Pennsylvania Department of Health
BROAD MOUNTAIN HEALTH & REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BROAD MOUNTAIN HEALTH & REHABILITATION CENTER
Inspection Results For:

There are 130 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.


BROAD MOUNTAIN HEALTH & REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on May 10, 2024, it was determined that Broad Mountain Nursing and Rehabilitation Center 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(a)(1) REQUIREMENT Free from Abuse and Neglect:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

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

§483.12(a) The facility must-

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

Observations:

Based on a review of the facility's abuse prohibition policy, select incident reports and clinical records, and staff interviews, it was determined that the facility failed to ensure that one resident (Resident 25) out of 20 sampled residents was free from sexual abuse perpetrated by another resident (Resident 46).

Findings include:

A review of facility policy titled Pennsylvania Resident Abuse, last reviewed by the facility on March 24, 2024, revealed the facility will not tolerate abuse of residents by anyone. The policy defines sexual abuse as includes, but is not limited to, non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault.

A review of the clinical record revealed Resident 46 was admitted to the facility on February 13, 2018, with diagnoses that include cerebral infarction (brain damage that results from a lack of blood), major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts), and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities).

A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 27, 2024, revealed that Resident 46 was moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate cognitive impairment).

Resident 46's care plan, initiated March 21, 2023, revealed that the resident displayed behaviors of threatening to punch staff, alleged perpetrator of sexual abuse towards roommate, and verbal \ with staff. Planned interventions were noted as approaching calmly, speaking in a calm voice, discussing with him that either doing an act of violence towards others or making threats may result in police involvement, remaining with the resident when anxiety is high, and protecting others from injury by removing other residents if needed.

A clinical record review revealed Resident 25 was admitted to the facility on May 22, 2020, with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks ).

A review of an annual MDS assessment dated March 20, 2024, revealed that Resident 25 was severely cognitively impaired with a BIMS score of 6 (a score of 0-7 indicates severe cognitive impairment).

Resident 25's care plan, initiated November 11, 2020, revealed that Resident 25 can become hyper-fixated on male residents and the planned approach was for staff to redirect at these times with an activity of preference, and consult a medication management provider.

An incident report dated January 3, 2024, at 3:25 PM indicated that Resident 25 and Resident 46 were observed kissing in the east lounge. The incident report indicated that Resident 46 was observed with his hand up Resident 25's shirt with his hand touching her breast.

A witness statement dated January 3, 2024, provided by Employee 1, Licensed Practical Nurse (LPN), indicated that around 1:45 PM she observed Resident 46 and Resident 25 kissing in the East resident lounge. Employee 1, LPN, explained that Resident 46's hand was on Resident 25's breast.

A witness statement dated January 3, 2024, provided by Employee 2, LPN, indicated that she observed Resident 25 and 46 kissing in the dining room. Employee 2, LPN, indicated that Resident 46's hand was inside Resident 25's shirt as he touched her breasts. Employee 2, LPN, indicated that the residents were immediately separated.

A witness statement dated January 3, 2024, at 4:15 PM revealed that Employee 3, Social Worker (SW), met with Resident 46 to discuss the incident. Resident 46 indicated that Resident 25 kissed him, and he did not touch her inappropriately or in any way. Resident 46 indicated Resident 25 kissed him because he looked good today.

A witness statement dated January 3, 2024, at 4:15 PM revealed that Employee 3, SW, met with Resident 25 to discuss the incident. Resident 25 indicated that nothing happened and that she feels safe in her surroundings.

The Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists- American Bar Association Commission on Law and Aging- American Psychological Association indicates that the most widely accepted criteria, which are consistent with those applied to consent to treatment, are: (1) knowledge of relevant information, including risks and benefits; (2) understanding or rational reasoning that reveals a decision that is consistent with the individual's values (competence); and (3) voluntariness (a stated choice without coercion).

A clinical record review failed to find evidence that the facility assessed Resident 25 or 46's capacity to consent to a sexual relationship.

Applying the reasonable person concept, in the case of Resident 25, who was unable to recall the incident, and the assessment of how most people would react to the situation of being sexually abused by Resident 46, Resident 25 would have suffered psychosocial harm and humiliation.

A nursing evaluation form dated January 3, 2024, at 4:21 PM revealed that Resident 25 was assessed to be disoriented, pleasant, and without indications of pain or complaints of pain.

A nursing evaluation form dated January 3, 2024, at 4:42 PM revealed that Resident 46 was assessed to be disoriented, pleasant, and without indications of pain or complaints of pain.

Resident 46 declined to be interviewed during the week of the survey, ending on May 10, 2024.

During an interview on May 10, 2024, at approximately 11:00 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) verified that the facility had no evidence that Residents 25 or 46 were assessed to determine if they had the cognitive capacity to consent to a sexual relationship. The NHA and DON confirmed that the facility failed to ensure that Resident 25 was free from sexual abuse perpetrated by another resident.

This deficiency is cited as past non-compliance.

The facility's corrective action plan was to assess Residents 25 and 46 for physical injuries or harm, provide both residents with emotional support, and notify the resident's physician and representatives.

The facility's corrective action plan was to identify residents who had the potential to be affected. The DON or designee reviewed residents with past sexual behavior to ensure appropriate personalized interventions were in place. The social worker or designee interviewed residents with BIMS scores 12-15 (BIMS score of 13-15 indicates the resident is cognitively intact) to ensure they were not inappropriately touched and felt safe. Licensed nursing staff completed skin evaluations on incapable residents with BIMS 99-11 to ensure there were no signs or symptoms of abuse. The residents' evaluations and interviews revealed no additional findings of sexual abuse.

To prevent this from reoccurring, the Assistant Director of Nursing (ADON) will educate current staff on the abuse prevention policy. The ADON will educate licensed nurses and the interdisciplinary team to ensure all care plans are individualized and related to residents' sexual behaviors.

To monitor and maintain ongoing compliance, the DON or designee reviewed residents with sexual behaviors weekly x 4 then monthly x 2 to ensure appropriate personalized interventions were in place.

To monitor and maintain ongoing compliance, the social worker or designee will interview five cognitively intact residents (BIMS 12-15) weekly x 4 then monthly x 2 to ensure they are not touched inappropriately and feel safe.

To monitor and maintain ongoing compliance, the ADON or designee will complete skin evaluations on five incapable residents (BIMS 99-11) weekly x 4 then monthly x 2 to ensure there are no signs or symptoms of abuse.

The facility's corrections were completed on January 5, 2024, which was verified during the survey of May 10, 2024.

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

28 Pa. Code 201.29(a) Resident Rights

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

Plan of Correction - To be completed: 05/20/2024

Past noncompliance: no plan of correction required.

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.

Plan of Correction - To be completed: 06/06/2024

Step 1

The facility cannot correct past practices but Resident #83 was reviewed by current IDT with decision made to initiate continuous feed and discontinue bolus feed on 2/1/24. Resident #83 has had a 10 pound beneficial weight gain since that time.

The Registered Dietician reviewed Resident #83 enteral feed and completed a comprehensive review to ensure caloric needs are being met. Negative findings will be corrected.

Step 2
To identify other residents that have potential to be affected, the RD/designee reviewed current residents with an enteral feeding to ensure order is followed and caloric needs being met.
To identify other residents that have the potential to be affected the RD/designee reviewed current residents to ensure if a weight loss was noted notification was completed timely.
Step 3
To prevent this from reoccurring, the Regional Dietician educated the RD and the IDT team on the weight policy, including reweights and notifications.
To prevent this from reoccurring the DON/designee educated licensed nurses on following enteral feed orders to ensure adequate caloric intake is achieved.
Step 4
To monitor and maintain compliance, the DON/designee will review residents weights to ensure reweights obtained and notification completed . The audits will be completed 5 days per week times 4 weeks and then monthly times 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.
To monitor and maintain ongoing compliance the DON/Designee will audit residents with enteral feedings to ensure order was followed correctly to maintain caloric intake 5 days per week X 4 weeks and monthly X2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.

Observations:

Based on a review of Food Committee Minutes (completed in addition to Resident Council meetings) and resident and staff interviews, it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during resident group meetings, including those voiced by three of the six residents interviewed during a group interview (Residents 32, 62, and 69) and one resident out of the 20 sampled (Resident 54).

Findings include:

A review of minutes from Food Committee meeting dated March 20, 2024, with 12 residents in attendance, revealed that residents brought up a concern that they were not being provided snacks prepared by the baker and a choice or variety of snacks were not being provided by the facility.

A review of minutes from Food Committee meeting dated April 22, 2024, with 7 residents in attendance, revealed that residents brought up a concern that nighttime were not being offered.

During a resident group interview on May 8, 2024, at 10:00 AM, three of the six residents in attendance (Residents 32, 62, and 69) stated that they still have concerns with the variety of snacks the facility offers. Resident 32 stated that she would like to have fresh fruit, like bananas or oranges, as a regular snack option. Resident 69 stated that sometimes there are no choices available for evening snacks, explaining that the only choice is ice cream. Residents 32, 62, and 69 stated that they have raised this concern regarding snack variety with the facility in the past but explained that the facility has not addressed their preferences for snacks.

During an interview on May 8, 2024, at 10:10 AM Resident 54 stated that bedtime snacks are offered but that there is not enough variety of snacks to choose from. Resident 54 stated that it is mostly the same flavor cookie or same flavor of ice cream over and over again. Resident 54 confirmed that she had requested more variety of snacks including fresh fruit in the past but nothing has been done yet to increase the variety available to residents.

The facility was unable to provide documented evidence that the facility had determined if the residents' felt that their complaints or grievances had been resolved through any efforts taken by the facility in response to the residents' expressed concerns regarding the variety of snacks being offered.

During an interview with the Nursing Home Administrator (NHA) on May 9, 2024, at approximately 10:00 AM, the NHA was unable to provide documented evidence that the facility had followed up with the residents to ascertain the effectiveness of the facility's efforts in resolving their concerns regarding the variety of snacks being offered.

28 Pa. Code 201.18 (e)(1)(3)(4) Management

28 Pa. Code 201.29 (a) Resident Rights

Plan of Correction - To be completed: 06/06/2024

Cannot be corrected retroactively.

The process of collecting concerns and grievances during group meetings will include a component of follow up by the grievance official (either present in meeting or follow up with Resident Council President post-meeting) to ensure any concerns are shared with the Interdisciplinary Team (IDT) going forward.

Education to Director of Food Services and Grievance Official by the NHA or designee on following the grievance policy and procedures when group meetings are held.

To monitor and maintain compliance, the NHA or designee will meet with a subset of residents, the Food Services Director and Grievance Offical Weekly for four weeks; then monthly for two months to ensure group concerns are collected and responded to in accordance with our grievance policy.
results of the audits will be forwarded to QAPI committee for further review and recommendations.

483.90(i)(5) REQUIREMENT Smoking Policies:

§483.90(i)(5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents.

Plan of Correction - To be completed: 06/06/2024

Step 1
Cannot retroactively correct, however, we immediately completed smoking observations (the official term for the assessment completed by the RN Supervisor) for Residents #50, 54, and 58.
Step 2
To identify other residents that have potential to be affected, an audit was conducted for smokers and no other out of date assessments were identified.
Step 3
To prevent this from reoccurring, the DON/designee educated licensed nursing staff on schedule of completion for smoking observations (assessment) in accordance with policy and procedures.

Step 4
To monitor and maintain compliance, the DON or designee will review these assessments monthly X 3 months.
The results of the audits will be forwarded to QAPI committee for further review and recommendations.

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 observation, a review of select facility policy and clinical records, and staff interviews, it was determined that the facility failed to adhere to acceptable storage and use by dates for multi-dose medication and herbal supplements on one of three medication carts and one of three medication storage rooms observed (west short cart, first floor storage room - Residents 9, and 77).

Findings include:

The facility policy "Storage and Expiration Dating of Medications, Biologicals," with a policy review date March 24, 2024, indicated that facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

Observation of West Short medication cart at approximately 9:13 AM, on May 7, 2024, in the presence of Employee 4, Licensed Practical Nurse (LPN) revealed the following opened multi-dose medications:

one (1) Insulin Aspart flex pen (medication used for diabetes), belonging to Resident 9, was observed to be opened and available for use and dated March 24, 2024, when initially opened.

One (1) Insulin Aspart flex pen, belonging to Resident 77, was observed to be opened and available for use and dated March 24, 2024, when initially opened and a second Insulin Aspart flex pen, belonging to Resident 77, was observed to be opened and available for use and dated February 20, 2024, when initially opened.

Employee 4, (LPN), confirmed the medications belonged to Resident 9 and 77, and that the insulins were beyond the manufacturer recommended use by date (28 days), and had not been discarded within 28 days of opening.

An observation of the first-floor medication storage room on May 8, 2024, at 1:04 PM, in the presence of Employee 5 (licensed practical nurse), revealed that stored within the medication refrigerator there was a multi-dose bottle of Tuberculin (solution used for screening for tuberculosis) that had been opened, available for use, and dated March 29, 2024, when initially opened. Employee 5 confirmed that the March 29, 2024, date was beyond the manufacturer's recommended use-by date to be discarded 30 days after opening.

Continued observation of the first-floor medication storage room revealed an opened bottle of Saw Palmetto 160 mg (herbal supplement) with an expiration date of July 2022.

Interview with the Director of Nursing (DON) on May 8, 2024, at approximately 1:50 PM, confirmed the facility failed to adhere to acceptable storage and use by dates for multi-dose medications and expiration date for the supplement.

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

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

Plan of Correction - To be completed: 06/06/2024

Step 1
Residents #9 and #77 had their expired insulin removed and replaced. Expired medication removed from medication room.

Step 2
Medication carts and medication rooms were audited to ensure no expired medications or medications present past acceptable storage. Negative findings were corrected.

Step 3
To prevent this from reoccurring, DON/designee educated the licensed nurse staff on medication storage policy to include multi-dose expirations.

Step 4
To monitor and maintain compliance, the DON/designee will review medication carts and medication rooms to ensure they are free from expired medication. The audits will be completed weekly X 4 and monthly X 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

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

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

Plan of Correction - To be completed: 06/06/2024

Step 1
Resident #54- added to case list of behavioral health services for behavioral health monitoring.
Step 2
To identify other residents that have potential to be affected, the SSD reviewed current residents who refuse services in order to determine if further behavioral health needs are warranted.
Step 3
To prevent this from reoccurring, the Regional Social Services Coordinator or designee educated the IDT on behavioral health services other then medication assistance when warranted including educating social services workers in providing therapeutic social services and making appropriate referrals to psychiatry/psychologist or other professional(s) as necessary and appropriate to meet the residents needs.
In addition to the above, we are currently changing providers for behavioral health services to better equip our social services office with more on-site counseling services available.

Step 4
To monitor and maintain compliance, the Social Workers and NHA will review residents with behaviors to ensure they are being followed for mental health services when appropriate. The audits will be completed 5 days per week times 4 weeks and then monthly times 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

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 a review of select facility policy and clinical records and staff interview it was determined that the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for bowel protocol for two residents out 20 sampled (Residents 89 and 50) to promote normal bowel activity to the extent possible

Findings include:

According to the American Academy of Family Physicians \ the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week).

The facility policy titled "Bowel Tracking Protocol," last reviewed by the facility, March 24, 2024, indicated the facility will record and monitor bowel activity of residents each shift and address issues identified. In the absence of resident specific orders, the facility will follow the suggested protocol as outlined below. If the resident has not had a bowel movement (BM) for 3 full days (72 hours), the nurse will determine if laxatives are indicated based on the resident's bowel habits and patterns: Step 1: Milk of Magnesia (MOM) 30 ml at bedtime the evening after 72 hours without a bowel movement. Step 2: If no BM by 10 am the following day, give bisacodyl suppository 10 mg PR. Step 3: If no BM within by next morning, contact provider for further orders.

A review of the clinical record indicated Resident 89 was admitted to the facility on February 7, 2024, with diagnosis to include diabetes, adult failure to thrive, cerebral infarction (stroke), and chronic kidney disease.

A review of the clinical record revealed that Resident 89 had physician orders dated February 7, 2024, for the following bowel regimen:

- Milk of Magnesia (MOM) Suspension 400 mg/5 ml (Magnesium Hydroxide), give 30 ml by mouth as needed for no BM X 3 days, give for no bowel movement in 3 days, start 3-11 shift.

- Dulcolax Suppository 10 MG (Bisacodyl), insert 1 suppository rectally every 72 hours as needed for no BM, give if no BM from milk of magnesia on 7-3 shift.

-Fleet Enema 7-19 gm/118 ml (Sodium Phosphates) insert 1 applicator rectally as needed for no BM. On 3-11 shift, give if no BM from suppository.

A nursing progress note dated February 13, 2024, at 1401 (2:01 PM) revealed that the resident had not had a bowel movement since admission to the facility (on February 7, 2024). Nursing spoke with the physician and obtained a new order for MOM, to start at the beginning of our facility bowel protocol.

The resident had physician orders upon admission for a bowel protocol and there was no documented evidence that nursing staff had administered the protocol as ordered in the seven days without a bowel movement from the time of the resident's admission on February 7, 2024, until February 13, 2024, when nursing staff obtained another physician order to start at the beginning of the bowel protocol.

Resident 89's bowel activity noted on the Documentation Survey Report v2 for February 2024, revealed that the resident did not have a bowel movement on February 7, 8, 9, 10, 11, 12, 13, and 14, 2024, (8 days).

Review of Resident's Medication Administration Record (MAR) for February 2024, revealed that MOM was administered on February 13, 2024, at 1848 (6:48 PM), on day 7 without a BM (February 7, to February 13, 2024).

A continued review of Resident 89's bowel activity for February 2024, revealed that he did not have a bowel movement on February 17, 18, 19, and 20, 2024, (4 days).

Review of Resident's (MAR) for February 2024, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time period of February 17, 18, 19, and 20, 2024, without a bowel movement to promote bowel activity.

A review of the clinical record indicated Resident 50 was admitted to the facility on April 22, 2023, with diagnosis to include diabetes, end stage renal disease, and constipation.
A review of the clinical record revealed that Resident 50 had physician orders dated April 21, 2023, for the following bowel regimen:
- MiraLAX Oral Powder 17 GM/scoop (Polyethylene Glycol), give 1 scoop by mouth as needed for PRN if no BM in 3 days.

- Dulcolax Suppository 10 MG (Bisacodyl), insert 1 suppository rectally as needed for no BM, give if no BM day #4 on 7-3 shift.

Resident 50's bowel activity noted on the Documentation Survey Report v2 for March 2024, revealed that she did not have a bowel movement on March 2, 3, 4, and 5, 2024, (4 days).

Review of Resident 50's Medication Administration Record (MAR) for March 2024, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time period of March 2, 3, 4, and 5, 2024, without a bowel movement to promote bowel activity.

During an interview with the Director of Nursing (DON) on May 10, 2024, at approximately 9:20 AM, confirmed that staff failed to consistently carry out physician orders for the bowel regimen prescribed for Resident 89, and 50 to prevent constipation and promote normal bowel activity, nor that the physician was timely notified of the extended time periods without bowel activity.

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

28 Pa. Code 211.5 (f) Medical records

Plan of Correction - To be completed: 06/06/2024

Step 1
Facility cannot retroactively correct past practices.
Step 2
To identify other residents that have potential to be affected, the DON/designee completed a 7 day look-back of residents on the bowel list to ensure bowel protocol was followed. Negative findings will be corrected.
Step 3
To prevent this from reoccurring, the DON/designee educated the licensed nursing staff on the bowel protocol steps and policy and re-educated the IDT team on monitoring of the bowel list.
Step 4
To monitor and maintain compliance, the DON/designee will audit the bowel list to ensure administration of bowel protocol. The audits will be completed 5 days per week times 4 weeks and then weekly times 4. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

483.20(g) REQUIREMENT Accuracy of Assessments:

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

Observations:

Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two residents out of 20 sampled (Residents 7 and 13).

Findings include:

According to the RAI User's Manual dated October 2023, Section A 1500 Preadmission Screening and Resident Review (PASRR) is to be completed if the type of assessment is an admission assessment, significant change, or annual assessment.

The annual MDS Assessment of Resident 7 dated October 1, 2023, revealed Section A 1500 was coded as "0," indicating that the resident was not considered by the state to require a Level II PASRR process, to have serious mental illness, and/or intellectual disability, mental retardation, or a related condition.

A review of Resident 7's clinical record revealed that a Level I PASRR was completed on March 7, 2018, indicating that the resident met the criteria for a Level II PASRR.

A further review of the resident's clinical record, revealed a letter of determination dated April 11, 2018, indicating the resident met the criteria for specialized services.

An interview with the Social Services Director on May 8, 2024, at approximately 1:35 PM confirmed that Resident 7's annual MDS Assessment Section A 1500 related to the PASRR, dated October 1, 2023, was inaccurate.

The annual MDS Assessment of Resident 13 dated February 6, 2024 revealed Section A 1500 was coded as "0," indicating that the resident was not considered by the state to require a Level II PASRR process, to have serious mental illness, and/or intellectual disability, mental retardation, or a related condition.

A clinical record review revealed a Level II PASRR letter of determination dated August 5, 2016, indicating that Resident 13 met the criteria for specialized services related to a mental health condition.

An interview with the Social Services Director on May 8, 2024, at approximately 1:35 PM confirmed that Resident 13's annual MDS Assessment Section A 1500 related to the PASRR, dated February 6, 2024, was inaccurate.

Plan of Correction - To be completed: 06/06/2024

Step 1
Residents #7 and #13 had their MDS updated to reflect accurate Section A 1500 to indicate a PASRR Level II was completed.
Step 2
To identify other residents that have potential to be affected, the RNAC completed a review of current residents who required a PASRR Level II to ensure Section A 1500 is accurate.
Step 3
To prevent this from reoccurring the RNAC educated Social Services on completing Section A 1500 accurately for those residents who have a PASRR Level II.
Step 4
To monitor and maintain compliance, the RNAC/designee will audit residents with a Level II PASRR during scheduled MDS to ensure accuracy of Section A 1500 weekly X 4 and monthly X 2 months.
The results of the audits will be forwarded to QAPI committee for further review and recommendations.

483.20(k)(1)-(3) REQUIREMENT PASARR Screening for MD & ID:

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(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability.

§483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with:
(i) Mental disorder as defined in paragraph (k)(3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission,
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
(B) If the individual requires such level of services, whether the individual requires specialized services; or
(ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission-
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
(B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability.

§483.20(k)(2) Exceptions. For purposes of this section-
(i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital.
(ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual-
(A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital,
(B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and
(C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services.

§483.20(k)(3) Definition. For purposes of this section-
(i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1).
(ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b)(3) or is a person with a related condition as described in 435.1010 of this chapter.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to accurately complete the PASRR (Preadmission Screening and Resident Review) according to the resident assessment for one of six residents reviewed related to PASRR assessments (Resident 58).

Findings include:

The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability.

The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A Level II PASRR evaluation must be completed if the Level 1 PASRR determined that the person is a targeted person with mental illness or an intellectual disability. The Level II PASRR would determine if placement or continued stay in the requested or current nursing facility is appropriate.

Review of the clinical record revealed that Resident 58 was admitted to the facility on September 4, 2022, with diagnoses which included depression and anxiety. Review of Resident 58's Level I PASRR dated September 2, 2022, indicated the resident had a negative screen for serious mental illness.

Further review of clinical record revealed that Resident 58 was discharged from the facility on January 17, 2023, and admitted to a behavioral unit. The resident was readmitted to the facility on February 3, 2023.

Review of Resident 58's PASRR Level I assessment, dated February 2, 2023, indicated that the resident had a mental health condition, with diagnoses of bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), depression, and anxiety. The assessment indicated that the resident was 302'ed (involuntary admission for psychiatric care) based on threats to kill herself and "mess up" her arms. During further assessments, resident denied having suicidal ideation. The screening outcome indicated the resident was noted to have a positive screen for serious mental illness and requires a further PASRR Level II evaluation.

Further review of Resident 58's clinical record revealed no documented evidence that a Level II PASRR evaluation had been completed.

Interview with the social services director on May 10, 2024, at 11:30 AM confirmed that there was no documented evidence available for review at the time of the survey that a Level II PASRR evaluation was completed for Resident 58.

28 Pa. Code 201.14 (a) Responsibility of Licensee

Plan of Correction - To be completed: 06/06/2024

Step 1
Resident 58' s MA408 was submitted; is currently pending level II processing.
Step 2
To ensure other residents are not affected, the SSD (Social Services Director)/designee completed an internal audit of PASRR Positive residents for completion of Level II processing conducted, no other errors identified.
Step 3
To prevent this from reoccurring, the Regional Social Services Director will educate social service workers on the system and process of processing and recording documentation for resdients who trigger PASRR positive assessments for Level II requirements.
Step 4
To monitor and maintain compliance, the NHA ordesignee will review any PASRR positive paperwork to ensure it is properly followed up on, processed, and documented by social services worker(s). The audits will be completed weekly for 4 weeks and then monthly times 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

483.25(m) REQUIREMENT Trauma Informed Care:

§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Observations:

Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 20 residents reviewed (Resident 58).

Findings include:

A review of the clinical record revealed that Resident 58 was admitted to the facility on September 4, 2022, with diagnoses that included Post Traumatic Stress Disorder (PTSD).

The resident's current care plan, in effect at the time of review on May 10, 2024, did not identify the resident's PTSD symptoms or triggers related to this diagnosis and resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization.

The facility failed to develop and implement an individualized person-centered plan to address, this resident's diagnosis of PTSD according to standards of practice to promote the resident's emotional well-being and safety.

Interview with the Nursing Home Administrator on May 10, 2024, at 10:00 AM confirmed the facility was unable to demonstrate that the facility provided culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident.

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

Plan of Correction - To be completed: 06/06/2024

Step 1
We completed a Trauma History Screen for resident 58.
Step 2
To identify potential other residents affected, an audit of residents with a diagnosis, care plan and/or history of known trauma or PTSD was conducted to identify any residents who did not have an assessment or care plan created for trauma or PTSD and if any were identified, the steps to correct were implemented.
Step 3
To prevent this from reoccurring, the Regional Social Services Coordinator will educate and train social service workers on completing timely and accurate assessments (Social Services Observation and Screening forms) and engaging the interdisciplinary team in addressing any triggers identified in order to create and implement an appropriate care plan as appropriate and necessary to meet the needs of the resident in the most effective and compassionate way.

Step 4
To monitor and maintain compliance, the DON or designee will audit residents who are admitted or are identified to have a history of trauma not previously identified and/or addressed daily X 5 for 4 weeks and then weekly X 4 weeks. 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:

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

§483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Observations:

Based on a review of clinical records and facility documentation and staff interview, it was determined that the facility failed to provide the required advance notice, a Notice of Medicare Non-Coverage (CMS 10123-NOMNC), regarding the termination of Medicare services for one of the three residents sampled (Resident 241).

Findings include:

A review of the Centers for Medicare and Medicaid Services Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 revealed that the NOMNC must be delivered at least two calendar days before Medicare-covered services end or on the second to last day of service if care is not being provided daily.

A clinical record review revealed that the facility provided Resident 241 with a Notice of Medicare Non-Coverage (CMS 10123-NOMNC) letter dated April 24, 2024. The notice indicated that Medicare would likely not pay for the resident's skilled services after April 26, 2024.

Further clinical record review revealed that Resident 241's effective date for current skilled nursing facility services ended on March 26, 2024, not April 26, 2024.

During an interview on May 9, 2024, at approximately 11:30 AM, the Nursing Home Administrator confirmed that the facility provided Resident 241 with inaccurate dates for Medicare non-coverage and failed to provide the required advance notice to Resident 241 regarding non-coverage of Medicare services.

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

28 Pa. Code 201.29 (a) Resident rights.

Plan of Correction - To be completed: 06/06/2024

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

Step 1
Cannot retroactively correct for inaccurate data on cut letter identified.
Step 2
To identify other residents that have potential to be affected , we reviewed cut letters of residents who discharged with medicare days remaining in the past 30 days and identified no further errors or missing data.
Step 3
Education on policy and procedure for issuing cut letters and the importance of their accuracy provided to social service workers by the NHA or designee to ensure they understand requirements and expectations.
Step 4
To monitor and maintain compliance, the NHA or designee will review cut letters for all required persons weekly for 4 weeks, then monthly for 2 months.
The results of the audits will be forwarded to QAPI committee for further review and recommendations.

§ 201.18(b)(2) LICENSURE Management.:

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

Observations:

Based on the review of select facility policy and clinical records and staff interview it was determined that the facility failed to maintain a complete and accurate record of a residents' personal possessions upon admission and discharge for one resident out of two sampled (Residents 89).

Findings included:

A review of facility policy entitled "Inventory of Personal Effects Procedure", policy review date March 24, 2024, states nursing personnel will inventory the resident's belongings on admission and record same on the inventory sheet. The admitting nurse will initiate the personal inventory list. Fill in resident's name, room number, medical record number and the date of inventory on the inventory of Personal Effects. Identify articles as listed, indicating quantity and presence with a check (x).

A review of the clinical record indicated Resident 89 was admitted to the facility on February 7, 2024, and expired at the facility on February 25, 2024.

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

Interview with the Nursing Home Administrator (NHA) on May 10, 2024, at approximately 9:25 A.M., confirmed that the facility was unable to provide the personal inventory sheet of belongings upon admission and discharge for Resident 89.

Plan of Correction - To be completed: 06/06/2024

Step 1
Resident #89 inventory sheet updated.
Step 2
To identify other residents that have potential to be affected, the RN Unit Managers reviewed inventory sheets to ensure completion on current residents and obtain new ones for any missing or incomplete inventory sheets identified.
Step 3
To prevent this from reoccurring, the DON/designee educated staff on completing/updating inventory sheets.
Step 4
To monitor and maintain compliance, the DON/designee will review new admission inventory sheets to ensure completion/accuracy. The audits will be completed 5 days per week times 4 weeks and then monthly times 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

§ 209.3(a) LICENSURE Smoking.:

(a) Policies regarding smoking shall be adopted. The policies shall include provisions for the protection of the rights of smoking and nonsmoking residents. The smoking policies shall be posted in a conspicuous place and in a legible format so that they may be easily read by residents, visitors and staff.

Observations:

Based on observation and staff interview, it was determined that the facility staff failed to post the smoking policy in a conspicuous place and in a legible format that could be easily read by residents, visitors and staff.

Findings include:

During observations conducted during a tour of the facility and grounds on May 8, 2024, the facility's smoking policy, including provisions for the protection of the rights of non-smoking residents, was not posted in a conspicuous location in the facility and was not accessible to residents, staff and visitors.

During an interview with the Nursing Home Administrator on May 9, 2024, at 9:30 AM, she confirmed that the facility failed to post the smoking policy in a conspicuous location and in a legible format that could be easily read.

Plan of Correction - To be completed: 06/06/2024

Step 1
Unable to retroactively correct placement of smoking policy which was previously located inside the elevator.
Step 2
The NHA displayed the smoking policy in common area at wheelchair height.
Step 3
The NHA acknowledges the requirement to prominently display the policy in a prominent location as discussed with surveyors on site during survey.
Step 4
To monitor and maintain compliance, the NHA/designee will ensure smoking policy is posted in facility in a prominent location at wheelchair height. The audits will be completed weekly for 4 weeks and then monthly times 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

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