Nursing Investigation Results -

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

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
CHRIST THE KING MANOR
Inspection Results For:

There are  69 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.
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, and Civil Rights Compliance survey completed on October 3, 2019, 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:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

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

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

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

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

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







Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to ensure that meals were served in a manner that maintained or enhanced each resident's dignity for seven of 70 residents reviewed (Residents 39, 52, 69, 87, 96, 109, 144).

Findings include:

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated July 20, 2019, revealed that the resident was severely cognitively impaired, required extensive assistance with her daily care, including eating, and had medical diagnoses that included hemiplegia (paralysis on one side of the body). The resident's care plan, dated November 7, 2018, revealed that the resident had required extensive assistance for eating.

Observations during the breakfast meal in the Skilled dining room on October 1, 2019, at 8:20 a.m. revealed that Resident 39 was seated at the same table as Residents 38 and 94. At 8:27 a.m. Resident 38 received her breakfast meal and at 8:29 a.m. Resident 94 received her breakfast meal. At 8:52 a.m. staff obtained a sippy cup with chocolate milk and sat down beside Resident 39 and helped her begin to drink it.

Interview with Licensed Practical Nurse 5 on October 1, 2019, at 1:05 p.m. revealed that Resident 39 had to wait for someone to come feed her.

Interview with the Director of Nursing on October 1, 2019, at 3:30 p.m. revealed that it was the facility's practice to feed all the residents seated at the same table at the same time. She confirmed that Resident 39 should have received her breakfast meal at the same time as the other residents seated at her table.

A quarterly MDS assessment for Resident 69, dated September 15, 2019, revealed that the resident was cognitively impaired and required staff assistance for eating.

Observations during the lunch meal in the Memory Support Unit (MSU) on September 30, 2019, at 12:05 p.m. revealed that Resident 69 was served puree consistency food items on a plate with raised edges, he was not given silverware, and he began to eat the food with his hands. Activity Aide 10 was seated next to Resident 69, was feeding Resident 81, and she did not get silverware for Resident 69. At 12:08 p.m., the Dietician gave Resident 69 some silverware and he finished his food by 12:10 p.m., at which time he tried scraping more food out of the plate, but it was empty. Activity Aide 10 called out multiple times for someone to get Resident 69 a sandwich. At 12:28 p.m., the Dietician brought Resident 69 a sandwich; however, Nurse Aide 11 removed the sandwich and stated, "He is pureed." Resident 69 was then given a bowl of mashed potatoes and some ice cream, and he ate all of it.

Interview with the Dietary Manager on October 1, 2019, at 5:14 p.m. confirmed that all of the residents should have silverware and drinks in front of them with their meals.

An admission MDS assessment for Resident 96, dated August 7, 2019, revealed that the resident was cognitively impaired and required extensive assistance for eating.

Observations during the lunch meal in the Memory Support Unit on September 30, 2019, at 11:57 a.m. revealed that Resident 96 was seated at a table with three other residents. She repeatedly wheeled herself away from the table, and staff redirected her and put her back to the table; however, she had no food, drink or anything else on the table. Resident 96's tablemates were served food at 12:07 p.m., 12:17 p.m. and 12:22 p.m. Resident 96 was not served food or drink until 12:24 p.m., and after the food and drink items were put in front of her, she continued to wheel herself away from the table. At 12:32 p.m., Nurse Aide 11 sat down to feed Resident 96. Interview with Nurse Aide 11 on September 30, 2019, at 12:45 p.m. revealed that she served Resident 96 last because the resident needs staff to cue her to eat and there was no one available to sit with her until after she (Nurse Aide 11) served all of the other residents, as other staff members who were scheduled to work had called off.

Observations during the lunch meal in the Memory Support Unit on September 30, 2019, at 11:57 a.m. revealed that Residents 87, 96 and 144 were seated in Broda chairs (an adaptive wheelchair that is low to the ground and that can be reclined) in a reclined position. The residents were served food, but were not placed into an upright position and could not reach their food and drink without stretching. Observations of Residents 52 and 109 revealed that they were seated in geri-chairs (a padded chair on wheels that can recline) and they were in a reclined position during the meal. Observations of Resident 109 revealed that each time he wanted a bite of food he had to reach up and over the table to get a bite, and then plopped back into the chair.

Interview with Nurse Aide 11 on September 30, 2019, at 12:45 p.m. revealed that Residents 52, 87, 96, 109 and 144 should have been seated in an upright position for their meals and they were not.

28 Pa. Code 201.29(j) Resident rights.


 Plan of Correction - To be completed: 11/25/2019

F-0550 Resident Rights/Exercise of Rights:
Christ the King Manor intents to ensure that meals are served in a manner that maintained or enhanced each resident's dignity. Corrective actions put into place for those residents found to have been affected by the deficient practice, Resident 39, 52, 69, 87, 96, 109, 144, re-education of new, current and agency staff related to entire meal services. Re-education included meals provided at same time for all resident sitting together at a dining table, timing of meal service, preparation of meal set up including having all silverware and beverages placed, positioning of residents during meals service, dignity during dining, appropriate support by staff for those residents needing assistance during dining and coordinating when residents are requesting second portions.

All residents have the potential to be affected by the alleged deficient practice. Corrective actions taken to eliminate potential deficient practice from potentially happening: re-education of staff related to entire meal services. Re-education included meals provided at same time for all resident sitting together at a dining table, timing of meal service, preparation of meal set up including having all silverware and beverages placed in advance, positioning of residents during meals service, dignity during dining, appropriate support by staff for those residents needing assistance during dining and coordinating when residents are requesting second portions. Additional corrective action steps include; presence of Licensed Nursing Staff or designee in the dining rooms to ensure timing of meal service, set up, positioning and support provided for those residents requiring assistance.
Measures put into place to ensure system changes are effective and do not recur; Daily audits will be conducted in each dining room for one meal by an RN Supervisor and designee for the next 4 weeks than weekly for the next 4 weeks and twice a week for the next 3 months.
Corrective actions will be monitored by submitted observations to Quality Assurance Committee for review, recommendations and compliance.

483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
483.75(g) Quality assessment and assurance.

483.75(g)(2) The quality assessment and assurance committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
Observations:








Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending November 1, 2018, and June 11, 2019, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending October 3, 2019, identified repeated deficiencies related to issues in the resident environment, developing and revising individualized care plans, ensuring that residents received care in accordance with physician's orders and/or professional standards, urinary catheters, feeding tubes, proper storage and labeling of medications, and proper food preparation and storage.

The facility's plan of correction for a deficiency regarding the resident environment, cited during the survey ending November 1, 2018, revealed that audits would be completed, and the results would be reported to the QAPI committee for review. The results of the current survey, cited under F584, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding providing a safe, clean, comfortable and homelike environment.

The facility's plan of correction for a deficiency regarding a failure to ensure that residents had individualized care plans, cited during the survey ending November 1, 2018, revealed that residents' care plans would be audited and the results of the audits would be reported to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding developing individualized care plans.

The facility's plan of correction for a deficiency regarding revising residents' care plans, cited during the survey ending November 1, 2018, revealed that audits of care plans would be completed, and the results would be reported to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding revising residents' care plans.

The facility's plans of correction for deficiencies regarding providing care in accordance with professional standards and residents' care plans, cited during the surveys ending November 1, 2018, and June 11, 2019, revealed that audits would be completed and the results would be reported to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding providing care in accordance with professional standards and residents' care plans

The facility's plan of correction for a deficiency regarding proper catheter care, cited during the survey ending November 1, 2018, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F690, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding urinary catheter care.

The facility's plan of correction for a deficiency regarding feeding tube care, cited during the survey ending November 1, 2018, revealed that audits would be completed and the results would be reported to the QAPI committee for review. The results of the current survey, cited under F693, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding feeding tubes.

The facility's plan of correction for a deficiency regarding the storage and labeling of medications, cited during survey ending November 1, 2018, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding proper medication storage and labeling.

The facility's plan of correction for a deficiency regarding sanitary food handling, cited during the survey ending November 1, 2018, revealed that audits would be completed and the results would be reported to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding food handling.

Refer to F584, F656, F657, F684, F690, F693, F761, F812.

28 Pa. Code 201.14(a) Responsibility of licensee.

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


 Plan of Correction - To be completed: 11/25/2019

Christ the King Manor intends to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively address recurring deficiencies; specifically as it relates to the resident environment, developing and revising individualized care plans, ensuring that residents receive care in accordance with physician orders and /or professional standards, urinary catheters, feeding tubes, proper storage and labeling of medications, and proper food preparation and storage. The facility is implementing new Performance Improvement and Action Plans for the repeated deficiencies cited.
All residents have the potential to be affect by the alleged deficient practices. Corrective actions for repeated deficiencies related to issues in resident environment, developing and revising individualized care plans, ensuring that residents receive care in accordance with physician orders and /or professional standards, urinary catheters, feeding tubes, proper storage and labeling of medications, and proper food preparation and storage.

System changes that have been put into effect to ensure alleged deficient practice does not recur; education will be conducted with the following areas, resident environment, developing and revising individualized care plans, ensuring that residents receive care in accordance with physician orders and /or professional standards, urinary catheters, feeding tubes, proper storage and labeling of medications, and proper food preparation and storage. Additional education will be provided to staff for any new systems that are developed out of Quality Assurance Committee. The Quality Assurance committee will root cause the deficiencies and the recurring deficiencies cited. Staff throughout the facility will have accountability in the understanding root causes and implementation of new processes.

Corrective actions that will be monitored to ensure that this alleged deficient practice will not recur; a separate Quality Assurance review team has been established to provide additional audits and assist in identifying root cause system opportunities for improvement. This will provide expanded team members to ensure that different disciplines are involved in identifying and sustaining system improvements.
Monitoring will be completed by the Administrator or designee to ensure the quality improvement are sustained.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(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 review of policies and clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to ensure that staff did not touch ready-to-eat foods with their bare hands, and failed to ensure that food was stored, prepared and/or served under sanitary conditions.

Findings include:

The facility's policy regarding the use of disposable gloves, dated August 29, 2019, revealed that gloves were to be worn whenever handling food directly with hands, when handling ready-to-eat food.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated July 19, 2019, revealed that the resident was cognitively impaired and required extensive assistance from staff for eating. The resident's care plan, dated April 26, 2019, revealed that she was dependent on staff for eating.

Observations during the breakfast meal in the Skilled dining room on October 1, 2019, at 8:27 a.m. revealed that Licensed Practical Nurse 5 fed the resident her meal. At 8:44 a.m., 8:45 a.m., 8:46 a.m., and 8:48 a.m., Licensed Practical Nurse 5 picked up a slice of toast using her bare hand, placed it near the resident's mouth, and the resident took a bite of the toast.

Interview with Licensed Practical Nurse 5 on October 1, 2019, at 9:15 a.m. revealed that she always handled residents' food with her bare hands when feeding them. She felt that using gloves to feed residents was "gross" and altered the taste of the food.

Interview with the Director of Nursing on October 1, 2019, at 3:30 p.m. confirmed that staff are not to touch residents' ready-to-eat foods, such as toast, with their bare hands. Interview with the Dietary Manager on October 1, 2019, at 3:40 p.m. confirmed that staff were not to touch ready-to-eat foods with their bare hands.


The facility's policy regarding cleaning the microwave oven, dated August 29, 2019, revealed that the microwave was to be kept clean, and any food particles were to be removed from the interior of the oven.

Observations of the D wing nourishment room on October 1, 2019, at 12:37 p.m. revealed that the entire top inside surface of the microwave was covered with dried, brownish food particles.

Interview with the Director of Nursing on October 1, 2019, at 12:58 p.m. confirmed that the inside of the microwave oven should not have been covered with debris.


The facility's policy regarding kitchenettes and pantries, dated August 29, 2019, revealed that each nursing unit with a refrigerator/freezer would be supplied with thermometers and the temperature would be monitored weekly.

Observations of the D north wing nourishment room on October 1, 2019, at 12:15 p.m. revealed that there was no thermometer in the freezer and no temperature log was found. Interview with Registered Nurse Supervisor 1 on October 1, 2019, at 12:39 p.m. confirmed that there was no thermometer in the freezer and no temperature log on or near the freezer.


The facility's policy regarding food storage, dated August 29, 2019, revealed that temperatures for refrigerators should be between 35-39 degrees Fahrenheit (F) and that thermometers should be checked and documented at least three times each day.

Observations of the silver refrigerator in the skilled unit's kitchenette on October 1, 2019, at 12:15 p.m. revealed that the internal temperature was 46 degrees F, and on October 2, 2019, at 11:12 a.m., 4:29 p.m. and 5:01 p.m. the temperatures were 50, 46 and 46 degrees F, respectively. Food items stored in the refrigerator at these times included small containers of yogurt, tuna salad, pureed bread, tomato slices, apple juice, mandarin orange slices, and Ensure nutrition drinks. Interview with the Maintenance/Housekeeping Director on October 2, 2019, at 5:20 p.m. revealed that the refrigerator was recently purchased and put into service on September 23, 2019. There was no documented evidence that the temperature was monitored on seven of the first ten days the refrigerator was in service.

Interview with the Dietary Manager on October 2, 2019, at 5:01 p.m. confirmed that the food in the refrigerator was for the residents, that the temperatures should not be 46 or 50 degrees F, and that documentation of temperature monitoring was not completed in accordance with the facility's policy.

42 CFR 483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve - Sanitary.
Previously cited 11/1/18.

28 Pa. Code 211.6(f) Dietary services.
Previously cited 11/1/18.


 Plan of Correction - To be completed: 11/25/2019

F-0812 Procurement, Store/Prepared/Serve-Sanitary
Christ the King Manor intends to ensure that staff do not touch read to eat foods with their bare hands, and ensure food is stored, prepared and/or served under sanitary conditions. Corrective action steps taken to ensure residents aren't receiving ready to eat foods with bare hands, the Licensed Practical Nurse was immediately counseled and re-educated on the policy and procedures of the facility, that we do not touch ready to eat foods with our bare hands. Microwave noted to have food particles on the top inside of microwave was cleaned immediately and all refrigerators/freezers has supplied with thermometers and temperatures were taken.
All residents have the potential to be affected by the alleged deficient practice. Corrective action steps taken that will be taken to eliminate potential deficient practice from reoccurring include re-education of new, current and agency staff on policy of using gloves with ready to eat foods, gloves during meal service, proper sanitation of all food preparation equipment, and the facility policy on safe food storage to include storage temperatures for refrigerators and freezers. The certified Dietary manager or designee is responsible for cleaning of the refrigerators, freezers and microwaves daily.
System changes put into effect to ensure alleged deficient practice will not recur; include daily audits by the dietary manager and/or designee reviewing at least 1 meal daily for 4 weeks. Audits will review using gloves with ready to eat foods, gloves during meal service, proper sanitation of all food preparation equipment, and the facility policy on safe food storage to include storage temperatures for refrigerators and freezers.

Corrective action will be monitored by the Dietary Manager and designee. Audits conducted will be submitted to Quality Assurance committee for review and compliance.


483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed: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.
483.60(c) Menus and nutritional adequacy.
Menus must-

483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

483.60(c)(2) Be prepared in advance;

483.60(c)(3) Be followed;

483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

483.60(c)(5) Be updated periodically;

483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.
Observations:


Based on review of written menus, as well as observations and staff interviews, it was determined that the facility failed to follow their planned menu, and failed to ensure that the menus met the nutritional needs of residents, by failing to ensure that portion sizes met established national nutritional guidelines.

Findings include:

The facility's written and posted menu for the lunch meal on September 30, 2019, revealed that the residents were to receive a slice of pizza, a 4 ounce spoodle (a serving spoon with a gray color-coded handle) of vegetables, and a "gloved hand" of banana-pineapple salad.

Observations during the lunch meal in the Memory Support Unit on September 30, 2019, at 11:57 a.m. revealed that Nurse Aide 11 and the Dietary Manager served residents part of a slice of pizza by cutting the top portion off each slice and a spoonful or two of vegetables served with a place spoon/tablespoon and not with a 4 ounce spoodle. The residents were then offered ice cream or sherbet for dessert, and they were not offered or served banana-pineapple salad.

Interview with the Dietary Manager on October 1, 2019, at 5:14 p.m. confirmed that the posted menu indicated that the residents were to receive a slice of pizza and that she cut the top off because it was not soft enough for residents who needed a mechanical soft consistency. She stated that she doubled the amount of sauce on these slices to ensure that the residents received the appropriate portion size. She also stated that she knows the residents on the Memory Support Unit prefer ice cream; therefore, they were not offered the banana-pineapple salad but should have been. When asked about the portion size for the vegetables and not using a serving utensil, the Dietary Manager indicated that she had been doing the job for a long time so she just knew what the portion size should be, but more inexperienced staff needed to use a standard serving utensil.


The facility's written menu for the fifth week of the fall/winter cycle, which were to be used to serve meals of September 30 through October 6, 2019, revealed that numerous portion sizes for a variety of food items and consistencies were listed as a "gloved hand" or a "tongs" full, and there was no specific portion size planned.

For example:

On September 30, 2019, residents on a "Dysphagia I" or puree consistency diet, a "Dysphagia II" or mechanically altered diet, a "Dysphagia III" or mechanical soft diet, and a "Dysphagia IV" or regular consistency diet, were to receive a "gloved hand" of cheesy eggs for the breakfast meal, of banana-pineapple salad for the lunch meal, and of garlic cubed potatoes for the supper meal.

On October 1, 2019, residents on puree and mechanically altered consistency diets were to receive a gloved handful of banana pancakes for breakfast, and a tongs full of chicken noodle soup and mashed oven french fries for lunch. As a secondary choice, residents on a puree consistency diet were to receive a gloved handful of cheesy ravioli alfredo for supper. Residents on mechanical soft and regular consistency diets were to receive a gloved handful of banana pancakes for breakfast, and a gloved handful of roast beef on a sandwich for lunch. Residents on a mechanical soft diet were also to receive a tongs full of cut up breakfast sausage for breakfast.

On October 2, 2019, residents on puree and mechanically altered consistency diets were to receive a tongs full of cream of wheat for breakfast, a gloved handful of tuna salad sandwich for lunch, and a tongs full of pureed garlic bread for supper. Residents on mechanical soft and regular consistency diets were to receive a tongs full of cream of wheat for breakfast, and a gloved handful of tuna salad on a sandwich for lunch. Residents on a regular consistency diet were also to receive a gloved handful of strawberry mousse for lunch.

On October 3, 2019, residents on a puree consistency diet were to receive a gloved handful of puree chicken patty sandwich and chocolate chip cookie for lunch, and a gloved handful of mashed potatoes and a tongs full of puree dinner roll for supper. Residents on a mechanically altered diet were to receive a gloved handful of ground chicken patty sandwich for lunch, and a gloved handful of mashed potatoes for supper. Residents on a mechanical soft consistency diet were to receive a gloved handful of mashed potatoes for supper. Residents on a regular consistency diet were to receive a tongs full of roast turkey and a gloved handful of green peas for supper.

On October 4, 2019, residents on puree and mechanically altered consistency diets were to receive one pureed waffle for breakfast, and one pureed grilled cheese sandwich for lunch; however, there were no instructions on the menu regarding what serving size constituted one of each of these items. Residents on a puree consistency diet were also to receive a dipper of puree blackened fish for supper; however, there was no dipper size listed, and they were to receive a tongs full of puree dinner roll. Residents on a mechanically altered diet were to receive a gloved handful of pasta salad for lunch, and a tongs full of pureed dinner roll for supper. Residents on a regular consistency diet were to receive a gloved handful of pasta salad for lunch.

On October 5, 2019, residents on a puree consistency diet were to receive a tongs full of pureed french toast for breakfast, of pureed cream of potato soup for lunch, and pureed pork chop and dinner roll for supper. They were also to receive one gingerbread for lunch and one strawberry shortcake for supper; however, there were no instructions on the menu regarding what serving size constituted one of each of these items. Residents on a mechanically altered diet were to receive two pureed french toast for breakfast and one pureed strawberry shortcake for supper; however, there were no instructions on the menu regarding what serving size constituted one or two of these items. They were also to receive a tongs full of pureed cream of potato soup for lunch, and pureed dinner roll and ground pork chop for supper. Residents on a mechanical soft consistency diet were to receive a tongs full of cream of potato soup for lunch and of diced pork chop for supper, and a gloved handful of strawberry shortcake for supper. Residents on a regular consistency diet were to receive a tongs full of cream of potato soup and fried shrimp for lunch, and a gloved handful of baked beans for lunch.

On October 6, 2019, residents on all consistency diets were to receive a tongs full of cream of wheat for breakfast. Residents on puree, mechanically altered and mechanical soft diets were to receive a gloved handful of mashed potatoes for lunch. Residents on a puree consistency diet were to receive a teaspoon of chicken with gravy for lunch. Residents on a puree consistency diets were to receive one pureed chocolate mousse cake; however, there were no instructions on the menu regarding what serving size constituted a piece of pureed chocolate mousse cake. Residents on puree and mechanically altered diets were to receive a tongs full of pureed dinner roll for supper, and as a secondary choice, were to receive a gloved handful of pureed or ground roast pork for supper. Residents on mechanically altered and mechanical soft diets were to receive a tongs full of ground or diced chicken with gravy for lunch. Residents on mechanical soft and regular consistency diets were to receive a gloved handful of parsley potatoes for supper. Residents on a regular consistency diet were to receive a tongs full of chicken with gravy for lunch and as a secondary choice, a tongs full of roast pork for supper.







 Plan of Correction - To be completed: 11/25/2019


F-0803 Menus Meet Residents needs/Prep in advance/followed:
Christ the King Manor intends to follow planned menu, ensure that menus meet nutritional needs of residents and portion sizes. Corrective actions accomplished for those residents found to be affected alleged deficient practice, all residents are at risk. Review of menu program and menu size/ portions by the Certified Dietary manager and Registered Dietician to ensure proper nutritional needs are being met and portion sizes are correct, along with personal dietary choices are honored.
All residents have the potential to be at risk for alleged deficient practice. Corrective actions steps taken will be to conduct re-education of staff serving meals. This training will be related to reading and following correct portion sizes including using correct portion utensils. The Certified Dietary Manager will ensure the menu program follows correct portion sizes and/or nutritional equivalent substitutions for mechanically altered meal items. Additional corrective action steps include the training of dining service staff to ensure correct portions listed upon printing of resident meal tickets and extension sheets.
System changes that were put into effect to ensure alleged deficient practice does not recur; re-education of staff related to reading and following correct portion sizes including using correct portion utensils and the training of dining service staff to ensure correct portions listed upon printing of resident meal tickets and extension sheets. Daily audits will be conducted by the Dietary manager and/or designee for 7 days, then weekly for the next 4 weeks, then monthly for 3 months.
Corrective action steps will be monitored by the Dietary Manager and /or designee for 7 days, then weekly for the next 4 weeks, then monthly for 3 months. Audits will be submitted to Quality Assurance Committee for review and compliance.


483.25(h) REQUIREMENT Parenteral/IV Fluids: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.
483.25(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:








Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that intravenous catheters and/or long-term intravenous catheters were flushed according to facility policy for one of 70 residents reviewed (Residents 57).

Findings include:

The facility's policy regarding intravenous (IV) catheters (a tube placed in a vein that can be used to deliver fluids and/or medications), dated August 29, 2019, revealed that peripheral IV catheters were to be flushed (a method used to clean a catheter of blood or medication) prior to each infusion to assess catheter patency and function, and after each infusion to clear the catheter lumen of medications, to prevent contact between incompatible medications. To flush before and after medication or fluid administration, the nurse was to use the push-pause technique to instill preservative-free 0.9% sodium chloride (amount per protocol), and when medication/fluid administration was complete, to flush with a preservative-free 0.9% sodium chloride. The procedure was to be documented in the resident's medical record.

Physician's orders for Resident 57, dated July 27, 2019, included orders to have his IV catheter flushed and checked every shift, and to receive 80 milligrams (mg) of Gentamicin (an antibiotic) intravenously every 24 hours. Physician's orders, dated July 29, 2019, included an order for the resident to receive 120 mg of Gentamicin intravenously every 24 hours, and the last dose was to be given on August 2, 2019.

Resident 57's Medication Administration Records (MAR's) for July and August 2019 revealed that staff administered IV Gentamicin as ordered on July 27 through 31, and August 1 and 2, 2019. However, there was no documented evidence that staff flushed Resident 57's IV catheter with a preservative-free 0.9% sodium chloride solution before and after the administration of Gentamicin on these days.

Interview with the Director of Nursing on October 3, 2019, at 7:25 a.m. revealed that as per the facility's policy, IV catheters were to be flushed with five milliliters (ml) before and after medication administration; however, this flush was not reflected on the MAR's.

Interview with the Director of Nursing on October 3, 2019, at 10:55 a.m. confirmed that there was no documented evidence that Resident 57's IV catheter was flushed pre and post medication administration.

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

Previously cited 9/13/19, 6/11/19, 4/1/19, 11/1/18.


 Plan of Correction - To be completed: 11/25/2019

F-0694 Parenteral/IV Fluids
Christ the King Manor intends to ensure that intravenous catheters and /or long-term intravenous catheters were flushed according to the facility policy. Corrective action for the residents affected by alleged deficient practice, Resident #57, cannot be retroactively corrected.
All residents with intravenous catheters have the potential for risk for alleged deficient practice. Corrective action steps, the one resident in the facility was receiving intravenous antibiotic which requires a flush of preservative free 0.9% sodium chloride before and after the medication on 10-15-19. This order was documented correctly in the medication administration record. There are currently no residents in the facility that are receiving intravenous medications which requires a flush.
Systems changes put into effect to ensure alleged deficient practice does not recur; education and policy review will be given to all new, current and agency licensed nursing regarding the proper steps to note an order which includes an intravenous flush. Policy for noting orders has been updated to include intravenous medication and flush orders. This policy will be reviewed with all licensed nursing staff. These steps will help ensure that orders are noted correctly on the medication administration record.
Corrective action steps will be monitored to ensure alleged deficient practice will not recur; audits for proper documentation of intravenous flushes will be completed first by a second licensed nurse who within 24 hours verifies the accuracy of the notation and second by the Registered Nurse or designee. The audits will be completed daily for 7 days then weekly for 4 weeks then monthly for 3 months. Audits will be submitted to Quality Assurance Committee for review and compliance.


483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:


Based on a review of cleaning forms, as well as observations and staff interviews, it was determined that the facility failed to provide a safe, clean and homelike environment related to residents' wheelchairs for one of 70 residents reviewed (Resident 96), and related to hallway carpeting.

Findings include:

Observations of Resident 96's geri-chair (a padded chair with wheels that can recline) on September 30, 2019, at 12:00 p.m. revealed that the vinyl material on both arm rests was torn, and the back of the left arm rest was repaired with duct tape.

Interview with Occupational Therapy Aide on October 3, 2019, at 11:13 a.m. revealed that there should not be any duct tape used on any equipment in the building and that Resident 96's chair should not have been repaired with duct tape on it. He replaced her chair at that time.

The facility's current carpet cleaning form, undated, indicated that the carpets were to be scrubbed on an "as needed" basis.

Observations of hallways on the Memory Support Unit on September 30, 2019, at 9:55 a.m. revealed that the carpet going into the unit had large stains on it. There were also large stains observed on the carpeting around both of the dining areas on the unit.

Interview with the Maintenance Director on October 2, 2019, at 3:44 p.m. revealed that he had a plan to have the carpets scrubbed or replaced, but the Memory Support Unit was last on the plan. He also stated that the facility recently purchased a large carpet scrubber and created a schedule for the carpets to be scrubbed.

42 CFR 483.10(i)(1)-(7) Safe/Clean/Comfortable/Homelike Environment.
Previously cited 11/1/18.

28 Pa. Code 201.29(j) Resident rights.

28 Pa. Code 207.2(a) Administrator's responsibility.
Previously cited 11/1/18.




 Plan of Correction - To be completed: 11/25/2019

Christ the King Manor intends to provide a safe, clean and homelike environment. Corrective actions put into place for those residents found to be affected by alleged deficient practice, Resident #96, the chair was immediately replaced with another chair in good repair.
Observations of hallways on the Memory Support Unit with stains on carpet were immediately cleaned on September 30, 2019.
All residents have the potential to be affected by alleged deficient practice. Corrective actions taken were all residents chairs were reviewed by therapy department for potential tears or tape and immediately replace if found. And all carpeting is immediately cleaned if stains or spots are identified by the Floor maintenance employee.
Systems put into place to ensure alleged deficient practice does not recur; new, current and agency staff have been re-educated that duct tape is not permitted to utilize to repairs torn chairs and all chairs in disrepair will be immediately reported to Maintenance department for proper repairs in the Maintenance log system Electronic Charting System. New, current and agency staff will be educated on how to submit repair or cleaning areas identified in Electronic Charting System. Additional systems put into place related to carpet cleaning, the facility purchased a new carpet scrubber on September 1, 2019 and a carpet cleaning protocols were put into place. All spills and stains noted will be immediately reported to the full time Floor Maintenance team and cleaned.
Corrective actions will be monitored by conducting weekly rounds by all department heads 3 times a week for 4 weeks, then weekly for 3 months. All findings will be reported to Maintenance Department for proper repairs and for cleaning for carpets identified with stains. The facility has also established a schedule for flooring cleaning that will be maintained by the Director of Environmental services. All findings from monitoring will be submitted to Quality Assurance Committee for review and recommendations.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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(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 policies and 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 three of 70 residents reviewed (Residents 90, 118, 130).

Findings include:The 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 2018, revealed that a Stage 1 pressure ulcer (skin breakdown caused by prolonged, unrelieved pressure) was a reddened area that does not blanche; a Stage 2 pressure ulcer was a superficial open area or blister; a Stage 3 pressure ulcer was full thickness skin loss; a Stage 4 pressure ulcer was full thickness tissue loss exposing bone, tendons or muscle; an unstageable pressure ulcer could not be staged related to a non-removable device, slough (yellow, tan, or green tissue, usually moist) or eschar (dead tissue this is black or brown in color and may appear scab like); and a deep tissue injury was an unstageable pressure ulcer that was a purple or maroon area of discolored intact skin due to damage of the underlying soft tissue.

A wound note for Resident 118, dated September 26, 2019, at 10:45 a.m. revealed that the resident had a Stage 4 pressure ulcer, but that it was a suspected deep tissue injury on the right heel and could not be staged. There was no documented evidence that the resident actually had a Stage 4 pressure ulcer other than this note, whose description of the wound as "unstagable" did not match the definition of a Stage 4 pressure ulcer.

Observations of Resident 118's right heel on October 2, 2019, at 2:37 p.m. revealed that there was a purple area on the inner aspect of the right heel and the skin was intact. Interview with Licensed Practical Nurse 9 on October 2, 2019, at 2:37 p.m. revealed that the wound on Resident 118's right heel was never open and the skin has always been intact.

Interview with Director of Nursing on October 2, 2019, at 2:16 p.m. revealed that there was a documentation issue and Resident 118 has a deep tissue injury, not a Stage 4 pressure ulcer as documented by the the wound nurse.A wound note for Resident 90, dated July 31, 2019, revealed that the resident had a Stage 2 pressure area on the right heel that measured 2.5 x 2.5 centimeters (cm) and was superficial. On August 12, 2019, the Stage 2 pressure area on the right heel was worse, had black tissue, was becoming smaller, but was now a suspected deep tissue injury and measured 1.0 x 2.5 cm and the depth was unable to be measured. A wound note dated August 19, 2019, revealed that the resident's right heel was yellow and black, had worsened to a Stage 4 pressure injury, and the depth was unable to be measured. There was no documented evidence prior to August 19, 2019, that the resident had a Stage 4 pressure injury, and the description in the wound note dated August 19, 2019, did not match the definition of a Stage 4 pressure ulcer, as the depth was not able to be measured.

A wound note for Resident 130, dated September 2, 2019, revealed that the resident had an unstageable deep tissue injury (blister opened) on the left heel that measured 2.0 x 3.0 cm and was superficial. A note on September 30, 2019, indicated that the Stage 4 pressure area on the left heel had worsened, had reddened and black tissue, swelling was present at the site, tenderness was present, it measured 3.2 x 3.2 cm, and the depth was unable to be measured. There was no documented evidence prior to September 30, 2019, that the resident had a Stage 4 pressure injury, and the description in the wound note dated September 30, 2019, did not match the definition of a Stage 4 pressure ulcer, as the depth was not able to be measured.

Interview with the Director of Nursing on October 2, 2019, at 2:10 p.m. confirmed that Residents 90 and 130 never had Stage 4 pressure ulcers and she did not think that the documentation was accurate.28 Pa. Code 211.5(f) Clinical records.


 Plan of Correction - To be completed: 11/25/2019

F-0842 Resident Records/ Identifiable Information
Christ the King Manor intends to ensure the clinical record are complete and accurately documented residents clinical condition. Corrective action accomplished for those residents found to have been affected by alleged deficient practice, Resident #90, 118, 130, have documentation that clearly reflects the staging of the skin breakdown they currently have as of 10-22-19.
All residents have the potential to be at risk to be affected by alleged deficient practice. Corrective action step that will be taken, all residents in house have been screened. All residents have accurate documentation that reflects the staging of pressure ulcers as defined by the Resident Assessment Instrument.
System changes put into effect to ensure alleged deficient practice will not recur; education is being provided to all Registered Nurses on wound staging. Resource and education will be completed by Smith, Nephew, and McKesson as well as from the Resident Assessment Instrument chapter 3 section M. The documentation in the electronic record has been clarified so there are no contradictions in staging. The Registered nurse assessment coordinator who completes the Minimum Data Set Assessment has received education on identified issue and collaborate with the documentation on wounds with wound nurse to ensure accuracy before coding of the Minimum Data set.
Corrective actions steps will be monitored by to ensure alleged deficient practice will not recur; monitoring will be completed by Director of Nursing and/or designee daily for 7 days, then weekly for 4 weeks, then monthly for 3 months. Audits will be submitted to Quality Assurance Committee for review and compliance.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
483.45(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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled for one of 70 residents reviewed (Resident 445), and failed to ensure that medications were properly secured on one of three nursing stations (A wing).

Findings include:

The facility's medication administration policy, dated August 29, 2019, indicated that if the label was wrong, staff were to contact the pharmacy for new directions.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 445, dated September 24, 2019, revealed that the resident received nutrition through a feeding tube (tube inserted into the stomach to receive nutrition). Physician's orders, dated September 17 and 18, 2019, included an order for the resident to be NPO (receive nothing by mouth) and receive all of her medications through the nasogastric feeding tube (tube inserted through the nose and into the stomach). Current physician's orders included orders for the resident to receive 20 milligrams (mg) of Pepcid (used for heartburn) through the feeding tube two times a day.

Observations on October 1, 2019, at 5:28 p.m. revealed that Licensed Practical Nurse 8 prepared and administered 20 mg of Pepcid to Resident 445 through the feeding tube. The label on the package indicated that the instructions were to give the Pepcid by mouth.

Interview with Licensed Practical Nurse 8 on October 1, 2019, at 5:50 p.m. confirmed that the label on Resident 445's Pepcid package did not include the correct instructions in accordance with the current physician's order.

Interview with the Director of Nursing on October 2, 2019, at 12:25 p.m. confirmed that the pharmacy sent the wrong instructions on the label of Resident 445's Pepcid, and the pharmacy was contacted to change the labeling on the package.


Observations of the A wing nursing station on October 3, 2019, at 2:19 p.m. revealed that packages of 2.5 milligrams/milliliter (mg/ml) of Albuterol (breathing treatment) and 250 mg of levetiracetam (used to treat seizures) were left on the counter and were unsecured.

Interview with Registered Nurse Supervisor 1 on October 3, 2019, at 2:19 p.m. revealed that the door to the nursing station was locked when no one was in the room; however, nurse aides entered the nursing station to do their documentation.

Interview with the Director of Nursing on October 3, 2019, at 2:25 p.m. confirmed that medications should not be laying on the counter in the nursing station and should have been secured.

42 CFR 483.45(g)(h)(1)(2) Label/Store Drugs and Biologicals.
Previously cited 11/1/19.

28 Pa. Code 211.9(a)(1) Pharmacy services.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 4/1/19, 11/1/18.


 Plan of Correction - To be completed: 11/25/2019

F-0761 Label/ Store Drugs and Biologicals
Christ the King Manor intends to ensure that medications are properly labeled for residents. Corrective actions accomplished for those residents found to have been affected by alleged deficient practice, Resident #445, we notified the pharmacy immediately of the labeling error and a new label for the medication was sent. The medications that were on the counter were scheduled for return to pharmacy were secured in a locked cabinet until they could be returned.
All residents have the potential to be affected by alleged deficient practice. Corrective action steps taken, residents that do not receive their medications by mouth were audited to ensure all medications labels were correct. No other residents were found to be affected. Education was provided to licensed staff regarding the safe storage of medication in a secure area that are awaiting return to the pharmacy for disposal.
System changes put into place to ensure alleged deficient practice does not recur; education to all licensed staff regarding proper storage of discontinued medications in a locked cabinet or locked medication room until medications can be disposed properly. Additional education was provided to all new, current and agency licensed staff passing medication regarding any medication that has been labeled wrong must be corrected immediately by notifying the Pharmacy of the error and need for corrected label.
Corrective action steps will be monitored by completion of audits by the Director of Nursing and/or designee daily for 7 days, then weekly for 4 weeks and then monthly for 3 months. Audits will be submitted to Quality Assurance Committee for review and compliance.



483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:







Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received oxygen as ordered by the physician for one of 70 residents reviewed (Resident 16).

Findings include:

The facility's policy regarding oxygen therapy, dated August 29, 2019, indicated that oxygen was to be administered by licensed staff and in accordance with physician's orders.

A diagnosis record for Resident 16, dated November 8, 2018, revealed that the resident had diagnoses that included atrial fibrillation (irregular heart rhythm) and a history of heart attack. Physician's orders, dated January 12, 2019, and the resident's care plan, dated January 14, 2019, revealed that the resident was to receive continuous oxygen at a flow rate of 2 liters per minute via nasal cannula (tubes that deliver oxygen into the nostrils).

Observations of Resident 16 on September 30, 2019, at 11:34 a.m. and 1:04 p.m., and October 1, 2019, at 12:27 p.m. revealed that the resident was receiving oxygen from a portable oxygen tank that was set at a flow rate of 3 liters per minute. Observations on September 30, 2019, at 12:29 p.m. revealed that the resident's portable oxygen tank was set at zero (not on), and observations on October 1, 2019, at 8:34 a.m. revealed that the resident was in her room receiving oxygen from an oxygen concentrator (electrical machine that concentrates oxygen from the air) that was set at 1.5 liters per minute.

Interview with Licensed Practical Nurse 2 on September 30, 2019, at 1:05 p.m. and October 1, 2019, at 8:36 a.m. confirmed that Resident 16's oxygen flow rate was not set at 2 liters per minute as ordered by the physician.

Interview with the Director of Nursing on October 1, 2019, at 10:00 a. m. confirmed that Resident 16's oxygen flow rate should be set at 2 liters continuously.

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

Previously cited 9/13/19, 6/11/19, 4/1/19, 11/1/18.


 Plan of Correction - To be completed: 11/25/2019

F-0695 Respiratory Tracheostomy Care and Suctioning
Christ the King Manor intends to ensure that all residents receives oxygen as ordered by physician. Corrective action for those residents to be affected by alleged deficient practice, Resident #16, which was immediately placed on correct liters according to physician orders.
All resident with oxygen orders have potential to be affected by alleged deficient practice. Corrective action steps take was all residents receiving oxygen were reviewed to ensure liters were set according to physician orders by licensed staff members.
System changes put into place to ensure the alleged deficient practice does not recur; all residents receiving oxygen will have the order noted in the treatment administration record and will be signed for by the licensed nurse. This is in an effort to assure all liter flows are correct.

All new, current and agency nursing staff will be educated on the oxygen policy regarding noting all orders into the treatment administration record to verify that the correct liter flow is documented. The Nurse must visually verify the oxygen flow liter is correct each shift for residents who have continuous oxygen or as need for those residents who use their oxygen as needed.
Corrective actions will be monitored be monitored by Registered Nurses or designee daily for 7 days, then weekly for 4 weeks, then monthly for 3 months. Audits will be submitted to Quality Assurance Committee for review and compliance.


483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills: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(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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications and water flushes were properly administered through a feeding tube, in accordance with physician's orders for one of 70 residents reviewed (Resident 445).

Findings include:

The facility's medication administration policy, dated August 29, 2019, indicated that all medications were to be administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis. The facility's policy for administering medications through a feeding tube, dated August 29, 2019, indicated that each medication was to be given separately and flushed with 10 milliliters (ml) of water, and then flushed with 30 ml of water at the end of the medication pass.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 445, dated September 24, 2019, revealed that the resident received nutrition through a feeding tube (tube inserted into the stomach to receive nutrition). Physician's orders, dated September 17, 18 and 19, 2019, included orders for the resident to be NPO (receive nothing by mouth), receive all of her medications through a nasogastric feeding tube (tube inserted into the stomach via the nose), and to flush the nasogastric tube with 30 ml of water prior to and following medication administration. Current physician's orders included orders for the resident to receive 20 milligrams (mg) of Pepcid (used for heartburn) through the feeding tube two times a day and 12.5 mg of metoprolol (used for high blood pressure) through the feeding tube twice a day.

Observations on October 1, 2019, at 5:28 p.m. revealed that Licensed Practical Nurse 8 disconnected Resident 445's feeding tube and inserted a plastic feeding tube syringe to check placement (to ensure the tube was in the stomach) by pushing air into the feeding tube. When she pushed the air into the feeding tube with the plastic feeding tube syringe, the air and some water squirted out of the sides of the feeding tube and syringe connection. She then flushed the tube with 10 ml of water and administered the Pepcid. While she was administering the Pepcid, the feeding tube syringe disconnected from the feeding tube and the medication and water leaked all over the resident and the floor. The nurse reconnected the feeding tube syringe to the feeding tube and continued to administer the 10 ml flush of water, which was leaking out of the connection. She then administered the metoprolol and a 30 ml flush of water following the administration of the medication. During the medication administration and water flushes, the nurse held the connection point of the feeding tube and feeding tube syringe with a paper towel and the paper towel and the resident's shirt continued to get saturated with water. At no time did Licensed Practical Nurse 8 keep the feeding tube connection from leaking or have anyone assess the feeding tube and feeding tube syringe for a proper connection.

Upon interview with Licensed Practical Nurse 8 on October 1, 2019, at 5:50 p.m., she indicated that the connection of Resident 445's feeding tube and syringe was always like that.

Interview with the Director of Nursing on October 2, 2019, at 12:25 p.m. confirmed that Licensed Practical Nurse 8 had trouble with Resident 445's feeding tube all the time, but it was not brought to her attention so the problem could be assessed and corrected.

42 CFR 483.25(g)(4)(5) Tube Feeding Mgmt/Restore Eating Skills.
Previously cited 11/1/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 9/13/19, 6/11/19, 4/1/19, 11/1/18.




 Plan of Correction - To be completed: 11/25/2019

F-0693 Tube Feeding Management/Restore Eating Skills
Christ the King Manor intends to ensure medications and water flushes are properly administered through a feeding tube. Corrective actions put into place for those residents found to have been affected by alleged deficient practice, Resident #445, the licensed practical nurse was required to completed competency with the Staffing Registered Nurse supervisor through this gastric-tube.
All residents with this type of feeding tube are at risk for potential alleged deficient practice. The facility does not have other resident in the facility on this type of tube feeding. Re-education will all new, current and agency licensed nurses who administer medications and flushes via feeding tubes are being reviewed on proper procedures to prevent leaking.
Systems put into place to ensure alleged deficient practice will not recur; . Re-education will all new, current and agency licensed staff who administer medications and flushes via feeding tubes are being reviewed on proper procedures to prevent leaking. The education will include the revised policy to include any leaking from tubing while administering medications will be reported to the Registered Nursing Supervisor with all licensed staff. Registered Nursing Supervisor and Development coordinator will monitor.
Corrective action steps will be monitored by conducting audits to ensure that all medications and flushes via tubes are being done according to policy and procedure. Audits will be completed daily for 7 days by Director of Nursing/Assistant Director of Nursing and/or designee, then weekly for 4 weeks, then monthly for 3 months. All results will be submitted to Quality Assurance for review and recommendations.


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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide appropriate care to prevent urinary tract infections for one of 70 residents reviewed (Resident 98) who had an indwelling urinary catheter.

Findings include:

The facility's policy regarding indwelling catheter care (care of a tube inserted and held in the bladder to drain urine into a collection bag), dated August 29, 2019, indicated that catheter care was done to aid in the prevention of infections and other complications by keeping the insertion site clean and maintaining the catheter in a sterile, closed gravity drainage system.

Physician's orders for Resident 98, dated August 16, 2019, and an annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) dated October 22, 2018, revealed that the resident had an indwelling urinary catheter. The resident's care plan, dated August 26, 2019, indicated that the resident was at risk for urinary tract infections and that the catheter bag and tubing were to be kept off the floor at all times.

Observations of Resident 98 while in bed on October 2, 2019, at 9:12 a.m. and 10:06 a.m. revealed that the resident's catheter bag was in a basin (off the floor); however, the catheter tubing was outside the basin and in direct contact with the floor underneath the resident's bed.

Interview with Nurse Aide 7 on October 2, 2019, at 10:06 a.m. confirmed that Resident 98's catheter tubing was in contact with the floor and should not have been.

Interview with the Director of Nursing on October 2, 2019, at 2:16 p.m. confirmed that Resident 98's catheter tubing should not have been in contact with the floor.

42 CFR 483.25(e)(1)-(3) Bowel/Bladder Incontinence, Catheter, UTI.
Previously cited 11/1/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 9/13/19, 6/11/19, 4/1/19, 11/1/18.




 Plan of Correction - To be completed: 11/25/2019

F- 0690 Bowel/Bladder Incontinence Catheter, Urinary Tract infection
Christ the King Manor intends to ensure appropriate care to prevent urinary tract infections who have indwelling catheter. Corrective action accomplished for those residents found to have been affected by alleged deficient practice, Resident #98, catheter tubing was immediately replaced per facility policy.
All residents with catheter tubing have the potential to be affected by alleged deficient practice. Corrective actions taken were all residents with Foley catheter were reviewed and any found to be in direct contact were immediate replaced.
System changes put into place to ensure that alleged deficient practice will not recur; education will be provided to all new, current and agency nursing staff regarding necessity to keep Foley bags and tubing off of the floor. This is in efforts to prevent infections and other complications. The policy for Foley/catheter care has been revised to include covering tubing with catheter tubing and replace tubing immediately if tubing is found to come in contact with the floor directly. Registered Nurse Supervisor and or designee will monitoring of the placement of the urinary drainage bags routinely to ensure proper placement.

Corrective action steps to monitor to ensure alleged deficient practice will not recur; Audits will be conducted by Director of Nursing / Assistant Director of Nursing and/or designee observations for all residents with Foley tubing daily once a week for one week, then weekly for 4 weeks, then monthly for 3 months. All audits completed will be submitted to Quality Assurance Committee for review and recommendations.

483.25 REQUIREMENT Quality of Care: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 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 review of policies, physican orders, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed regarding a double sign-off requirement to verify the correct dosage of a concentrated insulin for one of 70 residents reviewed (Resident 6).

Findings include:

The facility's policy regarding the administration of medication, dated August 9, 2019, indicated that a double sign-off (two staff members to check the dose) was required to verify the dose of U-500 insulin (an unusually concentrated insulin used to cover mealtime and long-acting insulin needs).

Physician's orders for Resident 6, dated August 6, 2019, included an order for the resident to receive Humulin insulin U-500 three times a day (breakfast, midday and bedtime) for Type 1 diabetes (a disease that interferes with the body's blood sugar control). Administration instructions included the need for a second licensed practical nurse to verify the proper dose prior to administration.

Resident 6's Medication Administration Records (MAR's) revealed no documented evidence of a double sign-off for the midday administration of U-500 insulin on August 9 and 20, and September 24, 2019, and for the evening administration on September 5 and 21, 2019.

An interview with the Director of Nursing on October 2, 2019, at 3:00 p.m confirmed that staff did not document a double sign-off for U-500 Humulin insulin on Resident 6's MAR's as above.

42 CFR 483.25 Quality of Care.

Previously cited 6/11/19, 11/1/18.

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

Previously cited 9/13/19, 6/11/19, 4/1/19, 11/1/18.


 Plan of Correction - To be completed: 11/25/2019

F-0684 Quality of Care
Christ the King Manor intends to ensure that physician's orders are followed and residents receive treatment and care in accordance with professional standards of practice. Corrective action put into place for those residents found to be affected by alleged deficient practice, Resident #6, the deficiency noted cannot be retroactively be corrected. No other residents in the facility receive U500 Insulin requiring double signature.
All residents have the potential to be affected by alleged deficient practice. Corrective action that will be take is education will be provided to all new, current and agency licensed staff who administer medications. The policy for medication administration will be reviewed with these staff members. Emphasis during education will be placed on the need for double verification of the U500 insulin dosage.
System changes put into effect to ensure alleged deficient practice does not recur; audits for double signature medications verification will be completed. Registered Nurse Supervisors will be responsible for monitoring. Audits will include the necessity of providing a printed medication administration report to the Registered nurse to assure there is evidence the insulin was verified by a second nurse.
Corrective actions will be monitored by conducting audits for the double sign medications verification will be completed daily for 7 days then weekly for 4 weeks then month for 3 months. All audits will be submitted to Quality Assurance Committee for review and recommendations.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to update residents' care plan to reflect their current and individualized care needs for two of 70 residents reviewed (Residents 55, 69).

Findings include:

The facility's policy regarding comprehensive care plans, dated August 29, 2019, indicated that a care plan was to identify problems areas and include interventions that were targeted and meaningful to the resident. The policy also indicated that assessments of residents were ongoing and care plans were to be revised as information about the resident and his/her condition changed.

A diagnosis record for Resident 55, dated July 14, 2019, revealed that the resident had diagnoses that included an enlarged prostate with lower urinary tract symptoms, overactive bladder, and the presence of urogenital implants (injections of material into the urethra to help control urine leakage). An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated August 3, 2019, indicated that the resident had an indwelling urinary catheter (a suprapubic catheter - a tube surgically inserted through the abdomen and into the bladder to drain urine).

Observations of Resident 55 on October 1, 2019, at 8:20 a.m. revealed that he was in bed and he had a urinary catheter.

Resident 55's care plan, dated September 5, 2019, included interventions for voiding urine, such as keeping a urinal within reach, and there was no documented evidence that the care plan was revised to reflect the resident's care needs related to having a suprapubic catheter.

Interview with Registered Nurse 4 on October 2, 2019, at 4:26 p.m. confirmed that Resident 55's care plan should have been updated to reflect his current care needs related to having a suprapubic catheter.


A quarterly MDS assessment for Resident 69, dated September 15, 2019, indicated that the resident was cognitively impaired and was dependent on staff for his daily care needs. A nursing note, dated May 10, 2019, revealed that the resident was having sexual behaviors toward staff. A nursing note, dated September 16, 2019, revealed that the resident was sexually abusive to female staff, grabbing their breasts and between their legs. The nurse documented that an order was obtained for the resident to have a consultation with psychiatry services for sexual behaviors.

Resident 69's care plan related to restlessness, most recently updated September 15, 2019, did not reflect that he had sexual behaviors.

An interview with Registered Nurse 4, the facility's Care Plan Coordinator, on October 3, 2019, at 11:37 a.m. revealed that she did not feel that Resident 69 was having sexual behaviors and he was just restless; therefore, the resident did not need a care plan to address sexual behaviors.

An interview with the Director of Nursing on October 2, 2019, at 3:07 p.m. confirmed that Resident 69 did not have a care plan for sexual behaviors and his care plan should have been revised to address the behaviors.

42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision.
Previously cited 11/1/18.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 11/1/18.






 Plan of Correction - To be completed: 11/25/2019

F-0657 Care Plan Timing
Christ the King Manor intends to update resident's care plan to reflect their current and individualized care needs. Corrective actions that have been accomplished for those residents found to have been affected by alleged deficient practice, Resident # 55 and #69. Resident #55 had the care plan corrected to reflect the suprapubic catheter and Resident #69 had care plan corrected to reflect behavior noted.
All residents have the potential to be affected by alleged deficient practice. Corrective action steps that will be taken, residents are being screened for adjustments and updates in their care plan to accurately reflect their current status.
System changes that will be put into effect to ensure alleged deficient practice does not recur; the updated policy for the comprehensive care plan will be reviewed with all licensed nursing staff. Education will be provided to new, current and agency staff to update plan of care as orders are noted, and as significant plan of care change. Review of the revised care plan policy will be provided to all licensed nursing staff. Specific emphasis will be placed on coordinating Med Options therapy assessment with care plans. The care plan coordinator will now receive, review and place all plans of action recommended by Med Options directly in the care plan. The interdisciplinary care plan team will review care plans for accuracy during their scheduled review.
Corrective action steps will be monitored to ensure alleged deficient practice does not recur; daily review of care plans for 7 days, then weekly for 4 weeks, then monthly for 3 months. Audits will be presented to Quality Assurance Committee for review and compliance.


483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:








Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were developed that included specific and individualized interventions regarding an intravenous catheter for one of 70 residents reviewed (Resident 57).

Findings include:

The facility's policy regarding comprehensive care plans, dated September 29, 2018, indicated that an individualized, comprehensive, person-centered care plan was to be developed to meet the medical, nursing, mental, and psychological needs of each resident, and each resident's care plan was designed to identify which professional services were responsible for each element of care.

Physician's orders for Resident 57, dated July 27, 2019, included orders for the resident's intravenous (IV) catheter (a tube placed in a vein that can be used to deliver fluids and/or medications) to be flushed (a method used to clean a catheter of blood or medication) and checked every shift, and for the resident to receive 80 milligrams (mg) of Gentamicin (an antibiotic) intravenously every 24 hours. However, there was no documented evidence that an individualized care plan was developed to included specific and individualized interventions regarding the resident's intravenous catheter and IV medication administration.

Interview with the Director of Nursing on October 3, 2019, at 10:55 a.m. confirmed that there was no documented evidence that an individualized care plan was developed for Resident 57 related to the resident's specific and individualized care needs for his IV catheter and medication administration.

42 CFR 483.21(b)(1) Develop/Implement Comprehensive Care Plan.

Previously cited 11/1/18.

28 Pa. Code 211.10(d) Resident care plan.

Previously cited 11/1/18.


 Plan of Correction - To be completed: 11/25/2019

F-0656 Development / Implement Comprehensive Care Plan
Christ the King Manor intends to ensure that care plans were developed that included specific and individualized interventions. Corrective actions accomplished for those residents found to have been affected by alleged deficient practice, Resident #57, corrective actions cannot be completed due to that IV has been discontinued.

All residents have the potential to be affected by the same deficient practice. Corrective actions that will be taken, all residents have been screened for intravenous antibiotic and care plans. There are not current residents receiving intravenous antibiotic, no revision of care plans is necessary. Two residents identified residents have implanted ports and both have appropriate care in place.
System changes put into effect to ensure that the alleged deficient practice does not recur; policy of care plan revision will be reviewed with all new, current and agency nursing staff. An individualized care plan will be initiated for all residents who receive intravenous medications and catheters. This will be the responsibility of the Registered Nurse who is on duty when the order is received. The interdisciplinary care plan team will routinely review for accuracy during the scheduled reviews.

Corrective action will be monitored to ensure that the alleged deficient practice will not recur; daily monitoring for 7 days then, weekly for 4 weeks then monthly for 3 months. Audits will be presented to the Quality Assurance Committee for review and compliance.



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


Based on 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 one of 70 residents reviewed (Resident 57).

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 2018, revealed that the intent of Section K was to assess the many conditions that could affect the resident's ability to maintain adequate nutrition and hydration. Section K0300 was to be coded to indicate if the resident experienced a significant weight loss, including a zero (0) for No or Unknown, a one (1) for Yes and on a physician's prescribed or weight loss regimen (planned weight loss), and two (2) for Yes and not on a physician's prescribed or weight loss regimen (unplanned weight loss).

An annual MDS assessment for Resident 57, dated August 22, 2019, revealed that Section K0300 was coded with a two (2), indicating that the resident had an unplanned, significant weight loss. However, there was no documented evidence that the resident had a weight loss.

Interview with Certified Dietetic Technician 3 on October 3, 2019, at 10:15 a.m. confirmed that Section K0300 should have been coded with a zero (0) because Resident 57 did not experience a weight loss. She indicated that she had inverted the numbers of the actual weight so it looked as though the resident had a weight loss, when in reality she did not have a weight loss.

28 Pa. Code 211.5(f) Clinical records.





 Plan of Correction - To be completed: 11/25/2019

F-0641 Accuracy of Assessment
Christ the King Manor intents to ensure a complete accurate Minimum Data Set assessment for all residents. Corrective actions that were accomplished for those residents found to be affected by alleged deficient practice, Resident #57, had a corrected assessment completed and submitted on 11-21-19. The assessment now correctly reflects no significant weight loss present.
All residents have the potential to be affected by alleged deficient practice. Corrective actions that have been done; all current residents are currently being screened to ensure that there are no incorrect coded items in the Section K0300. If a resident is identified as being coded incorrectly a correction assessment will be submitted.
System changes the facility will make to ensure alleged deficient practice does not recur; the dietary technician, Registered Dietician and Registered Nurse Assessment Coordinators will be re-educated on Section K0300 of the Resident Assessment Instrument. Residents will be coded correctly in K0300. The accurate coding will be verified by the Registered Nurse Assessment Coordinator before submission. All residents who experience a significant weight loss will be assessed by the Registered Dietician and reviewed at the weekly weight loss meeting for at least 2 weeks for possible interventions.
Corrective action will be monitored to ensure that the alleged deficient practice will not recur; audits for correct coding in Section K0300 will be completed by the Registered Dietician daily for 7 days, then weekly for 4 weeks, then monthly for 3 months. Audits will be presented to the Quality Assurance Committee for review and compliance.


483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing: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 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

483.20(b) Comprehensive Assessments
483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

483.20(b)(2) When required. Subject to the timeframes prescribed in 413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in 413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.
Observations:








Based on 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 ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for one of 70 residents reviewed (Resident 55).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2018, indicated that an admission MDS assessment was to be completed no later than 14 days (admission date + 13 calendar days) following admission.

A comprehensive admission MDS assessment for Resident 55, dated August 3, 2019, revealed that the resident was admitted to the facility on July 24, 2019, and the resident's admission MDS assessment was dated as completed on August 8, 2019, which was 16 days after admission.

An interview with Registered Nurse Assessment Coordinator 6 (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on October 2, 2019, at 9:30 a.m. confirmed that Resident 55's admission MDS assessment was not completed within the required time frame.

28 Pa. Code 211.5(f) Clinical records.


 Plan of Correction - To be completed: 11/25/2019

Christ the King Manor intends to ensure that comprehensive admission Minimum Data Set assessments are completed in the required time frame. Corrective actions completed to for those residents found to have been affected by the alleged deficient practice, Resident # 55, this assessment is not able to retroactively corrected.

All residents have the potential to be affected by the alleged deficient. All current residents had had their admission assessment completed within the required timeframe.

Review is being completed by the MDS Coordinators/Registered Assessment Coordinators for the past 30 days.

Systems put into place to ensure the alleged deficient practice does not recur; The Registered Nurse Assessment Coordinators are being re-educated on Section 2 of the Resident Assessment Instrument. This education includes the Resident Assessment Summary and the timelines for submission for newly admitted residents. All residents will have their admission assessment completed within the allotted 14 days. Registered Nurse Assessment Assistant will track all submissions to verified within required time frame.

Corrective action will be monitored to ensure alleged deficient practice will not recur; The Registered Nurse Assessment assistant will monitor for compliance. The audits will ensure all admission assessments will be completed by the Registered Nurse within the 14 days of admission. Audits will be completed daily for 7 days then weekly for 4 weeks then monthly for 3 months. All audits will be presents to Quality Assurance Committee for review and compliance.



483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months: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(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.
Observations:







Based on 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 ensure that quarterly Minimum Data Set assessments were completed within the required time frame for one of 70 residents reviewed (Resident 20).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (federally-mandated assessments of a resident's abilities and care needs), dated October 2018, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to be completed no later than the ARD plus 14 calendar days.

A quarterly MDS assessment for Resident 20 had an ARD of March 16, 2019, requiring the next quarterly MDS assessment ARD to be no later than June 22, 2019, which included seven days out of the facility at the hospital. However, the ARD of the next quarterly MDS assessment was July 10, 2019.

Interview with Registered Nurse Assessment Coordinator 6 (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on October 2, 2019, at 9:30 a.m. confirmed that the quarterly MDS assessment for Resident 20 was not completed within the required time frame.

28 Pa. Code 211.5(f) Clinical records.


 Plan of Correction - To be completed: 11/25/2019

Christ the King Manor intends to ensure that quarterly Minimum Data Set assessments are completed within the time frame required. Corrective action for those residents found to have been affected, Resident #20, this assessment cannot retroactively by corrected.

All residents have the potential to be affected by the alleged deficient practice.

Corrective actions steps taken were all active residents are being screened to ensure that the requirement for quarterly assessments are every 3 months is being followed. Review is being completed for the past 30 days.

Systems put into place to ensure alleged deficient practice does not recur; The Registered Nurse Assessment Coordinators are being re-educated on Section 2 of the Resident Assessment Instrument. This education includes the Resident Assessment Summary and the timelines for submission for quarterly assessments. All residents will have their quarterly assessment completed at least every 3 months according to the guidelines. Residents who are admitted to the hospital will stay on the calendar for assessment until they return to prevent reoccurrence of a late quarterly assessment.The Registered Nurse Assessment assistant will tracking of quarterly assessment completed in the required time frame.

Correction action steps put into place to monitor; the Registered Nurse Assessment assistant will monitor for compliance. These audits will ensure all quarterly assessments will be completed by the Registered Nurse no greater than 92 days of previous assessment reference date. Audits will be completed daily for 7 days, then weekly for 4 weeks, then monthly for 3 months. All audits will be presented to the Quality Assurance Committee for review and compliance.

Corrective action date 11/25/2019

483.20(f)(1)-(4) REQUIREMENT Encoding/Transmitting Resident Assessments: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.
483.20(f) Automated data processing requirement-
483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:
(i) Admission assessment.
(ii) Annual assessment updates.
(iii) Significant change in status assessments.
(iv) Quarterly review assessments.
(v) A subset of items upon a resident's transfer, reentry, discharge, and death.
(vi) Background (face-sheet) information, if there is no admission assessment.

483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.

483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:
(i)Admission assessment.
(ii) Annual assessment.
(iii) Significant change in status assessment.
(iv) Significant correction of prior full assessment.
(v) Significant correction of prior quarterly assessment.
(vi) Quarterly review.
(vii) A subset of items upon a resident's transfer, reentry, discharge, and death.
(viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment.

483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.
Observations:








Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete and/or transmit Minimum Data Set (MDS) assessments to the required electronic system, the CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within the required time frame for six of 70 residents reviewed (Residents 98, 396-399, 401).

Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2018, indicated that Entry, Death in Facility, and Discharge tracking records must be completed and transmitted within 14 days of the Event Date (Section A1600 plus 14 days for Entry records, Section A2000 plus 14 days for Death in Facility records, and Section A2300 plus 14 days for Discharge records). The manual also indicated that comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (Section V0200C2 + 14 days), and all other assessments must be submitted within 14 days of the MDS Completion Date (Section Z0500B + 14 days).

An entry MDS tracking record for Resident 98, dated June 24, 2019 (A1600), indicated that the resident was re-admitted to the facility on June 24, 2019; however, the entry tracking record was not completed until July 9, 2019 (Section A1600 plus 15 days).An entry MDS tracking record for Resident 396, dated June 21, 2019 (A1600), indicated that the resident was re-admitted to the facility on June 21, 2019; however, the entry tracking record was not completed until July 9, 2019 (Section A1600 plus 18 days).An entry MDS tracking record for Resident 397, dated June 24, 2019 (A1600), indicated that the resident was re-admitted to the facility on June 24, 2019; however, the entry tracking record was not completed until July 9, 2019 (Section A1600 plus 15 days).An entry MDS tracking record for Resident 398, dated June 23, 2019 (A1600), indicated that the resident was re-admitted to the facility on June 23, 2019; however, the entry tracking record was not completed until July 9, 2019 (Section A1600 plus 16 days).An entry MDS tracking record for Resident 399, dated July 15, 2019 (A1600), indicated that the resident was re-admitted to the facility on July 15, 2019; however, the entry tracking record was not completed until July 30, 2019 (Section A1600 plus 15 days).A death in facility MDS tracking record for Resident 401, dated June 26, 2019 (A1600), indicated that the resident died on June 26, 2019; however, the death in facility tracking record was not completed until August 26, 2019 (Section A2000 plus 61 days).Interview with Registered Nurse Assessment Coordinator 6 (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on October 3, 2019, at 10:01 a.m. confirmed that the entry tracking records for Residents 98, 396, 397, 398, 399 and 401, and the death in facility tracking record for Resident 401 were not completed within the required time frames.28 Pa. Code 211.5(f) Clinical records.


 Plan of Correction - To be completed: 11/25/2019


F-0640 Encoding/Transmitting Residents Assessments:

Christ the King Manor intends to complete and /or transmit Minimum Data Set assessments to the required electronic system, the CMS Quality Improvement and Evaluation System Assessment Submission and Processing System within the required time frame. Corrective actions put into place for those residents found to be affected by alleged deficient practice, Resident #98, cannot be retroactively corrected.
All residents have the potential to be affected by the alleged deficient practice. Corrective actions put into place; all current and discharged residents have had the correct timely assessments submitted to the Quality Improvement and Evaluation System Assessment Processing System. This is to ensure the submission of assessment is in compliance. Review was completed for the past 30 days.
Systems put into place to ensure alleged deficient practice does not recur; the Registered Nurse Assessment coordinators are being re-educated on Section 5.1 through 5.4 of the Resident Assessment Instrument. The entry and discharge records will now be tracked on a written schedule for compliance of timeliness. A second nurse will be obtaining user rights for submission into the Quality Improvement and Evaluation Assessment Processing System. This will prevent late submission of assessments. All residents will have their required Minimum Data Set assessment submitted within 7 days of completion.
Corrective actions will be monitored to ensure alleged deficient practice will not recur; the Registered Nurse Assessment assistant will monitor for compliance. Audits will ensure all assessments are submitted into the Quality Improvement and Evaluation Assessment Processing System within 7 days of completion. Audits will be completed daily for 7 days, then weekly for 4 weeks, then monthly for 3 months. Results of the audits will be presented to Quality Assurance Committee for review and compliance.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port