Pennsylvania Department of Health
NORTHERN DAUPHIN NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

NORTHERN DAUPHIN NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 204 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.


NORTHERN DAUPHIN NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights survey and a complaint survey completed on July 11, 2024, it was determined that Northern Dauphin Nursing and Rehabilitation Center 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:

483.70(a)-(c) REQUIREMENT License/Comply w/ Fed/State/Locl Law/Prof Std:

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.

§483.70(a) Licensure.
A facility must be licensed under applicable State and local law.

§483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards.
The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility.

§483.70(c) Relationship to Other HHS Regulations.
In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph.

Plan of Correction - To be completed: 08/13/2024

Unable to correct historical findings of past surveys
2. Review of facility master schedule to be completed to identify open positions required to comply with state laws. HR director to verify positions posted for recruitment. Last 7 days of staffing to be reviewed for areas of unmet minimum requirements to review cause. Staffing huddle to be held in the AM and PM, which will include review of current census, admission, discharges to best facilitate the coordination of staff to meet PPD/Ratio compliance.
3. Education to nursing administration and staffing coordinator on state law of minimum staffing requirements. Projection of minimum staffing requirements for next 7 days to be reviewed M-F in daily staffing huddles to identify unmet requirements.

4. NHA will audit staffing weekly x4 weeks, then monthly x2 to ensure compliance. Findings will be reported to QA monthly.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:

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.

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident or their representative received written notice of the facility bed-hold policy at the time of transfer for one of nine residents reviewed (Resident 9), and failed to ensure that the written notice of the facility bed-hold policy at the time of transfer included the reserve payment required for four of nine residents (Residents 3, 4, 9, and 136).

Findings Include:

Review of Resident 3's clinical record revealed diagnoses that included hypertension (high blood pressure), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow).

Further review of Resident 3's clinical record revealed that on May 29, 2024, the Resident was transferred out of the facility to the hospital and was subsequently admitted to the hospital.

Review of Resident 3's bed-hold policy notice provided to the Resident at the time of their hospital transfer indicated that a bed would be held for them for 15 days according to Medicaid regulations at no cost to Resident 3. In addition, a "Bedhold Reservation Request" was attached but failed to include the bed reservation cost.

Further review of Resident 3's clinical record census tab failed to identify Medicaid as their payer source at the time of their hospital transfer.

Review of Resident 4's clinical record revealed diagnoses that included intellectual disability (neuro-developmental condition that limits a person's cognitive function and skills), Aphasia (language disorder that affects a person's ability to communicate, and epilepsy (disorder in which nerve cell activity in the brain is disturbed causing seizures).

Further review of Resident 4's clinical record revealed that on April 25th, May 15th, and June 3rd, 2024, the Resident was transferred out of the facility to the hospital and was subsequently admitted to the hospital.

Review of Resident 4's bed-hold policy notice provided to the Resident Representative at the time of their hospital transfers indicated that a bed would be held for them for 15 days according to Medicaid regulations at no cost to Resident 4. In addition, a "Bedhold Reservation Request" was attached but failed to include the bed reservation cost.

Review of Resident 9's clinical record revealed diagnoses that included end stage renal disease (ESRD-a condition in which the kidneys lose the ability to remove waste and balance fluids) and atrial fibrillation (AFib- a irregular, often rapid heart rate that commonly causes poor blood flow).

Further review of Resident 9's clinical record revealed that she was transferred and admitted to the hospital on June 21, 2024.

During an interview with the Nursing Home Administrator on July 11, 2024, at 2:06 PM, she stated that the bed-hold notice was not provided to Resident 9 or her Responsible Party at the time of her hospital transfer.

Review of Resident 136's clinical record revealed diagnoses that included retention of urine, migraine (headache of varying intensity often accompanied by nausea and sensitivity to light and sound), cerebral infarction (stroke- as a result of disputed blood flow to the brain due to problems with the blood vessels that supply it), calculus in bladder and kidney (a small hard deposit of minerals and acid salts that stick together in concentrated urine), hemiplegia left non-dominant side (paralysis on one side of the body), and mild cognitive impairment (a condition that causes people to have more memory or thinking problems that others their age).

Further review of Resident 136's clinical record revealed that on March 14th and 25th, 2024, the Resident was transferred out of the facility to the hospital and was subsequently admitted to the hospital.

Review of Resident 136's bed-hold policy notice provided to the Resident at the time of their hospital transfers indicated that a bed would be held for them for 15 days according to Medicaid regulations at no cost to Resident 4. In addition, a "Bedhold Reservation Request" was attached but failed to include the bed reservation cost.

During an interview with the NHA, Director of Nursing, and Employee 8 (Regional Director of Clinical Services) on July 11, 2024, at 11:07 AM, the NHA indicated that she had no additional information to provide. She said that nursing staff generates the bed-hold notice at the time of a resident transfer, and they would not be aware of room rates. She said that the Business Office Manager would speak to individuals with questions. She further indicated that she could not confirm that all residents or their responsible parties were made aware of bed-hold reserve payments and that the facility would review its process and make appropriate changes.

28 Pa. Code 201.14(a) Responsibility of Licensee

Plan of Correction - To be completed: 08/13/2024

1. Unable to correct past occurrence for Residents 3, 4, 9, and 16.
2. Audit of residents currently in hospital to ensure bed hold completed and notices provided as identified
3. Education to licensed nursing staff and BOM on bed hold notice requirements for transfer to be completed
4. Audits of hospital transfers to be conducted weekly x 4; then monthly x 2 by DON/ Designee to ensure bed hold notice completed and copy on record

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§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.

Plan of Correction - To be completed: 08/13/2024

Unlabeled, undated, and expired foods and seasonings discarded as appropriate, ice machines and refrigerators cleaned at time of survey, appropriate test strips ordered and received, and air gap corrected at time of survey.
2. Facility audit of pantry, med room and kitchen refrigerators for cleanliness and appropriate labeling and dating will be completed by dietary staff. Facility dry storage areas will be audited for appropriate labeling and dating by dietary staff. Audit of facility ice machines for cleanliness and appropriate air gaps will be completed by maintenance staff. Audit of 3 compartment sink for appropriate test strip availability will be completed by dietary staff.
3. Education to dietary, nursing, and maintenance on appropriate labeling and storage of foods and seasonings, cleanliness of equipment and routine cleaning, and use of appropriate test strips for 3 compartment sink to be completed by NHA or designee
4. Audits of pantry, med room, and kitchen x3 per week x2 weeks; then weekly x2 weeks, then monthly x2 by FSD or Designee. Audit on Medication Room refrigerators by DON/Designee to be completed weekly x4; then monthly x2 months.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Observations:

Based on review of clinical records and staff interviews, it was determined that the facility failed to provide interventions to prevent accidents for one out of six residents reviewed for accident hazards (Resident 48).

Findings include:

Review of Resident 48's clinical record revealed diagnoses that included hypertension (high blood pressure) and chronic respiratory failure (when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body).

Review of Resident 48's clinical record revealed the Resident had a fall off their bed on March 13, 2024, while receiving bathing assistance in bed by one nurse aid.

Review of Resident 48's clinical record revealed that, after the fall on March 13, 2024, their comprehensive person-centered care plan was updated on March 18, 2024, with an intervention for bed mobility to include the resident requires assist of two to reposition and turn in bed.

Further review of Resident 48's clinical record revealed an Activities of Daily Living Bed Mobility task, which included the support that was provided relating to how the resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. Review of the task revealed Resident 48 received bed mobility assistance with only one-person physical assist on the following days: June 11, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28, and 29, 2024; and July 2, 3, 6, 7, 8, 9, 10, and 11, 2024.

During an interview with the Nursing Home Administrator on July 11, 2024, at 1:32 PM, she revealed that she would have expected Resident 48's care plan to have been followed with receiving two staff assist when completing bed mobility.

28 Pa. Code 201.18(b)(1)(2)Management
28 Pa. Code 211.12(d)(3)(5)Nursing services

Plan of Correction - To be completed: 08/13/2024

1. No negative effects for Resident 48 due to documentation of 1 assist.
2. Audit of residents requiring 2 assist for bed mobility to be completed to ensure documentation reflects use of 2 assist by DON/Designee.
3. Education to be provided to nursing staff to ensure 2 assist provided per care plan/Kardex and documented as such
4. Observation audits of 5 residents requiring 2 assist for bed mobility to ensure 2 assist utilized and documented as such to be completed weekly x 4; then monthly x 2 by DON or Designee.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§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 facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for two of three residents reviewed for pressure ulcers (Residents 1 and 135).

Findings include:

Review of facility policy, titled "Dressings, Dry/Clean", with a last revised date of September 2013, revealed the following, in part: "6. Put on clean gloves. Loosen tape and remove soiled dressing; 7. Pull glove over dressing and discard into plastic or biohazard bag; 8. Wash and dry your hands thoroughly; 13. Put on clean gloves; 14. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage; 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward); 16. Use dry gauze to pat the wound dry; and 17. Apply the ordered dressing."

Review of Resident 1's clinical record revealed diagnoses that included multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves which disrupts communication between the brain and the body) and quadriplegia (partial or complete paralysis of both arms and both legs).

Further review of Resident 1's clinical record revealed that the Resident had a stage 3 pressure ulcer (a full-thickness tissue loss wound where the tissue just under the skin may be visible, but no bone, tendon, or muscle is exposed) that was originally identified on February 28, 2024.

Review of Resident 1's current physician orders revealed an order to cleanse the sacral wound with wound cleanser, apply silver alginate to wound base, apply medical honey to maceration (the softening and breaking down of skin resulting from prolonged exposure to moisture), and cover with an ABD (absorbent dressing) twice a day and as need for soiling or dislodging, dated July 2, 2024.

Observation of Resident 1's dressing change on July 11, 2024, at 9:47 AM, performed by Employee 5 revealed that Employee 5 removed Resident 1's old dressing, cleansed the wound, and then removed their gloves, washed their hands, applied new gloves, and applied the ordered treatment.

During a follow-up interview with Employee 5 on July 11, 2024, at 10:32 AM, Employee 5 confirmed that they did not remove their gloves, wash their hands, and apply new gloves between removing Resident 1's old dressing and cleansing the wound.

Review of Resident 1's progress notes revealed a dietary note dated March 28, 2024, at 10:02 AM, written by the dietician which indicated, in part, "Stage 3 sacral wound and need for added protein. Daily protein needs increased 2 [secondary] to stage 3 wound and estimated at 80 grams per day, TF [tube feeding] providing ~[approximately] 70% of daily protein needs (57 grams per day). RECOMMENDATION: Obtain MD order for 30ml [milliliters] Pro-Stat (a protein supplement) Sugar Free (or house formulary equivalent) to provide [resident] with an added 17 g protein (TF + Pro-Stat= 74 grams per day)."

Further review of Resident 1's current and historical physician orders failed to reveal an order for the protein supplement recommended by the dietician on March 28, 2024.

During an interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Employee 8 (Regional Director of Clinical Services) on July 11, 2024, at 11:00 AM the NHA and DON confirmed that they would expect nurses to provide wound care according to facility policy. The NHA confirmed that the dietician's recommendation was not followed through with and that she would expect recommendations be addressed with a resident's physician for further orders. Employee 8 indicated that their current process was that the dietician would email nursing any recommendations for them to address with the resident's physician. She further revealed that they would be looking at the facility process.

Review of Resident 135's clinical record revealed diagnoses that included severe protein-calorie malnutrition (malnutrition caused when not enough proteins and calories are consumed) and dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning).

Further review of Resident 135's clinical record revealed that the Resident was admitted to the facility on January 27, 2024, with a stage 2 pressure ulcer (a partial thickness tissue loss wound that does not go deeper than the dermis or middle layer of skin) and deep tissue injury (DTI - pressure-related injury to subcutaneous tissues under intact skin).

Review of Resident 135's admission nutritional assessment dated February 2, 2024, revealed a recommendation to obtain a physician's order for Vitamin C 500 milligrams, Zinc 220 milligrams, and a multi-vitamin for 14 days based on Resident 135's protein-calorie malnutrition, stage 2 pressure ulcer, DTI, and use of a diuretic.

Review of Resident 135's progress note dated February 6, 2024, at 1:27 PM, by the dietician indicated that Resident 135 had experienced a significant weight loss over the past seven days, and again gave the recommendation to obtain a physician's order for vitamin C 500 milligrams, zinc 220 milligrams, and a multi-vitamin for 14 days.

Review of Resident 1's historical physician orders failed to reveal an order for the Vitamin C, Zinc, or multivitamin recommended by the dietician on February 2, 2024, and February 6, 2024.

During an interview with the NHA, DON, and Employee 8 on July 11, 2024, at 10:56 AM, Employee 8 indicated that they had no additional information to provide to show that the dietician's recommendations were reviewed with Resident 135's physician. The NHA confirmed that the dietician's recommendation was not followed through with and that she would expect recommendations to be addressed with a resident's physician for further orders. Employee 8 indicated that their current process was that the dietician would email nursing any recommendations for them to address with the resident's physician. She further revealed that they would be looking at the facility process.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(d) Resident Care Policies
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing Services

Plan of Correction - To be completed: 08/13/2024

1. Review by RD for Resident 1 completed to evaluate need for prior recommendations. No ill effects noted for Resident 1 treatment observation.
2. Residents with pressure injuries will be reviewed by RD to ensure current interventions are appropriate. Wound care competencies to be completed on licensed staff to ensure appropriate technique per policy.
3. Education to administrative nursing to ensure dietary recommendation are reviewed and executed as appropriate per MD. Education to licensed nurses on dressing change policy.
4. Audits of RD recommendations for review and execution to be completed weekly x 4 then monthly x 2 by DON/Designee. Random shift wound care competencies to be completed on 4 licensed nurses weekly x 4; then monthly x 2 to ensure appropriate technique per policy.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Plan of Correction - To be completed: 08/13/2024

1. MD made aware of missed labs for Resident 136, no new orders at this time. No negative effects noted to Resident 136, med error completed and MD aware. No negative effects for Resident 10, med error completed and MD aware.
2. Lab orders reviewed for last 14 days to ensure completed as ordered. Audit of residents with orders for beta blockers with parameters for administration reviewed to ensure documented vitals signs per order and administered as ordered. All active PRN analgesic orders will be reviewed to ensure numerical scale in place.
3. Education to licensed nurses on completion of labs per orders and administration of medications per MD order and PRN analgesic numerical scale.
4. Audit of new lab orders to be completed weekly x 4; then monthly x 2 to ensure completion per order to be conducted by DON/Designee. Audit of 5 residents with orders for beta blockers with parameters to be completed weekly x 4; then monthly x 2 to ensure administered appropriately. Audit of new orders for PRN analgesic numerical scale being in place weekly x 4; then monthly x 2.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§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 facility policy review, record review, and resident and staff interviews, it was determined that the facility failed to ensure the resident's right to participate in the care planning process, and failed to review and revise the resident plan of care for two of 31 resident's reviewed (Residents 10 and 125).

Findings include:

Review of facility policy, titled "Care Plans, Comprehensive and Person-Centered", last revised September 2022, read, in part, "The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care including the right to participate in the planning process and request meetings. The care planning process will facilitate resident and/or representative involvement. Assessments of residents are ongoing and care plans are revised as information about the resident and residents' conditions change."

Review of Resident 10's clinical record revealed diagnoses that included left hand contracture (a permanent shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), and muscle weakness.

Interview with Resident 10 on July 8, 2024, at 10:33 AM, revealed she does not remember getting invited to her care plan meetings.

Review of Resident 10's clinical record revealed an annual care plan meeting note dated November 11, 2023; and two quarterly care plan meeting notes dated February 20, 2024, and May 21, 2024. Review of the care plan meeting notes failed to reveal the Resident or her Representative attended the meetings.

Further review of Resident 10's clinical record failed to reveal notation she was invited to any of the aforementioned care plan meetings.

Review of select facility documentation provided revealed Resident 10's Representative was invited to attend the care plan meeting held in May 2024 via letter.

Review of Resident 125's clinical record revealed diagnoses that included muscle weakness, feeding difficulties, and COPD.

Interview with Resident 125 on July 8, 2024, at 10:39 AM, revealed he has not been invited to his care plan meetings.

Review of Resident 125's clinical record revealed three quarterly care plan meeting notes dated December 26, 2023, February 28, 2024, and May 28, 2024. Review of the care plan meeting notes failed to reveal the Resident or his Representative attended the meetings.

Further review of Resident 125's clinical record failed to reveal notation he was invited to any of the aforementioned care plan meetings.

Review of select facility documentation provided revealed Resident 125's Representative was invited to attend the care plan meeting held in May 2024 via letter.

Interview with the Nursing Home Administrator (NHA) on July 10, 2024, at 1:36 PM, revealed Employee 4 (Social Worker) is responsible for coordinating the care plan meetings and sends a letter to resident representatives, however, she is not sure how the meetings are communicated to the residents themselves.

Follow-up interview with the NHA, in the presence of Employee 8 (Regional Director of Clinical Services), on July 11, 2024, at 10:47 AM, revealed she is unable to locate any documentation to indicate that Residents 10 or 125 were invited to their care plan meetings.

During an interview with Employee 8 on July 11, 2024, at 10:48 AM, she confirmed they don't have evidence Residents 10 or 125 were invited to their care plan meetings. She revealed the misstep in their process is that Employee 4 sends a letter to resident representatives or, if residents are their own representative ,she will address the letter to the resident; however, residents who are not their own representative are not getting a letter, and they should be invited to their care plans regardless if they have a representative. She further revealed they are going to adjust their process to make sure residents are invited to their care plan meetings.

Review of Resident 125's physician orders revealed an order for "plastic utensils for all meals", with a start date of December 13, 2023.

Email correspondence with the NHA on July 9, 2024, at 11:42 AM, the surveyor requested information about Resident 125's need for plastic utensils at meals.

Review of an occupational therapy progress report from December 11, 2023, revealed a comment under objective progress for eating that stated "improving with plastic utensils."

Review of select facility documentation provided revealed a therapy treatment encounter note from December 13, 2023, that stated "Patient setup for self-feeding. Patient demonstrated improved ability to perform task with lightweight items. Small plastic cups and plastic utensils increase independence due to lightweight and ease to grab due to poor fine motor skills on bilateral hands."

Interview with the NHA on July 10, 2024, at 1:33 PM, revealed she would expect Resident 125's care plan to be updated to reflect the use of plastic utensils at meals for self-feeding ability.

28 Pa. Code 211.10(d)(a) Resident care policies
28 Pa. Code 211.11(d)(3)(5) Nursing services

Plan of Correction - To be completed: 08/13/2024

1. Unable to correct past occurrence for Residents 10 and 125 not invited to care plan meeting. Care plan for Resident 125 was updated at time of survey.
2. Review of last 14 days of care plan meetings to ensure residents and families received invitations. Audit of residents requiring adaptive equipment for meals to be completed to ensure care plans are up to date.
3. Education provided to Clinical Reimbursement, Receptionist, and SS on care plan invitation process to be completed by NHA/Designee. Education to RD, FSD, Therapy, and Licensed Nursing Staff on care plan timing and revision to include adaptive equipment with meals to be completed by DON/Designee.
4. Audit of weekly care conference invitations to be completed by NHA to ensure evidence of invitation to both resident and family for 3 months; Audit of care plans for 5 residents with new or existing orders requiring adaptive equipment with meals to be completed weekly x 4; then monthly x 2 by DOR/Designee.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:

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(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

Observations:

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to determine a resident's right to self-administer medications was clinically appropriate for one of one resident reviewed (Resident 3).

Findings include:

Review of facility policy, titled "Self-Administration of Medications", with a last revised date of December 2016, revealed the following, in part: "Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so; 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident; 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) a. ability to read and understand labels, b. comprehension of the purpose and proper dosage and administration time for his or her medications, c. ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication, and d. the ability to recognize risks and major adverse consequences of his or her medication."

Review of Resident 3's clinical record revealed diagnoses that included hypertension (high blood pressure), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and osteoarthritis (degeneration of joint cartilage and the underlying bone, causing pain and stiffness especially in the hip, knee, and thumb joints).

Review of Resident 3's physician orders revealed an order for Voltaren (Diclofenac Sodium Topical) Arthritis Pain External Gel 1% Apply to joints topically every 6 hours as needed for pain. Resident administers self (medication at bedside), dated June 21, 2024.

Review of Resident 3's clinical record failed to reveal an assessment for self-administration of medications.

During an interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Employee 8 Regional Director of Clinical Services (RDCS) on July 10, 2024, at 1:12 PM, Resident 3's medication self-administration order and lack of documented self-administration medication assessment was discussed for further follow-up.

A follow-up review of Resident 3's clinical record revealed a nurse's note dated July 11, 2024, at 2:08 AM, that indicated the nurse had "Discussed pt [patient] voltaren gel, and other medicated creams which [the Resident was] keeping in [their] drawer and whether [the Resident] would like to self-administer those creams. if so we could complete the self admin assessment. Pt states,"[the Resident has] nursing apply the creams and as long as they are applied when [the Resident] ask it's fine to keep them in the treatment cart.". All creams removed and placed in the nursing treatment cart."

During a final interview with the NHA, DON, and Employee 8 RDCS, on July 11, 2024, at 11:05 AM, Employee 8 RDCS indicated that when they spoke to Resident 3 regarding self-administering of medications, the Resident indicated that they did not wish to do so and all meds were removed. Employee 8 RDCS further indicated that she was not sure why the nurse had put the order in that way if the Resident did not want to self-administer. Employee 8 RDCS confirmed that no self-administration of medications assessment had been completed and that the medications should not have been left at the bedside.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(d) Resident Care Policies
28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services

Plan of Correction - To be completed: 08/13/2024

1. Resident chose not to self-administer medications
2. Orders for medications at bedside will be reviewed to ensure self-medication evaluation completed for those who wish to keep medication at bedside.
3. Education provided to licensed nurses that residents with medications at bedside must have self-medication evaluation completed to ensure appropriateness of order.
4. Audits of orders for meds at bedside will be conducted weekly by DON/Designee to ensure self-medication evaluation completed and order appropriate weekly x 4; then monthly x 2

483.25 REQUIREMENT Quality of Care:

§ 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 staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 31 residents reviewed (Resident 96).

Findings include:

Review of Resident 96's clinical record revealed diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event with triggers that can bring back memories of the trauma accompanied by intense emotional and physical reactions).

Review of Resident 96's current physician orders revealed an order for depakote (divalproex sodium-a medication used for the treatment of bipolar disorder) 25 milligrams administer three tablets daily at bedtime, dated June 4, 2024.

Review of Resident 96's psychiatry consult dated June 14, 2024, revealed a recommendation for a valproic acid level (a blood test used to determine safe dosing of depakote). Further, the review failed to reveal documentation that it had been reviewed by Resident 96's physician.

Further review of Resident 96's physician orders failed to reveal an order for a valproic acid level.

During an interview with the Nursing Home Administrator and Employee 8 Regional Director of Clinical Services (RDCS) on July 11, 2024, at 2:06 PM, Employee 8 RDCS indicated that they could not provide documentation that Resident 96's physician had reviewed the psychiatry consult report, which included the recommendation for the laboratory order and, therefore, no order had been obtained. She further indicated that Resident 96 had an order to obtain the lab in May 2024, but the Resident was in the hospital at the time. She also shared that the hospital records did not reveal the laboratory test had been obtained while hospitalized. Employee 8 RDCS indicated they would follow-up with Resident 96's physician regarding the psychiatry consult and recommendation.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Plan of Correction - To be completed: 08/13/2024

1. Valproic acid level ordered per psych recommendation for Resident 96. MD notified of error, no new orders received at this time.
2. Review of last 30 days of psych consults completed to ensure reviewed by MD and recommendations completed as per orders.
3. Education to licensed nurses to ensure psych recommendations for new orders sent to MD for review and orders implemented as received.
4. Audit of psych consults to be completed monthly x 3 months to ensure reviewed by MD and recommendations completed per orders by DON/Designee

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Plan of Correction - To be completed: 08/13/2024

1. Resident 10 and Resident 84 were screened by therapy for appropriate continued use of splints. Resident 84 geri-sleeves have been discontinued based on resident preference.
2. Observation audits of residents with current splint/brace and geri-sleeve orders to be completed by DOR or Designee to ensure in place per orders and documented appropriately.
3. Education to be provided to nursing staff on application of and appropriate documentation of residents with splint/brace and geri-sleeve orders.
4. Observation audits to be conducted on 5 residents with splint/brace orders to ensure in place and documented per orders weekly x 4; then monthly x 2 by DOR/Designee. Observation audits to be conducted on 5 residents with geri-sleeve orders to ensure in place and documented per orders weekly x 4; then monthly x 2 by DOR/Designee.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§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.

Plan of Correction - To be completed: 08/13/2024

1. Resident 81 weight has stabilized, Resident 47 weight for July obtained
2. Audit of resident weights in last 30 days to be reviewed to ensure obtained per MD orders. Residents who demonstrated significant loss in last 30 days to be audited to ensure review by RD and MD notification.
3. Education on weight process to be provided to nursing staff and RD to ensure weights obtained per MD order and significant loss reviewed by RD and MD notified.
4. Weight audit to be conducted weekly by RD to ensure weights obtained per MD orders x 3 mos. Residents identified as significant loss to be audited by DON or designee weekly x 4; then monthly x 2 to ensure RD review and MD notification.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 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, policy review, and resident and staff interviews, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for two of four residents reviewed for respiratory care (Residents 57 and 397).

Findings include:

Review of facility policy, titled "Oxygen Therapy", last reviewed April 2024, revealed that a physician must order the oxygen therapy.

Review of Resident 57's clinical record revealed diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage, or spasms in a blood vessel) and hypertension (high blood pressure).

During an observation of Resident 57 on July 8, 2024, at 11:13 AM, revealed Resident 57 was currently using oxygen. Further observation revealed the oxygen tubing was not dated.

During an interview with Resident 57 on July 8, 2024, at 11:13 AM, revealed Resident 57 had been using oxygen for four days.

Review of Resident 57's clinical record revealed a progress nursing note dated July 4, 2024, at 6:29 PM, with the following note text: Supplemental oxygen applied with positive effect.

Review of Resident 57's clinical record on July 8, 2024, revealed there was no order for oxygen to be administered or an order to change the oxygen tubing.

Review of Resident 57's clinical record on July 9, 2024, revealed an order for 02 at 2 liters per minute via nasal canal every shift for shortness of breath or to maintain oxygen saturation above or equal to 90%, with an active date of July 9, 2024.

During an interview with the Director of Nursing (DON) on July 10, 2024, at 1:47 PM, revealed Resident 57 should have had an order for oxygen prior to July 9, 2024, should have an order to change the oxygen tubing weekly, and that she would expect the oxygen tubing to be dated.

Review of Resident 397's clinical record revealed diagnoses that included hypertension (high blood pressure) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).

Observation of Resident 397 on July 9, 2024, revealed the Resident was using oxygen, with no date on the oxygen tubing.

Review of Resident 397's clinical record revealed a physician's order for 02 at 2 liters per minute via nasal canal, with an active date of June 28, 2024. Further review of Resident 397's physician's orders revealed no order for the oxygen tubing to be changed.

Review of Resident 397's comprehensive person-centered care plan revealed an intervention to change and label oxygen tubing and clean concentrator filter weekly and as needed, with an initiation date of July 2, 2024.

During an interview with the DON on July 10, 2024, at 1:47 PM, she revealed that Resident 397 should have an order for their oxygen tubing to be changed weekly, and that the tubing should be dated.

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

Plan of Correction - To be completed: 08/13/2024

1. Oxygen tubing changed and dated at time of survey and orders obtained for Resident 57.
2. Review of residents with oxygen orders to ensure tubing labeled and dated appropriately. Review of progress notes last 72hrs reviewed to ensure residents utilizing oxygen have appropriate MD orders.
3. Education to licensed nurses on oxygen policy to include obtaining MD orders and weekly changing of tubing to be labeled and dated.
4. Audit of residents utilizing oxygen to be completed weekly x 4 weeks; then monthly x 2 to ensure MD orders in place and tubing appropriately labeled and dated.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§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 clinical record review, policy review, observations, and staff interview, it was determined that the facility failed to maintain infection control practices to prevent the spread of infection for one of nine residents reviewed for infection control (Resident 17).

Findings include:

Review of facility policy, titled "Isolation - Multi Route Transmission-Based Precautions", last reviewed April 2024, revealed when a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and in front of the chart so that personnel and visitors are aware of the need for and type of precaution.

Review of Resident 17's clinical record revealed diagnoses that included chronic atrial fibrillation (an irregular and often very rapid heart rhythm) and hypertension (high blood pressure).

Further review of Resident 17's clinical record revealed a physician's order for contact precautions related to nasal MRSA (methicillin-resistance staphylococcus aureus), with an active date of May 24, 2024.

Review of Resident 17's comprehensive person-centered care plan revealed an intervention for contact precautions related to nasal MRSA, with an initiation date of May 24, 2024.

Observation of Resident 17's room on July 8, 9, 10, and 11, 2024, revealed no enhanced barrier precaution sign was posted on Resident 17's door.

During a staff interview on July 10, 2024, at 1:43 PM, the Director of Nursing confirmed that Resident 17 is on transmission-based precautions, and would expect signage to be posted on their door indicating that Resident 17 is on transmission-based precautions.

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

Plan of Correction - To be completed: 08/13/2024

1. Signage immediately placed for Resident 17 precautions per order
2. Audit of residents with orders for TBP/EBP to ensure appropriate signage in place.
3. Education to nursing staff on TBP/EBP and appropriate signage for same
4. Observational audits of 5 residents with orders for TMP/EBP to ensure signage in place weekly x 4 then monthly x 2 by Infection Control nurse or designee.

Back to County Map

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

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