Pennsylvania Department of Health
CEDARBROOK SENIOR CARE AND REHABILITATION
Patient Care Inspection Results

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CEDARBROOK SENIOR CARE AND REHABILITATION
Inspection Results For:

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CEDARBROOK SENIOR CARE AND REHABILITATION - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and a Civil Rights Compliance survey completed April 4, 2024, it was determined that Cedarbrook Senior Care and Rehabilitation was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.






 Plan of Correction:


483.10(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 interview, it was determined that the facility failed to ensure that meals were served in a manner that promoted and maintained each resident's dignity for two of 36 sampled residents. (Resident 82 and 175)

Findings include:

Observations of the lunch meal on the Station 5 unit on April 3, 2024, at 12:19 a.m., revealed Residents 82, 106, 117, 198, 490, and 497 were seated at a table together in the dining room. All the residents at the table were served and eating meals except Resident 82. Resident 82 was observed without a meal, looking around the room and reaching for the trays of other residents. Residents at other tables were being served their meals. Resident 82 was not served her lunch tray until 12:29 p.m.

Observations of the lunch meal on the Station 5 unit on April 2, 2024, at 12:50 p.m., revealed Residents 82, 106, 117, 175, 198, 490, and 497 were seated at a table together in the dining room. All the residents at the table were served and were eating their meals except Resident 175. Resident 175 was observed throwing her hands in the air, making the sign of praying hands to a person walking by, and reaching towards other resident's trays. At 1:20 p.m., staff members escorted Resident 175 to the resident's room and served the lunch tray.

In an interview on April 4, 2024, at 11:58 a.m., ADON 1 (Assistant Director of Nursing) confirmed that meals in the dining room should be served one table at a time.

28 Pa. Code 201.29(a) Resident rights.


 Plan of Correction - To be completed: 05/14/2024

1- R82 interviewed with no current concerns related to meal service. R82s meal tray schedule has been reviewed and receiving meals with the table. R82 has received meals along with R82s table since the occurrence.
R175 interviewed with no current concerns related to meal service. R175s meal tray schedule has been reviewed and receiving meals with the table. R175 has received meals along with R175s table since the occurrence.
2- The table schedules are being reviewed to ensure meals are arranged based on table assignments so that one table is served at a time.
3- Director of Education or designee will ensure that staff are educated to serve one table at a time during meals.
4- Director of Nursing or designee will conduct random audits of meal service to ensure that one table is served at a time, weekly x4, then monthly x2. Results of the audits will be reviewed by the QAPI committee.

483.20(g) REQUIREMENT Accuracy of Assessments: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.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessments were completed to accurately reflect the resident's status for two of 36 sampled residents. (Residents 310, 437)

Findings include:

Clinical record review revealed that Sections C (Brief Interview for Mental Status) and D (Mood Interview) of Resident 310's MDS assessment dated February 21, 2024, were incomplete.

Clinical record review revealed that Sections C and D of Resident 437's MDS assessment dated February 28, 2024, were incomplete.

In an interview on April 4, 2024, at 9:57 a.m., RN 1 (MDS Coordinator) confirmed that the MDS sections were not completed during the assessment period to reflect the resident's current status.




 Plan of Correction - To be completed: 05/14/2024

1. Cannot retroactively update R310s MDS from February 21, 2024. R310 was interviewed with BIMs and mood interview updated. Cannot retroactively update R437s MDS from February 28, 2024. R437 was interviewed with BIMs and mood interview updated.
2. The most current MDS will be reviewed to check if any update is needed for the resident's mood/cognition.
3. MDS Coordinator or designee will educate the relevant team members on the completion of MDS assessments to reflect the resident's current status.
4. Audits of the current MDSs will be assessed, once completed during the assessment period, to ensure that section C (Brief Interview for Mental Status) and section D (Mood Interview) are completed. The audits will be completed weekly x4 then monthly x2. Results of the audits will be reviewed by the QAPI committee.

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 resident interview, clinical record review, and staff interview, it was determined that the facility failed to ensure that physicians' orders were implemented for three of 36 sampled residents. (Residents 402, 437, 450)

Findings include:

Clinical record review revealed that Resident 402 had diagnoses that included congestive heart failure, diabetes mellitus, and dementia. On December 22, 2023, the physician ordered that staff weigh the resident daily and notify the physician if the weight was less than 150 pounds (lbs.) or greater than 160 lbs. Review of Resident 402's weight records revealed that the resident weighed 163.3 lbs on March 30, 2024, and 164 lbs. on March 31, 2024. There was no documented evidence in the clinical record that Resident 402's physician was notified of the weight changes.

In an interview on April 4, 2024, at 8:50 a.m., the ADON 1 confirmed that the physician was not notified of Resident 402's weight changes.

Clinical record review revealed that Resident 437 had diagnoses that included chronic kidney disease and edema (fluid retention in the lower legs). On February 6, 2024, the physician ordered that staff apply compression stockings (devices to relieve swelling in the legs) to both of the resident's lower legs while out of bed to prevent edema. The resident was observed without compression stockings on his lower legs on April 2, 2024, at 10:35 a.m., while out of bed in the solarium. The resident was observed again at 10:55 a.m., 12:18 p.m., and 3:05 p.m., without the compression stockings on while out of bed.

During an interview on April 4, 2024, at 1:24 p.m., the Director of Nursing confirmed that the physician order was not followed.

Clinical record review revealed that Resident 450 had diagnoses that included a history of stroke, high blood pressure, and dementia. On March 8, 2024, the physician ordered that staff administer 5 milligrams (mg) of a blood pressure medication (amlodipine besylate) daily. Staff was to hold the medication if the systolic blood pressure (SBP) (the top number on a blood pressure reading) was below 110 millimeters of mercury (mm Hg) and to call the physician if the SBP was greater than 150 mm Hg. A review of the March 2024 Medication Administration Record revealed that staff administered the medication when the resident's systolic blood pressure was over 150 mm Hg on March 17, 18, 22, 27, and 29, 2024. A review of the resident's progress notes revealed a lack of evidence to support that a physician was notified of the elevated SBP.

In an interview on April 4, 2024, at 8:52 a.m., ADON 1 confirmed that the physician was not notified of Resident 450's elevated SBP readings between March 17 and 29, 2024.

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




 Plan of Correction - To be completed: 05/14/2024

1. Cannot retroactively correct R402s weight notification documentation from March 30 and 31, 2024. R402s physician was updated and reviewed R402s weights. R402 with no change in clinical condition.
Cannot retroactively correct R437s compression stocking application from April 2, 2024. R437 currently with no change in status related to the compression stocking not observed on 4/2/24. R437s compression stocking has been applied per physician's order since that time. R437 provider was notified and was seen by the provider on 4/3/24.
Cannot retroactively correct R450s blood pressure medication administration and notification from March 17 and 29, 2024. R450s physician was updated on R450 blood pressures and seen by the provider on 4/3/24.
2. Residents with blood pressure parameters providing physician notification will be reviewed for blood pressure medication administration and notification per physician's order. Residents with compression stockings will be reviewed for placement per physician's orders. Residents with weight parameters will be reviewed for follow up documentation and provider notification per physician's order.
3. Director of Education or designee will ensure that licensed nursing staff are educated to review weight parameters and notify the provider with weight changes per physician's order. Director of Education or designee will ensure that licensed nursing staff are educated to review blood pressure parameters, med administration, and notify the provider per physician's order. Director of Education services or designee will educate staff on applying compression stockings according to the physician's order.
4. Director of Nursing or designee will ensure that random audits are completed of resident weight documentation with parameters and blood pressure medication administration with parameters according to the physician's order weekly x4 then monthly x2. DON or designee will ensure that random audits are completed of the application of resident's compression stockings, according to the physician's order, weekly x4 then monthly x2. Results of the audits will be reviewed by the QAPI committee.


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