Pennsylvania Department of Health
EMMANUEL CENTER FOR NURSING AND REHAB AT MARIA JOSEPH MANOR
Patient Care Inspection Results

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EMMANUEL CENTER FOR NURSING AND REHAB AT MARIA JOSEPH MANOR
Inspection Results For:

There are  76 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.
EMMANUEL CENTER FOR NURSING AND REHAB AT MARIA JOSEPH MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, and Abbreviated Complaint Survey completed on January 11, 2024, it was determined that Emmanuel Center for Nursing and Rehab at Maria Joseph Manor 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:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and one of two resident pantries.

Findings include:

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

During the initial tour of the food and nutrition services department with the foodservice director (FSD) conducted on January 9, 2024, at 10:00 AM the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness were identified:

There was a build-up of debris in the ceiling light shields located above the two-door refrigerator, trayline, handwashing sink, spice rack area, and food preparation area were dust covered. The ceiling vents and ceiling blocks in these areas were also dust covered.

The hood vents located above the stoves had a thick layer dust and were in need of cleaning.

The perimeter of the floors throughout the kitchen were visibly soiled and had an accumulation of debris.

Uncovered bowls of applesauce were being stored in the roll-in refrigerator.

There was a build-up of a chalky brownish colored substance (identified by the FSD as limescale) on the outside surface of the dishwasher.

The exterior surfaces of two garbage cans near the trayline were heavily soiled and in need of cleaning.

The interior surface of several hot beverage mugs identified as clean were stained with a brownish colored residue.

Interview with the foodservice director (FSD) at this time confirmed that the food and nutrition services department was to be maintained in a sanitary manner. The FSD also confirmed that at the present time the steamer (used to cook vegetables and other food items), the upper portion of the convection oven, and the trayline steamtable (one of five wells not heating up) needed repair. The FSD confirmed that a plan to cook items that would normally be cooked in the steamer on the stove top was in place.

Interview with the administrator on January 9, 2024, at approximately 11:30 AM confirmed that the top convection oven has not been working since March 2023 and the steamer has not been working since April 2023. The steamtable was identified as needing repair on December 30, 2023. The administrator noted that new equipment was ordered and expected to be installed on February 23, 2024.

Observation of the 100 nursing unit pantry on January 10, 2024, at 12:20 PM revealed a partially eaten breakfast tray on the counter and dirty mugs and plastic cups in the pantry sink; there was a build-up of a chalky brownish substance adhered to the dispensing spout and drip tray of the automatic ice dispenser; and there was a black substance on the end of the condensation hose of the automatic ice dispenser.

Observation at this time also revealed a utility cart with five partially eaten breakfast trays in the hallway located between the resident lounge and the resident pantry.

Interview with the administrator on January 10, 2024, at 1:15 PM confirmed that resident meal trays were to be timely collected and returned to the food and nutrition services department following each meal and resident pantry areas were to be maintained in a sanitary manner to prevent potential contamination of food and maintain acceptable practices for food storage items.

28 Pa. Code 201.18 (e)(2.1) Management

28 Pa. Code 211.6 (f) Dietary Services






















 Plan of Correction - To be completed: 02/12/2024

All dietary areas including all dietary equipment will be thoroughly cleaned and sanitized.
Dietary sanitation policy to be reviewed to include cleaning schedules, documentation, and inspections. Post meal clean up policy/process to be reviewed by the management team.
Dietary staff to be reeducated by the Executive Director or designee on dietary sanitation policy. Staff to be reeducated on post meal clean up policy/process.
Departmental area and equipment inspections will be conducted according to facility policy. Dietary Manager or designee will audit post meal clean up across all 3 meals on 3 separate days a week, one of which will be a weekend. These audits will be conducted for 1 month, then switched to 1 x a month across all 3 meals.
Results of inspections and audits will be reviewed at monthly facility QAPI meeting for further review and recommendations.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

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

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

Based on review of select facility policy and minutes from Resident Council meetings and resident and staff interviews it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints/grievances expressed during Resident Council Meetings including those voiced by five of five residents attending a resident group meeting (Residents 29, 46, 26, 49, and 16)

Findings include:

Review of the facility's current Grievance policy provided during the survey ending January 11, 2024, indicated that it is the facility's policy to provide an opportunity for residents to express concerns at any time. The facility's goal is to resolve resident and family concerns in a timely basis.

Review of the minutes from the Resident Council meetings held between October 2023 through December 2023, revealed that residents in attendance at these resident group meetings voiced their concerns regarding facility services during the meetings.

During the October 2023 Resident Council meeting the residents in attendance relayed concerns with staff responding their requests for assistance via the nurse call bell system, in a timely manner.

During the November 2023 Resident Council meeting the residents in attendance relayed concerns with staff responding their requests for assistance via the nurse call bell system in a timely manner.

During the December 2023 Resident Council meeting the residents in attendance relayed concerns with staff responding their requests for assistance via the nurse call bell system in a timely manner.

During a group meeting held on January 10, 2024, at 10:30 a.m., with five (5) alert and oriented residents, five of five residents (Residents 29, 46, 26, 49, and 16) stated that they often wait longer than 25-30 minutes for staff assistance after they ring their call bells. The residents stated that they have repeatedly brought this particular complaint to the facility's attention without resolution to date.

The facility was unable to provide documented evidence at the time of the survey ending January 10, 2024, that the facility had determined if the residents' felt that their complaints/grievances had been resolved through any efforts taken by the facility in response to the residents' expressed concerns regarding untimely call bell response time.

During an interview with the Nursing Home Administrator (NHA) on January 11, 2024, at 11:00 a.m. the NHA was unable to provide documented evidence that the facility had followed-up with the residents to ascertain the effectiveness of the facility's efforts in resolving their complaints regarding call bell timeliness.


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

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





 Plan of Correction - To be completed: 02/12/2024

The community will Interview 10% of all interviewable residents for resident satisfaction of call light response times and review their specific call logs weekly.
Conduct special resident council meeting to discuss any open grievances.
Resident council will be hosted Monthly, all grievance brought forth will be responded to according to the community policy.
The leadership team will report feedback related to residents' concerns bi-weekly in a town hall newsletter. The town Hall newsletter will be made available to residents and staff.
Results of audits will be reported to QAPI for further review and recommendations and shared with the Resident Council.

Staff will be reeducated regarding the facility call bell and grievance policies
policy.

Results of audits will be reported to QAPI for further review and recommendations.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on a review of clinical records, select facility policy, CDC and Pennsylvania Department of Health guidelines, observations, and staff interview it was determined that the facility failed to follow infection control practices designed to deter spread of RSV (Respiratory Syncytial Virus) infections in the facility.

Findings included:

Review of the facility's policy entitled "Management of Respiratory Syncytial Virus" last reviewed by the facility on March 16, 2023, indicated it is the policy of the facility to ensure that proper and appropriate infection control principles are utilized to help decrease the risk of transmission of RSV. RSV is a highly contagious respiratory virus that can affect any age but is greater risk for older adults. It is easily spread through air uninfected respiratory droplets or through direct contact. The use of proper infection control principles can help decrease the risk of transmission of RSV. Further it was indicated the nurse will observe residents for signs and symptoms that may be consistent with upper respiratory tract infections but could be diagnosis RSV. The facility we'll follow testing guidance for RSV per state and local guidance in accordance with physician's orders. Infection control principles will be followed to decrease the risk of transmission based on federal state and local guidance. Residents testing positive for RSD will be placed on transmission based precautions for 10 days. Symptoms persisting past 10 days require an evaluation from provider to clear transmission based precaution status.

According to PA HAN 720 initially dated September 29, 2023, testing should be used to diagnose respiratory infections due to the similarity of symptoms. Virus identification is crucial for making decisions regarding cohorting, implementing treatment, among other interventions. During increased respiratory virus activity, facilities are advised to use comprehensive respiratory panels to determine if multiple pathogens are circulating in the facility.

According to CDC guidelines when an acute respiratory infection is identified in a resident it is important to take rapid action to prevent the spread to others in the facility. Further it is indicated to test anyone with respiratory illness signs and symptoms. The selection of the diagnostic tests will depend on the suspected cause of the infection. The facility should investigate for potential respiratory virus spread among residents and preform active surveillance to identify any additional ill residents using symptom screening and evaluating potential exposures.

A review of an RSV line listing revealed the facility had an outbreak of RSV beginning on December 21, 2023, in the 100 hall nursing unit with Resident 34.

The following residents tested positive for RSV after the initial outbreak:

Resident 63 on December 22, 2023
Resident 61 on December 24, 2023
Resident 33 on January 2, 2024
Resident 64 on January 3, 2024.
Resident 223 was admitted to the facility on January 4, 2024, and was positive for RSV on admission.

A review of these clinical records revealed that the facility did not implement additional active respiratory surveillance on the residents once the outbreak began to promptly identify any additional respiratory illnesses.

A review of Resident 47's clinical record, who resides in the 100 hall nursing unit, revealed that the resident began to experience respiratory symptoms of a cough and congestion on December 30, 2023.

A nursing note dated January 1, 2024, at 7:00 AM revealed that the resident continued to have respiratory symptoms of a moist cough, moderate amounts of phlegm, a temperature of 99.1 degrees, and rhonchi (course sounds in the lungs caused by constricted airways). Nursing notes revealed that the resident continued to have respiratory symptoms from January 2, 2024 through January 7, 2024.

A review of Resident 46's clinical record, who resides on the 100 hall nursing unit, revealed on December 31, 2023, the resident began to experience cough. Nursing noted that the resident continued to experience a non-productive cough and cold like symptoms from January 1, 2024, through January 11, 2024.

A review of Resident 57's clinical record, who resides on the 100 hall nursing unit, revealed that on January 1, 2024, the resident began to experience respiratory symptoms of a cough.
Nursing noted on January 2, 2024, at 1:00 AM that the resident was having a coughing fit and a hard time clearing her phlegm. Nursing notes revealed that from January 3, 2024, through January 11, 2024, the resident continued to experience respiratory symptoms as noted above.

The facility failed to perform testing on the residents who were experiencing multiple respiratory symptoms to promptly determine if the residents had contracted RSV during the current outbreak and to prevent further spread throughout the facility.

A review a of resident council meeting minutes dated December 29, 2023, revealed that the residents in attendance at the meeting raised a concern about residents not being tested for RSV. The Resident Council asked the facility why residents are not being tested for RSV if they have symptoms and there are RSV infections in the facility. The DON (director of nursing) replied that "it was up to the doctor and RSV is viral and just has to run its course."

An observation on January 9, 2024, at approximately 10:45 AM revealed a red bin intended for disposal of used/contaminated PPE (personal protective equipment) in the doorway to room 103. Resident 233 resides in the room and was positive for RSV. The red bin was overflowing with PPE and dirty used contaminated PPE was hanging outside, overflowing from the bin.

An interview with the Infection Preventionist on January 10, 2024, at approximately 10:35 AM revealed she stated that residents that were experiencing respiratory symptoms should have been tested since the facility had an RSV outbreak.

An interview with the Director of Nursing on January 11, 2024, at approximately 1:40 PM confirmed the facility failed to implement policies and procedures to prevent the potential spread of RSV.




28 Pa Code 211.10(a)(d) Resident care policies

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




 Plan of Correction - To be completed: 02/12/2024

The community will follow the CDC guidelines, Management of Respiratory Syncytial Virus policy, and PA HAN 720 in relation to infections prevention.
All current residents reviewed for respiratory symptoms, test as indicated, and provider notified.
The Infection Preventionist or designee will test all residents with respiratory symptoms per CDC guidelines and per requested when the community has an identified active respiratory infection. Initial testing procedures will be completed by DON or designee from nursing staff. Medical director directive is that all residents exhibiting respiratory like symptoms will be rapid COVID test, if febrile with respiratory symptoms respiratory PCR to be completed.
The infection preventionist track all respiratory infections.
Housekeeping or designee will empty trash in isolation rooms every shift and as needed. If Housekeeping is unavailable, nursing staff will be empty trash.
The DON or designee will educate all staff on infection/isolation guidelines.
The clinical team will review all residents with new respiratory symptoms identified during the morning clinical meeting, that testing, care planning, and provider notification occurred.
The DON or designee will do physical audits on isolation rooms to check for trash control. 1x a week for 4 week and then monthly until 100% compliance or three months.
Infection trends will be reported in QAPI.


483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime: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(f) Frequency of Meals
§483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

§483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

§483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.
Observations:

Based on review of select facility policy and the minutes from Residents' Council meetings, and resident and staff interviews, it was determined that the facility failed to routinely offer bedtime snacks to residents as desired.

Findings include:

A review of facility policy titled "Residents Snacks" reviewed March 16, 2023, revealed that bedtime snacks will be offered to residents daily.

During a group meeting held on January 10, 2024, at 10:30 a.m., with five (5) alert and oriented residents, five of five residents (Residents 29, 46, 26, 49, and 16) stated that they have not received bedtime snacks "in a very long time."

The residents stated that they have repeatedly brought this particular complaint to the facility staff's attention without resolution to date.

During an interview on January 10, 2024, at 2 p.m., the Nursing Home Administrator and Director of Nursing were unable to verify that residents are routinely offered and provided snacks at bedtime as preferred by each resident on nightly basis.



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

28 Pa. Code 211.10(a) Resident care policies



 Plan of Correction - To be completed: 02/12/2024

Dietitian to interview residents 29,46,26,49 to ascertain snack preferences and address specific concerns. This topic will be included in a special resident food council meeting.
Mealtime and snack distribution policy to be reviewed and educated on by the DON or designee.
Dietary staff to be reeducated by Dietary General Manager or designee on Mealtime and snack distribution policy.
Evening snack distribution will be audited weekly by Dietary General Manager 1 x week for 4 weeks, and then monthly for 3 months.
Results of evening snack distribution audits will be reviewed at monthly facility QAPI and Resident Food Council Meeting for further review and recommendations.

Staff education to nursing staff and dietary staff re: offering bedtime snacks or when resident requests by DON or designee.

CNA and nursing staff are responsible for providing bedtime snacks as requested. All other staff to check with nursing staff on snack resident is requesting.
The snack is a tasked item to CNAs that will be audited and interviews will be conducted in which residents are asked if snack was offered by the DON or designee.


483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:


Based on observations, test tray results, resident and staff interviews, and test tray results it was determined that the facility failed to serve meals at safe and palatable temperatures.

Findings include:

According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements - the definition of "Danger Zone", found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness.

During an interview on January 9, 2024, at 10:47 AM, Resident 12 stated that the food served was "rarely ever hot", and she will often send it back to be reheated. She mentioned that she likes vegetables but could never eat them due to being mushy or not cooked.

During an interview on January 9, 2024, at 11:00 AM, Resident 29 stated that the food has "gone downhill and always comes out cold." She mentioned that she spoke with dietary staff related to a steam table and has voiced concerns during resident council meetings about the temperature of the food.

During an interview on January 9, 2024, at 11:25 AM, Resident 13 stated that the food could be better, and the temperature is never hot.

During an interview on January 10, 2024, at 9:27 AM, Resident 39 stated that the food is not the greatest and comes out cold.

Review of December 2023 Resident Food Committee minutes revealed residents voiced concerns that food temperatures of hot food were better but meals (hot foods) were still sometimes cold.

During interview with residents (Residents 29, 46, 26, 49, and 16) during a group meeting on January 10, 2024 at 10:30 AM, the residents reported that hot meals are often served cold and unpalatable.

A test tray performed on the 100 Nursing Unit on January 10, 2024, at 12:10 PM revealed that the planned hot meal served was beef brisket, mashed potatoes, and Asian vegetables.

At 12:25 PM, at the time the last resident was served, a test tray was completed and yielded the following results: beef brisket was 112 degrees Fahrenheit, mashed potatoes were 130 degrees Fahrenheit, and Asian vegetables were at 120 degrees Fahrenheit.

The hot food tasted lukewarm and was not palatable at the temperatures served.

Interview with the nursing home administrator (NHA) on January 10, 2024, at 1:15 PM, confirmed that food was to be served at safe and palatable temperatures.



















 Plan of Correction - To be completed: 02/12/2024

Dietitian interviews residents 12,29,13,39 to ascertain food preferences and address specific concerns. This topic will be included in a special resident food council meeting.
Food temperature policy to be reviewed. Food temperature logs to be completed and maintained for all meals.
Dietary staff will be reeducated by Dietary General Manager or designee on food temperature policy.
The Dietary General Manager or designee wil completed the following test trays weekly , 1 test tray for each of the 3 daily meals on at least 3 separate days, 1 of which is a weekend. The test tray will be the last tray delivered.
Results of test tray audits will be reviewed at monthly facility QAPI and Resident Food Council Meeting for further review and recommendations.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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.
§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on review clinical records and staff interviews, it was determined that the facility failed to ensure that a resident was free from unnecessary psychoactive medications by failing to attempt a gradual dose reduction, failing to ensure the presence of documented clinical rationale for the continued use of psychotropic medication and failing to monitor for potential adverse consequences of psychoactive drug use for two residents of 18 residents reviewed. (Resident 57 and 51)


Findings include:

A review of Resident 57's, clinical record revealed that the resident was admitted to the facility on January 31, 2023, with diagnoses to include vascular dementia with behavioral disturbances (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change).

The resident was transferred to the hospital on May 8, 2023, for a change in mental status and returned to the facility on May 16, 2023, after being treated for acute hypoxemic respiratory failure (difficultly breathing causing a lack of oxygen in the blood) and a urinary tract infection.

Review of Resident 57's clinical revealed a physician's order dated May 16, 2023, for Seroquel (an antipsychotic medication) 25 mg by mouth at bedtime for altered mental status.

A review of the resident's clinical record revealed no documented evidence that the facility had been monitoring the resident for potential adverse side effects for the newly prescribed antipsychotic medication.

A review of a Pharmacy Consultation Report dated May 17, 2023, indicated the resident had an acute illness and an antipsychotic was initiated due to worsening behavioral symptoms. The report noted that if acute illness has resolved, and behaviors have subsided, consider a gradual taper to discontinuation (of the antipsychotic drug).

A review of the facility's CRNP (certified registered nurse practitioner) response to the recommendation revealed that the CRNP solely noted that the "resident is stable."

The CRNP or prescribing physician failed to document the resident specific clinical rationale for continuing the newly prescribed antipsychotic.

A review of the resident's clinical record revealed revealed one incident documented of the resident record that she had a behavior of yelling out on October 3, 2023.

There was no documentation of any attempted non-pharmacological interventions to address the resident's behavior on that occasion.

A nursing note dated November 12, 2023, at 2:23 AM revealed that the resident continued to ring her call bell all evening and night. She rang the bell, to make sure her bell worked, have her blanket put over her feet, and because she thinks she has already slept for 12 hours.

A review of behavior tracking dated November 2023, revealed from November 1, 2023 through November 17, 2023, the resident only had two incidents of yelling out. There was no documentation of any attempted non-pharmacological interventions to address the resident's behavior on those occassions.

A physician orders dated November 18, 2023, was noted to increase the resident's dosage of Seroquel, to Seroquel 12.5 mg in the morning for paranoid behaviors in addition to the 25 mg she was already receiving at night.

A review of the resident's clinical record revealed no documentation of paranoid behaviors.

Interview with the acting Nursing Home Administrator on January 11, 2024, at approximately 1:40 PM confirmed that nursing staff failed to record adequate monitoring of potential side effects and confirmed the absence of physician documentation of the clinical necessity for the resident's antipsychotic drug use and dose increase.

A review of the Resident 51's clinical record revealed that the resident was admitted to the facility on March 16, 2021, with diagnoses which included late onset Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and anxiety.

Current physician orders were noted for Risperidone (antipsychotic medication) 0.25 mg (milligram) one tablet by mouth daily at 8:00 AM and 12:00 PM, and Risperidone 0.5 mg one tablet daily at 8:00 PM related to dementia with other behavioral disturbances.

Pharmacy consultations dated February 2023, July 2023, and October 2023, revealed that the pharmacist recommended a gradual dose reduction (GDR) of the physician prescribed medication Risperidone. The pharmacist identified that the resident had been receiving Risperidone since September 16, 2021, for expressions or indications of distress related to dementia, and a dose reduction was never attempted.

The response documentation provided to pharmacy solely noted that the "resident is stable" and failed to include resident specific clinical rationale for declination of a dose reduction attempt.

The Certified Registered Nurse Practitioner (CRNP) response documented noted that the resident's power of attorney (POA) was not in agreement with a reduction. However, failed to include prescriber clinical justification for the continued use of the antipsychotic medication and its benefit to the resident and how it maintained or improved the resident's functional abilities.

A review of a pharmacy consultation dated March 2023, revealed that the pharmacist identified that there was no documentation of specific target behaviors being treated requiring treatment with the antipsychotic drug or individualized behavioral interventions attempted to alleviate and behavioral symptoms in the resident's medical record. Recommendations to update the person-centered care plan and medical record to include specific target behaviors and the frequency and impact of the behaviors. The pharmacist identified that the diagnosis alone is insufficient to justify the use of an antipsychotic medication.

The resident's clinical record lacked documented clinical rationale from the resident's attending physician for administering antipsychotic drug, based upon an assessment of the resident's current condition and therapeutic goals and consistent with manufacturer's recommendations and clinical practice guidelines and clinical standards of practice

A review of a psychiatric consultation report dated August 7, 2023, at 9:45 AM, revealed that the resident was seen on that day for a psychiatric evaluation, to evaluate mental status and adjust medications for behavioral disturbance. The consult report noted that her mood has been stable, and she has not had any distressing behavior. "Appeared to be more frail than prior" the resident was hospitalized the month prior for a stroke. Her mood was calm and content and was cooperative with the staff. The report noted that the resident has been stable with no recent behavioral abnormalities, easily redirectable when she was sundowning.

A review of "Documentation Survey Report v2" intervention of monitoring behavior symptoms, dated from September 2023 through January 2024, revealed staff observed that the resident displayed no behaviors.

A review of the facility's "Behavioral Tracking" for use of an antipsychotic medication dated from September 2023 until December 2023, revealed no behaviors documented requiring continued treatment with Risperidone medication.

A review of the clinical record revealed that the resident's dose of Risperidone was increased on November 9, 2023, despite the recommendation from pharmacist to attempt a GDR.

A review of a psychiatric consultation report dated December 11, 2023, at 3:00 PM, revealed that the resident was seen on that day for psychiatric evaluation, to evaluate mental status and adjust medications for behavioral disturbances. The consult report noted that Risperidone dose was increased on November 9, 2023, to better manage distressing and irritable behavior after lunch time and into the afternoon. Staff reports that the resident's mood and behavior have improved with the medication adjustment. The report noted that there was a recent up-tick in distressing behavior that has subsided with the increase in the Risperdal dose, more easily re-directed now when she has sundowning.

When reviewed during the survey ending January 11, 2024, the resident's clinical record, documentation survey report and behavior tracking failed to reflect the above behaviors noted in the psychiatric consultation report.

An interview with the nursing home administrator (NHA) and director of nursing (DON) on January 11, 2024, at approximately 1: 00 PM confirmed no attempts at gradually reducing the dose of Risperidone had been made and confirmed that there was no documented evidence of the clinical assessments and prescriber documentation identifying the justification for the use of an antipsychotic medication.


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

28 Pa. Code 211.2(d)(3) Medical Director





 Plan of Correction - To be completed: 02/12/2024

For resident # 57 & 51 a psychological evaluation is scheduled. Staff were educated to document fully on behaviors by the DON. Staff were educated on non-pharmacological approaches that are specific to the residents. These approaches are in the care plan. Providers asked to write detailed notes why a GDR was contraindicated at this time.
The community will follow the Unnecessary Medication - Psychotropic Medication policy.
All residents with antipsychotic medications will have a Antipsychotic Medication review completed monthly.
All pharmacy recommendations will be reviewed by the physician and the DON or designee.
The DON or designee will monitor physician documentation for completeness.
The DON or designee will educate providers on need for increased documentation around antipsychotics.
Residents on antipsychotics will have personalized non-pharmacological approaches to behaviors listed in care plan. These interventions will also be on the Kardex and on the MAR/TAR for documentation. All PRN antipsychotics will have the wording "attempt non-pharmacological interventions prior to administering" added to the PRN order.
All staff will be educated on non-pharmacological interventions and documentation of such attempts by the DON or designee..
The community will audit the administration of Antipsychotic medications with documentation of behaviors and nonpharmacological approaches 1x week for 4 weeks, then monthly until substantial compliance is obtained.
All results will be discussed in the monthly antipsychotic review meeting as well as QAPI.


483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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.
§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on a review of clinical records and pharmacy recommendations and staff interview it was determined that the pharmacist failed to identify irregularities in the drug regimen of one resident (Resident 57) out of 18 residents reviewed.

Findings include:

A review of Resident 57's, clinical record revealed that the resident was admitted to the facility on January 31, 2023, with diagnoses to include vascular dementia with behavioral disturbances (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change).

A review of the resident's clinical record revealed a physician's order dated May 16, 2023, for Seroquel (an antipsychotic medication) 25 mg by mouth at bedtime for altered mental status.

Review of a consultant pharmacist drug regimen reviews conducted from May 2023 to January 2024 revealed that the pharmacist failed to identify the lack of a clinically supportable diagnosis for Resident 57's antipsychotic drug use.

Resident 57's Medication Administration Records (MAR) for December 2023 through January 2024, revealed that the resident continued to receive Seroquel daily for altered mental status.

An interview with the Director of Nursing on January 11, 2024, at approximately 1:40 PM, confirmed that the pharmacist failed to identify this drug irregularity in the resident's drug regimen.


28 Pa. Code 211.9 (k) Pharmacy services.




 Plan of Correction - To be completed: 02/12/2024

The DON or designee will initiate an antipsychotic meeting monthly. At said meeting they will assure all residents on psychotropics medications have an appropriate diagnosis, that Pharmacy reviews are discussed, and recommendations have been implemented. The DON or designee will track GDRs, Pharmacy reviews, and Physician documentation related to the pharmacy review/recommendations.
The DON or designee will ask the Physician to fully document reasoning behind declining pharmacy recommendations.
The pharmacist was updated regarding tag and was reviewing where breakdown occurred. Pharmacist reports will be reviewed by DON or designee.
Admissions and order listing report from last 24 hours to be reviewed on morning meeting by DON and IDT. They will address new orders related to psychotropic medications and review for indications. The team will review the Pharmacy report for all new medications.
The DON or designee will audit all residents with psychotropic medications 1x a week for 4 weeks and then monthly until substantial compliance is obtained.
The DON or designee will audit all pharmacy recommendations as well as physician responses 1x a week for 4 weeks and then monthly until substantial compliance is obtained.
All results will be brought forward in QAPI.

The pharmacist was involved with the POC. The Pharmacist POC is below:
Upon order entry, facility staff will verify and document an appropriate diagnosis for medication therapy in the order and if no such diagnosis exists, they will clarify with the prescriber prior to order entry.
The consultant pharmacist will review orders for appropriate diagnoses affiliated with the medication order and will leave a recommendation for clarification if a discrepancy is identified.



483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on review of clinical records and resident incident/accident reports, and staff interviews, it was determined that the facility failed to provide necessary staff supervision to monitor a resident's whereabouts to prevent an elopement from the facility for two residents (Resident 25 and 73) out of 18 reviewed.


Findings included:

Review of clinical record of Resident 25 revealed that the resident was admitted to the facility on January 6, 2023, with diagnoses including anxiety and depression.

A review of an Elopement Risk Assessment dated July 5, 2023, revealed that the resident was considered at high risk for elopement and a wanderguard bracelet was applied.

A review of Resident 25's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 28, 2023, revealed that the resident was cognitively intact.

A review of a nursing progress note dated September 27, 2023, revealed that "At around 13:25 (1:25 PM) \ was observed to be out under carport of front entrance/exit by therapy employee through therapy room window. Alarm sounding. Therapy staff and administration staff responded to alarm. \ approached by staff and was observed starting to stand up from wheelchair. \ was assisted to sit down in wheelchair and was brought back into the facility. \ was unable to state where she was trying to go or what she was trying to do when brought back in. Follow up interview by DON and therapist who responded and resident stated that "she was not outside and wished she had gone outside." Resident did not incur any injury related to incident and was ordered to have a medical workup by provider to rule out medical etiology related to increase in behaviors."

Review of facility incident report dated September 26, 2023, revealed that the resident was last seen in the hallway across from the conference room at 1:15 p.m., alarm was sounding at 1:25 p.m., and the resident was seen through window in front of main doors, and brought back into facility without injury.

A review of a written statement from the Director of Nursing, dated September 26, 2023, revealed that the DON saw the resident reading a magazine sitting outside the conference room and said hello to her at 1:15 p.m.

Further review of Resident 25's clinical record revealed a consistent escalation of exit seeking behavior by the resident beginning on September 8, 2023, when a visit with her daughter had to be cancelled, and through September 26, 2023, when the elopement occurred.

A review of a progress note dated December 2, 2023, revealed "At approximately 1500 (3 PM) alarm was sounding in short hallway on unit 200. Staff responded and found resident, observed sitting in wheelchair and holding the emergency exit door on unit 200 on short hall with door open. Wheelchair was observed to be past exit entrance with resident sitting in wheelchair. Resident was brought back into facility. She was unable to state where she was trying to go or what she was trying to do when brought back in. Resident did not have any injuries noted."

Review of facility incident report dated December 2, 2023, revealed that the resident was last seen in the common area of unit 200 at 2:50 p.m. Resident 25 was observed holding the emergency exit open and outside the door at approximately 3:00 p.m. Resident was brought back inside facility without injury.

Review of clinical record revealed resident had been out of facility with family for holiday leave and was previously noted to have an increase in exit seeking behavior when her routine changed and/or she spent time with family. There was no documented evidence that the facility increased supervision of the resident due to the increase noted in the resident's exit seeking behavior.

Review of clinical record of Resident 73 revealed admission to the facility on November 15, 2022, with diagnoses including dementia.

A review of Resident 73's Quarterly Minimum Data Set Assessment dated June 25, 2023, revealed that the resident was cognitively impaired.

A review of an Elopement Risk Assessment dated July 10, 2023, revealed that the resident was considered at high risk for elopement.

A review of a progress note dated August 25, 2023, revealed "Resident was observed walking in secure courtyard off main dining room on Friday, 8/25/23 around 1630 (4:30 PM). Resident was redirected back into the facility, stated she was trying to go home. Resident did not incur any injury related to incident. Resident did recently have family visit on 8/23/23, resident observed to have increased anxiety and behaviors after visit concluded."

Review of facility incident report dated August 25, 2023, revealed that the resident was seen outside the dining room in the locked courtyard. According to the report the dining room door was not locked as it should have been at time of incident.

A review of a written statement from the Employee 6 (LPN), dated August 25, 2023, revealed that the LPN was giving medications to other residents and saw Resident 73 in the courtyard and went to get her and brought her back in without injury at approximately 4:30 p.m.

A review of a progress note dated September 19, 2023, revealed "Resident 73 was observed in employee parking lot on backside of the building on Tuesday, September 19, 2023, around 1000 (10 AM). Resident was redirected back into facility, stated she was trying to find her mom. Resident did not incur any injury related to incident. Resident was last observed at 0930 (9:30 AM) sitting in recliner in common area on unit 200. Resident is care-planned, non-compliance with plan of care. Resident is continually non-compliant with transfer and ambulation orders. Resident with history of self-ambulating throughout facility with rolling walker. Resident has wanderguard to right ankle. Resident with history with inability to sit still for prolonged duration of time, inability to stay focused on task/activity provided to resident for redirection."

Review of a facility incident report dated September 19, 2023, revealed that a maintenance staff person was observed exiting the 200 hallway and the door was not closed completely. A staff member saw Resident 73 headed to the door and attempted to stop her, Resident 73 went out the (partially open) door. The wanderguard system was triggered and other staff members went outside and brought resident back inside without injury.

Resident 73 was transferred to a memory care unit after the second elopement on September 19, 2023. Surveyors tested the wanderguard system during survey ending January 11, 2023. The wanderguard system was functioning. Observation revealed elopement books on the units and at receptionist desk.

An interview with the Nursing Home Administrator and Director of Nursing on January 10, 2024, at approximately 2:00 PM confirmed the facility failed to provide adequate supervision of residents with an increased risk for elopement and exit seeking behaviors and ensure that means of exit, doors to the outside, were appropriately secured.



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









 Plan of Correction - To be completed: 02/12/2024

Residents care plan was updated to include resident specific interventions to address elopement behaviors when triggered.
All residents with increased risk to elopement behaviors will have a personalized care plan with interventions that address root cause.
Residents who are identified with elopement behaviors will be report to DON or Designee, IDT will discuss and implement individualized interventions.
The DON or designee will complete an audit of residents with elopement behaviors to ensure care plan is individualized. Results from Audits will be brought forward to QAPI.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.
Observations:

Based on a review of the facility's abuse prohibition policy and employee personnel files and staff interviews, it was determined that the facility failed to implement their established procedures for screening four of five employees for employment (Employee 1, 2, 3, and 4)

Findings include:

A review of the facility's Resident Abuse policy last reviewed March 16, 2023, revealed procedures for screening potential employees that included obtaining references from current/previous employers.

Review of employee personnel files revealed that Employee 1 (Activity aide) was hired October 9, 2023. The employee's application indicated that she had previous employers. There was no indication that the facility obtained any references for this employee's previous employers.

Review of employee personnel files revealed that Employee 2 (dietary aide) was hired September 19, 2023. The employee's application indicated that she had previous employers. There was no indication that the facility obtained any references from the prior employers.

Review of employee personnel files revealed that Employee 3 (LPN) was hired August 23, 2023. The employee's application indicated that she had previous employers. There was no indication that the facility obtained references from any prior employers.

Review of employee personnel files revealed that Employee 4 (LPN) was hired November 2, 2023. The employee's application indicated that she had previous employers. There was no indication that the facility obtained references for this employee from any prior employers.

Interview with the Administrator on January 11, 2024, at 12:15 p.m. the NHA verified that there was no evidence that previous employers were contacted for references according to the facility's Resident Abuse policy procedures for screening employees.


28 Pa. Code 201.19 (1) Personnel records

28 Pa. Code 201.29 (a) Resident rights





 Plan of Correction - To be completed: 02/12/2024

References will be secured for staff members identified during survey who did not have appropriate reference checks.
Community will audit employment files of current employees and volunteers to assure appropriate references are in place.
Human Resources staff will be reeducated by the Executive Director on Freedom from abuse, neglect, and exploitation policy.
Community onboarding checklist revised by HR Director to assure presence of references and secondary review and approval by Administrator or designee.
New hire employment files will be audited to assure appropriate reference checks and reported monthly for three months to the facility QAPI Committee for further review and recommendations.
Results of audits will be reported to QAPI for further review.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
§483.12(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, select facility incident reports, and the facility's abuse prohibition policy and staff interview it was determined that the facility failed to thoroughly investigate injuries of unknown origin to rule out abuse, neglect, or mistreatment as a potential cause of the injury sustained by one resident out of 18 sampled (Resident 19).

Findings included:

A review of the facility's policy, entitled Investigation of Abuse" last reviewed by the facility March 16, 2023, indicated that a complete investigation will be conducted. In case of injury of unknown origin, the facility will try to determine the source of the injury and rule out neglect or abuse. When investigating injuries of unknown origin the facility will interview staff and anyone coming in contact with the resident over the course of 24 hours prior to the noted injury. The investigation will include the signed statements of these contact people. Additionally, the facility will identify anyone who provided services to the resident during this 24 hour period and document the specific services provided and any unusual event occurring during the delivery of service.

A review of the clinical record revealed that Resident 19 had diagnoses. which included Alzheimer's disease and osteoporosis.

An annual Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated September 8, 2023, indicated that the resident was severely cognitively impaired, non-ambulatory, and required the assistance of two staff for bed mobility and transfers.

A late entry nurses note dated October 9, 2023, at 8:03 AM indicated that nursing observed Resident 19's left lower extremity to present +2 edema and warmth. The resident did not express signs or symptoms of pain when edema was assessed. The physician assistant was made aware. Staff were to monitor the resident's left lower extremity and the physician assistant planned to see the resident on October 10, 2023; staff were to call with any changes.

A physician order dated October 10, 2023, was noted to obtain a venous doppler to the left lower extremity for left lower extremity edema, redness, warmth, and pain.

A nurses note dated October 10, 2023, at 2:04 PM indicated that the doppler study was completed and the results were negative for DVT (deep vein thrombosis- blood clot in a deep vein) of the resident's left lower extremity.

A late entry nurses note dated October 12, 2023, at 9:00 AM revealed that swelling was observed to the resident's left lower extremity with no improvement with elevation. Nursing contacted the physician and an order was received to obtain an Xray of the left lower extremity and a CBC (complete blood count). The resident's representative made aware.

A nurses note dated October 13, 2023, at 9:02 AM revealed that the facility received the Xray results which indicated that the resident had acute fractures of distal left tibia (shin bone) and fibula (calf bone). The MD was made aware. A new order was received to send the resident to emergency room for evaluation. Resident representative aware.

A nurses note dated October 13, 2023, at 10:39 PM indicated that the resident returned from the emergency room. The emergency room reported that orthopedics saw the resident and returned the bone to its appropriate place and applied a splint. The resident will need to follow-up with ortho as outpatient according to the discharge instructions.

Review of a facility investigation summary report dated October 12, 2023, indicated that swelling of the resident's extremity was observed on October 10, 2023, in the morning and the provider was notified. A doppler was ordered, and resident was seen by the medical provider on October 10, 2023. On October 12, 2023, the resident's leg was still swollen with no improvement, the medical provider was contacted, and Xray of the left lower extremity was ordered. Xray results were positive for tibia/fibula fracture. Medical provider was made aware and orders for urgent ortho consult. The resident was not able to provide details related to the incident.

Review of the facility's summary and outcome of investigative findings revealed that staff witness statements did not recall/indicate any potential mechanism or means of injury. The resident was noted to be at increased risk for bone related injuries due to medical history including osteoporosis with contractures and vitamin D deficiency. Possible mechanism of injury was noted to be not limited to transfers via Hoyer lift to/from bed to chair, repositioning, and transport of resident in chair. Mandatory nursing education sessions were to be scheduled for proper lift use and transfer/positioning of residents with contractures.

However, further review of the facility investigation and provided witness statements, failed to provide documented evidence that the facility interviewed all staff and anyone coming in contact with the resident over the course of 24 hours prior to when the signs of injury (edema and warmth) were first noted on October 9, 2023. There was no documented evidence that all staff who provided care and services to the resident during that time period were identified and that the specific services provided to the resident were identified and documented, including any unusual event which occurred during the delivery of services prior to the fracture.

Interview with the administrator and director of nursing on January 12, 2024, at 10:00 AM confirmed that Resident 19 was non-ambulatory and totally dependent on staff for care. The NHA and DON confirmed that the facility was unable to provide a completed thorough investigation to rule out abuse, neglect, or mistreatment as a potential cause of Resident 19's injury of unknown origin, fractured lower leg.


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

28 Pa. Code 211.12(c) Nursing services

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















 Plan of Correction - To be completed: 02/12/2024

The community will investigate resident #19 injury completely by obtaining any witness statements from all employees who worked in or around the resident on 10/7/2023, 10/8/2023, & 10/9/2023.

Residents with injuries of unknown origin reported since 112/1/2023 will be reviewed to ensure witness statements obtained from staff who worked with resident within 24 hours prior to the identification of the injury.

The Don or designee will educate all leadership staff on the Investigation of Abuse Policy.

The DON will identify all staff that worked with or near the resident 24 hrs before the identification of an injury of unknown origin.
Results of investigations will be reviewed with NHA, ADON/DON, and Medical Provider when investigations are completed.
The community will audit all investigations for witness statements. 1 x a week for 4 weeks, then monthly x3 and then as needed.

All results will be reported through the QAPI process and root causes addressed community wide.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs: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(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

§483.45(d)(1) In excessive dose (including duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its use; or

§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
Observations:


Based on a review of clinical records and staff interviews it was determined that the facility failed to ensure that one resident's drug regimen was free of unnecessary antibiotic drugs for one out of 18 residents sampled (Resident 64).

Findings included:


A review of the clinical record revealed that Resident 64 was admitted into the facility on February 24, 2023, and has diagnoses including Alzheimer's disease, dementia and chronic kidney failure.

A review of nursing progress notes dated January 3, 2024, at 2:30 PM revealed that the resident was observed to have light hematuria (blood in urine) with a foul smell. The resident was unable to verbalize discomfort due to cognitive impairment.

A physician order dated January 3, 2024, was noted to obtain a urine analysis and culture and sensitivity (microscopic study of the urine culture performed to determine the presence of pathogenic bacteria in patients with suspected urinary tract infection [UTI]).

A review of a laboratory report for a urinalysis dated January 3, 2024, revealed that the results were abnormal with blood, protein, nitrates and bacteria in the sample.

A review of laboratory test results dated January 4, 2024, at 12:26 PM, revealed multiple flora suggesting contamination of the sample or colonization. The report noted that clinical correlation was needed and to consider repeat testing if symptoms worsen.

A review of McGeer's Criteria, used by the facility as part of antibiotic stewardship, dated January 4, 2024, indicated that the resident had a single symptom of fever and leukocytosis (higher than normal level of white blood cells in the blood) and no other symptoms of a UTI and the UTI criteria was not met to treat for a UTI.

A physician order dated January 4, 2024, at 7:13 PM was note for Keflex (antibiotic medication) 500 milligrams (mg) by mouth four times daily for UTI, although the urine culture and sensitivity report was inconclusive.

A review of the resident's medication administration record for the month of January 2024, revealed that the resident received 24 doses of Keflex, with the last dose received on January 10, 2024.

There was no corresponding physician documentation to indicate the clinical necessity of initiating antibiotic treatment with Keflex to treat the resident's suspected urinary tract infection prior to receiving accurate results of a repeat culture and sensitivity test.

At the time of the survey ending January 11, 2024, there was no evidence that a repeat urinalysis was completed.

Interview with the Infection Preventionist on January 10, 2024, at 9:45 AM, confirmed that the administration of Keflex was not clinically justified for treatment of Resident 64's urinary tract infection.



28 Pa. Code 211.2(d)(3)(5) Medical Director

28 Pa. Code 211.12 (d)(1)(3) Nursing Services

28 Pa. Code 211.5 (f) Medical records






 Plan of Correction - To be completed: 02/12/2024

The community will follow the following policies: Unnecessary Drugs and Infection Prevention and Control: Antibiotic Stewardship Program.
Review of all residents currently on antibiotics for supportive documentation for use.
When new antibiotic orders are received nursing notes will be reviewed by the DON/designee for documentation of symptoms noted and compared against McGeer criteria. When criteria is not met, Infection preventionist/designee will ask the physician for documentation to support the decision to use antibiotics. The DON or designee will educate staff and providers on McGreer's criteria and the antibiotic stewardship program policy and F757 regulation.
The Community will audit all antibiotic use to meet the above criteria 1x a week for 4 weeks and then monthly until substantial compliance is maintained or for three months.
Infection preventionist will present information at QAPI

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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.
§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:

Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of 18 residents reviewed (Resident 57).

Findings include:

A review of Resident 57's, clinical record revealed that the resident was admitted to the facility on January 31, 2023, with diagnoses to include vascular dementia with behavioral disturbances (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change).

A review of Resident 57's Significant Change Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 13, 2023, revealed that the resident was severely cognitively impaired.

A review of behavior tracking dated from May 2023 to December 2023, revealed that the resident displayed behaviors of repeat movements, yelling, and screaming, kicking, and hitting, pushing, grabbing, abusive language, threatening behavior, and rejection of care.

Further review of the resident's clinical record revealed that staff did not document the specific interventions attempted to address the above noted resident behaviors along with the effectiveness of any interventions employed to reduce, manage or modify the resident's dementia related behavioral symptoms.

The resident's current care plan, included a problem/need of the potential for complications with cognition related to dementia. This problem area was not initiated until January 3, 2024, despite the resident's admission diagnosis in January 2023, and tracking of behavioral symptoms from May 2023 through December 2023, noting multiple behavioral symptoms. The care plan did identify the specific behaviors that the resident exhibits and the interventions designed to address those behaviors.

The facility failed to develop and implement an individualized person-centered interdisciplinary plan to address, modify and manage this resident's dementia-related behaviors. The resident's care plan for dementia failed to include individualized interventions based on an assessment of the resident's preferences, social/past life history, customary routines, and interests in an effort to manage the resident's dementia-related behavioral symptoms.

Interview with Nursing Home Administrator on January 11, 2024, at approximately 1:40 PM, confirmed the facility was unable to provide evidence of the development and implementation of an individualized person-centered plan to address dementia-related behaviors.


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



 Plan of Correction - To be completed: 02/12/2024

The DON/designee will audit community wide for all residents with a cognitive Impairment. They will implement a cognitive care plan for each resident as well as personalized interventions.

The DON/designee will review all new admissions for cognitive impairment, when identified the Interdisciplinary team will put in place a cognitive acre plan with personalized interventions.
The Social Worker/ designee will complete PHQ 2 to 9 cognitive assessments quarterly on all residents, if this assessment indicates a new cognitive decline the Social Worker/designee completing the assessment will report it at the morning clinical meeting where a cognitive care plan and interventions will be put in place.
The interdisciplinary team will review all notes in morning meetings, noting any behaviors, these behaviors will be discussed, and root causes determined, interventions will be put in place that address the root cause of the behavior. The medical provider and psychological services will be notified if the nursing interventions do not have a positive impact on the behavior.
Nursing staff will be educated on approaches/intervention that are used with residents with cognitive impairment.
Nursing staff will be educated on the need to paint a picture with their notes for all behaviors.
The DON/designee will audit cognitive impairment care plans 1x a week for 4 weeks and monthly until substantial compliance has been obtained.
The Social Worker/designee will audit PHQ 2 to 9 assessment completion and notification 1x a week for 4 weeks and monthly until substantial compliance has been obtained.
The DON and Social Worker will report all audit findings at QAPI.
Resident 57 care plan to be reviewed and behavioral/cognitive to be update with individualized behaviors and individualized interventions
-Tasks to be updated with individualized behaviors/interventions

House wide audit of care plans and updates to be individualized




483.40 REQUIREMENT Behavioral Health Services: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.
§483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations:

Based on observations, clinical record review and staff interviews, it was determined that the facility failed to ensure each resident received the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one of 18 residents sampled (Resident 25).

Findings include:

Review of clinical record of Resident 25 revealed that the resident was admitted to the facility on January 6, 2023, with diagnoses including anxiety and depression.

A review of Resident 25's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 28, 2023, revealed that the resident was cognitively intact.

Further review of Resident 25's clinical record revealed that the resident exhibited multiple behaviors, including exit seeking and eloping from facility. Resident 25 was noted to display exit seeking behaviors almost daily, throughout the month of September 2023 through end of the survey January 11, 2024, according to a review of nursing progress notes.

Review of Resident 25's care plan, initiated by the facility on January 21, 2023, indicated that the resident has a behavioral problem regarding exit seeking/ elopement risk . However, the resident's care plan did not address the resident's specific behavioral health needs or the specific behavioral symptoms that were noted in the nursing documentation. According to nursing progress notes and the plan of care, the resident's exit seeking increases when family visits or routine changes. However, the care plan failed to include approaches developed to address this triggering factor.

Review of a Psychological evaluation dated October 17, 2023, indicated that Resident 25 continued to express the desire to return home and recommended that Resident 25 would benefit from continued psychological services every 6 months.

Further review of resident's clinical record revealed no further documented visits from psychological services after October 17, 2023, through the end of survey January 11, 2024.

The facility failed to demonstrate that qualified staff, with the competencies and skills necessary, had provided appropriate services and that the facility had implemented individualized approaches to the resident's care, including direct care and activities, directed toward understanding, preventing, relieving, and/or accommodating the resident's distress or loss of abilities, including the resident's desire to return home.

During an interview with the Nursing Home Administrator (NHA), on January 11, 2024, at approximately 10:00 a.m., the NHA was unable to provide evidence that Resident 25 was being provided the necessary behavioral health services.

Refer F689

28 Pa. Code 211.10 (d) Resident care policies



 Plan of Correction - To be completed: 02/12/2024

The community will ensure residents receive necessary behavioral health care services in a timely manner to attain or maintain the highest practicable mental and psychosocial wellbeing.
Resident 25 is scheduled to be seen by PGS(psychological services) on 2/5/24. Report and recommendations will be reviewed upon receipt. Provider at PGS and in house provider are updated on resident's behavior.
Resident has been screened by activities and an individualized care plan developed to incorporate activities as an alternative non-pharmacological approach. Resident is to be encouraged to remain in visible areas and offered activities of enjoyment.
All new admissions will be screened for the need for Psychological Services, and will be referred to these services by Social services within 30 days of admission.

The community will track when psychological service providers are in the community, which residents are seen, and request documentation of the visit within 48hrs of the visit.
The community will address all recommendations on the provided documentation immediately.
Community will educate staff on the need to document on all behaviors.
The Interdisciplinary team will review all notes at morning clinical meeting and initiate personalized interventions during this meeting.
The DON or designee with audit 25% of all Psychological visits to ensure recommendations are being followed 1x a week x 4 weeks, then monthly until 100% compliance is achieved .
DON or designee will audit progress note documentation related to resident behaviors and care plan interventions 1 time a week for 4 weeks then monthly until substantial compliance is achieved.
Results from Audits will be brought forward to QAPI.


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 resident interviews, clinical records, and staff interview, it was determined that the facility failed to timely provide prescribed respiratory care for one resident reviewed for one of 18 residents reviewed (Resident 49).

Findings include:

Resident 49's clinical record revealed an admission date of November 4, 20220 with diagnoses that included asthma, and sleep apnea.

Nursing progress notes revealed that the resident told nursing staff on January 7, 2024, that he was experiencing a sore throat, cough, and congestion.

A physician's order was obtained for Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 4 hours as needed for shortness of breath.

The resident's January 2024 Medication Administration Record (MAR) indicated that staff administered the above noted breathing treatment to Resident 49 on January 7, 2024, at 4:00 p.m., and January 10, 2024, at 7:00 a.m.

During an interview with Resident 49 at approximately 10:30 a.m., on January 10, 2024. Resident 49 stated he had requested a breathing treatment the previous evening January 9, 2024, at 7:00 p.m., so he could sleep better, but he did not receive the treatment at that time, He stated that he requested it again at 9:00 p.m., but staff still did not provide the breathing treatment. Resident 49 further stated that staff did not provide the breathing treatment until the day shift nurse came into facility at approximately 7:00 a.m., on January 10, 2024

During an interview on January 10, at 11:55 a.m. the Nursing Home Administrator and Director of Nursing were unable to provide evidence that Resident 49 had been provided the respiratory care as prescribed.



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



 Plan of Correction - To be completed: 02/12/2024

Residents was interviewed and has received all requested PRN treatments.

DON or designee will interview all interviewable residents with PRN respiratory treatments to determine if they have received requested treatments.
Staff education on meeting the needs of resident requests timely by DON or designee.
Staff education on relaying resident requests to medication nurse for follow up.
The DON or designee will audit, as well as interview with residents with PRN respiratory items. They will audit these items 1x a week x 4 weeks, then monthly for 3 months.
Results from audit will be delivered at resident council.
Results from Audits will be brought forward to QAPI.

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 select facility policies and clinical records it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to demonstrate that licensed nurses evaluated and recorded the provision of necessary nursing care for a change in condition for one resident out of 18 sampled residents (Resident 39).


Findings included:

According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and Subsection 21.18. (a)(5) document and maintain accurate records.

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records.

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care:
problems
with other health care professionals regarding the patient
with and education of the patient, family, and the patient ' s designated support person and other third parties.


A review of Resident 39's clinical record revealed that the resident was re-admitted to the facility on March 6, 2023, with diagnoses of Parkinson's Disease (a chronic and progressive movement disorder that initially causes tremor in one hand stiffness or slowing of movement), Depression (a mood disorder of persistent symptoms of depressed mood and sadness and Unspecified Convulsions (seizures that are classified as unknown onset).

A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated December 18, 2023, revealed Resident 39 was cognitively intact and required moderate to maximum assistance for activities of daily living.

The facility policy entitled "Notification to Physician/Family/Resident Representative of Change in Resident Health Status" dated as reviewed March 16, 2023, revealed that acute illness or significant change in a resident's physical, mental or psychosocial status (i.e., deterioration in health, mental or psychosocial status in either life-threatening condition or clinical complications). A need to alter treatment or change an existing form of treatment due to adverse consequences. A need to alter treatment significantly means to stop of form of treatment because of adverse consequences notification depending on the nursing assessment, appropriate notification may be immediate to 48 hours.

A nursing note dated December 17, 2023, at 11:55 PM indicated that several times, nursing observed the resident asleep in her wheelchair, slumped over to her left side, needing verbal cues to sit up. The resident's medications were withheld due to resident's inability to swallow. Nursing noted that they will continue to monitor the resident.

A review of the Resident 39's December MAR (medication administration record) revealed that on December 17, 2023, the following medications were held at approximately 8:00 PM due to the resident's inability to swallow; Melatonin 3 milligrams (mg), Mirtazapine (antidepressant medication) 7.5 mg, Carbidopa-levodopa 25-250 mg, Carboxymethlycellulose Sodium ophthalmic solution (eye drops) one drop in both eyes, Colace (stool softener) 100 mg, Tylenol arthritis extended release (ER) 650 mg, Multivitamin with minerals, Lamotrigine (anticonvulsant medication) 100 mg.

There was no documented evidence that licensed professional nursing staff conducted had fully assessed the resident, to include measured vital signs, or notified the nursing supervisor and/or physician of the resident's inability to swallow and observed lethargy.

There was no documented evidence of physician orders to hold the Resident 39's medications on the evening of December 17, 2023.

Interview with the Director of Nursing (DON) on January 10, 2024, at 11:00 AM, confirmed the facility's licensed and professional nursing staff failed to record complete and accurate assessment of the resident's change in condition in the resident's clinical record.


28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services

28 Pa. Code 211.5 (f) Medical Records



 Plan of Correction - To be completed: 02/12/2024

Nursing staff are to be provided with education related to notifying the provider when reporting resident change in condition. This staff will also be per the policy Notification to Physician/Family /Resident Representative of Change in Resident Health Status. Residents with a change in condition will be identified during morning clinical meeting.
All current residents will be audited for a change in condition.
Nursing staff to be provided education related to provider notification in regard to all reasons for medication not being given as ordered. This education Will follow our medication administration policy.
The DON or designee will audit MAR for medications not given, appropriate documentation, and provider notification 1x a week x 4 weeks, then monthly until 100% compliance is achieved or for three months.
Results from audits will be brought forward to QAPI.

483.21(b)(1)(3) 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.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on a review of clinical records and staff interview, it was determined that the facility failed to develop person-centered comprehensive care plans to meet the current needs and problems of three out of 18 residents sampled (Residents 33, 64, and 22).

Findings include:

A review of the clinical record revealed that Resident 33 was admitted to the facility on December 7, 2022, with diagnoses that included hypertensive heart disease.

A review of Resident 33's laboratory results report dated January 2, 2024, revealed that the resident had tested positive for RSV (Respiratory Syncytial Virus). However, the resident's care plan, in effect at the time of the survey ending January 11, 2024, failed to reflect the resident's diagnosis of RSV and interventions to treat and manage the resident's symptoms.

A review of the clinical record revealed that Resident 64 was admitted to the facility on February 24, 2023, with diagnoses that included Alzheimer's disease with late onset and epileptic seizures.

A review of Resident 64's laboratory results report dated January 3, 2024, revealed that the resident tested positive for RSV. However, the resident's care plan, in effect at the time of the survey ending January 11, 2024, failed to reflect the resident's diagnosis of RSV and interventions to treat and manage the resident's symptoms.

Interview with the Nursing Home Administrator and Director of Nursing on January 11, 2024, at approximately 1:40 PM confirmed the facility failed to ensure that comprehensive care plans were developed for Residents 33 and 64.

A review of the clinical record revealed that Resident 22 was admitted to the facility on October 11, 2023, with diagnoses that included depression.

A review of a nurse's note Employee 5, LPN, entered into the clinical record dated December 3, 2023, at 10:19 PM indicated that the resident's resident representative approached the desk and stated that he was upset because the resident stated that he wanted to kill himself. Employee 5 (LPN) sat with the resident and the resident stated, "I'm just down in the dumps." One to one supervision and reassurance were offered to resident. Resident stated,"I would never hurt myself." Every 15 minute checks were initiated. The registered nurse supervisor was made aware of the situation.

A nurses note dated December 4, 2023, at 1:43 PM indicated that Resident 22 stated that he feels safe and that he does not want to harm himself or others. Nursing noted that the resident was resident resting comfortably in bed watching television.

Review of a Psychiatric New Evaluation dated December 11, 2023, indicated that Resident 22 was evaluated for anxiety and adjustment issues. When the resident was asked about past suicidal statements the resident stated "that was just to get attention." The resident was diagnosed with adjustment disorder with anxiety, depressed mood and mild neurocognitive disorder. The plan was to continue current medications, supportive care, reorient, redirect, psychiatric team to monitor mood and behavior, encourage resident to participate in activities on the unit, and follow-up in four weeks.

Resident 22's clinical record revealed nurses notes dated December 24, 2023, December 28, 2023, December 30, 2023, January 1, 2024, January 4, 2024, January 6, 2024, and January 7, 2024, which indicated that the resident had displayed inappropriate verbal and physical sexual behaviors towards staff.

A review of Resident 22's current comprehensive care plan initially dated October 11, 2023, revealed that the resident's diagnosis of depression, suicidal statements, newly diagnosed adjustment disorder with anxiety and depressed mood, mild neurocognitive disorder, and inappropriate sexual behaviors were not identified along with corresponding treatment and management interventions.

Interview with the Nursing Home Administrator and Director of Nursing on January 11, 2024, at approximately 1:50 PM confirmed the facility failed to include the above residents' current problems and needs on their comprehensive plans of care.


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























 Plan of Correction - To be completed: 02/12/2024

The community will develop and update a person center care plan, said care plan will be updated when the need arises and per regulations.
Residents 33, 22, and 64 will have a new Care plan review completed by the IDT.
The interdisciplinary team will be educated on the care plan review process as
A Care plan review is completed on all residents at least quarterly.
The MDS coordinator will open and coordinate completion of the Care plan review within 14 days of each assessment reference date.
The community completed a designation of duties to assign acute issues that need to be addressed in the care plan to specific members of the interdisciplinary team.
The DON will audit assigned areas 1x a week x 4 weeks, then Monthly until 100% compliance is achieved .
DON or designee will audit Care plan reviews for timing and accuracy 1 time a week for 4 weeks then monthly until 100% compliance is achieved.
The team will complete a care plan audit based on diagnosis for the following Care plan items Cognition, Cardiac, Seizure, Anxiety, Depression.
Results from Audits will be brought forward to QAPI.

483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements: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.
§483.15(c) Transfer and discharge-
§483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i) Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the necessary resident information was communicated to the receiving health care provider for four residents out of 18 residents sampled (Residents 10, 29, 39, and 3).


The findings include:

A review of Resident 39's clinical record revealed that the resident was transferred to the hospital on September 7, 2023, and returned to the facility on September 11, 2023.

A review of Resident 10's clinical record revealed that the resident was transferred to the hospital on November 10, 2023, and returned to the facility on November 15, 2023.

A review of Resident 29's clinical record revealed that the resident was transferred to the hospital on December 5, 2023, and returned to the facility on December 6, 2023.

A review of Resident 3's clinical record revealed that the resident was transferred to the hospital on April 27, 2023, and returned to the facility on May 1, 2023. Resident 3 was also transferred to the hospital on May 4, 2023, and returned to the facility on May 10, 2023.

There was no documented evidence that the facility had communicated the necessary specific information to the receiving health care institution or provider for the resident is transferred and expected to return. For those transferred residents noted above, the facility failed to provide evidence that the resident's comprehensive care plan goals and all information necessary to meet the resident's immediate needs were communicated to the receiving health care institution.

Interview with the Nursing Home Administrator and Director of Nursing on January 11, 2024, at approximately 1:40 PM, confirmed that there was no evidence that the necessary information was communicated to the receiving health care institution or provider upon transfer or discharge.



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







 Plan of Correction - To be completed: 02/12/2024

The DON or designee will educate all nursing on the admission, transfers, and discharge policy.
The discharge nurse will complete a transfer note in the EMR to include all necessary documentation for each transfer.
The DON or designee will review all discharges to ensure proper documentation was sent to the receiving provider and that there is proof of such in the medical records as indicated in the EMR..
The DON or designee will audit all transfers weekly x 4 weeks, them monthly x3 months to ensure compliance.
Results of audits will be reported at QAPI.

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

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

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

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

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

Based on clinical record review and staff interview, it was determined that the facility failed to send copies of the written notices of facility initiated transfers to a representative of the Office of the State Long Term-Care Ombudsman for three out of 18 residents sampled (Resident 10, 29 and 39).

Findings include:

A review of Resident 39's clinical record revealed that the resident was transferred to the hospital on September 7, 2023, and returned to the facility on September 11, 2023.

A review of Resident 10's clinical record revealed that the resident was transferred to the hospital on November 10, 2023, and returned to the facility on November 15, 2023.

A review of Resident 29's clinical record revealed that the resident was transferred to the hospital on December 5, 2023, and returned to the facility on December 6, 2023.

There was no documented evidence that the facility sent copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman for these facility-initiated transfers.

Interview with the Nursing Home Administrator on January 11, 2024, at approximately 1:40 PM, confirmed that there was no evidence that copies of the written notifications of facility initiated transfers were provided to the Office of the State Long-Term Care Ombudsman.



28 Pa. Code 201.14(a) Responsibility of Licensee





 Plan of Correction - To be completed: 02/12/2024

All residents discharged from 12/1/2023 forward have had a letter of transfer sent to the state Ombudsman. This has been documented in the Ombudsman binder that is stored in the social services office.
An audit of all transfers/discharges from 12/1/2023 through 1/31/2023 occurred. All transfers/discharge notifications were sent to the state Ombudsman by 2/1/2023.
Education completed by the DON or designee to Interdisciplinary team on the process for notifying the Ombudsman Monthly of all Transfers.
Monthly audits x3 months.
Results of all audits are reported to QAPI.


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