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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

KADIMA REHABILITATION & NURSING AT LAKESIDE
Inspection Results For:

There are 88 surveys for this facility. Please select a date to view the survey results.

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KADIMA REHABILITATION & NURSING AT LAKESIDE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on abbreviated complaint survey completed on May 17, 2024, it was determined that Kadima Rehabilitation & Nursing at Lakeside was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:

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.

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:

Based on the review of the facility's abuse prohibition policy and clinical records, and staff interviews, it was determined that the facility failed to report multiple instances of resident abuse perpetrated by one of nine residents sampled to the State Survey Agency (Resident M1).

Findings include:

A review of the facility policy titled "Abuse Protection", last revised by the facility on April 19, 2022, revealed that regardless of how minor an accident or incident may be, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information or such accident/incident is learned. An investigation is implemented, and witness statements are obtained. An accident or incident form must be completed for all reported accident or incidents. The reporting and filing of accurate documents relative to incidents of abuse, reporting to state agencies as required. In Pennsylvania, include PA Department of Health/Pennsylvania Department of Aging/Area Agency on Aging as appropriate. A PB-22 will be completed within five (5) days.

A review of Resident M1's clinical record, revealed he was admitted to the facility on May 17, 2021, with diagnoses to include morbid (severe) obesity due to excess calories, gastro-esophageal reflux disease (GERD), abnormalities of gait and mobility, and difficulty walking.

A review of a nursing note dated December 8, 2023, at 1242 hours (12:42 PM), stating resident M1 yelling at another resident in the dayroom about how she is eating and was upsetting the other resident. The other resident stated "leave me alone", however Resident M1 continued to verbally abuse the resident.

A review of a behavior note, dated February 12, 2024, at 1415 hours (2:15 PM), indicated that Resident M1 was taunting a female resident, pulling his shirt up over his nose and teasing her because of her behaviors. He was making facial and hand gestures towards the female resident. Resident M1 was observed calling her "A crazy bitch!" Resident M1 confirmed he was "mocking" the other resident when staff asked.

A review of a nursing note dated February 25, 2024, at 1651 hours (4:51 PM), revealed that Resident M1 was in the dayroom arguing with staff about television remote. Resident became irate cursing at staff stating, "f*ck you", while throwing the middle finger stating, "I pay you to take care of me and that is your job, anything that goes on in this building is my business so f*ck off." Other residents in dayroom voiced concerns about Resident M1's behavior and were kept safe at time, staff attempted to de-escalate with no effect.

A nursing note dated March 18, 2024, at 1425 hours (2:25 PM), indicated that Resident M1 was verbally abusive with another resident in the dayroom.

A review of a behavior note, dated March 21, 2024, at 2055 hours (8:55 PM), revealed that Resident M1 was in the dining room and loud and argumentative. The note indicated that Residen M1 "Appears at times to intimidate the other residents. When asked to lower his voice a bit, he cursed."

A review of a behavior note dated April 4, 2024, at 1105 hours (11:05 AM), revealed that Resident M1 was heard yelling at a resident in activities. When approaching area, he was yelling at another resident and said "she's a f*cking retard."

A review of a behavior note dated April 10, 2024, at 1212 hours (12:12 PM), revealed that Resident M1 was heard screaming at another resident in the dayroom. Resident continues to yell at resident causing other resident to leave area.

A nursing note dated April 13, 2024, at 2236 hours (10:36 PM), indicated that there was a very loud verbal altercation in the hall and a Nursing Assistant (NA) was calling for help. Nursing noted "I noticed several aides trying to restrain one of the residents who was yelling back at Resident M1 who was yelling at him. This yelling and verbal threats from Resident M1 continued and the other resident reacted in anger. Resident M1 would not go back in his room as the other resident did and continued the verbal threats."

During an interview on May 16, 2024, at approximately 2:05 PM, the Nursing Home Administrator (NHA) confirmed that the facility did not report the instances of resident abuse perpetrated by Resident M1 against other residents to the State Survey Agency.

28 Pa Code 201.14 (c) Responsibility of licensee

28 Pa Code 201.18 (e)(1) Management

28 Pa. Code 201.29 (a)(c) Resident rights

Plan of Correction - To be completed: 07/01/2024

1.The facility investigated the allegations of abuse from Resident M1 cited and made reports to regulatory agencies as necessary.
2.The Social Worker conducted interviews with facility residents to determine if additional investigations needed to occur.
3.The facility staff were re-educated on the Resident Abuse definitions and policy. The NHA will read the 24 hour report daily to ensure abuse allegations are reported to the regulatory agencies as needed.
4.The NHA or designee will conduct an audit of 24 hour report weekly x 4 weeks then monthly x 2 months to ensure abuse allegations are reported to the regulatory agencies as needed. The results of the audit will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.

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

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

Observations:

Based on a review of select facility policy and clinical records, and staff interviews, it was determined that the facility failed to provide therapeutic social services to assess the psychosocial status and needs of residents following incidents of abuse perpetrated by Resident M1.

Findings include:

According to regulatory guidance under Medically-related social services means services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health, which include providing or arranging for needed mental and psychosocial counseling services and identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident.

Situations in which the facility should provide social services or obtain needed services from
outside entities include, but are not limited to the following:
Lack of an effective family or community support system or legal representative;
Expressions or indications of distress that affect the resident ' s mental and psychosocial
well-being, resulting from depression, chronic diseases (e.g., Alzheimer ' s disease and other
dementia related diseases, schizophrenia, multiple sclerosis), difficulty with personal interaction
and socialization skills, and resident to resident altercations;
Abuse of any kind (e.g., alcohol or other drugs, physical, psychological, sexual, neglect,
exploitation);
Difficulty coping with change or loss (e.g., change in living arrangement, change in condition
or functional ability, loss of meaningful employment or activities, loss of a loved one); and
al support.

A review of the facility policy titled "Abuse Protection", last revised by the facility on April 19, 2022, revealed verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms residents or their families or within their hearing distance, regardless of their age, or ability to comprehend or disability.

A review of Resident M1's clinical record, revealed he was admitted to the facility on May 17, 2021, with diagnoses to include morbid (severe) obesity due to excess calories, gastro-esophageal reflux disease (GERD), abnormalities of gait and mobility, and difficulty walking.

A review of a nursing note dated December 8, 2023, at 1242 hours (12:42 PM), stating resident M1 yelling at another resident in the dayroom about how she is eating and was upsetting the other resident. The other resident stated "leave me alone", however Resident M1 continued to verbally abuse the resident.

A review of a behavior note, dated February 12, 2024, at 1415 hours (2:15 PM), indicated that Resident M1 was taunting a female resident, pulling his shirt up over his nose and teasing her because of her behaviors. He was making facial and hand gestures towards the female resident. Resident M1 was observed calling her "A crazy bitch!" Resident M1 confirmed he was "mocking" the other resident when staff asked.

A review of a nursing note dated February 25, 2024, at 1651 hours (4:51 PM), revealed that Resident M1 was in the dayroom arguing with staff about television remote. Resident became irate cursing at staff stating, "f*ck you", while throwing the middle finger stating, "I pay you to take care of me and that is your job, anything that goes on in this building is my business so f*ck off." Other residents in dayroom voiced concerns about Resident M1's behavior and were kept safe at time, staff attempted to de-escalate with no effect.

A nursing note dated March 18, 2024, at 1425 hours (2:25 PM), indicated that Resident M1 was verbally abusive with another resident in the dayroom.

A review of a behavior note, dated March 21, 2024, at 2055 hours (8:55 PM), revealed that Resident M1 was in the dining room and loud and argumentative. The note indicated that Resident M1 "Appears at times to intimidate the other residents. When asked to lower his voice a bit, he cursed."

A review of a behavior note dated April 4, 2024, at 1105 hours (11:05 AM), revealed that Resident M1 was heard yelling at a resident in activities. When approaching area, he was yelling at another resident and said "she's a f*cking retard."

A review of a behavior note dated April 10, 2024, at 1212 hours (12:12 PM), revealed that Resident M1 was heard screaming at another resident in the dayroom. Resident continues to yell at resident causing other resident to leave area.

A nursing note dated April 13, 2024, at 2236 hours (10:36 PM), indicated that there was a very loud verbal altercation in the hall and a Nursing Assistant (NA) was calling for help. Nursing noted "I noticed several aides trying to restrain one of the residents who was yelling back at Resident M1 who was yelling at him. This yelling and verbal threats from Resident M1 continued and the other resident reacted in anger. Resident M1 would not go back in his room as the other resident did and continued the verbal threats."

During an interview on May 16, 2024, at approximately 1:50 PM, the Director of Social Services, was unable to provide documented evidence of the facility's efforts to identify those residents affected by the above incidents of resident abuse perpetrated by Resident M1 and of the supportive social service interventions provided to assist the residents involved, directly, and indirectly (within hearing distance) following the incidents of abuse perpetrated by Resident M1.

During an interview on May 16, 2024, at approximately 2:10 PM, the NHA confirmed that there was no documented evidence of social service assessment of psychosocial status and needs and provision of social service interventions provided to residents following episodes of abuse perpetrated by Resident M1.

28 Pa. Code 201.29 (a) Resident rights.

28 Pa. Code 211.5(f) Medical records

28 Pa. Code 211.16 (a) Social Services

Plan of Correction - To be completed: 07/01/2024

1.Resident M1's care plan was reviewed with the IDT and behavioral care plans addressing triggers and interventions were completed.
2.Residents with behaviors had their care plans reviewed with the IDT and behavioral care plans addressing triggers and interventions were completed.
3.The Social Worker was re-educated on providing therapeutic social services. The NHA will conduct reviews of the 24-hour report to ensure that social service needs are addressed.
4.The DON or designee will conduct care plan reviews of 25% of residents weekly x 4 weeks then monthly x 2 months to ensure social service needs are addressed. The results of the audit will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:

Based on a review of clinical records and the facility's abuse prohibition policy and staff interviews, the facility failed to investigate instances of resident abuse, protect residents from the potential for further abuse during the course of an investigation and submit the results of the completed investigations to the State Survey Agency within 5 working days of the incident for multiple instances of resident abuse perpetrated by one resident out of nine sampled (Resident M1).

Findings include:

A review of the facility policy titled "Abuse Protection", last revised by the facility on April 19, 2022, revealed the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. Residents must not be subject to abuse by anyone, including but not limited to facility staff and other residents. Abuse includes verbal abuse, and means the willful infliction of injury, unreasonable confinement, and intimidation, resulting in physical harm, pain or mental anguish.

Regardless of how minor an accident or incident may be, an investigation is implemented, and witness statements are obtained. An accident or incident form must be completed for all reported accident or incidents. The reporting and filing of accurate documents relative to incidents of abuse, reporting to state agencies as required. In Pennsylvania, include PA Department of Health/Pennsylvania Department of Aging/Area Agency on Aging as appropriate, a PB-22 (Pennsylvania Bulletin 22- form used to detail investigation, findings and actions) will be completed within five (5) days.

A review of Resident M1's clinical record, revealed he was admitted to the facility on May 17, 2021, with diagnoses to include morbid (severe) obesity due to excess calories, gastro-esophageal reflux disease (GERD), abnormalities of gait and mobility, and difficulty walking.

A review of a nursing note dated December 8, 2023, at 1242 hours (12:42 PM), stating resident M1 yelling at another resident in the dayroom about how she is eating and was upsetting the other resident. The other resident stated "leave me alone", however Resident M1 continued to verbally abuse the resident.

A review of a behavior note, dated February 12, 2024, at 1415 hours (2:15 PM), indicated that Resident M1 was taunting a female resident, pulling his shirt up over his nose and teasing her because of her behaviors. He was making facial and hand gestures towards the female resident. Resident M1 was observed calling her "A crazy bitch!" Resident M1 confirmed he was "mocking" the other resident when staff asked.

A review of a nursing note dated February 25, 2024, at 1651 hours (4:51 PM), revealed that Resident M1 was in the dayroom arguing with staff about television remote. Resident became irate cursing at staff stating, "f*ck you", while throwing the middle finger stating, "I pay you to take care of me and that is your job, anything that goes on in this building is my business so f*ck off." Other residents in dayroom voiced concerns about Resident M1's behavior and were kept safe at time, staff attempted to de-escalate with no effect.

A nursing note dated March 18, 2024, at 1425 hours (2:25 PM), indicated that Resident M1 was verbally abusive with another resident in the dayroom.

A review of a behavior note, dated March 21, 2024, at 2055 hours (8:55 PM), revealed that Resident M1 was in the dining room and loud and argumentative. The note indicated that Residen M1 "Appears at times to intimidate the other residents. When asked to lower his voice a bit, he cursed."

A review of a behavior note dated April 4, 2024, at 1105 hours (11:05 AM), revealed that Resident M1 was heard yelling at a resident in activities. When approaching area, he was yelling at another resident and said "she's a f*cking retard."

A review of a behavior note dated April 10, 2024, at 1212 hours (12:12 PM), revealed that Resident M1 was heard screaming at another resident in the dayroom. Resident continues to yell at resident causing other resident to leave area.

A nursing note dated April 13, 2024, at 2236 hours (10:36 PM), indicated that there was a very loud verbal altercation in the hall and a Nursing Assistant (NA) was calling for help. Nursing noted "I noticed several aides trying to restrain one of the residents who was yelling back at Resident M1 who was yelling at him. This yelling and verbal threats from Resident M1 continued and the other resident reacted in anger. Resident M1 would not go back in his room as the other resident did and continued the verbal threats."
At the time of the survey ending May 16, 2024, the facility had completed investigations into the above episodes of resident abuse perpetrated by Resident M1. The resident victims were not identified in the documentation available.
The facility failed to provide evidence of completed investigations, PB22's submitted to the State Survey Agency within five working days of the occurrence.

During an interview on May 16, 2024, at approximately 2:05 PM, the Nursing Home Administrator (NHA) confirmed that the facility failed to investigate Resident M1's abuse of other residents and submit the completed investigations to the State Survey Agency within 5 working days of the incident.

28 Pa. Code 201.14 (a) Responsibility of licensee

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

28 Pa. Code 201.29(a)(c) Resident Rights

Plan of Correction - To be completed: 07/01/2024

1.The facility investigated the allegations of abuse from Resident M1 cited and made reports to regulatory agencies as necessary.
2.The Social Worker conducted interviews with facility residents to determine if additional investigations needed to occur.
3.The NHA and DON will be re-educated on timely abuse reporting, facility investigations, and timeliness of PB22 submissions.
4.The NHA or designee will audit 24 hours report weekly x4 weeks then monthly x2 months to ensure all abuse allegations are investigated and reported timely. The results will be submitted to the QAPI Committee for review and analysis of the need for ongoing monitoring.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:

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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Observations:

Based on observations, review of clinical records, and staff interview, it was determined that the facility failed to provide reasonable accommodation of the needs of a bariatric resident for safe wheelchair equipment for one resident out of 9 residents observed (Residents M1).

Findings included

Review of the clinical record revealed that Resident M1 was admitted to the facility on May 17, 2021, with diagnoses to include morbid (severe) obesity, and polyosteoarthritis (swelling and tenderness causing joint pain or stiffness in five or more joints at the same time).

Review of Resident M1's weight record revealed that the resident weighed 528.6 pounds on May 13, 2024.

During an initial tour of the facility on May 16, 2024, at 9:05 AM, Resident M1 was observed seated in a bariatric wheelchair in the activities room. At 9:30 AM Resident M1 was observed self propelling the wheelchair down the hallway and into his room.

Observation of the resident's wheelchair on May 16, 2024, at 10:27 AM, in the presence of the Nursing Home Administrator (NHA) and Director of Nursing, revealed that the manufacturer's maximum weight capacity for the wheelchair the resident was using was 500 pounds, which Resident M1 exceeded. The resident's weight record revealed the resident exceeded 500 pounds on February 8, 2024, weighing 508.2 pounds, which had increased to 528.6 lbs on May 13, 2024.

At the time of the survey ending May 16, 2024, the facility was unable to provide documented evidence that the resident's wheelchair maximum capacity of 500 pounds was identified and addressed by the facility as the resident's current wheelchair did not accommodate his current bariatric weight.

Interview with the NHA on May 16, 2024, at approximately 3:00 PM confirmed that Resident M1's current weight exceeded the wheelchair maximum weight capacity and that the facility failed to provide wheelchair equipment to accommodate the needs of a bariatric resident.

28 Pa. Code 205.75 Supplies

Plan of Correction - To be completed: 07/01/2024

1.Resident M1 has a wheelchair that meets his weight requirements.
2.A facility wide audit was completed to ensure wheelchairs have weight limits that are within the resident's weight.
3.The Rehabilitation Director was re-educated on providing wheelchairs to residents that meet the chair's weight limits. The Maintenance Director will conduct random audits of wheelchair weight limits when performing preventative maintenance.
4.The Director of Nursing or designee will conduct 25% of resident wheelchairs weekly x 4 weeks then monthly x 2 months to ensure weight limits are followed. The results of the audit will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.

483.10(f)(10)(iv)(v) REQUIREMENT Notice and Conveyance of Personal Funds:

§483.10(f)(10)(iv) Notice of certain balances.
The facility must notify each resident that receives Medicaid benefits-
(A) When the amount in the resident's account reaches $200 less than the SSI resource limit for one person, specified in section 1611(a)(3)(B) of the Act; and
(B) That, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI.

§483.10(f)(10)(v) Conveyance upon discharge, eviction, or death.
Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility must convey within 30 days the resident's funds, and a final accounting of those funds, to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law.

Observations:

Based on a review of clinical records and residents' financial account records and staff interview, it was determined that the facility failed to return resident funds within 30 days of discharge/death to the appropriate party for one of five residents sampled (Residents CR1 ).

Findings include:

Clinical record review revealed that Resident CR1 was admitted to the facility on October 26, 2023, and expired on December 4, 2023.

A review of the resident's financial account statement provided by the facility dated April 2, 2024, revealed a credit on his account for $9,520.00. On April 8, 2024, an adjustment was noted with a revised credit amount of $6,584.48.

The facility failed to refund the resident's personal funds within 30 days of the resident's discharge.

A letter provided to the surveyor and signed by the Principal of the organization, confirmed that Resident CR1's account had not been issued a refund due to miscommunications within departments.

During an interview on May 16, 2024, at 11:00 AM, the Nursing Home Administrator verified that Resident CR1's personal funds were not refunded to the family within 30 days of his discharge/death from the facility.

28 Pa. Code: 201.18 (b)(2)(e)(1) Management.

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 07/01/2024

1.Resident CR1 was provided with a refund.
2.A 30-day lookback was completed to ensure there are no other refunds due.
3.The AP Supervisor was re-educated on providing timely refunds as requested. The BOM will complete a monthly audit to ensure refunds are processed timely.
4.The NHA or designee will conduct an audit of discharged residents weekly x 4 weeks then monthly x 2 months to ensure refunds are processed timely. The results of the audit will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.

§ 201.14(a) LICENSURE Responsibility of licensee.:

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on staff interview and the facility's Infection Control Program, it was determined that the facility failed to report applicable health care associated infections to Patient Safety Authority during the last 12 months (January 2023 through December 2023).

Findings include:

Review of Act 52 (The Act of March 20, 2002 P.L.154, No. 13) amended July 20, 2007, known as the Medical Care Availability and Reduction of Error (Mcare) Act -Reduction and Prevention of Health Care-Associated Infection and Long-Term Care Nursing Facilities, Chapter 4, Section 404(a) Nursing Home Reporting, revealed a nursing home shall electronically report health care-associated infection data to the department and the authority using recognized standards based on CDC definitions, provided that data is reported on a patient-specific basis in the form, with the time for reporting and the format as determined by the department and the authority. Data is to be reported on a monthly basis.

Review of the facility's infection control data for the last 12 months (January 2023 through December 2023), revealed upon request of reports to the Patient Safety Authority to show compliance with Act 52, the facility was unable to provide any reports at the the time of the survey ending May 16, 2024, but did verify with the monthly line listing the occurrence of health care-associated infections among its residents during that time frame.

During an interview with Employee 2 (Infection Preventionist) and the Nursing Home Administrator (NHA) on May 16, 2024, at approximately 1:00 PM, it was confirmed that no reports of facility HAI were made to the Patient Safety Authority during that 12 month period.

Plan of Correction - To be completed: 07/01/2024

1.The HAI were reported to the Patient Safety Authority for the 12-month period.
2.The new DON and ICN have access to report moving forward.
3.The ICN was re-educated on reporting HAI to the Patient Safety Authority timely. The DON will conduct periodic reviews of the Patient Safety Authority reporting to ensure HAIs are reported timely.
4.The DON or designee will conduct a monthly review of the Patient Safety Authority HAI reporting monthly x 6 months to ensure timely reporting. The results of the audit will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.

§ 201.14(c) LICENSURE Responsibility of licensee.:

(c) The licensee through the administrator shall report as soon as possible, or, at the latest, within 24 hours to the appropriate Division of Nursing Care Facilities field office serious incidents involving residents as set forth in § 51.3 (relating to notification). For purposes of this subpart, references to patients in § 51.3 include references to residents.

Observations:

Based on review of select facility policy and clinical records and staff interview, it was determined that the facility failed to notify the State Licensing Agency, Department of Health, Division of Nursing Care Facilities of an elopement from the facility for one resident (Resident M1) out of five sampled.

Findings include:

A review of the facility policy titled "Resident Elopement", last revised by the facility on April 19, 2022, revealed an elopement is defined as a resident leaving the physical structure of the facility without the knowledge of facility staff.

According to the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure regulations 201.3. Definitions an elopement is when a resident leaves the premises or a safe area without authorization.

A review of Resident M1's clinical record, revealed he was admitted to the facility on May 17, 2021, with diagnoses to include morbid (severe) obesity due to excess calories, gastro-esophageal reflux disease (GERD), abnormalities of gait and mobility, and difficulty walking.

A review of a nursing note (written by Employee 1, Registered Nurse - RN) dated April 22, 2024, at 1300 hours (1:00 PM), noted that Resident M1 left "LOA (leave of absence) out of building without signing book or notifying staff." Resident returned and was educated that he needs to notify staff when going LOA, and to have whoever is taking him sign the LOA book. Resident in stable condition. Body audit complete with no new areas. No complaints of pain.

During an interview on May 16, 2024, at approximately 12:05 PM, with Employee 1, RN, revealed resident M1 had informed staff of a friend coming to visit and would be stepping outside onto the patio for a visit. Employee 1, RN was not aware of the friend's arrival, nor which staff member opened the keyed exit door to allow Resident M1 outside onto the patio. She further stated that shortly after Resident M1 exited the facility onto the patio, staff observed him entering a motor vehicle operated by his friend and leaving the premises without notifying staff of his departure. Employee 1, RN, stated she immediately informed administration of this observation. According to Employee 1, RN, Resident M1 was out of the facility for approximately 1 hour.

The facility did not report this elopement to the Division of Nursing Care Facilities, Scranton Field Office.

During an interview on May 16, 2024, at approximately 2:10 PM, the NHA, confirmed the facility failed to report the resident's elopement to the State Licensing Agency.

Plan of Correction - To be completed: 07/01/2024

1.Investigation of alleged elopement was conducted.
2.The elopement was reported to the regulatory agency.
3.The DON was re-educated on timely reporting of elopement to the regulatory agency. The NHA will review the 24-hour report to ensure elopements are reported to the regulatory agency timely.
4.The NHA or designee will conduct a review of documentation weekly x 4 weeks then monthly x 2 months to ensure elopements are reported to the regulatory agency. The results of the audit will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:
Based on a review of nursing time schedules and the resident census and staff interview, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on the evening shift for three shifts out of 21 reviewed (May 12, May 14 and May 15, 2024).

Findings include:

A review of the facility's weekly staffing records May 9, 2024, through May 15, 2024, revealed that on the following dates the facility failed to provide a minimum one nurse aide per 12 residents on the evening shift based on the facility's census.

Review of facility census data indicated that on May 12, 2024, the facility census was 30, which required 2.50 nurse aides during the evening shift. Review of the nursing time schedules revealed 2.00 nurse aides worked the evening shift on May 12, 2024.

Review of facility census data indicated that on May 14, 2024, the facility census was 30, which required 2.50 nurse aides during the evening shift. Review of the nursing time schedules revealed 2.00 nurse aides worked the evening shift on May 14, 2024.

Review of facility census data indicated that on May 15, 2024, the facility census was 29, which required 2.42 nurse aides during the evening shift. Review of the nursing time schedules revealed 2.00 nurse aides worked the evening shift on May 15, 2024.

During an interview on May 16, 2024, at 3:00 PM the Director of Nursing confirmed that the facility failed to provide a minimum nurse aide staffing ratios on the above shifts.

Plan of Correction - To be completed: 07/01/2024

1.) The facility is unable to retroactively provide minimum nurse aide ratio for cited dates.
2.A facility wide audit was completed to ensure ratios were met. Recruitment increased, CNA sign on bonuses, and wages are competitive with surrounding areas.
3.The DON and Administrative Assistant were re-educated on ensuring that the nursing care ratios are provided, and that the facility is actively recruiting CNAs. DON will review census and schedule daily to ensure we have adequate staffing levels of CNA's daily.
4.The DON or designee will conduct an audit of the nursing care ratios to ensure it is provided weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:
Based on a review of nursing time schedules and the resident census and staff interview, it was determined that the facility failed to ensure the minimum licensed practical nurse (LPN) staff to resident ratio was provided on the day, evening, and night shifts for fifteen shifts out of 21 reviewed (May 9, May 10, May 11, May 12, May 13, May 14 and May 15, 2024).

Findings include:

A review of the facility's weekly staffing records May 9, 2024, through May 15, 2024, revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:25 on the day shifts, 1:30 on the evening shift, and 1:40 on the night shift based on the facility's census.

Review of facility census data indicated that on May 9, 2024, the facility census was 30, which required 1.20 LPN during day shift. Review of the nursing time schedules revealed 1.00 LPN worked the day shift on May 9, 2024.

Review of facility census data indicated that on May 10, 2024, the facility census was 30, which required 1.20 LPN during day shift. Review of the nursing time schedules revealed 1.00 LPN worked the day shift on May 10, 2024.

Review of facility census data indicated that on May 11, 2024, the facility census was 30, which required 1.20 LPN during day shift, 1.00 LPN during the evening shift, and 1.00 LPN during the night shift. Review of the nursing time schedules revealed 1.00 LPN worked the day shift, 0.50 LPN worked the evening shift, and 0.00 LPN worked the night shift on May 11, 2024.

Review of facility census data indicated that on May 12, 2024, the facility census was 30, which required 1.20 LPN during day shift. Review of the nursing time schedules revealed 1.00 LPN worked the day shift on May 12, 2024.

Review of facility census data indicated that on May 13, 2024, the facility census was 30, which required 1.20 LPN during day shift. Review of the nursing time schedules revealed 1.00 LPN worked the day shift on May 13, 2024.

Review of facility census data indicated that on May 14, 2024, the facility census was 30, which required 1.20 LPN during day shift. Review of the nursing time schedules revealed 1.00 LPN worked the day shift on May 14, 2024.

Review of facility census data indicated that on May 15, 2024, the facility census was 29, which required 1.16 LPN during day shift. Review of the nursing time schedules revealed 1.00 LPN worked the day shift on May 15, 2024.

If the facility census is 59 or under on the night shift and the facility has chosen to substitute an LPN for a Registered Nurse (RN), with an RN on call, this will require an additional LPN to satisfy the requirement.

A review of facility census data indicated that on May 9, 10, 12, 13, and 14, 2024 the facility census was 30 on night shift, and on May 15, 2024, the census was 29 on night shift.

The facility substituted an LPN for an RN on the night shift on May 9, 10, 12, 13, 14, and 15, 2024, but failed to ensure additional LPN to meet the LPN ratio on the overnight shift.

During an interview on May 16, 2024, at approximately 3:00 PM, the Director of Nursing confirmed that the facility failed to provide a minimum licensed practical nurse staffing ratios on the above shifts.

Plan of Correction - To be completed: 07/01/2024

1. The facility is unable to retroactively provide a minimum LPN ratio for cited dates.
2. A facility wide audit was completed to ensure ratios were met. Recruitment initiatives were increased, LPN sign on bonuses, and wages are competitive with surrounding areas.
3. The DON, Administrative Assistant and Recruitment were re-educated on ensuring that the nursing care ratios are provided, and that the facility is actively recruiting LPNs. The DON will review census and schedule daily to ensure adequate staffing of LPN's.
4. The DON or designee will conduct an audit of the nursing care ratios to ensure it is provided weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.

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