Nursing Investigation Results -

Pennsylvania Department of Health
JUNIPER VILLAGE AT BROOKLINE-REHABILITATION AND SKILLED CARE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
JUNIPER VILLAGE AT BROOKLINE-REHABILITATION AND SKILLED CARE
Inspection Results For:

There are  54 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
JUNIPER VILLAGE AT BROOKLINE-REHABILITATION AND SKILLED CARE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey, completed on January 10, 2020, it was determined that Juniper Village at Brookline-Rehabilitation and Skilled Care was not in 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(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.12(b) The facility must develop and implement written policies and procedures that:

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

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

483.12(b)(3) Include training as required at paragraph 483.95,
Observations:

Based on facility documentation, clinical record review, select facility policy review, and staff interview, it was determined that the facility failed to obtain proper attestations of Pennsylvania residency for four of five newly hired employees (Employee 1, 2, 3, and 4) and failed to thoroughly investigate injuries of unknown origin for 3 of 17 residents reviewed (Residents 35, 19, and 45).

Findings include:

The policy entitled "Pre-Employment Criminal Background Check-PA (Pennsylvania) Addendum," last reviewed on January 7, 2020 without changes, indicates that if an applicant/employee has not been a resident of the Commonwealth of Pennsylvania for two years without interruption immediately preceding the date of application for employment or currently lives out of state, the facility will obtain an FBI (Federal Bureau of Investigation) criminal history check.

Review of Employee 1's, registered nurse, personnel file revealed that the facility hired her on October 30, 2019. Employee 1 indicated that she lived in Pennsylvania from 2015 until 2018. There was no documented evidence in Employee 1's personnel file that she attested to living in the state of PA for a continuous two years prior to employment. There was no evidence that the facility obtained an FBI criminal history check for Employee 1.

Review of Employee 2's, registered nurse, personnel file revealed that the facility hired her on September 9, 2019. Employee 2 only documented the months she lived in PA, not indicating a continuous two-year residency. There was no documented evidence in Employee 2's personnel file to indicate that she attested to living in the state of PA for a continuous two years prior to employment. There was no evidence that the facility obtained an FBI criminal history check for Employee 2.

Review of Employee 3's, licensed practical nurse, personnel file revealed that the facility hired her on November 18, 2019. Employee 3 only documented the months she lived in PA, not indicating a continuous two-year residency. There was no documented evidence in Employee 3's personnel file to indicate that she attested to living in the state of PA for a continuous two years prior to employment. There was no evidence that the facility obtained an FBI criminal history check for Employee 3.

Review of Employee 4's, nurse aide, personnel file revealed that the facility hired him on December 4, 2019. Employee 4 only documented the months he lived in PA, not indicating a continuous two-year residency. There was no documented evidence in Employee 4's personnel file to indicate that he attested to living in the state of PA for a continuous two years prior to employment. There was no evidence that the facility obtained an FBI criminal history check for Employee 4.

Interview with the Administrator on January 10, 2020, at 9:18 AM confirmed the above findings for Employees 1, 2, 3, and 4, and confirmed that the facility did not obtain an FBI criminal history check on any of the noted employees.

The policy entitled "Abuse," last reviewed on January 7, 2020 without changes revealed through implementation of the training and prevention processes, all associates, residents, and families will be aware of how to identify and report incidents of abuse, or suspected abuse. Associates will identify events, such as suspicious bruising of resident occurrences, patterns and trends that may constitute abuse.

Clinical record review for Resident 35 revealed nursing documentation dated January 6, 2020, that indicated the nurse aide told the licensed practical nurse that Resident 35 had a 4 centimeter (cm) bruise on her inner left thigh. Resident 35 was "unaware of what might have caused bruise, or how long it had been there." Review of the Post Incident/Accident Investigation confirmed Resident 35 is not on any anticoagulant medications. Further review of the facility investigation notes dated January 7, 2020, revealed "a review of available records does not indicate anything suspicious at this time. Active investigation is ongoing, and interventions are needed as soon as possible."

Nursing documentation dated December 19, 2019, indicated the registered nurse was made aware by nursing staff that Resident 35 had a new bruise on her right side measuring 10 by 4 cm. Resident 35's stepdaughter was notified, and she stated, "there have been multiple bruises lately." The resident was unable to give a description of what happened. Review of the Post Incident/Accident Investigation confirmed Resident 35 is not on any anticoagulant medications.

Nursing documentation dated December 15, 2019, indicated the nurse aide notified the licensed practical nurse concerning a bruise on Resident 35's breast. Due to Resident 35's cognitive impairment, she was unable to articulate what happened.

Interview with the Director of Nursing on January 10, 2020, at 12:22 PM confirmed the facility did not identify and interview all involved persons, including witnesses, and others who might have knowledge of the allegations to rule out abuse and/or attempt to determine the cause of Resident 35's injuries of unknown origin.

Clinical record review for Resident 19 revealed nursing documentation dated December 27, 2019, that indicated Resident 19 had multiple bruises and a skin tear on his left arm. Resident 19's left upper arm bruise measured 5 by 1.3 cm, left elbow bruise measured 4.5 by 2.5 cm. Resident 19 stated he was not sure what happened. Review of the Post Incident/Accident Investigation confirmed Resident 19 is not on any anticoagulant medications. Further review of the facility investigation notes dated December 27, 2019 revealed "a review of available records does not indicate anything suspect. Additional investigation is appropriate and warranted."

Interview with the Director of Nursing on January 10, 2020, at 12:22 PM confirmed the facility did not identify and interview all involved persons, including witnesses, and others who might have knowledge of the allegations to rule out abuse and/or attempt to determine the cause of Resident 19's injuries of unknown origin.

Review of facility documentation for Resident 45 dated April 9, 2019, revealed that she had two bruises on her right lower arm. The resident was confused and could not state how this happened. One bruise was dark purple in color and measured 4 cm by 4.5 cm along with a smaller bruise below it, which measured 2 cm by 1.5 cm. The resident was transferred with a mechanical lift and was totally dependent for care and mobility. The writer of the report indicated that equipment was a predisposing environmental factor. Review of this report revealed the resident is not on any anticoagulant medicine and that abuse, and neglect was ruled out. The summary of findings indicated that the investigation continued. The facility's investigation revealed that statements were obtained from two nurse aides who both said they did not provide care to the resident on the days leading up to the bruises.

Additional review of facility documentation for Resident 45 dated May 9, 2019, revealed that the resident had a bruise that measured 7.5 cm by 7 cm to the right, bottom of her foot just below the great toe, and a bruise that measured 4 cm by 4 cm just below her inner left heel. The writer of the report indicated the predisposing environmental factor was "other" and did not specify what that was. The resident had an x-ray done of the foot, which was negative for fracture. The facility's investigation revealed that a statement was obtained from one nurse aide who was not involved in transferring the resident with a mechanical lift. The facility identified the possible cause of the bruising to be that the resident's foot may have been pinched at the footrest in her chair.

Additional review of facility documentation for Resident 45 dated December 13, 2019, revealed the resident had a purple bruise that measured 2 cm by 3 cm on her left upper arm. The facility did not provide any statements from staff members as to the possible cause. The summary of findings indicated the resident was not able to state what happened.

Interview with the Director of Nursing on January 10, 2020, at 12:45 PM confirmed the facility did not identify and interview all involved persons, including witnesses, and others who might have knowledge of the allegations to rule out abuse and/or attempt to determine the cause or suspected cause of Resident 45's injuries of unknown origin.

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

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


 Plan of Correction - To be completed: 03/01/2020

Upon interview of Employee 1, 2, 3, and 4, all employees confirmed Pennsylvania residency for a minimum of two continuous years prior to hire date at facility. All employee files of new hires in 2020 were reviewed and proper attestations of Pennsylvania residency were completed. All new hires will now complete proper attestation of Pennsylvania residency of two continuous years prior to employment or obtain a FBI criminal history check if employee has not lived in Pennsylvania for two continuous years prior to employment. Monthly audits will occur of personal files of new employees for compliance of proper new-hire paperwork and results will be presented at monthly QAPI meeting. The director of human resources or designee will be response for this process.
Residents 35, 19, 45 have not had further bruises of unknown origin. Upon report of an event, the RN on duty will begin the investigation of the causation to include interviews of all involved site staff through a written investigation tool and verbal discussion. Investigations will be reviewed through the weekly Risk/Event interdisciplinary committee team. Review will include written statements from those providing direct care to the resident for the previous 48 hours from the report of the event of unknown origin. Findings will be documented within the Event Report and eMAR with causation and follow up on investigations. All events will be evaluated for cause and to rule about abuse and neglect. Education to all employees on "Preventing, Recognizing, and Reporting Abuse" and for all RN's "Conducting an Abuse Investigation" via Relias, our internal electronic education platform, have been assigned with completion deadline of 2/7/2020. QAPI RN will audit monthly a 50% sample of all events for three consecutive months or until 100% compliance is maintained for two consecutive months. The audit will include the presence of witness statements, documentation of outcome of the investigation, ruling out of abuse and neglect or action taken if abuse or neglect was suspected. Results of the audits will be presented at weekly Risk Committee meeting and monthly QAPI meeting with additional education provided for audits below the acceptable 100% benchmark. The QAPI RN or designee will be responsible for this process.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(i) Food safety requirements.
The facility must -

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

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







Based on observation and staff interview, it was determined that the facility failed to store and distribute food in accordance with professional standards for food service safety in the facility's main kitchen and on one of two pantries (second floor).

Findings include:

An observation in the facility's main kitchen with Employee 5, dietary manager, on January 7, 2020, at 9:40 AM revealed the following:

The air vent in the wall leading to the kitchen and directly across from the dietary manager's office was filled with a build-up of greasy dirt.

The gas stove contained a build-up of greasy dust on the back of the stove and around the on-off knobs.

The floor drain that extended from under the gas stove to the oil fryer contained chunks of food. Concurrent interview with Employee 5 revealed this drain is cleaned with a hose monthly.

The walls behind the cold food preparation area had dried food splatter.

A container of oil was on the floor under the oil fryer.

Two carafes were under the sink.

There were no expiration dates on the bins containing flour and sugar. Hotdogs in the reach-in cooler were not labeled with an expiration date.

A tiered wire shelf had fabric on the bottom of the racks and was located near the tray line. Serving dishes and bowls were stored upright on the racks. Food crumbs were on the fabric covering the wired racks. The dishes and bowls had dried stains and a few dried-on food splatters. Concurrent interview with Employee 5 revealed the dishes and bowls went through the dishwasher and the stains were from water. The dishes and bowls were not protected from splatter.

The food preparation area near the sink was dusty and greasy.

Observation of the second-floor dining room on January 7, 2020, at 12:36 PM revealed Employee 6, licensed practical nurse, was serving Resident 14 her meal. Employee 6 opened a packet of mayonnaise and picked up a croissant with her bare hands to assist the resident.

The surveyor reviewed the above findings for the main kitchen and second-floor dining observation with the Nursing Home Administrator and Director of Nursing on January 8, 2020, at 2:15 PM.

Observation with Employee 5 on January 10, 2020, at 12:30 PM of the second-floor dining area revealed two open loaves of bread. One was dated with the use by date of December 25, 2019, and the other was dated with a use by date of January 9, 2020. Concurrent observation of the refrigerator in the pantry revealed a blue lidded plastic container of food and two small plastic Kentucky Fried Chicken containers that were not labeled with resident's names or use by dates.

The surveyor reviewed the above findings regarding the second-floor dining area and pantry with the Nursing Home Administrator on January 10, 2020, at 12:45 PM.

42 CFR 483.60(i) (1)-(3) Food Procurement, Store/Prepare/Serve-Sanitary

Previously cited 2/13/19

28 Pa. Code 211.6 (c) Dietary services

Previously cited 2/13/19


 Plan of Correction - To be completed: 03/01/2020

All improperly labeled foods were discarded at the time of the survey with exception of flour and sugar as they were dated based on delivery date, as flour and sugar are placed in clean vessels when arrived from shipping. All areas identified of need for cleaning: air vent, gas stove and knobs, floor drain, and walls were cleaned prior to end of survey and carafes were removed. All serving dishes and bowls that were stored on a tiered wire shelf have been moved to covered bins. The large walk-in cooler is being inspected daily to ensure food is labeled appropriately, pantry refrigerators on the nursing units are also being inspected daily. Dining services staff will be educated on appropriate food storage and labeling, proper routine cleaning of the kitchen including floor drains, by 2/7/2020. All wellness associates will be educated on proper food handling during meals by 2/7/2020. Observation will occur of five meals a week for a period of one week, four meals a week for a period of one week, three meals a week for a period of one week, two meals a week for a period of two weeks and one meal a week for a period of three weeks to ensure proper food handling is maintained during meal service. An audit of walk-in cooler and pantry refrigerators on the nursing units to ensure proper labeling and storage will be completed five times a week for a period of twelve weeks. Daily and weekly cleaning schedules have been updated to include areas identified in deficiency. Results of the dining observation and audits will be presented at monthly QAPI meeting. The administrator or designee will oversee this process.
483.25(n)(1)-(4) REQUIREMENT Bedrails:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.
Observations:







Based on observation, clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to complete assessments, consents, and education for the use of side rails for two of two residents reviewed (Residents 28 and 31).

Findings include:

The policy entitled "Proper use of Side Rails," last reviewed without changes on January 7, 2020, indicates that the facility will complete an assessment to determine the reason for using side rails. Informed consent for the side rail will be obtained from the resident or legal representative. Potential negative outcomes and benefits will be discussed.

Observation of Resident 28 on January 8, 2020, at 11:10 AM revealed he was lying in bed with bilateral enabler bars in the elevated position.

There was no documented evidence in Resident 28's clinical record to indicate that the facility completed a thorough entrapment risk assessment, obtained a consent for use, or that the risks and benefits of side rail use were reviewed with Resident 28.

Observation of Resident 31 on January 8, 2020, at 10:48 AM revealed that her bilateral enabler bars were in the elevated position. Resident 31 indicated that she uses them to help her move around in the bed.

There was no documented evidence in Resident 31's clinical record to indicate that the facility completed a thorough entrapment risk assessment, obtained a consent for use, or that the risks and benefits of side rail use were reviewed with Resident 31.

Interview with the Administrator on January 9, 2020, at 9:30 AM, confirmed the above findings for Resident 28 and 31.

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

Previously cited 2/13/19


 Plan of Correction - To be completed: 03/01/2020

Resident 28 and 31 were not harmed in this deficient practice. Resident 28 and 31 were assessed to ensure enabler rails are still warranted. Upon admission, all residents will be screened for potential issues related to mobility during the initial Physical Therapy Evaluation, and quarterly thereafter. Quarterly assessments will be done to develop an individualized plan of care, ensuring the residents mobility and alternatives for mobility enabling are implemented. Physical Therapy will assess each resident for the risk of entrapment prior to enabler bar placement. Physical Therapy will provide a wrote copy of the Proper Use of Side Rails Policy, obtain signed informed consent prior to installation of enabler bars, and will educate the resident or responsible party on the risk and benefits of the siderails. All current residents will have an assessment by 2/7/2020 to ensure the above requirements are met and the need for enabler bars is still warranted. All current residents will receive a written policy and have a consent signed. QAPI RN will audit a 10% sample of all residents with enabler bars monthly for three consecutive months or until 100% compliance with regulation is met for two consecutive months. Results of audits will be presented at monthly QAPI meeting. The QAPI RN or designee will be responsible for this process.
483.25(k) REQUIREMENT Pain Management:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:







Based on review of select facility policies, clinical record review, and staff and family interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications and pain management for one of one resident reviewed (Resident 264).

Findings include:

The facility policy entitled, "Pain Management," last reviewed on January 7, 2020, revealed that each resident who experiences pain or discomfort shall receive care to manage the pain or discomfort. The level of the resident's pain level will be determined and documented. Residents experiencing unrelieved pain will have follow-up with the physician.

The policy did not address "as needed" (PRN) pain medications and how they are administered according to physician orders following the pain scale parameters.

Clinical record review of Resident 264's diagnostic profile revealed that the resident had malignant (spreading cancer) pancreatic (pancreas, a gland located behind the stomach and in front of the spine) cancer.

Interview with a family member of Resident 264 on January 7, 2020, at 12:18 PM revealed that there was a breakdown with pain medications between shifts and that the resident did not have enough pain medication the first night of admission.

Clinical record review of Resident 264's physician orders revealed the following PRN medications for pain on January 2 and 3, 2020:

Acetaminophen Tablet 325 mg (milligram), administer two tablets by mouth every four hours PRN mild pain or temperature greater than 100 degrees Fahrenheit

Oxycodone (narcotic medication for moderate to severe pain) 5 mg tablet by mouth every four hours as need for pain related to malignant neoplasm (cancer growth) of pancreas

Morphine Sulfate Solution (narcotic medication for severe pain) 20 milligrams/milliliter (mg/ml), administer 5 mg/ 0.25 ml every two hours by mouth as needed for pain

Nursing documentation for Resident 264 dated January 2, 2020, at 9:58 PM revealed the resident was admitted to the facility at 5:00 PM. The resident arrived with a Fentanyl Patch (a narcotic pain medication absorbed through the skin from over a period of 72 hours). The resident complained of pain of a 10 out of 10 (pain scale of zero is no pain, pain scale of 10 is severe pain). The pain was treated with acetaminophen and roxanol (morphine sulfate solution).

Review of Resident 264's MAR (Medication administration record) for January 2, 2020 revealed that PRN Morphine Sulfate Solution, 5mg/0.25 ml by mouth was administered at 8:45 PM for a pain level of 10 and it was effective for pain relief.

Review of Resident 264's MAR for January 3, 2020, revealed that PRN Oxycodone 5 mg was administered at 8:15 AM for a pain level of 10. This was documented as ineffective pain relief. Staff administered PRN Morphine Sulfate 5mg/0.25 ml at 9:49 AM for a pain level of eight, which was documented as effective. There was no documentation to indicate that a PRN pain medication was attempted prior to the pain level going to a level of 10 at 8:15 AM. There were no parameters listed in the physician orders indicating when to administer the Morphine Sulfate versus the Oxycodone.

The surveyor reviewed the above findings with the Director of Nursing for Resident 264 on January 9, 2020, at 11:00 AM.

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

28 Pa. Code 211.10(d) Resident care policies

Previously cited 2/3/19

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

Previously cited 2/3/19


 Plan of Correction - To be completed: 03/01/2020

Resident 264 did not have additional harm based on this deficient practice. All resident charts will be reviewed to ensure the correct directions for administration of analgesic orders are in place by 2/7/2020. Those residents with pain management orders will have clear delineation between mild (1-3), moderate (4-6), and severe (7-10) types of pain. Inservice will be conducted with all Licensed RN's and LPN's by 2/7/2020 on the use of a PAINAD/Wong-Baker Pain Evaluation Tool for those residents who are unable to verbalize discomfort. Education to all Licensed RN's and LPN'S on "Pain Assessment and Management" via Relias, internal electronic education platform, will be completed by 2/7/2020. QAPI RN will audit 10% sample of all residents on analgesics monthly for three consecutive months or until 100% compliance with regulation is met for two consecutive months. Results of audits will be presented at monthly QAPI meeting. QAPI RN or designee will be responsible for this process.
483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:

Based on clinical record review, observations, and staff and resident interview, it was determined that the facility failed to develop and implement a comprehensive individualized care plan for one of 21 residents reviewed (Resident 2) .

Findings include:

Interview with Resident 2 on January 7, 2020, at 11:32 AM revealed the resident had a pacemaker (a small device placed in chest to help control abnormal heart rhythm) and the resident did not know when it was checked last.

Clinical record review of Resident 2's nursing progress notes revealed the last pacemaker check was completed on December 12, 2019.

Clinical record review of Resident 2's treatment administration record dated March 2019, revealed the pace maker check was not completed on March 8, 2019, when it was due every 90 days.

Clinical record review of Resident 2's physician orders and care plan revealed there were no recent orders to check the pacemaker or an individualized care plan addressing the care of a resident with a pacemaker.

The surveyor reviewed the above findings for Resident 2 during an interview with the Nursing Home Administrator and Director of Nursing on January 8, 2020, at 2:15 PM.

483.21(b)(1) Develop/Implement Comprehensive Care Plan
Previously cited 2/13/19

28 Pa. Code 211.11(c)(d) Resident care plan

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 2/13/19


 Plan of Correction - To be completed: 03/01/2020

Resident 2 was not harmed based on this deficient practice. Resident 2 care plan has been updated to reflect current plan of care. All residents with new orders, new diagnosis, or new care plan needs will be implemented according to the regulatory development of an individualized comprehensive care plan. Orders indicate a reason/diagnosis for each order. Orders received will have the order care planned in accordance with the regulation by the nurse taking off the order or admitting the resident. An order listing report from the HER will be run nightly by the RN on duty and compared with the orders to ensure each order has a corresponding care plan. The QAPI RN will conduct an audit weekly, alternating days of the week to include checking twenty orders per week to ensure the order is care planned in accordance to the comprehensive care plan development. The QAPI RN will continue to audit until 12 consecutive weeks of 100% compliance is met. Results of audits will be presented at monthly QAPI meeting. The QAPI RN or designee will be responsible for this process.
483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(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 family and staff interviews, it was determined that the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase and/or prevent further decrease in range of motion for one of four residents sampled with range of motion concerns (Resident 8).

Findings include:

The facility did not have a policy addressing how a resident with range of motion concerns gets appropriate treatment and services initiated.

Interview with Resident 8's family on January 7, 2020, at 12:55 PM revealed that he is concerned that Resident 8 is not receiving services addressing her limited range of motion.

Clinical record review for Resident 8 revealed the facility admitted her October 1, 2019. Review of Resident 8's admission Minimum Data Set (MDS, an assessment tool completed at specific intervals to determine care needs) dated October 17, 2019 revealed staff assessed her as having impairment on both sides for her upper and lower extremities.

There was no documentation that the facility assessed or implemented any treatment or services to address Resident 8's identified upper extremity limitation. The facility did not address Resident 8's lower extremity limitation until December 5, 2019 when they implemented a passive range of motion program (two months after admission).

The surveyor reviewed the above findings for Resident 8 during an interview with the Director of Nursing on January 10, 2020, at 12:51 PM. She confirmed there was no evidence the facility assessed and implemented appropriate treatment and services to increase and/or prevent further decrease in range of motion timely for Resident 8.

483.25(c)(1)(2)(3) Increase/Prevent Decrease in ROM/Mobility
Previously cited 2/13/19

28 Pa. Code 211.12(d)(1)(3)(5)Nursing services
Previously cited 2/13/19


 Plan of Correction - To be completed: 03/01/2020

Resident 8 has not had any additional harm based on these deficient practices. For Resident 8, the facility has initiated passive range of motion exercises to her upper extremities. Upon move in, all residents will be screened for range of month during the initial Physical Therapy Evaluation and at a minimum quarterly thereafter, to ensure an individualized plan of care is developed to address limited mobility for each resident. Physical Therapy will assess and implement a plan of care to ensure that those with limited range of month receive appropriate services, equipment, and assistance to maintain or improve their limited range of month. All current residents will have a ROM/Mobility assessment by 2/7/2020 to ensure the above requirements are met. Individualized plans of care will be implemented as needed. QAPI RN will audit 10% sample of all admissions monthly and current residents for three consecutive months or until 100% compliance is met for two consecutive months. Results of audits will be presented at monthly QAPI meeting. QAPI RN or designee will be responsible for this process.
483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(d) Food and drink
Each resident receives and the facility provides-

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

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







Based on observation, staff interview, and review of select policy and procedures, it was determined that the facility failed to ensure food was served at a safe temperature for one of one resident observed (Resident 114).

Findings include:

The facility policy entitled "Microwave Safety," last reviewed without changes on January 7, 2020, revealed that staff is to cover food with a lid or plastic wrap when possible, reheat or cook all foods to 165 degrees Fahrenheit, check food with a probe thermometer, and always allow a standing time of at least three minutes before serving.

Observation of the second floor dining room on January 7, 2020, at 12:37 PM revealed Employee 7 (nurse aide) took Resident 114's plate of mashed potatoes and placed them uncovered into the microwave oven and turned it on.

When the microwave oven bell rang, Employee 7 took the plate of mashed potatoes back to the table and proceeded to feed Resident 114 a bite of the potatoes.

An interview with Employee 7 at the time of this observation revealed that he only checks the temperature of liquids when he places resident food in the microwave. When the surveyor asked Employee 7 how he knows whether the food temperature is too hot he responded, "I give them a bite and then ask them."

An interview with the Nursing Home Administrator on January 8, 2020, at 2:30 PM revealed that staff is to always cover a resident's food prior to placing it in the microwave oven, stir the food, and check the temperature prior to feeding it to the resident.

28 Pa. Code 211.6(c) Dietary services

Previously cited 2/13/19


 Plan of Correction - To be completed: 03/01/2020

Resident 114 was not harmed in this deficient practice. All nursing staff will be re-educated on the "Microwave Safety" facility policy and how to handle food that is not at desired temperature for the resident being served. Observation will occur of five meals a week for a period of one week, four meals a week for a period of one week, three meals a week for a period of one week, two meals a week for a period of two weeks and one meal a week for a period of three weeks to ensure the "Microwave Safety" policy is being followed to ensure proper heating of resident food. Results of observation will be presented at monthly QAPI meeting. The administrator or designee will over this process.

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