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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 68 surveys for this facility. Please select a date to view the survey results.

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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 May 16, 2024, 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:

483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities:

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.

§483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

§483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

§483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

§483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

§483.24(b)(2) Mobility-transfer and ambulation, including walking,

§483.24(b)(3) Elimination-toileting,

§483.24(b)(4) Dining-eating, including meals and snacks,

§483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.

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

- Residents 34 and 36 were not harmed based on this deficient practice. Therapy evaluation completed for both residents to evaluate ambulation status, follow up based on findings.

- Director of Wellness or Designee will conduct initial Quality Improvement (QI) monitoring of the documentation of residents with current orders for restorative nursing programs to ensure programs being completed as ordered, follow up based on findings.

- The Director of Wellness will reeducate the Restorative Nursing Department on documentation and completion of restorative programs as ordered.

- Director of Wellness or Designee will conduct Quality Improvement (QI) monitoring of the documentation of residents with current orders for restorative nursing programs to ensure programs are being completed as ordered weekly x4, then monthly x 2. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI)

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§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 the facility failed to store food and maintain food service equipment in a safe and sanitary manner in the facility's main kitchen.

Findings include:

An observation of the facility's main kitchen on May 13, 2024, at 10:40 AM revealed the following:

The dish machine and several black utility carts in the dish machine area were observed with white buildup. Food service staff working in the area indicated there is a problem with limescale buildup from the water and they have water softeners that seem to sometimes be working and sometimes not. The staff members also indicated they use a limescale remover in the dish machine itself once a week, but the problem remains.

A ceiling light cover in the dish room area was covered with dried food/liquid splatter.

A large stack of resident meal serving trays was observed on a cart in the dish washing area that food service staff just completed washing. The plastic trays were significantly discolored and stained and contained cracks, broken edges, and pieces of plastic that were worn/broken off on the bottoms of the tray surfaces.

A large industrial floor mixer was observed not in use and uncovered. Dust and debris were observed on the interior of the mixing bowl.

A panini press on a preparation counter in the corner of the kitchen contained buildup of dried food. The white tile wall surrounding the area where the panini press was located was covered in dried orange and brown food splatter.

The lower shelf of a preparation table under the pot/pan storage area where plastic bins and equipment were stored was covered in dust and debris.

A tan foot pedal garbage can located next to the pot/pan storage area was observed with dried brown liquid runs and dried food on the exterior of the can.

The lower shelf liners in the dry storage area where multiple food products were stored had a buildup of dust and debris.

The flooring under shelving units that surrounded the perimeter of both the walk-in cooler and walk-in freezer was observed with food debris.

A soiled glove, coffee filter, and dried food was observed under the ice machine.

The above information was reviewed with the Nursing Home Administrator and Director of Nursing on May 14, 2024, at 1:30 PM.

28 Pa. Code 201.14 (a) Responsibility of licensee

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

- The Environmental Services Director will place a service call to the water softener contractor and Dish Machine contractor, follow up based on findings.

- Areas where sanitation/cleanliness identified were corrected. Resident meal serving trays that were discolored stained or cracked were discarded and replaced with new meal serving trays.

- Director of Dining Services will conduct initial Quality Improvement (QI) monitoring of main kitchen to ensure food is stored, prepared, distributed and served in accordance with professional standards for food service safety, follow up based on findings.

- The Nursing Home Administrator or Designee will reeducate the Dining Department on professional standards for food service safety and sanitation of the department.

- Nursing Home Administrator or Designee will conduct Quality Improvement (QI) monitoring of main kitchen to ensure food is stored, prepared, distributed and served in accordance with professional standards for food service safety weekly x4, then monthly x 2. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI)

483.20(g) REQUIREMENT Accuracy of Assessments:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for one of 14 residents reviewed (Resident 21).

Findings include:

Review of Resident 21's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated December 21, 2023, and March 18, 2024, that indicated the facility assessed her with an active pneumonia infection. Resident 21 had not had an active pneumonia infection since October 1, 2023.

Documentation provided by the facility on May 15, 2024, at 9:00 AM confirmed the above MDS errors for Resident 21. Interview with the Administrator and Director of Nursing on May 15, 2024, at 1:00 PM confirmed the above findings.

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

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

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

- MDS errors for Resident 21 corrected.

- The Registered Nurse Assessment Coordinator will conduct initial quality Improvement (QI) monitoring of prior 90 days of MDS Assessments to ensure assessments are complete and accurate.

- The Director of Wellness or designee will reeducate the Registered Nurse Assessment Coordinator and Licensed Practical Nurse Assessment Coordinator on Accuracy of MDS assessments specifically coding for section I.

- The Director of Wellness or Designee will conduct Quality Improvement (QI) monitoring 20% of residents MDS Assessments weekly x4, then monthly x 2. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI)

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding integrated hospice care and services for one of two residents reviewed for Hospice (Resident 10).

Findings include:

Clinical record review for Resident 10 revealed that on August 9, 2023, she was admitted to Hospice related to a terminal diagnosis of sequelae of other cerebrovascular disease (complications that can develop after a stroke or other damage to the blood vessels in the brain).

Review of Resident 10's current care plan revealed that the facility failed to implement an integrated plan of care with hospice services. The plan of care did not include evidence of all services that hospice will provide for the management of Resident 10's terminal illness.

Resident 10's current care plan failed to identify the hospice entity providing services, the hospice disciplines that would provide her care and services, and how often.

The findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on May 15, 2024, at 2:05 PM. An interview with Employee 1 (social services) on May 16, 2024, at 10:50 AM confirmed the facility had no further documentation related to Resident 10's hospice services and plan of care.

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services

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

- Integrated hospice care and services care plan developed and implemented for Resident 10.

- Social Service Director or Designee will conduct Initial Quality Improvement (QI) monitoring of residents receiving hospice services to ensure that an integrated plan of care for hospice services to address care and services provided has been developed and implemented, follow up based on findings.

- The Nursing Home Administrator will reeducate the Hospice providers, Social Service Department and MDS Department on hospice integrated plan of care to provide the highest practicable level of care.

- Nursing Home Administrator or Designee will conduct Quality Improvement (QI) monitoring of residents receiving hospice services to ensure that an integrated plan of care for hospice services to address care and services provided has been developed and implemented weekly x4, then monthly x 2. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI)

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

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

Observations:

Based on clinical record review and resident and staff interview, it was determined that that facility failed to address or implement consultant service recommendations to aid in healing skin break down and prevent pressure ulcers in one of five residents reviewed for altered skin conditions (Resident 36).

Findings include:

In an interview with Resident 36, on May 13, 2024, at 11:54 AM the resident was observed lying in bed. Resident 36 stated she had an open area on her buttocks, and it hurts. The resident stated staff do put some cream on it.

Clinical record review for Resident 36 revealed a skin evaluation completed by facility staff on April 9, 2024. Resident 36 was assessed as having an altered skin area on her left buttocks 0.8 cm (centimeters) in length and 0.8 cm in width and an area on her right buttocks 2.5 cm by 0.5 cm. Both areas were noted as moisture associated skin damage.

Further clinical record review for Resident 36 revealed the resident was also seen by the facility's contracted wound specialists on April 9, 2024, who noted the same areas as moisture associated skin damage (MASD) and included a treatment plan, which included recommendations of a Multivitamin once daily and Vitamin C 500 mg (milligrams) twice daily for the resident's plan of care.

Resident 36 continued to be followed by the wound specialist weekly on April 16, 23, 30, May 7, and 14, 2024, at the time of review.

The wound specialist report dated April 16, 2024, noted the area of Resident 36's areas of MASD on the left and right buttocks and continued to recommend the Multivitamin and Vitamin C as noted above as part of the treatment plan.

The wound specialist report dated April 23, 2024, noted the MASD area on the resident's left buttocks was now 1.5 cm x 1.0 cm and area on the right buttocks was now 3.1 cm x 2.0 cm. The report noted the exacerbation of the areas due to generalized decline and the resident being non-compliant with wound care. Part of the treatment plan continued to recommend the addition of the Multivitamin and Vitamin C.

The wound specialist report dated April 30, 2024, noted continued exacerbation of the left buttocks area due to decline of the resident, nutritional compromise, and resident non-compliance. The treatment plan continued to note the recommendation of the Multivitamin and Vitamin C.

The wound specialist report dated May 7, 2024, noted some improvement of the area on the resident's left buttocks, and right buttocks. Recommendations continued to be listed for the resident for Multivitamin and Vitamin C.

The wound specialist report dated May 14, 2024, the last report available for review, noted the left buttocks area as 4.5 cm x 1.4 cm with some improvement, the right buttock area was noted as 5.0 x 2.5 x 0.1 and required debridement during the visit. The wound specialist continued to recommend a Multivitamin once daily and Vitamin C 500 mg twice daily continued.

Upon review of Resident 36's clinical record there was no evidence the resident was ordered a Multivitamin or Vitamin C at any time since the April 9, 2024, wound specialist visit or subsequent visits when they continued to be recommended. There was no evidence that the recommendation was addressed with the resident's primary care physician as to whether the physician wished to implement the Multivitamin or Vitamin C or decline them.

In an interview with the Director of Nursing on May 16, 2024, at 12:15 PM it was confirmed Resident 36 was never ordered any Multivitamin or Vitamin C per the recommendations by the wound specialist as noted, nor was there any evidence the recommendations were addressed by the resident's primary physician.

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

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

28 Pa. Code 211.12(d)(1)(3)(5) Nursing care services

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

- Resident 36 was not harmed based on this deficient practice. Attending physician reviewed wound specialist recommendations for resident, follow up based on findings.

- Director of Wellness or Designee will conduct initial Quality Improvement (QI) monitoring of current residents wound specialist recommendations to ensure recommendations are addressed or implemented to aid in healing skin breakdown and prevent pressure ulcers, follow up based on findings.

- The Director of Wellness will reeducate the Licensed Nursing Department along with the Attending Physician and Wound Specialist on addressing or implementing recommendations to aid in healing skin breakdown and prevent pressure ulcers.

- Director of Wellness or Designee will conduct Quality Improvement (QI) monitoring wound specialist recommendations to ensure timely follow up weekly x4, then monthly x 2. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI)

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

§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to implement a restorative nursing program as recommended by therapy to maintain range of motion for two of five residents reviewed (Residents 21 and 32).

Findings include:

Review of Resident 21's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated December 21, 2023, indicating that the facility assessed Resident 21 as having range of motion limitations to one side of her lower extremities. A previous MDS assessment dated October 12, 2023, indicated that the facility assessed Resident 21 as having no range of motion limitations to her lower extremities.

A physical therapy form entitled "Restorative Nursing Program," dated December 19, 2023, indicated that physical therapy was implementing an ambulation program for Resident 21 to ambulate 40 to 80 feet in the hallway three to five times a week with the goal of maintaining her lower extremity strength.

Review of documentation dated February 2024, March 2024, and April 2024, revealed that Resident 21 was only provided the restorative nursing ambulation three times in February 2024, four times in March 2024, and one time in April 2024. There was no documented evidence to indicate that the facility was providing the restorative nursing ambulation program per therapy recommendations.

Review of a physical therapy form entitled "Restorative Nursing Program," dated May 7, 2024, indicated that physical therapy was implementing a range of motion program for Resident 32 to receive passive range of motion to his lower extremities for 15 minutes three to five times a week with the goal of maintaining range of motion and to prevent progression of joint contractures.

Review of documentation dated May 2024, revealed that there was no documented evidence to indicate that Resident 32 was provided the passive range of motion program since it was implemented on May 7, 2024.

Interview with the Director of Nursing on May 15, 2024, at 12:50 PM confirmed the above findings for Residents 21 and 32.

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

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

- Residents 21 and 32 were not harmed based on this deficient practice. Therapy evaluation completed for both residents, follow up based on findings.

- Director of Wellness or Designee will conduct initial Quality Improvement (QI) monitoring of the documentation of residents with current orders for restorative nursing programs to ensure programs being completed as ordered, follow up based on findings.

- The Director of Wellness will reeducate the Restorative Nursing Department on documentation and completion of restorative programs as ordered.

- Director of Wellness or Designee will conduct Quality Improvement (QI) monitoring of the documentation of residents with current orders for restorative nursing programs to ensure programs are being completed as ordered weekly x4, then monthly x 2. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI)

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

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

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

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

Observations:

Based on clinical record review and resident and staff interview, it was determined that the facility failed ensure safe self-administration of a tube feeding to ensure acceptable parameters of nutritional status for one resident reviewed. (Resident 2)

Findings include:

Interview with Resident 2 on May 13, 2024, at 1:36 PM revealed that she administers her own tube feeding. She indicated that she administers the feeding and water but not her medications.

Clinical record review for Resident 2 revealed a current physician's order that was initiated on April 4, 2024, for an Enteral Feed (feeding provided through a tube into the stomach) four times a day Twocal HN (a dietary supplement) 2.0 150 ml by gastrostomy tube (a tube into the stomach), resident may self-administer.

Interview with the Director of Nursing on May 14, 2024, at 2:22 PM confirmed that Resident 2 self-administers her tube feeding but not her medications.

On May 15, 2024, 9:00 AM the surveyor was provided with a self-administration of medication form that was completed for Resident 2, dated July 21, 2023, with a lock date of April 3, 2024. The form addressed administration of medications with no indicators related to safely self-administer a tube feeding.

Interview with the Director of Nursing on May 15, 2024, at 10:00 AM confirmed that the self-administration of medication assessment did not address indicators to ensure Resident 2 was capable of safely self-administering her tube feeding.

Review of Resident 2's current care plan related to her enteral feeding failed to address self-administration of the feeding. The Director of Nursing, on May 16, 2024, at 9:56 AM confirmed that Resident 2's plan of care did not address self-administration of her tube feeding.

Interview with the Director of Nursing on May 16, 2024, 9:56 AM confirmed that the facility failed to assess Resident 2's ability to self-administer her tube feeding to ensure that she maintained acceptable parameters of nutritional status.

28 Pa. Code 211.10(d) Resident care policies

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

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

- Resident 2 was not harmed based on this deficient practice. Assessment completed for Resident to ensure competency of safely self-administering her tube feeding with updated competency form addressing indicators to safely self-administer tube feeding.

- No other residents with potential to be affected by deficient practice.

- The Director of Wellness will educate the Licensed Nursing department on the updated resident competency assessment for self-administration of tube feeding.

- Director of Wellness or Designee will conduct Quality Improvement (QI) monitoring of Resident 2 competency of safely self-administering her tube feeding weekly x4, then monthly x 2. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI)

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

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by two of three residents reviewed (Residents 8 and 10).

Findings include:

Clinical record review for Resident 8 revealed the facility admitted him on June 27, 2022, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 8's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated June 9, 2023, indicated that the facility assessed Resident 8 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 8's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.

Clinical record review for Resident 10 revealed the facility admitted her on August 7, 2023. Resident 10's admission MDS dated August 13, 2023, indicated that the facility assessed Resident 10 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 10's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.

The findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on May 15, 2024, at 2:05 PM. Interview with Employee 1 (social services) on May 16, 2024, at 10:50 AM confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address Residents 8 and 10's dementia and cognitive loss.

483.40(b)(3) Dementia Treatment and Services
Previously cited 5/18/23

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

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

- Person centered care plan developed and implemented for Resident 8 and 10.

- Social Service Director or Designee will conduct Initial Quality Improvement (QI) monitoring of residents with a diagnosis of dementia and/or cognitive loss to ensure that a person-centered care plan to address the residents' dementia and cognitive loss has been developed and implemented, follow up based on findings.

- The Nursing Home Administrator will reeducate the Social Service Department and MDS Department on development of individualized approaches to care to address dementia and cognitive loss.

- Nursing Home Administrator or Designee will conduct Quality Improvement (QI) monitoring of residents with a diagnosis of dementia and/or cognitive loss to ensure that a person-centered care plan to address the residents' dementia and cognitive loss has been developed and implemented weekly x4, then monthly x 2. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI)

483.55(a)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in SNFs:

§483.55 Dental services.
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

§483.55(a) Skilled Nursing Facilities
A facility-

§483.55(a)(1) Must provide or obtain from an outside resource, in accordance with with §483.70(g) of this part, routine and emergency dental services to meet the needs of each resident;

§483.55(a)(2) May charge a Medicare resident an additional amount for routine and emergency dental services;

§483.55(a)(3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility;

§483.55(a)(4) Must if necessary or if requested, assist the resident;
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services location; and

§483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure dental concerns were addressed for one of three residents reviewed (Resident 27 ).

Findings include:

Clinical record review for Resident 27 revealed a wellness progress note dated March 30, 2024, at 4:00 PM that indicated she was found chewing on a piece of her own tooth but had no complaints of pain. There was no follow-up documentation to this in Resident 27's clinical record.

Further clinical record review revealed a wellness progress noted dated May 3, 2024, at 10:31 AM that indicated Resident 27's spouse declined dental services.

Interview with the Director of Nursing on May 15, 2024, at 12:41 PM revealed that there was no evidence that Resident 27's spouse was made aware that she was found to be chewing on a piece of her own tooth on March 30, 2024, or if they addressed Resident 27 being seen by a dentist due to this.

Clinical record review revealed a progress note dated May 15, 2024, at 11:31 AM that indicated Resident 27's husband was made aware of the broken tooth and agreed to allow the dental hygienist see Resident 27 for one visit that is to occur on May 16, 2024.

The facility failed to ensure Resident 27's husband was made aware of her dental concerns in order to make an informed decision regarding her dental care.

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

28 Pa. Code 211.15(a) Dental services

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

- Resident 27 was not harmed based on this deficient practice. Resident seen by hygienist 5/16/2024, follow up based on findings.

- Director of Wellness or Designee will conduct initial Quality Improvement (QI) monitoring of current residents to determine any need for routine or emergency dental care, follow up based on findings.

- The Director of Wellness will reeducate the Wellness department on policy for offering/providing dental care and receiving informed decisions regarding dental care.

- Director of Wellness or Designee will conduct Quality Improvement (QI) monitoring of nursing documentation and dental providers recommendations to ensure timely follow up weekly x4, then monthly x 2. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI)

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

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

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

- Residents were not found to be affected by deficient practice.

- Director of Wellness conducted initial Quality Improvement (QI) monitoring of schedules for past week to review CNA staffing ratios.

- The Director of Wellness will reeducate staff responsible for the nursing schedule related to the required CNA ratios.

- The Director of Wellness will conducted Quality Improvement (QI) monitoring of the nursing schedule related to CNA staffing ratios 5x week x2, weekly x2, then monthly x2. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI)

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

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

Observations:

Based on a review of nursing staffing hours and staff interviews, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 40 residents during the night shift for four of 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following licensed practical nurse (LPN) scheduled for the following resident census:

Night shift:

November 22, 2023, 1.09 LPNs for a census of 49, requires 1.23 LPNs.
November 23, 2023, 1.03 LPNs for a census of 49, requires 1.23 LPNs.
February 11, 2024, 1.03 LPNs for a census of 47, requires 1.18 LPNs.
February 12, 2024, 1.00 LPN for a census of 48, requires 1.20 LPNs.

Interview with the Nursing Home Administrator on May 15, 2024, at 2:05 PM confirmed the above findings.

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

- Residents were not found to be affected by deficient practice.

- Director of Wellness conducted initial Quality Improvement (QI) monitoring of schedules for past week to review LPN staffing ratios.

- The Director of Wellness will reeducate staff responsible for the nursing schedule related to the required LPN ratios.

- The Director of Wellness will conducted Quality Improvement (QI) monitoring of the nursing schedule related to CNA staffing ratios 5x week x2, weekly x2, then monthly x2. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI)

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Observations:

Based on a review of nursing staffing hours and staff interviews, it was determined that the facility failed to ensure a minimum of one registered nurse (RN) per 250 residents on the overnight shift on three of the 21 days reviewed.

Findings include:

A review of nursing staff care ratios provided by the facility revealed the following shifts where the facility did not ensure a minimum of one RN worked in the capacity of an RN per 250 residents:

Overnight shift:

November 19, 2023, zero RN with a census of 48, requires one RN.
November 24, 2023, zero RN with a census of 48, requires one RN.
May 10, 2024, zero RN with a census of 46, requires one RN.

An interview with the Nursing Home Administrator on May 15, 2024, at 2:05 PM confirmed the above findings.

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

- Residents were not found to be affected by deficient practice.

- Director of Wellness conducted initial Quality Improvement (QI) monitoring of schedules for past week to review RN staffing ratios.

- The Director of Wellness will reeducate staff responsible for the nursing schedule related to the required RN ratios.

- The Director of Wellness will conduct Quality Improvement (QI) monitoring of the nursing schedule related to RN staffing ratios 5x week x2, weekly x2, then monthly x2. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI)

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