Pennsylvania Department of Health
CHRIST THE KING MANOR
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CHRIST THE KING MANOR
Inspection Results For:

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CHRIST THE KING MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and complaint survey completed on June 13, 2024, it was determined that Christ the King Manor 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:

483.20(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 the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for seven of 42 residents reviewed (Residents 17, 52, 63, 64, 98, 103, 117).

Findings include:

The Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that Section O0110G1b (non-invasive mechanical ventilator) and Section O0110G3b (CPAP- Continuous positive airway pressure - a machine that uses mild air pressure to keep breathing airways open while sleeping) was to be checked if a CPAP device was used while a resident at the facility during the seven-day assessment period.

Physician's orders for Resident 17, dated March 25, 2024, included an order for the resident to use a CPAP with humidification at bedtime with oxygen at 2 Liters per minute (L/min) every night.

A quarterly MDS for Resident 17, dated April 20, 2024, revealed that Section O0110G1b and Section O0110G3b were not checked indicating that the resident did not use a CPAP device during the seven-day assessment period.

Review of the MAR for Resident 17 dated April 2024 revealed that the resident used a CPAP device every night during the seven-day assessment period.

Interview with the Director of Nursing on June 13, 2024, at 7:46 a.m. confirmed that Section O0110G1b and Section O0110G3b of Resident 17's quarterly MDS assessment, dated April 20, 2024, should have been checked to indicate that he used a CPAP device during the seven-day assessment period but was not.

The Long-Term Care Facility RAI User's Manual, dated October 2023, revealed that Section N0415C should be checked if the resident received an antidepressant medication, Section N0415G was to be checked if the resident received a diuretic medication, and Section N0415H was to be checked if the resident received an opioid (pain medication) medication during the seven-day assessment period.

Physician's orders for Resident 52, dated May 15, 2024, included an order for the resident to receive 2 milligrams (mg) of Bumetanide (diuretic) one time a day and 10 mg of Fluoxetine (an antidepressant) one time day. Physician's orders, dated April 5, 2024, included an order for the resident to receive 50 mg of Tramadol (opioid pain medication) once daily at bedtime.

A quarterly MDS for Resident 52, dated May 21, 2024, revealed that Section N0415C, Section N0415G, and Section N0415H where not checked, indicating that the resident did not receive a diuretic medication, an antidepressant medication, or an opioid medication during the seven-day look-back assessment period.

Review of the MAR for Resident 52, dated May 2024 revealed that the resident received 2 mg of Bumetanide once a day, 10 mg of Fluoxetine once a day, and 50 mg of Tramadol once a day during the seven-day assessment period.

Interview with the Director of Nursing on June 13, 2024, at 7:45 a.m. confirmed that Section N0415C, Section N0415G, and Section N0415H of Resident 52's quarterly MDS assessment for May 15, 2024, was checked incorrectly and should have been checked to indicate that she received a diuretic, antidepressant, and opioid medication during the seven-day assessment period.

The Long-Term Care Facility RAI User's Manual, dated October 2023, revealed that Section O0110J1b was to be checked if the resident was receiving dialysis treatment while a resident at the facility during the seven-day assessment period.

Physician's orders for Resident 63, dated August 2, 2023, included an order to ensure communication forms are sent with the resident to dialysis every Monday, Wednesday, and Friday, and to ensure the form is received back upon return.

A quarterly MDS for Resident 63, dated June 5, 2024, revealed that section O0110J1b was not checked, indicating that the resident did not receive dialysis treatment during the seven-day assessment period.

Interview with the Director of Nursing on June 13, 2024, at 9:46 a.m. confirmed that section O0110J1b of Resident 63's quarterly MDS assessment, dated June 5, 3024, was not checked to indicate that she was receiving dialysis treatments while a resident at the facility during the seven-day assessment period and it should have been.

The RAI User's Manual, dated October 2023, revealed that if a resident used oxygen, then Section O0110C was to be checked if it applied.

Physician's orders for Resident 64, dated February 23, 2024, and March 21, 2024, included orders for the resident to use a CPAP with oxygen at 2 liters per minute (lpm) during the evening and night shift and to receive 2 liters of oxygen per minute every shift.

Review of Resident 64's MAR for March 2024 revealed that the resident used a CPAP device during the evening and night shift and received 2 liters of oxygen every shift from March 1 to 31, 2024. However, a quarterly MDS assessment, dated May 29, 2024, revealed that Section O0110G1b and Section O0110G3b were not checked, indicating that the resident did not use a CPAP device during the review period, and Section O0110C was not checked, indicating that the resident did not receive oxygen during the review period.

Interview with the Director of nursing on June 13, 2024, at 7:45 a.m. confirmed that Resident 64's quarterly MDS of May 29, 2024, was coded incorrectly.

The RAI User's Manual, dated October 2023, revealed that if the resident had a fall since admission, entry or re-entry, or a prior assessment, then Section J1800 was to be coded (1) Yes, and Section J1900 was to be completed. If the resident had a fall with no injury since admission, entry or re-entry, or a prior assessment then J1900A was to be coded with the number of falls. If the resident had a fall with an injury (skin tears, abrasions, lacerations, superficial bruises, hematoma) since admission, entry or re-entry, or a prior assessment then Section J1900B was to be coded with the number of falls. If the resident had a fall with a major injury (bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma) since admission, entry or re-entry, or a prior assessment then Section J1900C was to be coded with the number of falls.

An investigation report and nursing note for Resident 98, dated March 27, 2024, at 10:53 p.m. revealed that the resident was found lying on the floor in the resident's room. He was having some pain with his knee and was reluctant to bend it. An x-ray result, dated March 28, 2024, revealed that the resident had an acute fracture of the right hip.

A significant change MDS assessment for Resident 98, dated April 6, 2024, revealed that Section J1800 was incorrectly coded zero (0) - No, indicating that the resident had no falls since admission, entry or re-entry, or the prior assessment. By coding Section J1800 as (0) No, the computerized MDS software did not allow Sections J1900C to be completed to reflect that the resident had a fall and fracture.

Interview with the Director of nursing on June 13, 2024, at 7:45 a.m. confirmed that Resident 98's significant change MDS assessment of April 6, 2024, was coded incorrectly.

An investigation report and nursing note for Resident 103, dated May 14, 2024, at 6:57 a.m. revealed that the resident was found lying on the floor beside his bed and had a 3.0 centimeter (cm) superficial scratch to his forehead.

A significant change MDS assessment for Resident 103, dated May 18, 2024, revealed that Section J1900 was coded (1) indicating that the resident had one fall with a major injury.

Interview with the Director of nursing on June 12, 2024, at 1:25 p.m. confirmed that Resident 103's admission MDS assessment of May 18, 2024, was coded incorrectly.

A discharge MDS for Resident 117, dated April 28, 2024, revealed that section A2105 indicated the resident was discharged to a short-term general hospital.

Physician's orders for Resident 117, dated April 28, 2024, included an order to discharge to home.

Interview with the Director of Nursing on June 13, 2024, at 9:46 a.m. confirmed that Section A2105, Resident 117's discharge MDS assessment, dated April 28, 2024, should have been checked to indicate that the resident was discharged to home.

28 Pa. Code 211.5(f) Clinical Records.

Plan of Correction - To be completed: 07/17/2024

Christ the King Manor intends to ensure to complete accurate Minimum Data Set assessments for all residents. Corrective actions for those resident found to have been affected were as follows; Resident #17,52,63,64,98,103,and 117 all have had modification assessments completed and all information corrected to reflect proper coding of the Minimum Data Set assessment. These have all been accepted by Centers for Medicare and Medicaid Quality Improvement and Evaluation System.

No other residents have been affected or identified to be affected by the deficient practice.

Measures put into place to ensure deficient practice does not recur; education has been provided to the Registered Nurse Assessment Coordinators on accurate coding of the Minimum Data Set (MDS) according to the Resident Assessment Instrument manual.

Corrective action will be monitored to ensure deficient practice will not recur is audits will be completed by the Director of Nursing and or her designee to assure accurate Minimum Data Set assessments in the items identified for all assessments for 14 days. Audits will continue weekly for 4 weeks then monthly for 2 months.

Audits will be monitored and reviewed by Quality Assurance Committee for compliance.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:

§483.25(g)(4)-(5) Enteral Nutrition
(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)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

Observations:

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an enteral feeding was administered in accordance with physician's orders for one of 42 residents reviewed (Resident 67).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 67, dated April 25, 2024, revealed that the resident was understood, could understand others, and had a feeding tube. A care plan for the resident, dated February 9, 2024, revealed that the resident required supplemental tube feed (a way to provide nutrition when you cannot eat or drink safely by mouth) and fluids via percutaneous endoscopic gastrostomy (PEG -the placement of a feeding tube through the skin and the stomach wall) tube to meet nutritional/hydration needs. Staff were to give 240 milliliters (ml) of Glucerna (a tube feeding formula) daily for inadequate oral intake via PEG-tube as ordered. A care plan, dated May 6, 2024, revealed that the resident has a potential nutritional problem related to impaired oral intake and the need for a mechanically altered diet. Staff was to provide and serve supplements as ordered: Give 240 ml of Glucerna 1.5 Cal via PEG-tube after meals for impaired oral intake when she consumes less than three points of her meal (a system used to explain the amount eaten).

Physician's orders for Resident 67, dated November 8, 2023, included an order for staff to give 240 ml of Glucerna 1.5 Cal via PEG-tube after meals for impaired oral intake when she consumes less than three points of her meal.

Resident 67's amount eaten record for April and May 2024 indicated that the resident ate four points during the lunch meal and five points during the supper meal on April 15, 2024; ate three points during the lunch meal on April 29, 2024; ate six points during the lunch meal on May 7, 2024; ate four points during the supper meal on May 15, 2024; ate three points during the lunch meal on May 19, 2024; ate three points during the lunch meal on May 23, 2024; and ate four points during the supper meal on May 27, 2024.

However, Resident 67's Medication Administration Records, dated April and May 2024, indicated that she received the 240 ml bolus feeding of Glucerna 1.5 Cal on the above dates.

Interview with the Director of Nursing on June 13, 2024, at 9:56 a.m. confirmed that Resident 67 received the 240 ml bolus feeding of Glucerna 1.5 Cal on the above dates when her meal points were three and/or above and that she should not have been given the 240 ml bolus feeding of Glucerna 1.5 Cal.

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

Plan of Correction - To be completed: 07/17/2024

Christ the King Manor intends to ensure that enteral feeding is administered in accordance with physician's orders. The facility cannot retroactively correct the citation that was identified for Resident # 67.

No other residents in the facility are identified to be in be affected by the same deficient practice.

Measures put into place to ensure that the deficient practice does not recur; education will be provided to all licensed staff, including agency staff, regarding supplemental feedings when residents also eat by mouth. Medication administration record for recording resident's meal intake will now be completed by the Licensed Practical Nurse to ensure accurate documentation.

Corrective actions will be monitored to ensure the deficient practice will not recur; Audits will be completed by Director of Nursing and or her designee to ensure supplemental feedings are only administered when they are in the guidelines of the physician's orders.

Audits will be completed daily for 14 days then weekly for 4 weeks then monthly for 2 months.

Corrective actions will be monitored by audits completed and will be submitted to Quality Assurance Committee for compliance.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations:

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for two of 42 residents reviewed (Residents 24, 67).

Findings include:

A significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated April 20, 2024, revealed that the resident was usually understood, could usually understand others, and had a diagnosis of dementia.

Physician's orders for Resident 24, dated April 16, 2024, included an order for staff to cleanse the resident's left buttocks with wound cleanser then apply Chamosyn ointment (used to protect skin from wetness, urine, or stools) to her Peri wound (the area around the wound) and place Xeroform (a fine mesh gauze occlusive dressing impregnated with petrolatum and 3 percent Xeroform) to her open wounds. Then place an ABD pad (a gauze dressing that absorbs fluid from large or heavily draining wounds) every day and evening shift and as needed with each incontinence.

Physician's orders for Resident 24, dated April 15, 2024, included an order for the resident to receive 0.25 milliliters (ml) of morphine sulfate (used to treat moderate to severe pain) every three hours as needed for pain/shortness of breath.

Physician's orders for Resident 24, dated June 7, 2024, included an order for staff to administer the as needed Roxanol (the brand name for morphine) 15-20 minutes prior her to wound care every shift.

Resident 24's Treatment Administration Record (TAR), dated June 2024, indicated that the night shift staff documented as administering the as needed Roxanol 15-20 minutes prior her to wound care June 7 through 11, 2024. However, there was no documented evidence in the resident's clinical record and/or TAR that the night shift completed any wound care.

Interview with the Director of Nursing on June 12, 2024, at 12:15 p.m. confirmed that there was no documented evidence that the night shift completed any wound care on Resident 24 and that they should not be documenting the administration of the Roxanol 15-20 minutes prior to her wound care.

A quarterly MDS assessment for Resident 67, dated April 25, 2024, revealed that the resident was understood, could understand others, and had a feeding tube. A care plan for the resident, dated February 9, 2024, revealed that the resident requires supplemental tube feed (a way to provide nutrition when you cannot eat or drink safely by mouth) and fluids via percutaneous endoscopic gastrostomy (PEG -the placement of a feeding tube through the skin and the stomach wall) tube to meet nutritional/hydration needs. Staff were to give 240 milliliters (ml) of Glucerna (a tube feeding formula) daily for inadequate oral intake via PEG-tube as ordered. A care plan, dated May 6, 2024, revealed that the resident has a potential nutritional problem related to impaired oral intake and the need for a mechanically altered diet. Staff was to provide and serve supplements as ordered: Give 240 ml of Glucerna 1.5 Cal via PEG-tube after meals for impaired oral intake when she consumes less than three points of her meal.

Physician's orders for Resident 67, dated November 8, 2023, included an order for staff to give 240 ml of Glucerna 1.5 Cal via PEG-tube after meals for impaired oral intake when she consumes less than three points of her meal.

Physician's orders for Resident 67, dated November 2, 2023, included an order for staff to flush the resident's PEG-tube with 30 ml of warm water before and after each feeding.

Resident 67's Medication Administration Records (MARs), dated May and June 2024, indicated that staff did not give the 240 ml of Glucerna 1.5 Cal via Peg-tube on May 7, 2024, at 8:30 a.m.; on May 12, 2024, at 8:30 a.m. and 12:30 p.m.; on May 17, 2024, at 8:30 a.m.; on May 19, 2024, at 8:30 a.m.; on May 20, 2024, at 8:30 a.m. and 6:30 p.m.; on May 21, 2024, at 8:30 a.m., 12:30 p.m., and 6:30 p.m.; on May 22, 2024, at 8:30 a.m., 12:30 p.m., and 6:30 p.m.; on May 23, 2024, at 8:30 a.m.; on May 24, 2024, at 8:30 a.m.; on May 25, 2024, at 8:30 a.m. and 6:30 p.m.; on May 26, 2024, at 12:30 p.m.; on May 27, 2024, at 12:30 p.m.; on May 30, 2024, at 6:30 p.m.; on May 31, 2024, at 12:30 p.m.; on June 1, 2024, at 8:30 a.m.; on June 2, 2024, at 8:30 a.m.; on June 3, 2024, at 6:30 p.m.; on June 6, 2024, at 6:30 p.m.; on June 7, 2024, at 8:30 a.m., 12:30 p.m., and 6:30 p.m.; on June 8, 2024, at 6:30 p.m.; on June 9, 2024, at 6:30 p.m.; on June 10, 2024, at 8:30 a.m. and 12:30 p.m.; on June 11, 2024, at 8:30 a.m., and 12:30 p.m.; and on June 12, 2024, at 8:30 a.m.

However, Resident 67's TARs, dated May and June 2024, indicated that the staff documented as flushing the resident's PEG-tube with 30 ml of warm water before and after each feeding on the above dates and times.

Interview with the Director of Nursing on June 13, 2024, at 7:50 a.m. confirmed that staff documented as flushing the resident's PEG-tube with 30 ml of warm water before and after each feeding on the above dates and times when the resident did not receive the 240 ml of Glucerna 1.5 Cal via Peg-tube.

28 Pa. Code 211.5(f) Clinical Records.

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

Plan of Correction - To be completed: 07/17/2024

Christ the King Manor intents to ensure that clinical records are complete and accurate. The facility cannot retroactively correct the resident records for Resident # 24 and 67.

To identify other residents with the potential to be affected by the same deficient practice were as follows; all resident records for as needed medication were reviewed and changes made to the electronic record as necessary.

Measures put into place to ensure that the deficient practice does not recur; education was provided to all licensed nursing staff, including agency staff, regarding accurate documentation and the correct way to enter orders into the computer. The policy for noting orders will be reviewed by all licensed nurses.

Corrective action will be monitored to ensure deficient practice will not recur; audits will be completed daily for 14 days then weekly for 4 weeks, then monthly for 2 months. All audits will be submitted to Quality Assurance Committee for review and compliance.

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