Pennsylvania Department of Health
GARDENS AT TUNKHANNOCK, THE
Patient Care Inspection Results

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GARDENS AT TUNKHANNOCK, THE
Inspection Results For:

There are  108 surveys for this facility. Please select a date to view the survey results.

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GARDENS AT TUNKHANNOCK, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on January 22, 2024, it was determined that The Gardens at Tunkhannock 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(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

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

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

Based on a review of select facility policy and grievances lodged with the facility and and interviews with the facility, and staff interviews, it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings.

The findings include:

A review of the facility's "Grievance Policy", last revised by the facility January 14, 2019, revealed that "This facility has a system in place to ensure the resident's right to prompt efforts to resolve grievances that they may have." The policy noted "The reasonable timeframe within which the resident can expect a completed review of the grievance is within 5 to 7 business days."

A review of the facility's grievance log dated August 2023, provided by the facility during the survey of January 22, 2024, revealed that there were no grievances lodged during the month of August 2023.

However, the facility provided four grievances that were raised on August 24, 2023, through Resident Council, that were not included on the log. These complaints indicated that residents in attendance at the Resident Council meetings, expressed concerns that staff were not providing showers, staff using their personal phones and being on social media while working, and night shift staff being loud while residents are trying to sleep.

There was no documented record of the facility's response to those grievances, including and corrective actions, or grievance resolution as of the time of the survey ending January 22, 2024.

A review of facility grievance log dated September 2023, revealed that there was one grievance submitted during that month, on September 2, 2023.

A grievance was submitted on September 14, 2023, following the Resident Council meetings during which a complaint was raised about residents being permitted to use chewing tobacco in a "tobacco free" facility.

There was no documented record of the facility's response to those grievances, including and corrective actions, or grievance resolution as of the time of the survey ending January 22, 2024.

The facility's grievance log dated October 2023, revealed that there were no grievances for the month of October 2023, but six complaints were raised at Resident Council on October 12, 2023, and not included on the log. These complaints included cold food, not receiving snacks, that nurse aides are "throwing briefs on floor leaving room to smell like urine.

There was no documented record of the facility's response to those grievances, including and corrective actions, or grievance resolution as of the time of the survey ending January 22, 2024.

There was no grievance log and/or grievances provided for the month of November 2023, when requested during the survey ending January 22, 2024.

A review of grievance log dated December 2023, revealed that there were no grievances for the month of December 2023, but three grievances were submitted through Resident Council, dated December 28, 2023, and not noted on the facility's grievance log. Resident 1 expressed a concern that the resident "still hasn't received a reasoning to why residents area allowed to use tobacco [chewing tobacco] in a tobacco free facility."

There was no documented record of the facility's response to those grievances, including and corrective actions, or grievance resolution as of the time of the survey ending January 22, 2024.

During an interview with the Nursing Home Administrator (NHA) on January 22, 2024, at 2:30 p.m., the NHA confirmed that there was no evidence that the facility had timely addressed the residents' complaints raised at their resident group meetings and that the facility had followed up with the residents to ascertain the effectiveness of the any facility efforts in resolving their complaints.


28 Pa. Code 201.18 (e)(1)(2) Management

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



 Plan of Correction - To be completed: 03/04/2024

1. Grievances indicated in 2567 will be documented on and re-reviewed with residents for appropriate signature per facility policy.
2. Grievance policy will be educated to residents and staff through in-services and a resident/family letter.
3. SS director will receive grievances and distribute to department heads based on grievance reason. Investigation and grievance responses will be due to SS director in 7 business days. Grievances will require signing off from NHA and placed on monthly grievance log.
4. Grievances logs will be audited monthly X 3 months to ensure all grievances are accounted for and answered timely. Results of audits will be reviewed by QA committee X 3 months to ensure compliance.
5. POC compliance date 3/4/2024

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).
Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to notify the resident's interested representative of the need to alter treatment as the result of the reoccurrence of a pressure sore for one resident out of 8 sampled (Resident CR1).

Findings include:

A review of the clinical record revealed that Resident CR1 was admitted into the facility on October 17, 2020, with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), skin cancer of the left lower limb, and diabetes.

A review of Resident CR1's clinical record revealed that on August 31, 2023, a stage 1 pressure area was identified on the resident's coccyx and treatment to the area was initiated.

A review of Resident CR1's wound evaluation flow sheet dated October 13, 2023, revealed that the resident's coccyx pressure wound had "healed."

According to the resident's Treatment Administration Record, treatment to the area with peri-guard continued until October 24, 2023.

On October 25, 2023, the treatment was ordered to be changed to skin prep to coccyx two times a day for two weeks.

A review of nursing documentation dated October 27, 2023, at 5:09 PM revealed that Resident CR1 experienced a change in condition. During nursing observation of the previously healed stage 1 pressure sore on the resident's coccyx, revealed that a "small break in skin integrity" was now identified.

According to the nursing documentation, the resident's daughter/RP was "already aware of area as area being followed by nursing since September 13, 2023."

On October 28, 2023, the consultant wound care physician ordered Medi-Honey (wound gel used to promote healing) to be applied to the resident's pressure sore on the coccyx.

There was no documented evidence that the resident's interested representative, her daughter, was informed that the resident's pressure sore had reoccurred, as an open area, and was being treated by the wound care physician and the new treatment of Medi-Honey.

An interview with the Director of Nursing on January 22, 2024, at approximately 2:00 PM confirmed that the facility did not notify the resident's representative that the resident's had a current pressure sore and the treatment plan.



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



 Plan of Correction - To be completed: 03/04/2024

1. Facility cannot correct deficiency as it relates to resident CR1 as resident is deceased.
2. Licensed nursing staff to be educated on proper notification procedures to resident's representatives for changes in wounds and/or treatment changes.
3. DON/designee will audit nursing documentation residents with new or existing wounds to identify if notifications to resident representatives was completed. Deficiencies will be corrected.
4. DON/designee will provide audits to NHA weekly to ensure all audits are completed daily. Results will be reviewed by the QA committee X 3 months to ensure compliance.
5. POC compliance date 3/4/2024

§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on review of nursing time schedules and resident census, it was determined that the facility failed to provide a minimum of one nurse aide per 12 residents during the day and evening shifts, and one nurse aide per 20 residents during the night shift on 6 of 7 days reviewed. (1/15/24, 1/16/24, 1/18/24, 1/19/24, 1/20/24, and 1/21/24).

Findings include:

Review of facility census data indicated that on 1/15/24, the facility census was 78, which required 6.5 nurse aides during the evening shift.

Review of the nursing time schedules revealed only six nurse aides provided care on the evening shift on 1/15/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/16/24, the facility census was 78, which required 6.5 nurse aides during the evening shift.

Review of the nursing time schedules revealed only six nurse aides provided care on the evening shift on 1/16/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/18/24, the facility census was 77, which required 4 nurse aides during the night shift.

Review of the nursing time schedules revealed only three nurse aides provided care on the night shift on 1/18/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/19/24, the facility census was 77, which required 6.5 nurse aides during the evening shift.

Review of the nursing time schedules revealed only six nurse aides provided care on the evening shift on 1/19/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/20/24, the facility census was 77, which required 6.5 nurse aides during the day shift.

Review of the nursing time schedules revealed six nurse aides provided care on the day shift on 1/20/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/20/24, the facility census was 77, which required 4 nurse aides during the night shift.

Review of the nursing time schedules revealed only three nurse aides provided care on the night shift on 1/20/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/21/24, the facility census was 77, which required 6.5 nurse aides during the day shift.

Review of the nursing time schedules revealed only six nurse aide provided care on the day shift on 1/21/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/21/24, the facility census was 77, which required 6.5 nurse aides during the evening shift.

Review of the nursing time schedules revealed only six nurse aides provided care on the evening shift on 1/21/24. No additional excess higher-level staff were available to compensate this deficiency.

The facility had not met the required nurse aide to resident ratios on the above shifts.




 Plan of Correction - To be completed: 03/04/2024

1. Facility cannot retroactively correct past CNA to resident ratios.
2. Facility is focusing on retention of existing nursing assistants and recruitment of new nursing assistants, through efforts of the Human Resources Manager and Nursing Administration. A third-party recruitment agency has been contracted to assist with candidates.
3. The scheduler has been re-educated regarding the CNA ratio regulatory requirements. Calculation of the daily CNA ratios will be completed and reviewed for accuracy by the scheduler/designee.
4. Daily ratios will be audited weekly X 4 weeks then monthly X 2 months. Audits will be reviewed at QAPI for compliance.
5. 03/04/2024
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on a review of nurse staffing schedules and the resident census it was determined that the facility failed to provide one licensed practical nurse per 25 residents on the day shift, one LPN per 30 residents on the evening shift, and one LPN per 40 residents on the night shift on 3 of the 7 days reviewed. (1/16/24, 1/19/24, and 1/20/24.

Findings include:

Review of facility census data indicated that on 1/16/24, the facility census was 78, which required 2 LPNs during the night shift.

Review of the nursing time schedules revealed one LPN provided care on the night shift on 1/16/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/19/24, the facility census was 77, which required 2.5 LPNs during the evening shift.

Review of the nursing time schedules revealed two LPNs provided care on the evening shift on 1/19/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/20/24, the facility census was 77, which required 3 LPNs during the day shift.

Review of the nursing time schedules revealed two LPNs provided care on the day shift on 1/20/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/20/24, the facility census was 77, which required 2.5 LPNs during the evening shift.

Review of the nursing time schedules revealed 2 LPNs provided care on the evening shift on 1/20/24. No additional excess higher-level staff were available to compensate this deficiency.

The facility had not met the required LPN to resident ratios on the above shifts.




 Plan of Correction - To be completed: 03/04/2024

1. Facility cannot retroactively correct past LPN to resident ratios.
2. Facility is focusing on retention of existing LPNs and recruitment of new LPNs through efforts of the Human Resources Manager and Nursing Administration. A third party recruitment agency has been contracted to assist with candidates.
3. The scheduler has been re-educated regarding the LPN ratio regulatory requirements. Calculation of the daily LPN ratios will be completed and reviewed for accuracy by the scheduler/designee.
4. Daily ratios will be audited weekly X 4 weeks then monthly X 2 months. Audits will be reviewed at QAPI for compliance.
5. 03/04/2024


§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing schedules and resident census it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident:

January 16, 2024 - 2.78 nursing hours per resident per 24 hours.

January 20, 2024 - 2.70 nursing hours per resident per 24 hours

On the above noted dates, the facility failed to provide the minimum of 2.87 hours of direct nursing care daily for each resident.




 Plan of Correction - To be completed: 03/04/2024

1. Facility cannot retroactively correct past nursing hours.
2. Facility is focusing on retaining current nursing staff and recruitment using in-house recruitment resources and a third-party recruitment firm dedicated to only nursing applicants to correct nursing hours.
3. Facility is implementing staff incentives for current and new staff as well as reinforcing the facility call off policy to deter unnecessary call offs. NHA or designee will educate staff on incentives and call off policy.
4. NHA/designee will audit nursing hours weekly for three weeks then monthly X 3 months. Audits will be reviewed by QA monthly X 3 months to ensure compliance with POC.
5. 3/4/2024


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