Nursing Investigation Results -

Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT LUZERNE
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
KADIMA REHABILITATION & NURSING AT LUZERNE
Inspection Results For:

There are  66 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.
KADIMA REHABILITATION & NURSING AT LUZERNE - 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 26, 2022, it was determined that Kadima Rehabilitation & Nursing at Luzerne was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e)

This includes:
483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who-
(i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is:
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.
Observations:


Based on observation and staff interview, it was determined that the facility failed to employ a full-time qualified dietary services supervisor in the absence of a full-time qualified dietitian.

Findings include:

Observation and interview with Employee 2 (cook) during the initial tour of the food and nutrition services department on May 24, 2022 at 9:05 AM revealed that the facility did not currently have a full-time qualified dietary services supervisor working onsite at the facility or a full time qualified dietitian.

Employee 2 confirmed that the current full-time dietary services supervisor was available by phone, but was currently working onsite at a "sister" facility.

Interview with the Nursing Home Administrator (NHA) on May 24, 2022 at 10:00 AM confirmed that the current full-time qualified dietary services supervisor was working full-time at a "sister" facility.

The NHA confirmed that the facility does not provide the services of a full-time qualified dietitian in the absence of a qualified dietary services supervisor.



28 Pa. Code 211.6 (c)(d) Dietary services.

28 Pa Code 201.18 (e)(1)(6) Management.











 Plan of Correction - To be completed: 06/30/2022

1. Our Full Time CDM returned to the facility on 6/1/2022 after providing training and support to a sister facility.
2. Our Full Time CDM will continue at Kadima at Luzerne on a full-time basis.
3. The NHA was re-educated on the requirements of 0801 and will safeguard compliance. This was an isolated incident to assist a sister facility. The sister facility has stabilized and has full time, properly credentialed coverage.
4. The NHA or designee will complete a one-time audit to verify that a full time CDM or Registered Dietitian is on staff to ensure compliance with 0801. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

483.20(g) REQUIREMENT Accuracy of Assessments: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.
483.20(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 four residents out of 12 sampled (Residents 4, 1, 17, and 19).

Findings include:

A review of Resident 4's quarterly MDS Assessment dated February 21, 2022, Section P0100 Physical Restraints (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) Section D. Other was used less than daily as a restraint for the resident.

Review of the clinical record revealed no documented evidence that a physical restraint was being used for the resident during the look back period.

Interview with the Nursing Home Administrator on May 26, 2022 at approximately 12:00 p.m., confirmed that the above MDS assessments were inaccurate with respect to restraint use.

A review of Resident 1's clinical record revealed the resident was admitted to the facility on February 17, 2022.

A review of Resident 1's admission MDS Assessment dated February 22, 2022, indicated in Section N0410 Medications Received that an anticoagulant (blood thinner) medication was received seven times in the last seven days.

Review of the Resident 1's February 2022 Medication Administration Record (MAR) revealed that no anticoagulant medication was received during the 7 day lookback making the February 22, 2022 admission MDS Assessment inaccurate.

A review of Resident 17's clinical record revealed the resident was admitted to the facility on April 27, 2022.

A review of Resident 17's admission MDS Assessment dated May 4, 2022, indicated in Section N0410 Medications Received that an antianxiety medication was received six times in the last seven days.

Review of the Resident 17's April 2022 and May 2022 MAR's revealed that no antianxiety medication was received during the 7 day lookback period. The resident's May 4, 2022 admission MDS Assessment was inaccurate.

A review of the clinical record of Resident 19 revealed admission to the facility on November 13, 2020, with diagnoses that included hypertension and depression.

A review of Resident 19's significant change MDS Assessment dated April 15, 2022, indicated in Section N0410 Medications Received that an anticoagulant medication was received two times in the last seven days. Section N0410 Medications Received also noted that an opioid medication was received seven times in the last seven days.

Review of the Resident 19's April 2022 MAR revealed that no anticoagulant medication was received during the 7 day lookback. An opioid medication was only received twice in the 7 day look back period. Resident 19's April 15, 2022 significant change MDS Assessment was inaccurate.

Interview with the RNAC on May 26, 2022 at 11:15 a.m. she confirmed the MDS errors for Resident 1, Resident 17, and Resident 19.



28 Pa. Code 211.5(g)(h) Clinical records.

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








 Plan of Correction - To be completed: 06/30/2022

1. Residents #4, #1, #17, and #19 MDS corrections were submitted.
2. A 14 day look back was completed to ensure MDS accuracy. Corrections were submitted if indicated.
3. The RNAC was re-educated on accurate MDS completion. The DON will conduct random MDS reviews to ensure accuracy.
4. The DON or designee will complete a MDS audit weekly x 4 weeks then monthly x 2 months to ensure accuracy. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

483.20(e)(1)(2) REQUIREMENT Coordination of PASARR and Assessments: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.
483.20(e) Coordination.
A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes:

483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care.

483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to incorporate the recommendations from the Pre-Admission Screening and Resident Review (PASARR) level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for three of three residents reviewed (Residents 26, 4 and 7).

Findings include:

Review of clinical record of Resident 26 revealed diagnoses to include Schizoaffective Disorder (Schizoaffective disorder is a mental disorder in which a person experiences a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania).

Further review of Resident 26's clinical record revealed a PASARR Level I (federally required assessment to help ensure that all individuals with serious mental disorders and/or intellectual disabilities are not inappropriately placed in nursing homes for long term care) dated September 8, 2020, with the following outcome: "Individual has a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition; requires further evaluation (Level II)."

A PASARR Level II determination letter dated September 10, 2020 indicated that, "You do have evidence of a Mental Health condition that meets the criteria for review by the Office of Mental Health and Substance Abuse Services (OMHSAS). "You may benefit from specialized mental health services. The County Mental Health office shall assist the nursing facility in accessing mental health services for you in accordance with OMHSAS Bulletin-16-11. The treatment must be provided by qualified mental health professionals, and treatment can include partial psychiatric hospitalization, peer support services, psychiatric outpatient clinic services, mobile mental health treatment, crisis intervention services, targeted mental health care management, and outpatient drug and alcohol services. Residents who reside in the Nursing Facility may receive specialized mental health services either in the facility or in the community."

Review of Resident 26's current care plan conducted during the survey ending May 26, 2022, revealed no care plan developed in relationship to the PASARR II determination. The care plan failed to identify the individual and specific referrals made, or services recommended and/or provided to the resident as the result of the resident's mental health condition and PASARR II.

Review of clinical record of Resident 4 revealed diagnoses to include mild Intellectual Disability (mild to severe impairment in intellectual ability equivalent to an IQ of 70 to 75 or below that is accompanied by significant limitations in social, practical, and conceptual skills (as in interpersonal communication, reasoning, or self-care) necessary for independent daily functioning and that has an onset before age 18).

Further review of Resident 4's clinical record revealed a PASARR Level I (federally required assessment to help ensure that all individuals with serious mental disorders and/or intellectual disabilities are not inappropriately placed in nursing homes for long term care) dated July 3, 2021, with the following outcome: "Individual has a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition; requires further evaluation (Level II)."

A PASARR Level II determination letter dated July 7, 2021 indicated that, "You have evidence of an Intellectual Disability. The Office of Developmental Programs, Department of Human Services has reviewed your information for nursing facility placement and the possibility that you are a person with an ID. Additional ID specialized services are available for individuals who are in a nursing facility. These services can include training, treatments, therapies and related services to help people function as independently as possible. Based on the review of your information the departments determination appears below: You do require ID/MR specialized services."

Review of Resident 4's current care plan conducted during the survey ending May 26, 2022, revealed no care plan in effect related to the PASARR II determination. The resident's care plan failed to identify the individual and specific referrals made, or services recommended and/or provided to the resident as the result of the resident's intellectual disability and PASARR II.

Review of clinical record of Resident 7 revealed diagnoses to include bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).

Further review of Resident 7's clinical record revealed a PASARR Level I (federally required assessment to help ensure that all individuals with serious mental disorders and/or intellectual disabilities are not inappropriately placed in nursing homes for long term care) dated January 12, 2022, with the following outcome: "You have had a PASARR Level I screening process done and you are in need of a further PASARR Level II evaluation to make certain that a nursing facility is the most appropriate setting/placement for you and to identify the need for possible MI (mental illness), ID/DD, or ORC (community outreach) services in the nursing facility's plan of care for you, if you choose to be admitted to a nursing facility.

A PASARR Level II determination letter dated February 23, 2022 indicated that, "You do have evidence of a Mental Health condition that meets the criteria for review by the Office of Mental Health and Substance Abuse Services (OMHSAS). "You may benefit from specialized mental health services. The County Mental Health office shall assist the nursing facility in accessing mental health services for you in accordance with OMHSAS Bulletin-16-11. The treatment must be provided by qualified mental health professionals, and treatment can include partial psychiatric hospitalization, peer support services, psychiatric outpatient clinic services, mobile mental health treatment, crisis intervention services, targeted mental health care management, and outpatient drug and alcohol services. Residents who reside in the Nursing Facility may receive specialized mental health services either in the facility or in the community."

Review of Resident 7's current care plan conducted during the survey ending May 26, 2022, revealed no care plan in relation to the PASARR II determination. The care plan failed to identify the individual and specific referrals made or services recommended and provided to the resident as the result of the resident's mental health condition and PASRR II.

An interview with the Nursing Home Administrator and Director of Nursing on May 25, 2022, at 2:00 p.m. confirmed that the PA-PASARR-ID II form completed had identified Residents' 26, 4, and 7 as target residents requiring services. The NHA and DON were unable to identify the services to be provided for the residents while in the skilled nursing facility.

There was no evidence at the time of the survey that the facility had timely identified and coordinated the provision of specialized services for these targeted residents.

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

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

28 Pa. Code 211.5(f) Clinical Records








 Plan of Correction - To be completed: 06/30/2022

1. Residents #26, #4, and #7 Care Plans were reviewed by the IDT and updated (if indicated) to incorporate the referrals made, services recommended and/or provided to the resident as a result of the resident's mental health condition and PASRR II.
2. The Care Plans of residents with PASRR II assessments completed were reviewed by the IDT and updated if indicated.
3. The SSD was re-educated on updating Care Plans to incorporate referrals made, services recommended and/or provided to residents with mental condition and PASRR II. The IDT will review residents with PASRR II assessments completed to ensure appropriate care plans reflect additional services needed and provided.
4. The DON or designee will complete Care Plan audits on residents with mental condition and PASRR II weekly x 4 weeks then monthly x 2 months to ensure additional services needed are provided and documented. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a written notice of transfer to the hospital, containing the necessary details, was provided to the resident and the residents' representative for two of 12 residents reviewed (Residents 11 and 19).

Findings include:

A review of the clinical records revealed that Resident 11 was transferred and admitted to the hospital on March 25, 2022, and returned to the facility April 1, 2022.

A review of the clinical record of Resident 19 revealed admission to the facility on November 13, 2020, with diagnoses that included hypertension and depression. Further review of the resident's clinical record revealed that the resident was admitted to the hospital on April 11, 2022 and returned to the facility April 14, 2022.

Further review of the clinical records of the above residents revealed documented evidence that written notice was provided to these residents and their representatives regarding the transfers. However, these notice did not include the reason for the transfer, a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; if applicable, the mailing and email address and if applicable telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities, and the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

Interview with the Nursing Home Administrator on May 26, 2022, at approximately 10:30 a.m. confirmed that the notices of transfer the facility provided failed to contain the necessary information.



28 Pa. Code 201.14(a) Responsibility of Licensee

28 Pa. Code 201.29(i) Resident rights





















 Plan of Correction - To be completed: 06/30/2022

1. The facility is unable to retroactively provide written notices of transfer containing necessary details to the hospital, to residents #11 and #19, and the residents' representative.
2. Residents transferring out have the potential to be affected by this deficiency, transfer letter was updated to contain all necessary details.
3. Facility Business Office Manager was re-educated and updated current written notice of transfer which contains necessary details. The new transfer letter will be provided to future residents transferring out of the facility. Transfers will be reviewed at the morning meeting to ensure notices are sent timely.
4. The NHA/designee will conduct an audit of residents transferring out of facility weekly x 4 weeks and monthly x2 to ensure transfer letters containing required information were sent. The results will be submitted to the QAPI committee for review and analysis for need of ongoing monitoring.

483.21(c)(1)(i)-(ix) REQUIREMENT Discharge Planning Process:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(c)(1) Discharge Planning Process
The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and-
(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident.
(ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
(iii) Involve the interdisciplinary team, as defined by 483.21(b)(2)(ii), in the ongoing process of developing the discharge plan.
(iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.
(v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.
(vi) Address the resident's goals of care and treatment preferences.
(vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community.
(A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose.
(B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities.
(C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.
(viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences.
(ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.
Observations:

Based on a review of clinical records and staff and resident interview it was determined that the facility failed to develop and implement an individualized discharge plan for one of one resident reviewed for discharge planning (Resident 11).

Findings Include:

A review of the clinical record of Resident 11 revealed admission to the facility on February 10, 2022, with diagnoses including Dementia with Behavioral Disturbance.

Further review of Resident 11's clinical record revealed a social service note dated February 25, 2022, that the resident's responsible party relayed that he wanted his wife to be moved to a facility closer to his home.

There was no further documentation regarding the resident's discharge planning until May 12, 2022.

There was no documented evidence that the facility had been continuously evaluating the resident's discharge goals throughout the resident's stay to ensure a successful discharge as desired by the resident and the resident's representative.

Review of Resident 11's current active care plan initiated on February 10, 2022, revealed no active care plan regarding resident 11's discharge goals.

There was no documented evidence that social services had been actively involved and had discussed this resident's ongoing discharge plans and responsible party's desire for resident to be closer to home.

During an interview on May 26, 2022, at 11:00 a.m. the Director of Nursing was unable to provide documented evidence of the ongoing process in developing Residents 11's discharge plans and meeting the residents' current transfer/discharge goals.


28 Pa. Code 201.25 Discharge policy

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

28 Pa. Code 201.18 (e)(1)(2)(3)(6) Management

28 Pa. Code 201.29 (i)(j) Resident rights.





 Plan of Correction - To be completed: 06/30/2022

1. The facility is unable to retroactively document discharge planning information that was completed on behalf of the resident. Resident #11's Care Plan was updated with individualized Discharge Planning goals.
2. Current facility resident's care plans reviewed regarding discharge planning and updated as necessary.
3. SSD re-educated on importance of developing and implementing individualized discharge planning. The IDT will review resident discharge planning goals at least quarterly during care plan meetings.
4. NHA or designee will audit 25% of facility residents weekly x4 weeks then monthly x2 to ensure adequate and continuous discharge planning documentation and care plan goals. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on review of clinical records, and staff interview, it was determined that the facility failed to thoroughly assess and evaluate bladder function and implement individualized interventions to restore or maintain bladder function to the extent possible for two out of 12 sampled residents (Residents 3, and 19).

Findings include:

Review of Resident 3's clinical record indicated that the resident was admitted to the facility on May 30, 2021, and had diagnoses that included diabetes, hypertension, and dementia.

A quarterly Minimum Data Set Assessments (MDS -a federally mandated standardized assessment completed at specific intervals to define resident care needs) dated September 12, 2021, indicated that the resident was severely cognitively impaired, dependent on staff for activities of daily living (ADLs- the basic tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring and repositioning) and was occasionally incontinent of urine.

A review of a March 3, 2022 Comprehensive Bladder and Bowel Evaluation indicated the resident was incontinent of bladder, but not appropriate for toileting or retraining program.
However, there was no evidence of a corresponding bladder tracking or voiding diary that had been completed in an attempt to identify any patterns of incontinence or voiding habits in an effort to develop and implement a scheduled for timed toileting plan for this resident to decrease episodes of incontinency.

A quarterly MDS assessment dated March 9, 2022, indicated that the resident was severely cognitively impaired, dependent on staff for ADL's and was now frequently incontinent of urine.

A review of the clinical record of Resident 19 revealed admission to the facility on November 13, 2020, with diagnoses that included hypertension and depression.

An annual MDS dated November 14, 2021, indicated that the resident was moderately cognitively impaired, dependent on staff for ADLs and was continent of urine.

A significant change MDS Assessment dated April 15, 2022, indicated that the resident was severely cognitively impaired, dependent on staff for ADLs and was now occasionally incontinent of urine.

Review of an April 18, 2022, Comprehensive Bladder and Bowel Evaluation indicated that the resident was incontinent of bladder, but not appropriate for toileting or retraining program.

However, there was no documented evidence of corresponding bladder tracking or voiding diary that had been completed in an attempt to identify any patterns of incontinence or voiding habits in an effort to develop and implement a scheduled for timed toileting plan for this resident to decrease episodes of incontinency.

Interview with the Director of Nursing on May 26, 2022 at 10:30 a.m. verified that Residents 3 and 19 were not placed on a scheduling toileting program or individualized timed toileting in an attempt to decrease episodes of incontinency.


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

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


























 Plan of Correction - To be completed: 06/30/2022

1. Residents #3 and #19 had three-day bowel and bladder diaries completed with a RN assessment and program developed.
2. Facility wide bowel and bladder diary and RN assessment completed to ensure those requiring bowel and bladder programs had appropriate programs in place.
3. Licensed Nurses were re-educated on the facility's Incontinence Management Protocol. The DON will review residents Incontinence Management programs at least quarterly and PRN.
4. The NHA or designee will complete audits on 25% of facility residents weekly x 4 weeks then monthly x 2 months to ensure adequate and appropriate Incontinence Management programs are in place. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs: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.
483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

483.55(b) Nursing Facilities.
The facility-

483.55(b)(1) Must provide or obtain from an outside resource, in accordance with 483.70(g) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

483.55(b)(2) 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 locations;

483.55(b)(3) 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;

483.55(b)(4) 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; and

483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.
Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to offer routine annual dental services for one Medicaid payor sources out of 12 residents sampled. (Resident 3).

Findings include:

Review of Resident 3's clinical record indicated that the resident was admitted to the facility on May 30, 2021, and that the resident's payor source was Medicaid.

There was no documented evidence that the resident had been offered dental services in the past year.

Interview with the Director of Nursing on May 25, 2022 at 10:30 a.m. confirmed that the facility had no documented evidence that Resident 3 was offered routine dental services in the past year.



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

28 Pa. Code 211.15(a) Dental services








 Plan of Correction - To be completed: 06/30/2022

1. Resident #3 will be offered dental services.
2. Current facility residents will be offered routine annual dental services.
3. DON re-educated on importance of residents being offered dental services. Admission documents will include dental permission form. The Social Worker will monitor resident dental appointments to ensure they are offered services at least annually.
4. NHA or designee will complete an audit of 25% of facility residents weekly x4 weeks then monthly x2 to ensure dental services were offered. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(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 of the food and nutrition services department and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for microbial growth in food, which increased the risk of food-borne illness.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

Interview with employee 2 (cook) during the initial tour of the food and nutrition services department on May 24, 2022, at 9:05 AM revealed that the facility did not currently have a full-time dietary services supervisor working onsite at the facility. Employee 2 confirmed that the current full-time dietary dietary supervisor was available by phone but was currently working onsite at a "sister" facility.

Observation of the food and nutrition services department on May 25, 2022 at 11:45 AM revealed dried debris adhered to the surface of two of three ceiling lights in the food-prep area.

There was also a thick build-up of a white substance adhered to the outer surface of the dish machine. Interview with the administrator at this time failed to provide documented evidence a procedure was in place to minimize the build-up of the white substance on the dish machine.

Interview with the administrator at this time confirmed the food and nutrition services department was to be maintained in a sanitary manner.



28 Pa. Code 211.6 (c)(d) Dietary services.















 Plan of Correction - To be completed: 06/30/2022

1. The ceiling lights were cleaned. Cleaning of the ceiling light added to routine monthly maintenance. A procedure was put in place to minimize the build-up of limescale on the outside of the dish machine.
2. A kitchen and food storage area sanitation audit was completed by a Registered Dietitian.
3. The dietary department was re-educated on maintaining acceptable practices for the storage and service of food. The CDM or designee will complete random sanitation audits.
4. The NHA or designee will conduct sanitation audits weekly x 4 weeks then monthly x 2 months. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

483.90(e)(1)(ii) REQUIREMENT Bedrooms Measure at Least 80 Sq Ft/Resident: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.
483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms;
Observations:

Based on observations and space measurements provided by the facility, it was determined that the facility failed to provide the regulatory required minimum square footage in nine of 21 resident rooms.

Findings include:

Observations made on May 25, 2022 at 9:00 AM, revealed square footage was not adequate in the following rooms:

Room 22 is a single-bedded resident room, which requires a minimum of 100 square feet. The square footage of this room measured 85 square feet.

Resident rooms 15, 16, 17, 18, 19, 20, 21, and 23 are two- bedded resident rooms with square footage measurements of only 143 square feet.

These multi-bed rooms failed to provide the minimum square footage requirement of 80 square feet per bed, or a total of 160 square feet in a semi-private room.


483.70(d)(1)(ii) Bedrooms

28 Pa. Code: 205.20 (d)(f) Resident bedrooms







 Plan of Correction - To be completed: 06/30/2022

1. This situation poses no threat to the safety or well-being of the residents in these rooms; therefore, the facility has requested a waiver continuation of 42CFR 483.70 (d) (1) (ii) by a previously submitted letter. Please note that the facility meets the variation in square footage requirements adopted by the Commonwealth of Pennsylvania at 28 PA Code section 205.20 (e) and 205.30 (g)
2. The facility is selective in room placement and considers resident's needs and safety when assigning rooms. This facility remains committed to assuring the special needs of the residents in these rooms are met to ensure that their health and safety are not adversely affected.
3. If a resident or family member requests a room change, the facility make every effort to place the resident in a different room.
4. NHA or designee will discuss room change requests at the Interdisciplinary Team meeting. NHA or designee will audit resident Council meeting minutes to ensure concerns regarding room placement are addressed monthly x 6 months. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

201.19 LICENSURE Personnel policies and procedures.:State only Deficiency.
Personnel records shall be kept current and available for each employe and contain sufficient information to support placement in the position to which assigned.
Observations:

Based on review of personnel records of newly hired employees since the last standard survey, and staff interviews, it was determined that the facility failed to verify an employee's health status prior to reporting to their assigned department and having resident contact (Employee 1) for one employee out of five sampled

Findings include:

Review of employee personnel files revealed that Employee 1 (Occupational Therapy Assistant) was hired February 3, 2022. However, a review of the employee's physical health exam revealed that it was dated July 9, 2021.

There was no indication that the facility had verified the employee's health status and that the employee was free of communicable disease at the time of hire. The employee had resident contact from his hire date through the time of the survey ending May 26, 2022.

Interview with the Administrator on May 26, 2022 at 11:15 a.m. confirmed that the employee's health status was not verified and the employee determined to be free of communicable disease upon hire and prior to resident contact.






 Plan of Correction - To be completed: 06/30/2022

1. Employee #1 contacted his PCP and most recent annual physical 3/23/2022 was sent which includes that he is free of communicable diseases.
2. An employee chart audit was completed to identify other new hires with unverified health status. None were found.
3. The Onboarding and Recruitment Specialist was re-educated on verifying health status on hire. The NHA will complete new hire chart reviews before new employees are scheduled.
4. The NHA or designee will complete a new hire chart review weekly x 4 weeks then monthly x 2 months to ensure health status is verified prior to scheduling new hires. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

211.6(d) LICENSURE Dietary Services.:State only Deficiency.
(d) If consultant dietary services are used, the consultant's visits shall be at appropriate times and of sufficient duration and frequency to provide continuing liaison with medical and nursing staff, advice to the administrator, resident counseling, guidance to the supervisor and staff of the dietary services, approval of menus, and participation in development or revision of dietary policies and procedures and in planning and conducting inservice education and programs.
Observations:

Based on observation and staff interview it was determined that the facility failed to ensure that onsite visits by the consultant dietitian were of sufficient duration and frequency to include the provision of comprehensive individualized nutritional assessments for residents and resident counseling, guidance to the supervisor and staff of the dietary services, and planning and conducting inservice education and programs.

Findings include:

Observation and interview with Employee 2 (cook) during the initial tour of the food and nutrition services department on May 24, 2022, at 9:05 AM revealed that the facility's full-time dietary services supervisor (certified dietary manager) was not currently working onsite at the facility. Employee 2 confirmed that the current certified dietary manager was available by phone, but was currently working onsite at a "sister" facility.

Interview with the Nursing Home Administrator (NHA) on May 24, 2022, at 10:00 AM confirmed that the current full-time qualified dietary services supervisor was working full-time at a "sister" facility. The NHA confirmed that the facility does not provide the services of a full-time qualified dietitian in the absence of a qualified dietary services supervisor. The NHA confirmed that the facility employs a consultant dietitian on a part-time basis with the majority of consultant services being provided via remote computer access.

A review of the certifying board for dietary managers (the credentialing agency for the association of nutrition and food service professionals) scope of practice for certified dietary managers revealed that the scope of practice did not include the clinical assessment and evaluation of residents for medically related nutritional therapy or to make recommendations regarding medications or supplementation.

Review of the consultant dietitian's signed contract with the facility dated December 14, 2020, revealed that the contractor agrees to perform the services listed in the "Registered Dietitian Job Description."

Review of the Registered Dietitian Job Description revealed that the primary purpose of the job position is to implement, coordinate and evaluate the medical nutrition therapy for the residents, provide resident and family education, provide nutritional assessment and consultation to assist in planning, organizing and directing the food and nutritional services of the facility.

Review of documentation submitted to the facility by the consultant dietitian for services provided during the months of January 2022 through May 2022 revealed that all documented consultant dietary services provided for residents at the facility were completed via remote computer access. There were no onsite visits completed by the consultant dietitian during this time frame

Interview with the administrator on May 26, 2022 at 12:30 PM confirmed there were no onsite visits completed by the consultant dietitian.

Interview with the administrator on May 26, 2022 at 12:30 PM failed to provide documented evidence that onsite visits by the consultant dietitian were completed at a frequency sufficient enough to meet the regulatory requirements for consultant dietary services.





 Plan of Correction - To be completed: 06/30/2022

1. A facility employed Registered Dietitian will conduct onsite visits to provide comprehensive individualized nutrition assessments for residents in addition to counseling and guidance services for staff and residents.
2. The facility will employ a Registered Dietitian onsite for eight hours per week. The Registered Dietitian will be available PRN and by phone for additional needs. The facility's NHA also holds the credentials of Registered Dietitian and will provide direct oversight of the dietary needs of the residents to relay to the Registered Dietitian.
3. The NHA was re-educated on the requirements of 1755. The NHA will ensure ongoing, adequate Registered Dietitian coverage.
4. The NHA or designee will complete a one-time audit to verify that a Registered Dietitian is onsite for eight hours per week to ensure compliance with 1755. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.


211.12(f)(1) LICENSURE Nursing services.:State only Deficiency.
(f) In addition to the director of nursing services, the following daily professional staff shall be available:

(1) The following minimum nursing staff ratios are required:

Census Day Evening Night
59 and under 1 RN 1 RN 1 RN or 1 LPN
60/150 1 RN 1 RN 1 RN
151/250 1 RN and 1 LPN 1 RN and 1 LPN 1 RN and 1 LPN
251/500 2 RNs 2 RNs 2 RNs
501/1,000 4 RNs 3 RNs 3 RNs
1,001/Upward 8 RNs 6 RNs 6 RNs



Observations:

Based on review of facility nurse staffing and staff interview, it was determined that the facility failed to ensure that, in addition to the Director of Nursing (DON), there was a registered nurse on duty, on the day and evening tours of duty on three of 21 days reviewed.

Findings include:

A review of nursing time schedules revealed there was no registered nurse on duty, on the day tour of duty, on April 18, 2022, from 7:00 AM to 3:00 PM (8 hours) with a resident census of 24; on the evening tour of duty, on April 20, 2022, from 3:00 PM to 11:00 PM (8 hours) with a resident census of 25; and on April 22, 2022, from 3:00 PM to 11:00 PM (8 hours) with a resident census of 23.

During an interview with the Nursing Home Administrator (NHA), on May 26, 2022, at approximately 12:00 PM, confirmed that the facility failed to provide evidence, that in addition to the DON, there was a RN was on duty during the day and evening shifts on the above dates.





 Plan of Correction - To be completed: 06/30/2022

1. The facility is unable to retroactively provide another RN on the cited dates. The RNAC was also in the facility during the cited times.
2. The facility will employ a RN on the day shift and evening shift tour of duty in addition to the DON.
3. The DON was re-educated on the RN requirements under 2000. The NHA and DON will hold daily staffing meetings to ensure RN coverage in addition to the DON.
4. The NHA will complete an audit of the RN schedule weekly x 4 weeks then monthly x 2 months to ensure RN coverage in addition to the DON. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.


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