also verified that despite the medication not being unavailable, licensed nursing staff signed the resident's MAR indicating that the medication was administered to the resident as scheduled.

During an interview with the acting Director of Nursing (DON) on March 28, 2024, at 1 PM she confirmed that when there are three doses of the medications remaining, staff should reorder medications through PCC (Point Click Care - electronic healthcare software provider). She confirmed that facility staff failed to follow this policy for reordering medications, failing to ensure consistent availability of a prescribed medications.

A review of Resident C4's clinical record revealed admission to the facility on April 20, 2023, with diagnoses that included urinary tract infections (UTI) and personal history of traumatic brain injury.

Physician orders dated March 25, 2024, were noted for Macrobid Oral Capsule 100 MG [(Nitrofurantoin Monohyd Macro) an antibiotic used to treat urinary infections], give 1 capsule by mouth two times a day and Cipro Oral Tablet 500 MG (Ciprofloxacin HCl), give 1 tablet by mouth two times a day related to related to urinary tract infection.

Resident C4's Medication Administration Record (MAR) dated March 2024, revealed that on March 25, 2024, Macrobid and Cipro antibiotic administration was noted as "8" or other. The nurse's administration note indicated that the medications were not available from pharmacy for administration on the date.

A review of the facility's Omnicell [an automatic medication administration system that stores medications for availability to prevent delays in administration of medications] inventory list dated March 28, 2024, revealed that both Macrobid Oral Capsule 100 MG and Cipro Oral Tablet 500 MG were available in the system, for administration to Resident C4 but were not accessed and administered to the resident on that date.

An interview with the acting Director of Nursing (DON) on March 28, 2024, at 1:10 p.m., confirmed that the facility's Omnicell contained both antibiotics, but staff failed to administer them to Resident C4 when the drugs were not available in the resident' supply on March 25, 2024.



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

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















 Plan of Correction - To be completed: 04/19/2024

F 0755 Medications unavailable

Resident B3, B4, B5 and C4 have received their medication from pharmacy and have suffered no ill effect from missing dose.
1. The facility has determined that residents have the potential to be affected.
2. Staff Educator/designee will educate the licensed nursing staff on the facility pharmacy procedures for ordering/reordering routine prescribed medications. Licensed nursing staff will order medications when there are only 8 doses left for administration. Licensed nurses shall check the Omni Cell for availability of the medications. The nurses shall contact the Pharmacy and they will order it from the backup pharmacy for delivery. The nurse management team will review and address pharmacy order alerts in PCC. During AM clinical meeting
3. The Director of Nursing/designee will conduct random audits to assure that prescribed medications are available for administrations. Audits will be completed weekly for four weeks, then monthly for two months or until compliance is sustained.
4. Date of compliance 4.19.2024

483.12(b)(1)-(5)(ii)(iii) 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,

483.12(b)(4) Establish coordination with the QAPI program required under 483.75.

483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.
Observations:


Based on review of select facility policy and staff interview, it was determined that the facility failed to fully develop and implement an abuse prohibition policy with corresponding written procedures to assure staff carry out the tasks necessary to fulfill required components for abuse prevention.

Findings include,

A review of a facility policy for, Abuse, Neglect and Exploitation reviewed February 7, 2024 revealed guidelines to include:
1. The facility will develop and implement written policies and procedures that;
a. Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property.
b. Establish policies and procedures to investigate any such allegations

The abuse policy did not include Involuntary seclusion as a form of abuse or any definitions of the types of abuse included in the policy.

Screening procedures included:

A. Potential employees will be screened for a history of abuse, neglect, exploitation or misappropriation of resident property.
1. Background, reference, and credential's checks shall be conducted on potential employees, contracted temporary staff

Prevention of abuse, neglect and exploitation to include:

The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation that achieves:

--Providing residents, representatives and staff information on how and to whom they may report concerns, incidents and grievances without fear of retribution and providing feedback regarding the concerns that have been expressed.

Reporting/Response:

The facility will have written procedures that include:
1. Reporting all alleged violations to the administrator, state agency, adult protective services and to all other required agencies(e.g. law enforcement when applicable) within specified timelines.
a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegations involve abuse or result in serous bodily injury, or
b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serous bodily injury

B. The administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

The policy does not include the criteria for notifying the local Area on Aging or the State Department of Aging. The policy did not include procedures making the state nurse aide registry and licensing agency's aware of any actions taken by the courts regarding an employee unfit for duty, and notification of law enforcement for the following criteria abuse or neglect resulting in physical bodily injury, sexual abuse, misappropriation of resident funds/property and unexplained/unexpected death.

The facility abuse prohibition policy provided to the survey team at the time of the survey ending March 28, 2024, did not contain components to include identifying all types of abuse. The facility failed to identify state specific screening requirements if potential employees had resided in Pennsylvania the previous 2 years, and if not, conduct an FBI (Federal Bureau of Investigation) criminal background check.

The policy for investigation into Alleged abuse, neglect and exploitation include:

A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.
B. Written procedures for investigation include:
1. Identifying staff responsible for the investigation
2. Investigating different types of alleged violations
3. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations.

The facility failed to include corresponding procedures for screening, abuse prevention, investigation and reporting.

The policy provided included a " Abuse/Neglect allegation checklist." There was no documented evidence at the time of the survey that this policy statement and check list of requirements included written procedures for implementation by staff to investigate allegations of abuse, timeframes for investigation and reporting to the State Licensing Agency, AAA, PDA and local law enforcement and staff training requirements.

There was no evidence that the facility's abuse policy included written procedures to meet all required components including screening, training, prevention, identification, investigation, protection or reporting procedures.


During an interview March 28, 2024 at approximately 2 PM, the interim NHA verified that the abuse prevention policy provided at the time of the survey did not contain all the required components and there were no written procedures for staff to follow to carry out the steps noted on the checklist to assure timely and consistent implementation by staff.


Refer F600


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

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













 Plan of Correction - To be completed: 04/19/2024

F 0607

1. The facility Abuse Policy & Procedure has been updated to include all aspects of 483.12(b)(1)-(5)(ii)(iii) Development/Implement Abuse/Neglect Policies.
2. The Staff will be educated by the Staff Development Coordinator / Designee on the updated abuse policy.
3. The DON/designee shall review the 24 report during the morning meeting to ensure that the policy and procedures for abuse are maintained.
4. The DON /Designee will complete random audits that will be conducted weekly for four weeks, then monthly for two months or until compliance is sustained. The DON/Designee shall review any concerns during the monthly QAPI meeting.
5. Date of compliance 4.19.2024


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

Based on observation, clinical record review and staff interview, it was determined that the facility failed to timely develop and implement a person-centered care plan to meet one resident's current needs for the use of an implantable cardiac devices for one of nine sampled residents (Resident B1).

Findings including:

Clinical record review revealed that Resident B1 was admitted to the facility on April 20, 2023, with diagnoses to include A-V block (atrioventricular block (AV block) is a disease of the electrical conduction system of the heart in which electrical impulses conduct from the cardiac atria to the ventricles through the atrioventricular node (AV node) more slowly than norma and heart disease), implantable cardiac pacemaker and hypertensive chronic kidney disease with heart failure.

Review of quarterly Minimum Data Set Assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 7, 2024, revealed that Resident B1 was moderately cognitively impaired with a BIMS score BIMS (Brief Interview for Mental Status) is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) of 10 required assistance from staff for activities of daily living.

A review of the resident's current plan of care initially dated April 24, 2023, did not include any reference to the presence of, or the care, for the resident's implantable pace maker.

During an interview on March 28, 2022, at 1 PM, the acting Director of nursing confirmed that the implantable cardiac pacemaker was not addressed on the resident's plan of care.



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








 Plan of Correction - To be completed: 04/19/2024

F 0656
1. Resident B1has had their care plan reviewed and it has been updated to reflect the presence of and care for the implantable pacer maker.
2. The DON/designee shall review residents with pacers to verify that the care plan reflects the presence and care for the implantable pacemaker.
3. The Licensed Nursing staff shall be educated by staff development coordinator / designee on development of comprehensive care plans to include goals and interventions for resident with implantable cardiac pacemakers. Don / Designee verified that current residents with pacemakers have a care plan to reflect the pacemaker use.
4. The DON /Designee will complete audits of any newly admitted resident or current resident with new pacemaker devices to ensure the plan of care includes pacemaker device. Audits will be conducted weekly for four weeks, then monthly for two months or until compliance is sustained. The DON/Designee shall review any concerns during the monthly QAPI meeting.
5. Date of compliance 4.19.2024

483.95(c)(1)-(3) REQUIREMENT Abuse, Neglect, and Exploitation Training: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.
483.95(c) Abuse, neglect, and exploitation.
In addition to the freedom from abuse, neglect, and exploitation requirements in 483.12, facilities must also provide training to their staff that at a minimum educates staff on-

483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at 483.12.

483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property

483.95(c)(3) Dementia management and resident abuse prevention.
Observations:

Based on staff interviews and a review of employee personnel records it was determined that the facility failed to provide abuse prevention training to one employee out of five reviewed. (Employee 2).

Findings include:

During an interview with Employee 2 (agency LPN) on March 28, 2024 at 9:45 a.m she stated that this was the first shift she worked at the facility. Employee 2 stated that she was never trained on the facility's abuse prohibition policy prior to assuming her duties today.

There was no documentation that Employee 2 was trained on the facility's abuse prohibition policies and procedures as part of staff orientation and training on the prohibition of all forms of abuse, neglect, and exploitation prohibition.

Interview with the Administrator on March 28, 2024 at 11:15 a.m., confirmed that the facility had no written records to show that Employee 2 was trained on the facility's policy and procedures on as part of staff orientation and training before assuming job duties.


28 Pa. Code 201.20 (b) Staff development

28 Pa. Code 201.19 (7) Personnel policies and procedures







 Plan of Correction - To be completed: 04/19/2024

F 0943
1. Employee # 2 was trained on facility abuse prevention policy that same day.
2. The HR Department shall verify that new staff shall be trained on the abuse policy prior to their assuming job duties.
3. The Staff Educator / designee shall review the abuse policy with new staff prior to start of shift to ensure compliance.
4. The HR director /designee shall complete an audit tool weekly x4 weeks then monthly x2. The audits shall be sent to the QAPI monthly meeting for a review of trends/issues.
5. Date of compliance 4.19.2024

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

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

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

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

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

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

Based on review of clinical records and select investigative reports and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice for one of nine sampled residents (Resident A1).

Findings include:

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties.

According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and Subsection 21.18. (a)(5) document and maintain accurate records.

According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.145. (a) The licensed practical nurse (LPN) is prepared to function as a member of a health-care team by exercising sound nursing judgement based on preparation, knowledge, skills, understanding and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place.

A review of Resident A1's clinical record revealed that the resident was admitted to the facility on September 21, 2023, with diagnoses which included morbid obesity.

A review of a facility incident report dated March 24, 2024, revealed that the resident had accused a staff member of calling her a "whore." Resident A1 notified facility nursing staff on March 26, 2024, that 2 nights prior, "a nurse aide had called her a "whore" as she was walking out of the room."

A review of the resident's clinical record revealed no documentation in the resident's clinical record regarding the resident's allegation of verbal abuse.

An interview with the Nursing Home Administrator on March 28, 2024, at approximately 2:45 PM confirmed that there was no documented evidence that the resident's allegation of verbal abuse was documented in the resident's clinical record.


28 Pa. Code 211.5 (f)(iii) Medical records.

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








 Plan of Correction - To be completed: 04/19/2024

F 0842
1. The facility cannot retroactively correct resident A1 record, resident has suffered no ill effects.
2. The facility has determined that all residents' records potentially could be effected.
3. The Licensed staff will be educated by the staff development coordinator/ designee on ensuring proper documentation is completed in the medical record according to Professional and Vocational Standards .
4. The DON/designee shall review the 24 hour report during the morning meeting and complete audits to identify current issues with the documentation. Audits will be completed weekly times four, monthly times two or until compliance is sustained. Issues or concerns with documentation shall be reviewed during the QAPI monthly meeting for compliance.
5. Date of Compliance Date of compliance 4.19.2024

483.35(g)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
483.35(g) Nurse Staffing Information.
483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.

483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.
Observations:

Based on observation and staff interview, it was determined that the facility failed to correctly post daily nursing time.

Findings include:

During an observation on March 28, 2024, at approximately 9:30 a.m. the facility's posted nursing time was observed in the lobby of the facility. The schedule was posted for the entire day at 9:30 a.m. for the next two shifts of nursing duty.

The nursing time was also posted in full time staff equivalents and not the total number of nursing staff members on duty and the actual hours worked by these nursing staff members

An interview with the interim NHA (nursing home administrator) on March 28, 2024, at the time of this observation confirmed that the nursing time is to be posted before each shift not for the entire day and should include total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift



28 Pa. Code 211.12 (c) Nursing services















 Plan of Correction - To be completed: 04/19/2024

F0732
1. The staff posting sheet has been updated and implemented to reflect the total number of nursing staff members on duty and the hours worked by these nursing staff members.
2. The facility cannot retroactively correct this issue.
3. The Nursing management team & supervisors will be educated by the staff development coordinator / designee on the new staffing sheets how to and the need to complete for the current shift.
4. The sheets shall be reviewed during the AM meeting by the staff schedule coordinator / designee to ensure the sheets are being completed as directed. Audits will be completed daily for seven days, weekly for four weeks, then monthly for two months or until compliance is sustained. The compliance with the process shall be reviewed during the monthly QA meeting.
5. Date of compliance 4.19.2024

211.10(a) LICENSURE Resident care policies.:State only Deficiency.
(a) Resident care policies shall be available to admitting physicians, sponsoring agencies, residents and the public and shall reflect an awareness of, and provision for, meeting the total medical, nursing, mental and psychosocial needs of residents.

Observations:

Based on observation and staff interview, it was determined that the facility failed to ensure that resident care policies were available to facility staff and other entities to meet the total needs of residents.

Findings include:

Observations during a tour of all resident units in the facility on March 28, 2024, between 9 A.M. and 9:30 AM revealed no resident care policies were available for reference on any of the resident units.

During an interview March 28, 2024 at 9 AM, Employee 1 (RN unit manager,Spruce) stated she was hired about three months ago. She stated that there were no resident care policies available on the unit for staff resource. She stated that if she needed a specific facility policy she would ask the RNAC (RN assessment coordinator, whose office was located in the administrative offices in the offices in the front of the building).

During an interview March 28, 2024 at approximately 9:45 AM, however, the facility's RNAC stated that she did not know where facility policies were located within the facility.

During an interview March 28, 2024 at 1 P.M., the interim Nursing Home Administrator verified that resident care policies were accessible to staff or other entities.



 Plan of Correction - To be completed: 04/19/2024

5350
1. Resident care policies were made available for staff
2. The facility has determined that all residents could potentially be affected.
3. The staff development educator/ designee educated licensed staff on the placement of the care policy binders and the included content.
4. The Medical Records Director/ Designee will conduct audits to ensure that that resident care policy binders remain in place for staff reference. Audits will be conducted weekly times four, then monthly times two or until compliance is sustained.
5. Date of compliance 4.19.2024

211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(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.
Observations:


Based on review of nursing time schedules and resident census and staff interviews, it was determined that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift, 1 LPN per 30 residents on the evening shifts, and one LPN per 40 residents on the night shift on two of 13 days (March 16, 2024 and March 27, 2024 ).

Findings include:

Review of facility census data indicated that on March 16, 2024, the facility census was 179, which required 4.77 LPNs during the night shift.

Review of the nursing time schedules and time punch card documentation revealed 4.27 LPNs provided care on the night shift on March 16, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 27, 2024, the facility census was 176, which required 4.69 LPNs during night shift.

Review of the nursing time schedules and time punch documentation revealed 4.27 LPNs worked the night shift on March 27, 2024. No additional excess higher-level staff were available to compensate this deficiency.


An interview March 28, 2024, at 1 PM the interim Nursing Home Administrator confirmed that the facility did not meet the minimum nursing staff ratios for LPNs on the above shifts.

















 Plan of Correction - To be completed: 04/19/2024

5530 (This was the facilities previously approved POC)
1. The facility cannot retroactively correct this issue. No residents were negatively affected.
2. The daily staffing sheet was reviewed to ensure that the minimum licensed practical nurse staff to resident ratio was met.
3. The Regional HR consultant/designee will educate the staff scheduler on reviewing daily staffing schedule to ensure minimum licensed practical nurse staff to resident ratio is being met.
4. NHA/DON / designee will review during daily staffing meeting the daily staffing schedules to ensure minimum licensed practical nurse staff to resident ratio are being met. The facility continues to hire open positions & prn staff, offer incentive for shifts picked up and continue to utilize agency to meet minimum licensed practical nurse staff to resident ratio. The staffing coordinator will update the NHA and DON on any staffing needs that arise throughout the day. During off shifts the nurse supervisor will address staff call off that arise and communicate any concern with the NHA/ DON.
5. Date of compliance 4.19.2024

211.15 LICENSURE Dental services.:State only Deficiency.
In addition to the requirements in 42 CFR 483.55 (relating to dental services), a facility shall make provisions to assure that resident dentures are retained by the resident. Dentures shall be marked for each resident.

Observations:

Based on observation and staff interview it was determined that the facility failed to assure that dentures were retained by the resident and marked for each resident.

Findings include:

An observation on March 28, 2024 at 9 AM revealed an unmarked denture cup containing a full set of upper and lower dentures (in solution/water) on the corner of the desk in the Spruce hallway RN unit manager's office. The denture cup was on top of piece of paper with "whose are these?" written on the paper.

During an interview at the time of the observation, Employee 1 (the Spruce hallway RN unit manager) stated that she did not work weekends and when she came into work on this past Monday (March 25, 2024) the unmarked dentures were on her desk. She stated that she did not know who left the dentures on her desk. She stated that on the last day she had worked, Friday March 22, 2024, the dentures were not on her desk.

Employee 1 (RN) stated the unit nurse aides had not informed her of any resident that was missing dentures. She stated that there was further action taken to identify the resident who may be missing dentures. She further stated, during interview at that time, that she was unaware of any established facility policy or protocols for the storage and maintenance of resident dentures.






 Plan of Correction - To be completed: 04/19/2024

5710
1. Facility has made an effort to identify the owner of the found dentures.
2. The facility has determined that all residents who have dentures have the potential to be affected.
3. The staff development coordinator educated all licensed staff on the facility policy for denture care, which includes the labeling of resident dentures. An audit of all residents who have dentures was completed to ensure that their dentures are placed in denture cups with resident's name when not in use.
4. Social service director/ designee will complete random weekly audits of residents who have dentures to assure resident has their dentures and that dentures are placed when not in use in a labeled denture cup.
5. Date of Compliance 4.19.2024


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