Nursing Investigation Results -

Pennsylvania Department of Health
ORCHARD MANOR INC
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ORCHARD MANOR INC
Inspection Results For:

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ORCHARD MANOR INC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on August 23, 2019, it was determined that Orchard Manor, Inc. was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.






 Plan of Correction:


483.60(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 observations, staff interviews and review of facility documentation, it was determined that the facility failed to maintain kitchen sanitation procedures regarding the dishmachine for the main kitchen.

Findings include:

The current Dishmachine Operation Policy indicated that the Rinse cycle must be 180 degrees Fahrenheit (F) for sanitation purposes or a manual sanitizer must be used at 50 parts per million (ppm) on a test strip. If manual additive is turned on, activation and ppm must be documented. If rinse temperature does not reach 180 degrees F, management must be notified immediately if required temperatures are not reached.

Observation of the dishmachine cycles on 8/20/19, at 12:50 p.m. revealed that wash temperatures ranged from 161 to 164 degrees F with the rinse temperatures ranging from 174 to 177 degrees F. The rinse cycle did not reach 180 degrees Fahrenheit.

During an interview on 8/20/19, at 1:00 p.m. Dietary Manager (DM) Employee E16 stated that "I use a chemical sanitizer called Eco-San that pumps automatically into the water on every rinse so if the temperature does not go above 180 degrees F, I know I have a backup." DM Employee E16 further indicated that they do not keep a log sheet that documents the sanitizer levels to ensure that the sanitizer is mixing correctly and that the Service Representative for the dishwasher sanitation comes once per month and tests to make sure it is pumping correctly.

Dishwasher Temperature Logs for the month of August, revealed that temperatures did not reach 180 degrees F daily for the rinse cycle. There was no documentation to demonstrate that the dishmachine was tested for the Eco-San ppm with each dishwasher cycle that was under 180 degrees F.

During an interview on 8/21/19, at 3:35 p.m. the Service Representative for the dishwasher sanitation stated that "The staff should be keeping a log daily and testing to be sure that the Eco-San is reaching 50 ppm on the testing strips if the temperatures are not reaching 180 degrees F to be sure that the dishes are properly sanitized. The kitchen has the test strips to use and have been shown how to test with them."

483.60(i) Previously Cited 9/21/18

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 9/21/18

28 Pa. Code 201.18(b)(1) Management
Previously cited 9/21/18

28 Pa. Code 201.18(b)(3) Management
Previously cited 9/21/18



















 Plan of Correction - To be completed: 10/15/2019

1. Dietary staff members and Dietary Manager will be in-serviced on proper temperature requirement for sanitizing dishes and maintaining a log sheet that documents the sanitizer levels to ensure that the sanitizer is mixing correctly when temperature is under 180 degrees.

2. All dietary staff and Dietary Manager will be in-serviced on the facility's Dish Machine Operation Policy by the Administrator/Designee. In-service training will include observation of each employee performing testing strips to determine if employee was performing the procedure correctly. Findings will be reviewed with each employee.

3. The Dietary Manager or designee will complete audits 5 times week for 3 weeks, then weekly for 4 weeks, then semimonthly for 4 months, on dietary staff when the temperature of dish machine is under 180 degrees to ensure testing strips are properly being utilized in accordance with facility's policy.

All audit results will be forwarded to the QAPI Committee for review and recommendations.



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

Based on observations, review of clinical records and facility policies and staff interview, it was determined that the facility failed to update and/or individualize care plans for six or 26 residents (Residents R44, R80, R83, R87, R90 and R38).

Findings include:

The "Care Plan Revisions Upon Status Change" policy dated 7/23/19, revealed that "the comprehensive care plan will be reviewed, and revised as necessary, when a Resident experiences a status change" and indicated that refusal of treatments and updated interventions should be documented in the care plan.

The admission record revealed that Resident R44 was admitted to the facility on 1/02/18, with diagnoses that included dementia, anxiety and depressive episodes.

During an interview on 8/21/19, at 11:33 a.m. Family member of Resident R44 indicated that the resident had an open area in the crack of the buttocks.

Nursing documentation revealed on 6/27/19, at 10:22 p.m. that Resident R44 had a small red area blister to the sacrum area.

Review of the potential for pressure ulcer development care plan did not address the open area that Resident R44 had developed.

During an interview on 8/22/19, at 2:10 p.m. the Director of Nursing confirmed that the blistered area had not been care planned from 6/27/19.


Resident R38's clinical record revealed an admission date of 2/28/18, with diagnoses that included dementia (decline in memory or other thinking skills), high blood pressure, and osteoarthritis (inflammation or loss of cartilage in the joint).

Resident R38's care plan for pressure ulcer development dated 9/24/19, included interventions to change position for prevention of pressure ulcers, offload heels while in bed, Prafo boots (soft, pillow boots to protect heels) to bilateral feet at all times, and specialty pressure relieving mattress.

During an interview on 8/22/19, at 10:32 a.m. Nurse Aide Employee E3 stated that Resident R38 doesn't like to wear the Prafo boots, elevate heels, offload heels, or turn and reposition.

Resident R38's care plan was not updated to reflect his/her refusal for the above interventions nor did it get updated with new or modified interventions to assist in healing his/her bilateral heel pressure ulcers.

During an interview on 8/23/19, at 10:30 a.m. the Director of Nursing confirmed that the care plan should have been updated to reflect refusal of care for pressure ulcers.


The Quarterly Minimum Data Set (periodic review of resident care needs) dated 7/25/19, revealed that Resident R80 was admitted to the facility on 5/01/15, with diagnoses that included high blood pressure, circulatory problems, dementia and Parkinsons disease.

Review of the fall care plan did not reflect falls from 3/21/19, 6/03/19, and 7/20/19 as identified from incident reports for Resident R80.

During an interview on 8/23/19 at 12:06 p.m., the Licensed Practical Nurse Assessment Coordinator Employee E10 confirmed that the fall interventions from the incident reports were not created and/or updated and transferred to the fall care plans.


The admission record revealed that Resident R87 was admitted to the facility on 9/26/18, with diagnoses to include but not limited to diabetes, anxiety, and repeated falls.

Review of the fall incidents revealed eight falls had occurred between 4/20/19 and 8/09/19. Review of the care plans lacked new interventions developed from the fall incident reports.


The admission record revealed that Resident R90 was admitted to the facility on 2/25/19, with diagnoses that included dementia, high blood pressure, depression, heart problems and a history of falling.

Review of a nurses note written on 7/09/19, revealed that Resident R90 had fallen in their room and the room was cluttered with packed bags of the residents clothing. There were no interventions documented in the care plan how the staff would divert the activity of packing the clothing to maintain Resident R90's safety.

During an interview on 8/23/19, at 1:39 p.m., the Director of Nursing confirmed that the care plans were not updated with the new interventions developed from the falls that occurred between 4/20/19 thru 8/09/19 for Resident R87 or that new interventions were developed to deter Resident R90 from packing their clothes in bags in their room.


Resident R83's clinical record revealed an admission date of 1/25/19 with diagnosis that included altered mental status, Rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), overactive bladder, osteoarthritis (inflammation or loss of cartilage in the joint), and dementia (decline in memory or other thinking skills).

Accident/ Incident Report from a fall on 8/9/19, at 5:30 p.m. revealed that Resident R83 unclipped the alarm.

Accident/ Incident Report from a fall on 8/12/19, at 7:30 a.m revealed that Resident R83 had a clip alarm on and removes alarm when he/she feels it pulling on him/her.

Accident/ Incident Report from a fall dated 8/15/19, at 11:50 a.m. revealed that Resident R83 removed his/her alarm.

Progress note dated 8/16/19, at 10:55 a.m. stated that resident R83 was found on the floor on his/her hands and knees just behind room 501 door, and his/her clip alarm was unclipped and still on the wheelchair. The note also indicated that a clip lock to the alarm string would be added.

Accident/ Incident Report from a fall dated 8/16/19, at 4:15 p.m. revealed that a clip alarm was present but Resident R83 had unclipped it.

During an interview on 8/22/19, at 12:40 p.m. LPN Employee E22 asked if Resident R83 had a clip lock on the alarm clip, LPN Employee E22 was unable to find the clip lock and stated, "It is broken." LPN Employee E22 called the supervisor for a new clip lock.

During an interview on 8/22/19, at 1:15 p.m. RN Employee E4 stated that the clip lock that was placed on the resident on 8/16/19 was broken, was trying to find a new one but could not obtain a new clip lock for the alarm string clip.

Resident Resident R83's care plan was not updated to include the use of a clip lock so that the alarm string clip could not be removed.

28 Pa. code 211.5(f) Clinical records
Previously cited 9/21/18

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 9/21/18







 Plan of Correction - To be completed: 10/15/2019


1. The DON updated the care plan for Resident #44 to include pressure relieving/reducing interventions.
The DON updated the care plan for Resident #38 to include Resident's education and choice related to interventions for prevention of pressure ulcers.
The DON updated the care plan for Resident #80 to include fall interventions.
The LPNAC updated the care plan for Resident #87 to include fall interventions.
The DON updated the care plan for Resident #90 to include diversional interventions to attempt and keep resident from packing and maintain a safe environment.
The DON updated the care plan for Resident #83 to include the use of a clip lock.

2. All residents of the facility have the potential to be affected by this practice. All current care plans will be reviewed and updated to reviewed and updated to reflect current care and services.

3. The facility's LPNACs, RN Supervisors and Interdisciplinary Team will attend an in-service regarding any changes of status presented by the clinical nurse consultant.

4. RN Supervisors will review care plans daily for 2 weeks for those residents experiencing a change in status to ensure new or modified interventions have been addressed and documented regarding the resident's care. The Director of Nursing or designee will review a random sample of 3 care plans 1 time per week for 4 weeks, then semi- monthly for 4 months to assure the review and revision of care plans.

All audit results will be forwarded to the QAPI Committee for 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 observations, review of facility policies, and staff interviews, it was determined that the facility failed to ensure proper handwashing during a dressing change for one of 26 residents (Resident R38), and failed to prevent cross contamination (bacteria unintentionally transferred from one object to another) related to a dressing change, breathing equipment, administering eye drops and glucometer (device used to check blood sugar levels) usage for five of 26 residents (Resident R37, R106, R92, R62, and R14) .

Findings include:

The "To change dressings using aseptic technique" policy, dated 7/23/19, revealed that during a dressing change, hands should be washed after removing the soiled dressing.

During a dressing change observation for Resident R38 on 8/21/19, at 10:45 a.m. Licensed Practical Nurse (LPN) Employee E1 did not sanitize or wash hands after removing Resident R38's soiled dressing. LPN Employee E1 confirmed the above information on 8/21/19 at 10:55 a.m.

During an interview on 8/22/19, at 11:13 a.m. the Interim Director of Nursing confirmed that the LPN's hands should have been washed or sanitized after removal of the soiled dressing.


The "Infection Prevention and Control" policy dated 7/23/19, revealed that cross contamination is to be prevented and controlled by facility staff.

During a breathing treatment for Resident R37, on 8/21/19, at 2:08 p.m. his/her breathing treatment cord (connected from the breathing treatment machine to the breathing mask) came unconnected and fell to the floor. LPN Employee E1 took off Resident R37's breathing mask, took the breathing treatment cord off the floor and reattached it to the breathing mask, and put the breathing mask back on him/her to finish the breathing treatment.

LPN Employee E1 did not clean the part of the breathing treatment cord that fell to the ground with alcohol to prevent cross contamination of bacteria to Resident R37. LPN Employee E1 confirmed the above information on 8/21/19, at 2:11 p.m.

During an interview on 8/22/19, at 11:14 a.m. the Interim Director of Nursing confirmed that the breathing treatment cord should have been cleaned with alcohol or replaced.


Resident R14's clinical record revealed an admission date of 4/01/15, with diagnoses that included Parkinson's disease (a progressive nerve disease impacting muscles), atrial fibrillation (an irregular heart rhythm originating in the upper chamber), and a delusional disorder. An 8/22/19 Weekly Wound Observation form revealed that Resident R14 had a Stage II (partial thickness loss of skin presenting as a shallow ulcer with a red/pink wound bed) pressure ulcer of the left buttock, measuring 0.3 centimeters (cm) by 0.3 cm by 0.0 cm.

An observation of wound care to Resident R14's pressure ulcer, on 8/22/19, at 9:54 a.m. revealed LPN Employee E5, washing the wound with saline and wiping over the wound from multiple directions, in some instances from the direction of the rectal area upward over the wound bed.

LPN Employee E5 confirmed at the time of the observation that cleansing from multiple directions without changing the gauze or wiping from a clean to dirty area increased the risk for contamination of the wound.


The "Cleaning Thermoscan Ear Thermometer and Glucometer," policy dated 7/23/19, revealed "cleaning and disinfecting should be done after each use."

Observation of administration of eye drops to Resident R106 on 8/20/19 at 3:03 p.m. revealed that Registered Nurse (RN) Employee E17 did not wash their hands prior to administering the eye drop, gave one drop in each eye and removed their gloves. The RN did not wash their hands after removal of their gloves. The RN proceeded to administer a second drop into Resident R106's eyes, did not wash/sanitize their hands before administering the eye drops and again, did not wash their hands after removal of their gloves.

Observation of obtaining a blood sugar reading on Resident R62 on 8/20/19, at 4:55 p.m. revealed that LPN Employee E18 entered Resident R62's room, obtained a fingerstick blood sugar and returned to the medication cart without first washing their hands or cleaning the glucometer. LPN Employee E18 then entered Resident R92's room at 5:09 p.m., placed the glucometer on the residents walker in the room, and when LPN Employee E18 returned to the medication cart, LPN Employee E18 did not cleaned the glucometer.

During an interview on 8/23/19 at 3:07 p.m. LPN Employee E13 confirmed that the LPN should have washed their hands prior to donning gloves and washed their hands after removal of their gloves after administering the eye drops and removal of gloves and the glucometer should be cleaned before after each use.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 9/21/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 9/21/18










 Plan of Correction - To be completed: 10/15/2019

1. Resident #38, Resident #37, Resident #14, Resident #62 and Resident #92 show no signs and symptoms of infections in relation to areas identified as deficient. Resident 106 was not identifiable.

2. Current policies and procedures regarding standard and transmission-based precautions to be followed to prevent spread of infection, specifically regarding hand washing, dressing changes, breathing equipment, administering eye drops and glucometer usage will be reviewed and updated as needed. All Licensed Nursing staff will be in-service/re-educated on policies and procedures.

3. Wound care, administering eye drops, and glucometer usage competencies will be performed on all Licensed Nurses to ensure adherence to policies and procedures. Any non-compliance will be addressed with further education occurring immediately after the competency. The Licensed Nurse will perform the competency over to ensure adherence and understanding to the re-education.

4. The DON, or designee, will complete visual checks to ensure standard and transmission-based precautions are being followed to prevent spread of infection, specifically regarding handwashing, dressing changes, breathing equipment, administering eye drops and/or glucometer usage daily on rotating shifts for four weeks, then 3 times a week for 4 weeks, then semi-monthly for 4 months to ensure compliance with policies and procedures. Any issues will immediately be noted and addressed.

All audit results will be forwarded to the QAPI Committee for review and recommendations.




483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on observations, review of facility policies and clinical records and staff interviews, it was determined that the facility failed to document observations of wounds and/or provide care to facilitate healing of pressure wounds for three of 26 residents identified with pressure ulcers (Residents R44, R14, and R38).

Findings include:

The facility policy related to pressure ulcers, dated 7/23/19, indicated that when pressure ulcers are identified, the area is to be thoroughly assessed and detailed documentation completed to include the location, stage, measurements, if drainage is present and amount, a description of the wound base, if tunneling or undermining is present, and the physician notified to obtain a treatment order.

Resident R14's clinical record revealed an admission date of 4/01/15, with diagnoses that included Parkinson's disease (a progressive nerve disease impacting muscles), atrial fibrillation (an irregular heart rhythm originating in the upper chamber), and a delusional disorder. Weekly Skin Check Flowsheets indicated that on 8/02/19, Resident R14 was noted to have a Stage II (partial thickness loss of skin presenting as a shallow open area with a red-pink wound base), measuring 0.1 centimeters (cm) by 0.3 cm by 0.1 cm, of the left buttock. The wound lacked any further assessment and the record lacked evidence that the doctor was notified of the onset of the pressure ulcer to obtain a treatment order. A Weekly Skin Check Flow sheet, dated 8/08/19 (six days later), indicated that Resident R14's skin was intact without evidence of a pressure ulcer. On 8/13/19, clinical documentation indicated that Resident R14's physician was contacted to obtain a treatment order for "Allevyn (an absorbent foam dressing) to the left coccyx after cleaning with normal saline and Calvin wipe (a skin barrier product). Change every 72 hours and as needed." The 8/15/19, Weekly Skin check Flow Sheet lacked evidence of a pressure ulcer to the left buttock. On 8/22/19 (nine days after obtaining a treatment order), a "Weekly Wound Observation - Registered Nurse to complete" form indicated a Stage II pressure ulcer of the left buttock, measuring 0.3 cm by 0.3 cm by 0.0 cm.

Observations of Resident R14's left buttock on 8/22/19, at 9:54 a.m., revealed a small, shallow pressure ulcer of the left buttock, with a red-pink base and clean edges.

During an interview on 8/22/19, at 1:30 p.m. Registered Nurse (RN) Employee E4 confirmed that Resident R14's clinical record lacked comprehensive monitoring and assessment of Resident R14's pressure ulcer.


The admission record revealed that Resident R44 was admitted to the facility on 1/02/18, with diagnoses that included dementia, generalized weakness and a subarachnoid hemorrhage (brain bleed).

During an interview on 8/21/19, at 11:33 a.m. a Family Member of Resident R44 stated that Resident R44 had an open area in between the buttocks.

The clinical record showed no evidence that Resident R44 had any open areas at the time the family member was interviewed on 8/21/19. A nurses note, dated 6/27/19, revealed that the resident had a small red area/blister to sacrum area.

During an interview on 8/22/19, at 2:10 p.m. the Director of Nursing (DON) confirmed there was no evidence that the blister identified on 6/27/19, had been assessed by a nurse or that the physician was notified of the red area/blister to Resident R44's sacrum.

An RN assessment was not completed until 8/22/19, and it was determined that Resident R44 had a stage two pressure ulcer on the sacrum.

During an interview on 8/23/19, at 9:15 a.m. the DON confirmed that there was no documentation from 6/27/19 through 7/15/19, concerning the sacral area and Resident R44 was currently assessed by RN who identified that Resident R44 had a stage two pressure ulcer at the sacrum site.


The "Pressure Ulcer Prevention and Intervention" policy, dated 9/21/18, revealed that preventative measures for pressure ulcers included a turning and repositioning program and having pressure reducing or relieving devices specific to the resident.

Resident R38's clinical record revealed an admission date of 2/28/18 with diagnoses that included dementia (decline in memory or other thinking skills), high blood pressure, and osteoarthritis (inflammation or loss of cartilage in the joint). In addition, Resident R38 has had bilateral heel pressure ulcers since 12/28/18. On the Weekly wound observation for 8/15/19, the right heel was a Stage 1 pressure ulcer (intact skin with non-blanchable redness of a localized area) measuring length 2 centimeters (cm), width 2.5 cm and depth 0.1 cm; the left heel was a stage II (partial thickness loss of dermis-layer of skin between the epidermis and subcutaneous tissues) measuring length 2 cm, width 2.5 cm and depth 0.1 cm.

The physician orders dated 7/9/19, for Resident R38 revealed that resident was to have a Sentech 1200 air mattress (alternating pressure mattress designed to prevent bed sores), elevate heels at all times when in bed, Prafo boots (soft, pillow boots to protect heels) at all times when in bed, and offload (shifts weight to the mid and forefoot) heels when in bed.

Observations of Resident R38 on 8/21/19 at 12:55 p.m., 8/21/19 at 2:05 p.m., 8/22/19 at 10:30 a.m., and 8/22/19 at 1:30 p.m., revealed that he/she was lying in bed with bilateral heels lying directly on the mattress and slipper socks on. Resident R38 was not wearing Prafo boots, elevating heels, or offloading heels. Interview on 8/22/19, at 10:32 a.m. revealed that Nurse Aide Employee E3 stated that Resident R38 doesn't like to wear the Prafo boots, elevate heels, or offload heels.

Observation on 8/22/19 at 1:00 p.m., with the sheets already taken off Resident R38's bed, appeared like he/she was lying on a well-worn mattress because the color was faded and it didn't seem as thick as other residents' mattresses that were observed. On 8/22/19 at 1:30 p.m., Purchasing Manager Employee E6 stated that Resident R38 was lying on a Geo-Matt 80 Span America mattress (minimizes the effects of pressure and shearing) and not a Sentech 1200 air mattress (alternating pressure relief to zero pressure).


28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 9/21/18

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 9/21/18


 Plan of Correction - To be completed: 10/15/2019

1. Residents #14, #38 and #44 will have skin assessment completed by a Registered Nurse (RN), current orders will be reviewed for appropriateness based on assessment results, physician will be notified of any abnormal findings, and care plan updated if needed.

2. On 8/25/19 Resident #38 received a Sentech 1200 specialty pressure relieving mattress.
3. The facility has determined that all residents have the potential to be affected. All residents identified at high risk for pressure injury development (Braden of 12 or lower) will be reviewed. All residents with pressure injuries will be reviewed to determine accurate assessment and monitoring plan.

4. Licensed nurses will be educated on accurate assessment and monitoring for pressure injuries and providing residents with risk vs. benefit education when declining care and/or pressure relieving interventions. Resident #38 will have risk vs. benefit education provided and care plan updated to reflect her choices.

5. The DON or designee will audit skins assessments to ensure current orders are appropriate based on assessment results, physicians being notified of any abnormal findings, and care plans being updated if needed as follows: 3 skin assessments a week for 4 weeks, then 2 skin assessments for 4 weeks, then 2 skin assessments semimonthly for 4 months to ensure appropriate interventions are in place.

6. The DON or designee will do an initial check to ensure that all specialty pressure relieving mattresses (Sentech) are in place by 09/18/2019. The DON or designee will audit specialty pressure relieving mattress(Sentech) placement to ensure the specialty pressure relieving mattresses (Sentech) are in place as ordered as follows: visual checks on 75% of the specialty pressure relieving mattresses(Sentech) 3 times a week for 4 weeks, then visual checks on 75% of the specialty pressure relieving mattresses (Sentech) 2 times a week for 4 weeks, then visual checks on 75% of the specialty pressure relieving mattresses (Sentech) semimonthly for 4 months to ensure appropriate interventions are in place.

All audit results will be forwarded to the QAPI Committee for review and recommendations.




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

Based on observations, review of clinical records and staff interview, it was determined that the facility failed to develop a care plan for the use of oxygen for one of five residents (Resident R63).

Findings include:

Resident R63's clinical record revealed an admission date of 5/20/19, with diagnoses that included heart problems, a pacemaker, and stroke.

The physician's order dated 8/19/19, revealed orders for oxygen at one to three liters by nasal cannula (tubing into the nose to deliver oxygen) as needed to keep oxygen saturation greater than 90 percent. Also ordered was specific care for the concentrator, portable oxygen, and tubing.

Observation on 8/21/19, at 9:58 a.m. revealed that Resident R63 had oxygen in use at two liters by a portable oxygen tank hooked to the back of their wheelchair.

The clinical record lacked evidence that a care plan was developed for the use or care of the oxygen for Resident R63.

During an interview on 8/23/19, at 11:50 a.m. Licensed Practical Nurse Employee E10 confirmed that there was not a care plan developed for the use of oxygen for Resident R63.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 9/21/18

28 Pa. Code 211.11(a) Resident care plan

28 Pa. Code 211.12(d)(3)(5) Nursing services
Previously cited 9/21/18





 Plan of Correction - To be completed: 10/15/2019

1. Care plan of Resident #63 was reviewed and updated as indicated to include use of oxygen and reflect current status and interventions.

2. The facility has determined that all residents with oxygen have the potential to be affected. Current residents that utilize oxygen will have their care plans reviewed and updated as appropriate to reflect current conditions and interventions.

3. All nurses responsible for writing care plans will be re-educated on the facility's policy and procedure for developing Comprehensive Care Plans to ensure that resident's care plan is accurate.

4. Care plans will be reviewed weekly in accordance with the care plan review schedule by the Licensed Practical Nurse Assessment Coordinator(s) (LPNAC). All care plans will be updated as indicated.
The LPNACs/designee will complete an audit of 4 residents weekly for 5 weeks and then monthly for 2 months to ensure that care plans are up to date and accurately reflect the residents' new orders, needs and current interventions.

Audit results will be forwarded to the QAPI Committee for review and recommendations.





483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:

Based on observations, review of facility policy and staff interview, it was determined that the facility failed to safely secure medications on one of three nursing units (B Wing)

Findings include:

The facility policy entitled "Medication Administration," dated 7/23/19, indicated that during medication administration, the medication cart is to be kept closed and locked when out of sight of the medication nurse and that the cart must be clearly visible to the personnel administering medication when unlocked.

On 8/20/19, between 3:35 p.m. and 3:50 p.m. Licensed Practical Nurse (LPN) Employee E11 proceeded to prepare medications for Resident R96, and when completed, pulled the medication cart to the doorway with the drawers facing into the room and the cart unlocked. LPN Employee E11 then went into the room and with the cart out of sight, administered medications and washed hands in the resident bathroom. LPN Employee E11 then proceeded to prepare medications for Resident R66, and when completed, pulled the medication cart to the doorway with the drawers facing into the room and the cart unlocked. LPN Employee E11 then went into the room and with the cart out of sight, administered medications and washed hands in the resident bathroom.

During an interview on 8/20/19, at 3:50 p.m. LPN Employee E11 confirmed that the medication cart was left unlocked, out of view and the medications unsecured in a hallway with potential resident, visitor and staff traffic.

28 Pa. Code 211.9(a) Pharmacy services

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 9/21/18







 Plan of Correction - To be completed: 10/15/2019

1. Licensed Nurses were reminded that the medication carts are to be closed and locked when the medication nurse is not present/not in sight. The medication cart will be closed and locked when medication nurse is not present/not in sight to ensure medications are safe and secure.

2. An in-service education will be conducted by the DON with staff nurses addressing the facility policy regarding the proper storage of medications.

3. RN Supervisors will inspect medication carts once per day on rotating shifts for two weeks then weekly on rotating shifts for three months to ensure it is locked when the medication nurse is not present.
All audit results will be forwarded to the QAPI Committee for review and recommendations





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 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(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 review of clinical records and facility policy and staff interviews, it was determined that the facility failed to act on pharmacy recommendations in a timely manner for two of 26 residents (Residents R51 and R44).

Findings include:

The facility policy entitled "Gradual Dose Reduction of Psychotropic Drugs," dated 7/23/19, indicated that within the first year in which a resident is admitted on a psychotropic (affecting brain activity) medication, the facility will attempt a gradual dose reduction (GDR) in two separate quarters (with at last one month between the attempts), unless clinically contraindicated.

Resident R51's clinical record revealed an admission date of 4/17/18, with diagnoses that included Alzheimer's disease, anxiety and depressive episodes. Resident R51's current physician orders included an order for Quetiapine (a medication for psychosis [a mental disorder marked by changes in personality, impaired functioning, and a distorted sense of reality], 150 milligrams (mg) twice a day (BID). A "Note to Attending Physician/Prescriber" form from the facility's clinical pharmacist dated 6/29/19, requested Resident R51's physician to "consider decreasing Quetiapine to 100 mg twice a day (BID) from 150 mg BID". The form included documentation "faxed to MD (medical doctor) 7/09/19." The sections of the form for the physician/prescriber response to indicate if the physician agreed, disagreed, or wished to provide other documentation in response to the request were blank.

During an interview on 8/22/19, at 9:34 a.m. Licensed Practical Nurse Employee E5 confirmed that the form requesting a physician response to the gradual dose reduction was not addressed by the physician in a timely manner (54 days after the request).


Resident R44's clinical record revealed an admission date of 1/02/18, with diagnoses that included dementia, anxiety and depressive episodes.

The "Note to Attending Physician/Prescriber" form dated 3/25/19, revealed that a recommendation was made to decrease the morning dose of Sertraline (antidepressant) to 50 mg daily from 75 mg daily.

The pharmacy review sheet was not signed by the Certified Registered Nurse (RN) Practitioner until 7/08/19, or 74 days later.

During an interview on 8/22/19 at 11:10a.m. RN Supervisor Employee E4 confirmed that the pharmacy form requesting a physician response to the recommendation was not addressed in a timely manner.

28 Pa. Code 211.5(f)(h) Clinical records
Previously cited 3/15/19, 9/21/18

28 Pa. Code 211.9(k) Pharmacy services

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 9/21/18












 Plan of Correction - To be completed: 10/15/2019

1. Order received that physician denied dose reduction of Quetiapine at this time due to benefits outweighing the risks for Resident #51. Resident #44's Sertraline was decrease per physician order on 07/08/2019.

2. All pharmacy recommendations regarding antipsychotic usage that were received over the past 30 days will be audited to ensure 100% compliance in physicians addressing the pharmacy recommendations in a timely manner. Any non-compliance will immediately be addressed.

3. A facility procedure regarding the timely review and action taken on identified medication irregularities as a result of the monthly MRR was developed on September 10, 2019. The DON will review the guidelines with the staff nurses and RN Supervisors. A letter will be sent to MDs', CRNPs' and PA-Cs' offices to educate on regulation of antipsychotic dose reduction.

4. RN Supervisors will address any irregularities identified by the pharmacist's medication regimen review within one week of receipt of the report. Documentation will be provided of action taken for each irregularity noted, i.e. if MD does not respond in a timely manner. The Director of Nursing will review each pharmacist's recommendation and/or medication irregularities monthly for 6 months for compliance.

All audit results will be forwarded to the QAPI Committee for review and recommendations.



483.30(b)(1)-(3) REQUIREMENT Physician Visits - Review Care/Notes/Order: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.
483.30(b) Physician Visits
The physician must-

483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section;

483.30(b)(2) Write, sign, and date progress notes at each visit; and

483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.
Observations:

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to ensure that physicians wrote, signed and dated progress notes at required visits for two of 26 residents (Residents R3 and R51).

Findings include:

The facility policy entitled "Physician Review Schedule Guidelines," dated 7/23/19, indicated that physicians must make resident visits every 30 days following admission for the first 90 days and every sixty days thereafter. The policy further indicated with each visit the physician must write, sign and date a progress note, unless their Certified Physician Assistant (PA-C) or Certified Registered Nurse Practitioner (CRNP) completed the progress note on an alternating basis at which point they will review, co-sign and date the note.

Resident R3's clinical record revealed an admission date of 12/30/16, with diagnoses that included Parkinson's disease (a progressive nerve disease impacting the muscles), dementia without behavioral disturbance and a history of falls. Physician Progress Notes revealed notes written by a PA-C dated 9/27/18, 10/25/18, 11/27/18, 1/22/19, 2/26/19, 3/12/19; 4/9/19; 5/21/19; 5/28/19, and 6/11/19. All the notes were co-signed, but not dated, by the physician. There was one Physician Progress Note written and signed by the physician, dated 5/02/19.

Resident R51's clinical record revealed an admission date of 4/17/18, with diagnoses including but not limited to Alzheimer's disease, anxiety and depressive episodes. Physician Progress Notes revealed notes written by a PA-C, dated 9/27/18,10/25/18, 11/27/18, 1/22/19, 3/19/19, 5/21/19, 6/04/19, and 6/11/19. All the notes were co-signed, but not dated, by the physician. There was one Physician Progress Note written and signed by the physician, dated 5/02/19.

During an interview on 8/22/19, at 9:34 a.m. Licensed Practical Nurse Employee E5 confirmed that Residents R3 and R51's physician had written, signed and dated only one progress note in the last eleven months, not alternating the visits and progress notes with the PA-C.

28 Pa. Code 211.2 (a) Physican's services

28 Pa. Code 211.5 (f)(h) Clinical records
Previously cited 3/15/19, 9/21/18
















 Plan of Correction - To be completed: 10/15/2019

1. Residents #3 and #51, moving forward will have signed and dated progress notes when the physician visits.

2. Physicians will be educated on the need to sign and date their progress notes at required visits. Physicians will also be educated that visits are every 30 days following admission for the first 90 days and every 60 days thereafter. Alternating visits with a Certified Registered Nurse Practitioner (CRNP) or Physician Assistant-Certified (PA-C) is an option; however the Physician will need to review, co-sign and date the CRNP's/PA-C's note.
The Physician for R3 and R51 currently has 15 other Residents in the facility. The medical records for those Residents will be reviewed for accuracy in timeliness for PA-C co-signing and dating PA-C notes, and, that the Physician has made the required amount of visits with Progress notes appropriately signed and dated. Any infractions will be immediately addressed with the Physician.

3. Medical Records will audit 5 residents weekly for 3 weeks, then 3 residents weekly for 4 weeks, then 3 residents semimonthly for 4 months to ensure compliance with Physician's responsibilities.

All audit results will be forwarded to the QAPI Committee for review and recommendations.






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 observations, clinical record review, and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and services for one of 26 residents (Resident R98).

Findings include:

Clinical record review of Resident R98 revealed that he/she was admitted on 7/18/17, with diagnoses that included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), heart failure, and asthma (airways narrow, swell and produce extra mucus).

Resident R98's physician's orders dated 8/3/19, revealed an order for continuous oxygen at two liters per minute (lpm) via nasal cannula (tubing into the nose used to deliver supplemental oxygen).

Observations on 8/20/19 at 11:30 a.m. and 8/22/19 at 1:07 p.m. revealed that Resident R98's oxygen concentrator (device that delivers a concentrated flow of oxygen) was set at three lpm. Licensed Practical Nurse Employee E2 confirmed the above information on 8/22/19 at 1:10 p.m.

During an interview on 8/23/19, at 10:30 a.m. the Director of Nursing confirmed that Resident R98's oxygen lpm was not set in accordance with the physician's orders.

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 9/21/18






 Plan of Correction - To be completed: 10/15/2019


1. The DON placed Resident #98's oxygen concentrator on the correct flow of oxygen per physician's order and her care plan has been updated to indicate that resident will turn her oxygen up on her own.

2. The LPNAC educated Resident 98 on the importance of the oxygen concentrator being on the correct flow of oxygen per physician's order. Resident #98 acknowledge understanding and was able to identify and recall the correct liter flow per physician order.

3. The facility has determined that all residents with oxygen concentrators have the potential to be affected. All residents with oxygen use will be reviewed to ensure the correct flow of oxygen per physician's order.

4. An in-service education program will be conducted will all nurses and direct care staff addressing the correct setting of oxygen concentrators based on physician orders.

5. The DON, or designee, will audit residents with oxygen use daily 5 days a week for 3 weeks, then weekly for 4 weeks, then semi-monthly for 4 months for a total of 6 months regarding physician ordered oxygen settings.
All audit results will be forwarded to the QAPI Committee for review and recommendations.



483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on observations, review of clinical records and facility policy and staff interviews, it was determined that the facility failed to have a pressure ulcer assessed by a Registered Nurse (RN) in a timely manner and failed to provide physician ordered positioning devices for two of 26 residents (Residents R14 and R27).

Findings include:

The facility policy entitled "Presure Ulcer Prevention and Intervention," dated 7/23/19, indicated that when a resident develops a pressure ulcer, a thorough assessment with detailed documentation will be completed by the RN, completing an "Orchard Manor Pressure Ulcer Documentation" form. The policy further indicated that daily monitoring will be completed by the Licensed Practical Nurse (LPN), with any changes reported to the RN for follow-up and assessment, and weekly comprehensive assessments to be conducted weekly.

Resident R14's clinical record revealed an admission date of 4/01/15, with diagnoses that included Parkinson's disease (a progressive nervous system disease impacting movement), atrial fibrillation (an irregular heart rhythm originating in an upper chamber of the heart), and a delusional disorder.

Clinical record review revealed a "Weekly Skin Check Flowsheet - Licensed Nurse," dated 8/02/19, and completed by LPN Employee E14, indicated that Resident R14 had a Stage II (partial thickness loss of skin presenting as a shallow open ulcer with a red/pink wound base) pressure ulcer of the left buttock. Subsequent "Weekly Skin Check Flowsheets - Licensed Nurse" forms dated 8/08/19, and 8/15/19, and completed by LPN's indicated that Resident R14's skin was intact and did not contain any pressure areas. Physician orders dated 8/13/19, included a new order for wound care to Resident R14's left coccyx with Allevyn (a dressing with antimicrobial properties), after cleaning with normal saline and applying Cavilon to be done every 72 hours and as needed. There was no comprehensive assessment by an RN of Resident R14's pressure ulcer until 8/22/19, 20 days after it was first identified.

On 8/22/19, at 9:54 a.m., during an observation of wound care, Resident R14 was noted to have a Stage II pressure ulcer to the left buttock being treated per physician order with a normal saline wash, Allevyn to the wound bed, and Cavilon to surrounding area.

During an interview on 8/22/19, at 1:30 p.m., RN Employee E4 confirmed that Resident R14's wound was not consistently assessed by an RN or in a timely manner.


Resident R27's clinical record revealed an admission date of 4/27/19, with diagnoses that included dementia without behavioral disturbance, an irregular heart rhythm, and dorsalgia (pain radiating from the back).

Resident R27's current physician orders, dated 8/09/19, included an order to "continue the use of a high back recliner wheelchair with pressure relieving cushion, head support and right lateral support (built up cushion device placed behind the upper back/shoulder area) and elevating leg rests."

Observations of Resdient R27 on 8/21/19, from 9:30 through 10:30 a.m., and again on 8/22/19, from 9:00 a.m., through 11:30 a.m., seated in a high back wheelchair in the activity/dining area with a head support and elevated leg rests on a reclining wheelchair but no visible right lateral support in place.

During an interview on 8/22/19, at 1:15 p.m. Rehabilitation Director Employee E15 confirmed that Resident R27 did not have the physician ordered right lateral support in place on the reclining wheelchair.

483.25 Previously cited 9/21/18

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 9/21/18

28 Pa. Code 201.18(b)(1)(e)(1)(6) Management
Previously cited 9/21/18

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 9/21/18


 Plan of Correction - To be completed: 10/15/2019

1. Resident #14 will have a skin assessment completed by a Registered Nurse (RN), current orders will be reviewed for appropriateness based on assessment results, physician will be notified for any abnormal findings, and care plan updated if needed.

The facility has determined that all residents have the potential to be affected. Current residents with wounds will be assessed by a RN to ensure that staging/treatment is appropriate for the wound description. Also that appropriate interventions are in place and documented.

Licensed Nurses will be educated on proper wound assessment on admission and weekly staging, treatments, interventions, and need for reporting changes to the RN for follow-up and assessment. RN Supervisors will do weekly wound rounds and comprehensive wound assessments.

The DON, or designee will audit 3 residents a week for 30 days, then 2 residents a week for 4 weeks, then 2 residents semi-monthly for 4 months for a total of 6 months. The audits will address that skin/wound orders are current and are appropriate based on assessment results, physician are notified for any abnormal findings, and care plan are updated if needed.

All audit results will be forwarded to the QAPI Committee for review and recommendations.

2. Resident #27 had a right lateral support placed in high back recliner on August 22, 2019.

The facility has determined that all residents that have a physician order for a support device have the potential to be affected but none show any ill effect. Current residents that have an order for a support device will be reviewed to ensure device is in place.

All staff will be educated regarding physician orders for pressure relieving and support devices along with follow through in providing/ensuring residents have devices in place.

RN Supervisors, or designee will audit 3 residents weekly for 4 weeks, and then monthly for 2 months to ensure ordered devices are in place.

All audit results will be forwarded to the QAPI Committee for review and recommendations.





483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on observations and staff interviews it was determined that the facility failed to provide assistance with dining to eight of 19 dependent residents (Residents R97, R29, R47, R43, R90, R65, R27, R101, and R85).

Findings include:

Observations of dining on the Sunshine Way Unit on 8/21/19, at 9:30 a.m. revealed Resident R27 being fed breakfast by Nursing Assistant (NA) Employee E7, nine residents with meals were seated at two other tables, and Residents R85, R101 and R65 were seated at a table for residents requiring dining assistance without meals. Between 9:40 a.m. and 9:45 a.m. two additional NA's arrived and began to make toast and serve other trays still in the dining cart.

Observations of dining on the Sunshine Way Unit on 8/22/19, at 9:00 a.m. revealed NA Employee E8 feeding Resident R97 breakfast. Residents R27, R101, R85, and R65 were seated at, or near, a semi-circular table wearing clothing protectors awaiting their meal. At another table, Residents R29, R47, R43 and R90 were seated at a table with their meals, but not consistently eating for extended periods or being cued by staff. A Licensed Practical Nurse was seated at the nurse station desk adjacent to the dining room writing. At 9:20 a.m. NA Employee E9 entered the dining room, removed a tray from the enclosed dining cart and proceeded to set up and feed Resident R65. The other residents continued to await for assistance and their meals.

During an interview on 8/22/19, at 9:25 a.m. NA Employee E9 indicated that Residents R97, R27, R101, R85 and R65 required extensive assistance of a staff member to eat. NA Employee E9 further confirmed that most of the other residents in the dining room, due to dementia, required cueing to fully consume their meals. NA Employee E9 also indicated that the breakfast dining cart was delivered daily to the unit between 8:00 a.m. and 8:15 a.m., over an hour before some residents were served their meal.

During an interview on 8/22/19, at 9:30 a.m. NA Employees E8 and E9 confirmed that they were unable to meet the dining needs of the dependent residents in a timely manner.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 9/21/18

28 Pa. Code 201.18(b)(3) Management
Previously cited 9/21/18

28 Pa. Code 201.29(j) Resident rights

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 9/21/18









 Plan of Correction - To be completed: 10/15/2019

1. The Licensed Nurse is now responsible for ensuring that R97, R29, R47, R43, R90, R65, R27, R101, and R85 are assisted with dining at the same time as other Residents at their table.

2. The facility has determined that all residents on Sunshine Way Unit have the potential to be affected. The LPNACs and RN Supervisor will alternate a schedule to be present on Sunshine Way Unit seven (7) days per week during breakfast hours to assess and assist, to ensure enough help is present to provide assistance to all residents with dining.

3. Observations will be made by the LPNACS and/or RN Supervisors 7 mornings a week for a period of one month, then 3 mornings a week for one month and findings will be discussed with Administrator.

4. The Administrator or designee will conduct four unannounced morning visits a month on Sunshine Way Unit to ensure compliance.
All audit results will be forwarded to the QAPI Committee for review and recommendations






483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities: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.
483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

483.24(b)(2) Mobility-transfer and ambulation, including walking,

483.24(b)(3) Elimination-toileting,

483.24(b)(4) Dining-eating, including meals and snacks,

483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to provide restorative care as care planned for one of 26 residents (Resident R44).

Findings include:

Resident 44's the care plan revealed that since 3/01/18, he/she should be walked 100-150 feet with extensive assist of two and wheelchair to follow; ambulate in morning and evening as tolerated; and passive range of motion to legs prior to walking.

Documentation completed for the restorative task of ambulation for Resident R44 revealed that from 7/24/19, through 8/22/19, Resident R44 was walked just 28 times and refused twice out of 60 available opportunities during that timeframe.

During an interview on 8/23/19, at 1:49 p.m. Licensed Practical Nurse Employee E13 verified that documentation showed Resident R44 was only walked 28 times with two refusals and confirmed that Resident R44 was not walked according to the restorative care plan.

28 Pa. Code 211.12 (d)(1)(5) Nursing services
Previously cited 9/21/18














 Plan of Correction - To be completed: 10/15/2019

1. Resident #44s will have his restorative program re-evaluated for appropriateness and his care plan will be updated and is reflective of current service needs. After re-evaluation Resident #44 will receive restorative care as per his care plan, if applicable.

2. All residents of the facility that are receiving restorative care have the potential to be affected but none show any ill effect. All residents on a restorative program will be re-evaluated to ensure their program is appropriate and being followed per their plan of care.

3. Nursing staff will be in-serviced on the importance of our restorative programming and necessity of completion to prevent decline and the importance of documenting.

4. Restorative nurse, or designee will monitor restorative documentation on ten (10) residents; five days per week for the first 30 days, then weekly for 4 weeks, then semi-monthly for 4 months for a total of six months ensuring compliance of the restorative programming needs of residents as care planned.
All audit results will be forwarded to the QAPI Committee for review and recommendations.




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 notify the resident and the resident's representative in writing of the transfer out of the facility for four of 26 residents (Residents R87, R51, R98 and R106).

Findings include:

Resident R87's clinical record revealed an admission date of 9/26/18. The Minimum Data Set (MDS-periodic review of resident care needs), dated 7/12/19, revealed that Resident R87 was discharged from the facility with return anticipated and subsequently returned to the facility on 7/16/19. There was no evidence that the resident and resident representative were notified in writing of the transfer.

The clinical record revealed that Resident R98 was transferred to an acute care hospital on 7/10/19, and subsequently returned to the facility on 7/15/19. There was no evidence that the resident and resident representative were notified in writing of the transfer.

During an interview on 8/21/19, at 12:50 p.m., Resident R106 indicated that he/she was transferred to the hospital on several occassions for breathing problems and didn't remember receiving a notice of transfer.

Resident R106's clinical record revealed transfers to the hospital related to respiratory distress on 10/18/18, with a return to the facility on 10/22/18; on 1/26/19, with a return to the facility on 2/08/19; on 3/23/19, with a return to the facility on 3/25/19; and on 4/30/19, with a return to the facility on 5/06/19. There was no evidence that the resident and resident representative were notified in writing of the transfers.

Resident R51's clinical record revealed a transfer to the hospital on 5/28/19, following a fall, with a return to the facility on 6/01/19. There was no evidence that the resident and resident representative were notified in writing of the transfer.

During an interview on 8/21/19, at 11:56 a.m. Social Services Employee E12 confirmed that written notices of transfer were not provided to residents/resident representatives upon transfer out of the facility.

28 Pa. Code 201.14 (a) Responsibility of licensee
Previously cited 9/21/18

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


 Plan of Correction - To be completed: 10/15/2019

1. Residents #87, #51, #98 will be provided the reason for transfer/discharge in writing by the Social Services Department and understanding will be verified and documented. The Resident's representative will also be notified and given a copy of the notice, if applicable. Resident #106 was listed as an interview and is unable to be identified.
2. Any Residents that were transferred/discharged over the past 30 days will be provided the reason for transfer/discharge in writing by the Social Services Department.
3. An in-service education will be conducted by the Administrator/Designee with all Social Services staff addressing circumstances regarding required notices for residents upon transfer and discharge from the facility.
4. The Administrator, or designee, will conduct a record audit weekly for four weeks and then monthly for 2 months, of all residents who have been transferred or discharged from the facility to ensure the record includes a copy of the transfer/discharge notice. If the resident is still residing at the facility at the time of the record audit, the resident and their representative (if applicable) will be interviewed to ensure that they have received a transfer/discharge notice written in a language that they can understand. If the resident is no longer residing at the facility at the time of the audit, the resident and their representative will be contacted by phone to ensure they received the transfer/discharge notice.






483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.21 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:

Based on review of clinical records and facility policies and staff interviews, it was determined that the facility failed to provide the resident and resident representative with a written summary of the baseline care plan for two of 26 residents (Residents R63 and R90).

Findings include:

The "Baseline Care Plan" policy, dated 7/23/19, revealed "a copy of the baseline care plan shall be provided to the resident and resident representative in a language that the resident and/or residents representative can understand."

Resident R63's Admission Minimum Data Set (MDS-periodic assessment of resident care needs), dated 2/20/19, revealed that Resident R63 was admitted on 2/13/19, with diagnoses that included dementia and a fracture.

Resident 90's Admission MDS, dated 5/27/19, revealed Resident R90 was admitted on 5/20/19, with diagnoses that included heart problems, stomach problems, arthritis, dementia, depression and a stroke .

There was no evidence to indicate that Residents R63 and R90 or their representatives were provided a written summary of the baseline care plan.

During an interview on 8/22/19, at 12:43 p.m. Registered Nurse Supervisor Employee E1 confirmed that there was no evidence to support that base line care plans were provided in writing to residents and their representatives.

28 Pa. Code 201.18(a)(2) Management
Previously cited 9/21/18













 Plan of Correction - To be completed: 10/15/2019


The attestation. I hereby attest that the CMS 2567 A issued to Orchard Manor, Survey ending 08/23/2019, and attest that all deficiencies noted will be addressed.









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