Nursing Investigation Results -

Pennsylvania Department of Health
RENAISSANCE HEALTHCARE & REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
RENAISSANCE HEALTHCARE & REHABILITATION CENTER
Inspection Results For:

There are  67 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.
RENAISSANCE HEALTHCARE & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to two complaints completed on January 28, 2020, it was determined that Renaissance Health and Rehabilitation Center, was not in compliance with the 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 related to the health portion of the survey process.























































 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 interviews with staff, it was determined that the facility failed to ensure the proper functioning of the dish machine, and the sanitation and maintenace of the kitchen.

Findings include:

Observation of the food and nutrition department on January 22, 2010 at 10:30 a.m., in the presence of the Food Service Director, Employee E12, revealed the following findings:

Observation of the facility's low temperature dish machine used to clean and sanitize the pots, pans, dishes and utensils revealed that Employee E12, conducted a test of the cleaner/sanitizer levels in the dish machine, which revealed that the proper amount of sanitizer (hydrochloride 50 to 100 parts per millions) was not being used to clean and sanitize the pots, pans, dishes and utensils. Employee E12, reported that a hose required to dispense the correct chemical concentration into the low temperature dish machine was not connected.

Continued observation of the dietary kitchen revealed floors, walls and ceiling throughout the dish machine area were heavily soiled with dirt, food spillage and food debris. The flooring was noted with discarded papers, saturated cardboard boxes and broken pieces of dishwashing equipment. The floor drain was clogged and water was noted pooling on the floor in the room. Floor tiles were noted with water damage and low grouting that contained water and food debris.

The cast iron baseboard heating unit was covered with dirt, rust and a black substance. The black substance and dirt continued up the wall area behind the overhead sprayer and sink and along the extended dish table. The sink in the dish room was observed to be continuously dripping water. The faucet could not be turned off.

Observation of a door that was located across the hall from the dish room area which opened directly to the outside, had a one inch gap at the bottom of the door not allowing the door to closed properly. Observation of an additional door located near the dry food storage area that opened directly to the outside, revealed that it was not sealed properly upon closing. A one inch gap was noted at the threshold of the door when closed.

Interview with Employee E12, the Food Service Director, during the tour, confirmed the observations made during the physical environment review of the main kitchen.

The facility failed to to ensure the proper functioning of the dish machine, and the sanitation and maintenace of the kitchen.


483.60 Food and Nutrition Services Food Procurement, Storage/Preparation/Serve-Sanitary
previously cited 02/07/2019

28 Pa. Code: 205.13(b) Floors

28 Pa. Code: 201.18(b)(3) Management
Previously cited 02/07/2019

28 Pa. Code: 207.2(a) Administrator's responsibility
Previously cited 02/07/2020










 Plan of Correction - To be completed: 03/08/2020

The dish machine (chemical sanitizing machine) hose was unkinked and functioned properly immediately. The "Dish Machine Log" will have the ppm (parts per million) measured daily for each wash cycle after breakfast, lunch, and dinner.

Dietary Manager or Designee will review "Dish Machine Log" weekly for 3 months to ensure proper ppm for the dishmachine.

Administrator or designee will review audits weekly for one month and then periodically thereafter. Any findings will be submitted to the monthly QAPI meeting for review and recommendations.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

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

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

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

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

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

Based on observation and staff interviews, it was determined that the facility failed to maintain dignity and respect for two of 41 residents reviewed. (Resident R33 and R39).

Findings include:

A review of the facility policy titled " Dressings, Dry/Clean", dated revised September 2013, revealed that steps in the procedure include to label tape or dressing with date, time and initials and place it on the clean field.

A review of Resident R33's clinical record revealed that the resident was admitted with diagnosis including, but not limited to, sacral (lower back) pressure ulcer (localized areas of tissue damage or necrosis that develop because of pressure over bony prominence's), and stroke.

A review of January 2020 physician orders for Resident R33 revealed an order to clean the sacral area with normal saline (salt solution) and apply purical plus and calcium alginate (chemical debriding agent), and cover with a 4 inches by 4 inches border gauze.

Observation of Resident R33 on January 23, 2020, at 9:30 a.m. during a wound care revealed that Employee E3, proceeded to write her initials and the date on the 4 x 4 inch gauze bandage that was on the bandage already placed on the residents' sacral area.

Interview with Employee E3, on January 23, 2020, at 9:40 a.m., confirmed that she wrote her initials and the date on the bandage that was on the residents sacral wound.

A review of Resident R39's clinical record revealed that the resident was admitted to the facility on January 19, 2019, with diagnoses, including but not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning) and depression.

Observation of Resident R39 on January 24, 2020, at 10:30 a.m., revealed the resident was seated in a geri chair (a lounge chair on wheels) while being pulled backwards down the hallway by Employee E4, a nursing assistant.

Interview with licensed nursing staff, Employee E5, on January 24, 2020, at 11:00 a.m. confirmed that residents were not to be pulled backwards in their geri chairs.

The facility failed to maintain dignity and respect for two residents.

28 Pa Code 201.29(f) Resident rights

28 Pa Code 201.29(j) Resident rights

28 Pa. Code 211.12 (d)(1) Nursing services.
Previously cited 2/7/19.








 Plan of Correction - To be completed: 03/08/2020

Resident R 33 has had no further instances of the wound nurse writing on her bandages after the bandage has been placed.

Resident R 39 has had no further instances of being pulled backwards down the hallway.

Employee E 3 and Employee E 5 have had one to one re-education regarding Resident's Rights with a focus on maintaining resident dignity.

All staff are being re-inserviced regarding the Residents Rights Policy by the Assistant Director of Nursing or designee. The inservice will include a focus on maintaining resident dignity.

The Director of Nursing , or designee, will audit compliance via a random Dignity Audit weekly for 3 months and forward the results of the audit to the QAPI Committee for further review and recommendations.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:

Based on observations and staff interviews, it was determined that the facility failed to prevent verbal abuse for one out of 41 residents reviewed. (Resident R18).

Findings include:

A review of the facility policy titled "Abuse Prevention Program", date revised December 16, 2016, revealed that " our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms."

A review of Resident R18's clinical record revealed that the resident was admitted to the facility on October 25, 2018, with a diagnosis including but not limited to, Down's Syndrome (congenital disorder caused by a chromosome defect and causing intellectual impairment and physical abnormalities).

Observation of Resident R18 on January 23, 2020, at 9:30 a.m. revealed the resident sitting in the hallway in her wheelchair on the second floor. Employee E6, a physical therapy aide, was behind the resident stating " no, no, no." Employee E6's voice was getting louder every time he stated " no." He stated " no, that's the brake." Then Employee E6 stated to the resident "oh, never mind" and took her to the physical therapy room.

Interview with the unit manager on the second floor, on January 23, 2020 at 9:35 a.m. was informed of the observation and allegation of verbal abuse. The unit manager " stated that he would inform the Nursing Home Administrator and the Director of Nursing, and an investigation would be initiated immediately."

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

28 Pa. Code 211.12 (d)(1) Nursing services
Previously cited 2/7/19










 Plan of Correction - To be completed: 03/08/2020

Resident R 18 has had no further instances of verbal abuse.
An investigation was initiated immediately. Employee E 6 was suspended immediately. An Event Report was submitted to the Department of Health on the day of the allegation. The investigation has been completed and the allegation was found to be substantiated. The Employee E6 has been terminated. A PB-22 has been submitted as required.

All staff are being re-inserviced regarding the policy "Abuse Prevention Program" by the Assistant Director of Nursing or designee.

Director of Nursing or designee will audit compliance weekly for 3 months and report the findings to the QAPI Committee for review and recommendations.

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 clinical record review, review of policies and procedures and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation for one of 28 residents reviewed. (Resident R87)

Findings include:

Review of the facility policy entitled investigating and reporting accidents and incidents, revealed that the facility was responsible for investigating all accidents or incidents involving residents and employees. The policy further indicated that all accidents and incidents were to include documentation of the circumstances surrounding the situation, the names and witnesses of the event were to be recorded and that all accounts of the accident or incident were to be recorded. The report was to include any follow-up information and other pertinent data as necessary.

Review of Resident R87's clinical record revealed that the resident sustained a fall on December 14, 2019 in the dining room on the 1st floor nursing unit. Review of the facility investigation into the fall incident revealed that the facility failed to obtain the name of the employee assigned to supervise Resident R87, who witnessed the fall and did not obtain a detailed witness statement from this employee.

Interview with the Nursing Home Administrator at January 28, 2020 at 10:00 a.m., confirmed that there was no statement obtained from the employee assigned to supervise Resident R87.

Review of nursing documentation dated December 26, 2019 at 7:34 p.m. revealed that "nurse walked into dining area and observed resident lying on left side on the floor hold his head. nurse ask resident what happened, resident stated he was putting his pants in a box. Supervisor informed. Full body assessment done, resident noted with a lump on the back of his head."

Interview conducted with the Director of Nursing on January 28, 2020 at 10:00 a.m. revealed that Resident R87 was required to be supervised by a nursing assistant, while being in the dining room on December 26, 2019; because this resident was at high risk for falls and injury.

Review of the facility documentation dated December 26, 2019 at 6:30 p.m. revealed that this fall was unwitnessed.
Further there was no evidence that the facility determined which nursing staff member was assigned to provide supervision in the dining room to residents on December 26, 2020; when the fall occurred. There was no evidence that a detailed report was obtained from the staff member responsible for the care of Resident R87 and the circumstances surrounding the fall in the dining room.

Interview with the nursing home administrator at 10:00 a.m., on January 28, 2020 confirmed that the facility failed to conduct a complete investigation, related to the fall incident sustained by Resident R87 on December 26, 2019.


The facility failed to thoroughly investigate incidents of falls to rule out neglect for Resident R87.

28 Pa. Code: 201.18(b)(1) Management
Previously cited 04/10/2019

28 Pa. Code: 211.12(d)(1) Nursing services
Previously cited 04/10/2019

28 Pa. Code: 211.12(d)(5) Nursing services
Previously cited 04/10/2019










 Plan of Correction - To be completed: 03/08/2020

Resident R87 has been discharged from the facility. Residents who have had fall incidents starting 2/1/20 were reviewed to determine that incidents are thoroughly investigated to rule out neglect.

Nursing staff are being re- inserviced regarding Accident/Incident reporting policy by the Assistant Director of Nursing or Designee.

The Unit Manager or Designee will conduct complete investigations through obtaining statements from employees that are supervising or in the same room as a resident during an incident. An audit will be conducted weekly for 3 months to determine that incidents are thoroughly investigated to rule out neglect.

The Administrator or designee will review incidents weekly for 3 months determine that incidents are thoroughly investigated to rule out neglect. Any findings will be presented to the monthly QAPI meeting for recommendations.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(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 observations and interviews with residents and staff, it was determined that the facility failed to provide an appropriate discharge notice as required for one of 41 residents reviewed (Resident R73).

Findings include:

Interview on January 23, 2020, at 10:00 a.m. Resident R73 stated that she was upset because she received a note from the business office which indicated that she would be discharged due to owing the facility money. Interview with Resident R73's family member revealed that she found a handwritten note, written in marker across three sheets of steno pad paper on the resident's table yesterday.

Observation of the handwritten note revealed, "We need to contact your daughter. She owes us money for your stay here. If we don ' t get payment we will have to discharge you." The note included the name and phone number for the Business Office Manager.

Interview on January 23, 2020, at 2:22 p.m., the Nursing Home Administrator (NHA) stated that he was not aware of any discharge notices or billing issues for Resident R73. The NHA agreed that a handwritten note was not an acceptable means of notice to give to a resident.

Follow-up interview on January 24, 2020, at 11:23 a.m. the NHA confirmed that the paper discharge notice that was given to Resident R73 was not appropriate, that it should not have been given to her and confirmed that the resident was not being discharged from the facility.

Interview on January 24, 2020, at 12:54 p.m., the Business Office Manager stated that Resident R73's financial issues have been resolved and that the resident was not being discharged.

The facility failed to provide an appropriate discharge notice as required.

28 Pa Code 201.14(a) Responsibility of licensee

28 Pa Code 201.29(f) Resident rights






 Plan of Correction - To be completed: 03/08/2020

The Business Office Manager (BOM) had an individual education completed regarding proper discharge and written notices.
R73 was spoken to and is aware that she is not being discharged from the facility.

BOM or designee will conduct a random audit of resident rooms to see if any improper postings are in resident rooms once a week for one month.

Administrator or designee will review audits weekly for one month. Any findings will be submitted to the monthly QAPI meeting for recommendations.

483.21(a)(1)-(3) REQUIREMENT Baseline 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 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 clinical record review and interviews with staff, it was determined that the facility failed to develop a person-centered baseline care plan within 48 hours of a resident's admission for one of 41 residents reviewed . (Resident R87)

Findings include:

Review of Resident R87's clinical record revealed that the resident was admitted to the facility on December 6, 2019 at 11:30 a.m., with diagnoses that included: urinary retention, hypertension (elevated blood pressure), previous falls, cerebral vascular accident (stroke or brain hemorrhage), dementia (progressive irreversible loss of memory) and heart failure.

Further review of Resident R87's clinical record revealed a falls risk assessment completed by the nursing staff on December 6, 2019. The fall risk assessment identified the Resident R87 at high risk for falls.

Review of Residetn R87 nursing documenation dated December 9, 2019 indicated that Resident R87 was observed lying directly on the floor in the bed room, after falling. The nurse documented an assessment of this resident at the time of the fall and it revealed that the resident had a skin tear and a swollen area on the back of the head.

Review of the resident's care plan revealed that there was no base line care plan developed by the interdisciplinary team related to fall prevention.

Interview with the Director of Nursing at 10:30 a.m., on January 24, 2020 revealed that Resident R87 fell from the bed on December 9, 2019, attempting to take himself to the bathroom.

Interview conducted with the Director of Nursing on January 24, 2020 at 1:00 p.m. confirmed that a baseline care related to falls was not developed and implemented for for Resident R87.


28 Pa. Code: 211.11(a) Resident care plan

28 Pa. Code: 211.11(b) Resident care plan

28 Pa. Code: 211.11(c) Resident care plan

28 Pa. Code: 211.11(d) Resident care plan





 Plan of Correction - To be completed: 03/08/2020

Resident R 87 had a baseline care plan initiated on 12/6/19. A fall prevention focus was initiated on 12/9/2019.
New admissions to the facility since 2/1/20 have been audited to ensure that a Baseline Care Plan had been initiated timely and that a fall prevention focus was initiated in the Baseline Care Plan.
RN and LPN staff, Recreation Therapy, Social Work, Dietician, and Therapy Staff are being re-inserviced by the
Assistant Director of Nursing or designee regarding the Baseline Care Plan Policy with a focus on ensuring that the Baseline Care Plan is initiated timely and includes a focus regarding fall prevention.

The Director of Nursing , or designee, will audit compliance weekly for 3 months to ensure that the Baseline Care Plan is started timely and includes a focus regarding fall prevention. Results of the audit 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 clinical record review and staff interviews, it was determined that the facility failed to develop a comprehensive care plan for one out of 41 resident reviewed. (Resident R44).

Findings include:

A review of Resident R44's clinical record revealed that the resident was admitted to the facility on April 24, 2019, with a diagnosis including but not limited to: end stage renal disease and dialysis.

A review of a physician order dated November 19, 2019, revealed a renal diet, regular texture, thin consistency. Avoid foods high in phosphorus and high potassium foods related to high phosphorus and high potassium levels. Gluten free diet.

A review of Resident R44's meal ticket for January 27, 2020, revealed a gluten free diet and double portions.

A review of the care plan titled "The resident is at nutritional risk" dated March 26, 2019, revealed no evidence available for review that a care plan with interventions was developed for a gluten free diet and double portions.

An interview with the licensed nursing staff, Employee E5, on January 28, 2020, at 8:55 a.m. confirmed that the care plan did not include a gluten free diet or double portions.

28 Pa. Code 211.12 (d)(1) nursing services
Previously cited 2/7/19






 Plan of Correction - To be completed: 03/08/2020

Resident R 44's care plan has been updated to indicate " diet as ordered".
Current residents in the facility have had their care plans audited to ensure that the Care Plan is reflective of the residents' current status.

The RN and LPN staff, Recreation Therapy, Social Work, Dietician, and Therapy Staff are being re-inserviced by the Assistant Director of Nursing or designee regarding the policy "Care Plans, Comprehensive Person Centered. The inservice will focus on the need to ensure that the Care Plan is reflective of the residents' current status.

The Director of Nursing or designee will audit a random sampling of care plans weekly for 3 months to ensure that the Care Plan is reflective of the residents current status. Results of the audit 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 clinical record review and interviews with staff, it was determined that the facility failed to notify the physician of elevated blood sugars for one out of 41 resident reviewed. (Resident R2)

Findings include:

A review of Resident R2's clinical record revealed that the resident was admitted to the facility on April 16, 2019, with a diagnosis including but not limited to diabetes ( a chronic condition that affects the way the body processes's blood sugar (a group of diseases that results in too much sugar in the blood).

A review of a physician's order dated June 25, 2019, stated accu checks (blood sugar testing) at bedtime, please call physician if results are less than 80 milligrams per deciliters (mg/dl) and more than 250 milligrams per deciliters.

A review of the medication administration record (MAR) for the month of November 2019, at 9:00 p.m. revealed that on November 13, 2019, the blood sugar was recorded at 349 mg/dl. On November 27, 2019, the blood sugar was recorded as 282 mg/dl, and on November 28, 2019, the blood sugar was recorded as 282 mg/dl.

Further review of the MAR for December 2019, revealed that on December 13, 2019, the blood sugar was recorded as 282 mg/dl and on December 15, 2019, the blood sugar was recorded as 315 mg/dl.

A review of the MAR for January 2020, revealed that on January 12, 2020, the blood sugar was recorded as 277 mg/dl, on January 17, 2020, the blood sugar was recorded as 256 mg/dl and on January 22, 2020, the blood sugar was recorded as 293 mg/dl.

An interview with licensed nursing staff, Employee E5 on January 27, 2020 at 12:00 p.m. confirmed that the above accu checks were above 250 mg/dl.. It was also confirmed that the physician was not been notified as ordered for blood sugar levels over 250 mg/dl.

The facility failed to notify the physician for accu checks over 250 mg/dl as ordered by the physcian for Resident R2.

28 Pa. Code 211(d)(1) Nursing services
Previously cited 2/7/19





 Plan of Correction - To be completed: 03/08/2020

Resident R 2's blood sugars for the last 3 months were reviewed by the physician.
Current residents in the facility with orders for accu checks have been reviewed to ensure physician notification occurred for blood sugars out of parameters based on physician orders.

RN and LPN have been re-educated regarding the need to call the physician for blood sugars out of parameters based on physician orders by the Assistant Director of Nursing or designee.

A random sampling of residents with orders for accu checks will be audited weekly for 3 months by the Director of Nursing or designee to ensure physician notification for blood sugars out of parameters based on the physician order. Results of the audit will be forwarded to the QAPI Committee for review and recommendations.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(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 clinical record review, interviews with staff and review of policy, it was determined that the facility failed to provide supervision consistent with this resident's needs to reduce the risks of falls for one of 28 residents reviewed. (Resident 87)

Findings include:

A review of the facility policy title "Falls and Falls risk, Managing" undated, revealed that the facility was responsible for evaluating current data to identify interventions related to each resident's specific risks for falls and causes of the falls, to prevent the resident from further falls and to minimize complications from falling. The policy indicated that the staff were to be advised by the physician and developed and implement a resident centered fall prevention plan for each resident at risk for falls or with a history of falls.

Clinical record review indicated that Resident R87 was admitted to the facility on December 6, 2019 with diagnoses that included: urinary retention, hypertension (elevated blood pressure), previous falls, cerebral vascular accident (stroke or brain hemorrhage), dementia (progressive irreversible loss of memory) and heart failure.

A falls risk assessment was completed on December 6, 2019 which identified the resident at high risk for falls.

Review of Resident R87's care plan initiated December 9, 2019 identified the resident with the potential for falls and injury related to history of falls. Interventions included for the resident to be out of bed to personal wheelchair with cushion and elevating leg rests.

Review of the admission Minimum Data Set (MDS- assessment of resident care needs) assessment dated December 12, 2019 indicated that Resident R87 required a two person physical assist with bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed). The assessment also identified the resident as requiring one person physical assist with transfers (how a resident moves between surfaces including to or from bed).

Review of physician's notes dated December 9, 2019 at 3:54 p.m. noted that the resident was confused, and it further indicated "safety precautions."

Review of nursing documentation dated December 26, 2019 at 7:34 p.m. revealed that "nurse walked into dining area and observed resident lying on left side on the floor hold his head. nurse ask resident what happened, resident stated he was putting his pants in a box. Supervisor informed. Full body assessment done, resident noted with a lump on the back of his head."

Review of the facility documentation dated December 26, 2019 at 6:30 p.m. revealed that this fall was unwitnessed. Interview conducted with the Director of Nursing on January 28, 2020 at 10:00 a.m. revealed that Resident R87 was required to be supervised by a nursing assistant, while being in the dining room on December 26, 2019; because this resident was at high risk for falls and injury.


The facility failed to provide proper supervision to Resident 87 while in the dining area resulting in the resident sustaining a fall incident.

28 Pa. Code 211.10(d) Resident care policies

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












 Plan of Correction - To be completed: 03/08/2020

Resident R87 has been discharged from the facility. Nursing staff was re-inserviced by the ADON or designee regarding the Falls and Fall risk Managing Policy with an emphasis on adequate supervision in the dining area.

Unit Manager or designee will audit dining area during random weekly audits to ensure adequate supervision.

Administrator or designee will review audits weekly for one month. Any findings will be submitted to the monthly QAPI meeting.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on clinical record review and interviews with staff, it was determined that the facility failed to ensure that each resident maintained acceptable parameters of nutritional status for one of four residents reviewed (Resident R87).

Findings include:

Review of Resident R87's clinical record revealed documentation dated December 11, 2019, by Employee E10, dietitian, which revealed that Resident R87 had a usual body weight of 140 pounds. The dietitian indicated that the resident had a body mass index (BMI-an anthropometric measurement used as one parameter to determine nutritional status) that was within normal range with a height of 71 inches and a weight of 143 pounds. The BMI listed for Resident R87 was 19.9.


Review of the clinical record for Resident R87 revealed an admission comprehensive assessment dated December 12, 2019, which indicated that the resident was 71 inches tall and weighed 143 pounds. Continued review of the
clinical record for Resident R87 revealed that the resident's weight was listed as 128 pounds on January 2, 2020, a loss of 15 pounds. Additional clinical documentation indicated that the resident weighed 126 pounds on January 24, 2020. This reflected a loss of two additional pounds, yielding a total loss of 17 pounds. This weight loss was significant over one month and represented a greater than 5% weight loss over 30 days. According to the guidelines established by the Medicare and Medicaid Services (CMS) significant weight loss is defined as a 5% weight loss over 30 days.

Review of physician's orders for Resident R87 dated December 2019, indicated that the resident was ordered Ensure Plus (nutritional supplement) twice a day. The physician's order further directed nursing staff to record the amount of the nutritional supplement that the resident consumed daily.

Further review of Resident R87's clinical record revealed no documentation of the percentage of Ensure Plus supplement consumed by Resident R87 daily during the month of December 2019.

Interview with Employee E11, registered nurse, on January 27, 2020, at 11:00 a.m. confirmed there was no documentation of the amount of Ensure Plus consumed by Resident R87 during the month of December 2019, as ordered by the physician.

Additional review of Resident R87's clinical record revealed a dietary assessment dated January 3, 2020 which indicated that the weight loss for Resident R87 was undesirable. The dietitian further indicated that the nutritional supplement (Ensure Plus) was now increased to four times a day to maintain the resident's weight.

Review of the physician's order for Resident R87 dated January 2020 directed staff to give Ensure Plus to Resident R87 four times a day and to record the amount consumed by the resident. Further review of the clinical record for Resident R87 revealed no documentation of the amount of Ensure Plus consumed by the resident during the month of January 2020.

Interview with Employee E11, Registered Nurse, on January 27, 2020, at 11:15 confirmed there was no documentation of the amount of Ensure Plus consumed by Resident R87 during the month of January 2020.

The facility failed to ensure that Resident R87 maintained acceptable parameters of nutritional status.

28 Pa Code: 211.6(c) Dietary services
Previously cited 02/07/2019

28 Pa Code: 211.12(c) Nursing services
Previously cited 04/10/2019

28 Pa Code: 211.12(d)(1) Nursing services
Previously cited 04/10/2019

28 Pa Code: 211.12(d)(3) Nursing services
Previously cited 04/10/2019

28 Pa Code: 211.12(d)(5) Nursing services
Previously cited 04/10/2019



 Plan of Correction - To be completed: 03/08/2020

Resident R87 has been discharged from the facility. Dietician has completed an audit of residents on supplements to ensure residents are receiving supplements as ordered. Inservice was completed with Dietician regarding nutritional supplements and if needed, will order and document percentage consumed.

Dietician or designee will conduct a random audit of 10 care plans a week for 3 months to ensure that nutritional interventions are present.

Dietician or designee will conduct a random audit of residents using supplements weekly for 3 months to ensure that supplement intake is being documented as ordered to ensure resident is maintaining acceptable parameters of nutritional status.

Administrator or designee will review audits weekly for 3 months. Any findings will be submitted to the monthly QAPI meeting.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:

Based on observations and interviews with residents and staff, it was determined that the facility failed to ensure that medications were administered in accordance with pharmacy instructions for one of 34 medications reviewed. The faciilty failed to ensure that medications were discarded according to pharmacy instructions for two of five medication carts reviewed (1 South cart and 1 Central cart).

Findings include:

Observation of medication pass on January 23, 2020, at 10:46 a.m. revealed that Employee E7, licensed practical nurse (LPN), prepared medications for Resident R310. Resident R310 stated that she preferred to have her medications crushed. Employee E7 took four of Resident R310's medications, including a Metoprolol Succinate Extended Release 50 milligram (mg) tablet (a medication used to treat high blood pressure), crushed them and then administered them to Resident R310 in applesauce. Interview during the medication administration with Employee E7 confirmed that she crushed the Extended Release Metoprolol Succinate prior to administering it to the resident.

Review of the pharmacy label attached to the Metoprolol Succinate Extended Release 50 mg tablet, revealed that the label indicated "Do not crush." Employee E7 confirmed that according to the pharmacy label, that the medication should not have been crushed.

Review of the 1 South medication cart with Employee E7 on January 23, 2020, at 10:50 a.m. revealed a vial of opened Lantus (long acting insulin). The vial was not dated when it was opened. Continued observation of the medication cart revealed a vial of opened Novolog (short acting insulin) for Resident R98 which indicated that the vial was opened on December 6, 2019. Observation of the label on the vial of Novolog revealed that the medication should not be used after it has been opened for more than 28 days.

Interview with Employee E7, at the time of the observation, confirmed that the vial of Lantus was undated and that the vial of Novolog was opened for more than 28 days. Employee E7 further stated that both medication vials should have been discarded.

Observation of the 1 Central medication cart with Employee E8, LPN, on January 23, 2020, at 11:09 a.m. revealed a vial of Lantus, dated as opened November 14, 2019. Observation of the label on the vial of Lantus indicated that the medication should not be used after it has been opened for more than 28 days.

Continued review of the 1 Central medication cart revealed a Novolog 70/30 Flexpen (a blend of short and long acting insulins) for Resident R82 was dated as opened on January 1, 2020. Observation of the pharmacy label for the flexpen indicated that it should not be used after it has been opened for longer than 14 days.

Interview with Employee E8, at the time of the observation, confirmed that the vial of Lantus was opened for more than 28 days and that the Novolog 70/30 Flexpen was opened for more than 14 days. Employee E8 further stated that both the vial of Lantus and the Novolog flexpen should have been discarded.

The facility failed to store and prepare medications according to pharmacy instructions.

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

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









 Plan of Correction - To be completed: 03/08/2020

A Medication Error Report was completed for Resident R 310 for having her medication crushed when it should not have been crushed. Resident R 310 had no adverse effect after the medication administration.

Medication Pass Competencies are being completed for RN and LPN staff by the Assistant Director of Nursing or designee.

The medication carts in the facility have been audited to ensure that medications are stored per pharmacy instructions , labeled/ dated and discarded according to pharmacy instructions.

The RN and LPN staff are being re-inserviced by the Assistant Director of Nursing regarding the policy Administering Medications and the Policy Storage of Medications.

Random medication cart audits will be completed weekly x 90 days to ensure that medications are stored per pharmacy instructions, labeled/ dated and discarded according to pharmacy instructions by the Director of Nursing or designee. Results of the audit will be forwarded to the QAPI Committee for review and recommendations.

Random weekly Medication Competencies will be completed by the Director of Nursing or designee. Results of the audit will be forwarded to the QAPI Committee for review and recommendations.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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.
483.60(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 review of facility policy and procedure, review of facility documentation, observation of meal service and interviews with residents and staff, it was determined that the facility failed to provide meals at temperatures satisfactory to the residents.

Findings include:

Review of facility policy and procedure related to point of service temperatures revealed that hot entrees were to be served at greater than 130 degrees Fahrenheit. The facility policy further indicated that hot foods served to residents at less than 120 degrees Fahrenheit were unacceptable temperatures.

Review of Food Committee minutes, dated October 23, 2019, revealed, "Meals are often cold, even when residents are eating in the dining room". "Tray trucks often sit in the pantry area for 15 minutes or more before being handed out". Continued review of Food Committee minutes from November 2019, indicated, "Coffee provided with tray service is often cold ... ".

A temperature test tray completed during the breakfast meal service on January 24, 2020 on the second floor nursing unit revealed that the hot breakfast foods were being served tepid or cool for the residents satisfaction. The scrambled eggs that were tested were 116 degrees Fahrenheit and the sausage patty was 115 degrees Fahrenheit.

Interview with Employee E12, Director of Dietary Services, reported during the breakfast meal test tray on January 24, 2020 on the second floor nursing unit, revealed that the facility had been using a hot box to warm the plates (ceramic dishes) for the residents. Employee E12 further reported that the hot box was not functioning properly. Observations of this essential piece of equipment revealed that it was inoperable and not available for food service operation.

Interview on January 22, 2020, at 9:49 a.m. with Resident R105 stated that items served at breakfast were cold.

Interview on January 22, 2020, at 10:16 a.m., with Resident R40 stated that the food was cold, that the meat was too hard, and that she eats chips and cookies that her family brings her because she doesn ' t like the food.

Interview on January 22, 2020, at 10:17 a.m.,with Resident R57 stated that the food was cold, tasted bad and that the food was of poor quality.

The facility failed to ensure that hot foods were being served at temperatures that were appetizing to the residents.

483.60 Food and Nutrition Services Nutritive Value/Appearance/Palatable/Preferred Temperature
Previously cited 02/07/2020

28 Pa Code 201.29(j) Resident rights

28 Pa Code: 211.6(a) Dietary services
Previously cited 02/07/2019

28 Pa Code: 211.6(b) Dietary services
Previously cited 02/07/2019

28 Pa Code: 211.6(c) Dietary services
Previously cited 02/07/2019






 Plan of Correction - To be completed: 03/08/2020

The hot box (plate warmer) was repaired immediately on 1/24/20. A test tray was completed for dinner that evening and for breakfast the following morning which tested at the appropriate temperature.

Maintenance Director or Designee will inspect the hot box once a week for one month then periodically and as needed to ensure the device is working properly.

Dietary Manager or designee will complete a random test tray food temperature audit weekly for 3 months to ensure that food is at the appropriate temperature.

Administrator or designee will review audits weekly for one month and then periodically thereafter. Any findings will be submitted to the monthly QAPI meeting for review or recommendations.


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