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

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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/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on April 25, 2025, 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:

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

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.

§483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

§483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

Observations:

Based on clinical record review, review of facility documents, and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet resident needs on one of two nursing units (second floor), and three of 12 residents reviewed (Resident 3, 20, and 248).

Findings include:

The facility's third floor was unoccupied by residents at the time of the onsite visit, and all facility residents were residing on the second-floor nursing unit.

Interview with Resident 20 on April 22, 2025, at 11:50 AM revealed that she needed to rely on staff to go to the bathroom, as she was not supposed to take herself, and she sometimes has "accidents" waiting for the staff. Resident 20 stated she sometimes waits up to an hour for staff to come when she rings her call bell.

Clinical record review for Resident 20 revealed a social service note dated January 13, 2025, at 11:09 AM indicating a family member of the resident expressed concern at a care plan meeting about call bell response times when the resident needs to utilize the bathroom. There was no follow up identified to the concern.

A review of Resident 20's electronic call bell activation and response records for April 10 to 24, 2025, revealed the following call bell response times greater than 20 minutes after the resident activated the call bell:

April 10, 2025, activated at 3:47 PM; response time of 22 minutes.
April 10, 2025, activated at 9:15 PM; response time of 24 minutes.
April 12, 2025, activated at 10:18 PM; response time of 26 minutes.
April 14, 2025, activated at 10:59 AM; response time 26 minutes.
April 17, 2025, activated at 6:47 AM; response time 22 minutes.
April 17, 2025, activated at 4:42 PM; response time 25 minutes.
April 17, 2025, activated at 7:00 PM; response time 22 minutes.
April 18, 2025, activated at 5:29 AM; response time 21 minutes.
April 19, 2025, activated at 8:35 PM; response time 50 minutes.
April 20, 2025, activated at 3:05 PM; response time 23 minutes.
April 10, 2025, activated at 4:56 PM; response time 24 minutes.
April 21, 2025, activated at 12:34 AM; response time 28 minutes.
April 22, 2025, activated at 3:58 PM; response time 50 minutes.
April 22, 2025, activated at 6:26 PM; response time 22 minutes.
April 23, 2025, activated at 3:57 PM; response time 30 minutes.
April 23, 2025, activated at 8:50 PM; response time 27 minutes.

A review of Resident 20's bowel and bladder elimination records revealed staff documentation did not occur exactly at the point of service, but at some time during the shift the care occurred. Although a longer call bell response time could not be linked to the exact documentation time, it was determined that Resident 20's incontinent episodes of bowel, bladder, or both, on April 10, 14, 17, 18, and 25, 2025, had longer call bell response times.

The above information regarding Resident 20's call bell response times was reviewed with the Nursing Home Administrator on April 25, 2025, at 9:45 AM.

Clinical record review for Resident 248 revealed an admission Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated April 11, 2025, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 15, which indicated no cognitive impairment.

Clinical record review for Resident 3 revealed an admission MDS dated April 3, 2025, that noted facility staff assessed the resident as having a BIMS of 6, which indicated cognitive impairment.

An interview with Residents 3 and 248 on April 22, 2025, at 1:26 PM revealed concerns related to staff response to activated call bells. Resident 248 further stated that staff take "half an hour" to respond to the call bell and "that's a problem."

An interview with the Nursing Home Administrator and Director of Nursing on April 24, 2025, at 1:45 PM revealed that the facility documentation provided upon surveyor request for call bell response records accounted for the entire room for Residents 3 and 248.

A review of the facility documentation titled "Alerts," for Residents 3 and 248 revealed the following call bell activation dates/times with an elapsed time greater than 20 minutes:

April 9, 2025, at 10:56 AM; response time 36 minutes.
April 9, 2025, at 12:56 PM; response time 34.2 minutes.
April 9, 2025, at 3:50 PM; response time 32.3 minutes.
April 9, 2025, at 5:29 PM; response time 25.2 minutes.
April 9, 2025, at 6:00 PM; response time 43.1 minutes.
April 9, 2025, at 6:57 PM; response time 39.5 minutes.
April 9, 2025, at 9:50 PM; response time 27.7 minutes.
April 10, 2025, at 10:50 PM; response time 31.7 minutes.
April 11, 2025, at 5:12 AM; response time 34.2 minutes.
April 11, 2025, at 7:25 PM; response time 23.5 minutes.
April 12, 2025, at 11:02 AM; response time 40.9 minutes.
April 12, 2025, at 8:00 PM; response time 26 minutes.
April 12, 2025, at 8:10 PM; response time 46 minutes.
April 12, 2025, at 9:56 PM; response time 23.6 minutes.
April 13, 2025, at 7:10 PM; response time 44.1 minutes.
April 13, 2025, at 8:35 PM; response time 24.7 minutes.
April 14, 2025, at 6:13 AM; response time 22.6 minutes.

The excessive call bell response times for Residents 3 and 248 were reviewed during an interview with the Nursing Home Administrator on April 25, 2025, at 1:14 PM.

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

28 Pa. Code 211.12(d)(1)(3)(4)(5) Nursing services

Plan of Correction - To be completed: 06/09/2025

- Call Bell audit completed for Resident # 3,20,248 with follow up reporting no unmet needs.

- The Director of Wellness or Designee will conduct initial quality Improvement (QI) monitoring of Call Bell response times and resident interviews to ensure resident needs are being met.

- The Director of Wellness or designee will reeducate staff on call bell response time and response to resident needs.

- The Director of Wellness or Designee will conduct Quality Improvement (QI) monitoring of call bell response time and response to resident needs 5x per week x2, then weekly x3, then monthly x 2. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI)

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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

§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:

Based on observation and staff interview, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of 15 residents sampled (Resident 28).

Findings include:

Clinical record review for Resident 28 revealed a Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated April 1, 2025, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 6, which indicated cognitive impairment.

Clinical record review for Resident 28 revealed the resident had current physician orders for an indwelling urinary foley catheter (a tube inserted into the bladder that drains urine) and associated care.

Resident 28's current care plan revealed that the resident had a foley catheter due to obstructive uropathy (when the urine cannot flow properly through the body). An intervention included always having a dignity bag (a device such as a cover to promote dignity that conceals the urine in the collection bag).

Review of Resident 28's task list (located in the electronic health record where staff document specific care related events for a resident) revealed the resident is to have a dignity bag at all times.

Observation of Resident 28 on April 25, 2025, at 10:16 AM, 10:46 AM, and 11:31 AM revealed the resident was seated in his wheelchair in the main hallway located in front of the nurse's station. Resident 28's foley catheter collection bag was attached to the frame of the wheelchair and urine was visible. Several staff members and other residents were observed passing by Resident 28 as he sat in the hallway.

An interview with Employee 2, licensed practical nurse, on April 25, 2025, at 11:31 AM revealed that Resident 28's foley catheter bag should be covered.

The above information for Resident 28 was reviewed with the Nursing Home Administrator during an interview on April 25, 2025, at 1:08 PM.

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

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 06/09/2025

- Dignity bag replaced for Resident #28.

- Director of Wellness or Designee will conduct Initial Quality Improvement (QI) monitoring of residents who have catheters to ensure that dignity bags are in place and catheter bags covered properly, follow up based on findings.

- The Director of Wellness will reeducate the wellness team on use of dignity bags to maintain Resident dignity.

- Director of Wellness or Designee will conduct Quality Improvement (QI) monitoring of residents who have catheters to ensure that dignity bags are in place and catheter bags covered weekly x4, then monthly x 2. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI)

483.20(g) REQUIREMENT Accuracy of Assessments:

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected residents' status for one of 15 residents reviewed (Resident 28).

Findings include:

Clinical record review for Resident 28 revealed a Medicare Five-Day MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated April 1, 2025, in which facility staff assessed the resident as having a feeding tube.

Further clinical record review revealed no evidence that Resident 28 had a feeding tube.

An interview with Employee 1, registered nurse assessment coordinator, on April 22, 2025, at 2:04 PM confirmed that Resident 28 did not have a feeding tube during the assessment period, and this was marked in error on the MDS.

The Nursing Home Administrator and Director of Nursing were informed of the above findings during a meeting on April 23, 2025, at 1:49 PM.

483.20(g) Accuracy of Assessments
Previously cited 5/16/2024

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

Plan of Correction - To be completed: 06/09/2025

- MDS errors for Resident 28 corrected.

- The Registered Nurse Assessment Coordinator conducted initial quality Improvement (QI) monitoring of prior 90 days determined no further residents effected by miscoding of Tube feeding.

- The Director of Wellness or designee will reeducate the Registered Dietician on Accuracy of MDS assessments specifically coding for section K.

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

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:

§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a resident's medication regime was free from potentially unnecessary medications for two of five residents reviewed (Residents 11 and 24).

Findings include:

Review of Resident 11's clinical record revealed a physician's order dated March 10, 2025, that indicated nursing staff may administer Ativan (for anxiety) 2 mg/ml (milligrams per milliliters) 0.5 ml (milliliters) every four hours as needed for anxiety. There was no documented evidence in Resident 11's clinical record to indicate that his physician documented a rational for the continued use of the Ativan beyond a 14-day period.

Review of Resident 11's Medication Administration Record (MAR, a form utilized to document the administration of medications) for both March and April 2025, indicated that Resident 11 was not administered any as needed Ativan.

Review of Resident 24's clinical record revealed a physician's order dated April 22, 2025, that indicated nursing staff may administer Ativan 2mg/ml 0.25 mg every four hours as needed for agitation or anxiety.

There was no documented evidence in Resident 24's clinical record to indicate that her physician documented a rationale for the continued use of the Ativan beyond a 14-day period. The facility obtained a physician's order dated April 24, 2025, to initiate a 14 day time span after the surveyor questioning.

Interview with the Administrator and Director of Nursing on April 24, 2025, at 1:50 PM confirmed the above findings for Residents 11 and 24.

28 Pa. Code 211.9(k) Pharmacy services

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

Plan of Correction - To be completed: 06/09/2025

- Physician Review of Resident #11 and Resident #24 PRN psychotropic medications and orders updated.

- Director of Wellness or Designee will conduct Initial Quality Improvement (QI) monitoring of residents who have orders for PRN psychotropic medications to ensure that residents are free from potentially unnecessary medications and PRN medications do not exceed 14 day stop and/or 14 day reevaluation, follow up based on findings.

- The Director of Wellness will reeducate the Licensed nurses, Physicians, and Hospice providers on use of PRN psychotropic medications and 14 day requirements to prevent potential use of unnecessary medications.

- Director of Wellness or Designee will conduct Quality Improvement (QI) monitoring of residents who have orders for PRN psychotropic medications to ensure that residents are free from potentially unnecessary medications and PRN medications do not exceed 14 day stop and/or 14 day reevaluation weekly x4, then monthly x 2. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI)

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on observations and staff interview, it was determined that the facility failed to properly store resident medications on one of two nursing units reviewed (Second Floor West Nursing Unit; Residents 4 and 250).

Findings include:

Observation during the medication pass on the Second Floor West Nursing Unit on April 24, 2025, at 9:35 AM revealed two medications carts being utilized by Employee 2, licensed practical nurse.

Observation of Medication Cart 1 revealed the following:

There was a significant accumulation of debris and dirt in the platform located below the bottom drawers of the medication cart.

There were two medication punch cards located on the platform under the drawers of the medication cart. One medication card belonged to Resident 4 and contained a dose of Hydralazine (a medication used to treat high blood pressure). The other medication card belonged to Resident 250 who was discharged from the facility on February 5, 2024, per clinical documentation. The medication card for Resident 250 contained several doses of Docusate (a stool softener), which had expired on November 17, 2024.

There were several unsecured and unidentified medication tablets on the platform of the medication card located under the drawers that included several unidentified pills: a white colored oblong pill, a pink colored oval pill, a white colored capsule, and a white colored round pill.

Observation of Medication Cart 2 revealed the following:

Significant accumulation of debris and dirt on the platform located below the bottom drawers of the medication cart.

An unsecured and unidentified white colored round pill located on the platform of the medication cart under the drawers.

The above findings were reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 24, 2025, at 1:30 PM.

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

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

Plan of Correction - To be completed: 06/09/2025

- West Nursing Cart cleaned on 4/24/25 and medication Cards for Resident #4 and Resident # 250 were properly disposed.

- Director of Wellness or Designee will conduct Initial Quality Improvement (QI) monitoring of medication carts to ensure that medication carts are clean and medications properly stored, follow up based on findings.

- The Director of Wellness will reeducate the wellness team on proper storing/labeling of medications and cleaning of medication carts.

- Director of Wellness or Designee will conduct Quality Improvement (QI) monitoring of medication carts to ensure that medication carts are clean and medications properly stored weekly x4, then monthly x 2. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI)

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