Nursing Investigation Results -

Pennsylvania Department of Health
MAJESTIC OAKS REHABILITATION AND NURSING 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
MAJESTIC OAKS REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  106 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.
MAJESTIC OAKS REHABILITATION AND NURSING 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 September 29, 2021, it was determined that Majestic Oaks Rehabilitation and Nursing 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 observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Findings Include:

A tour of the food service department was conducted on September 27, 2021 at 9:30 a.m. with Employee E7, Food Service Director.

An initial tour of the main kitchen revealed the following observations.

Observations on the loading dock revealed the presence of a washer/dryer unit which was no longer working and awaiting removal.

Observations in the hallway located near the exit for the loading dock were boxes of paper good products being stored directly on the floor.

Observations in the hot food productions area revealed a large stainless-steel oven and steamer which had a build-up of grease and food particles.

Observations of the steam table for tray line revealed the tracks above the steam table had a build-up of food.

Observations of the dry food storage area revealed food spillage and trash on floor. Containers of food coloring were observed stored on the shelves with spillage on the outside of the containers and was sticky to touch.
Continued observations of the dry food storage closet revealed that the boxes of juice syrups and associated pumps were stored in the corner of the room. Observations revealed splattered juice on the wall behind the boxes and was sticky to touch.

Observations of the walk-in refrigeration unit revealed the floors had a heavy build up of food and debris. Lose papers were observed embedded into the floor.

Observations of the walk-in freezer unit revealed the shelves were so tightly packed that boxes of food were hanging off the shelves and falling off the shelves. Multiple boxes of food were observed to be stored directly on the floor of the freezer. A build-up of ice was observed accumulating on boxes of food stored directly on the floor. The floor of the freezer was observed to have a heavy build-up of food and debris.

Continued observations of the walk-in freezer revealed a left-over roast beef poorly secured in cling wrap and did not have any labeling or dating. Observations revealed left-over tortellini stored in a facility container that was not securely wrapped.

Interview with Employee E7 on September 27, 2021, at the conclusion of the tour confirmed the above findings.

The facility failed to ensure that foods were stored, prepared, and served in accordance with professional standards for food service safety

28 Pa. Code 207.2 (a) Administrator's responsibility



 Plan of Correction - To be completed: 11/05/2021


Loading dock was cleaned and swept. Washer/dryer was removed from loading dock. All disposables currently are up, off the floor. Steamer and oven are clean. Steamtable and steamtable tracks have been cleaned. Dry storage has been cleaned, mopped, and organized. Walk in fridge shelves were cleaned and floors were swept and mopped. Roast beef and tortellini were discarded. Food on floor in freezer was removed from floor or was placed on crates, up off the floor. Daily cleaning assignments have been reviewed and updated with all dietary staff. All dietary staff to be in-serviced on importance of completing cleaning assignments. FSD or designee will conduct random audits 3X week, to ensure cleaning assignments are being followed. Findings will be reported at monthly QAPI meetings, for a period of 3 months.

483.10(g)(4)(i)-(vi) REQUIREMENT Required Notices and Contact Information: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(g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including:
(i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes -
(A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section;
(B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act.
(C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and
(D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.
(ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.)
(iii) Information regarding Medicare and Medicaid eligibility and coverage;
(iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program;
(v) Contact information for the Medicaid Fraud Control Unit; and
(vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.
Observations:

Based on observation, group resident interview and interviews with staff, it was determined the facility failed to post in a prominent location and in an easy to read format, a list of names, addresses (mailing and email) and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the Pennsylvania Department of Health Hot Line, the Long-Term Care Ombudsman Program located within the Local Area Agency on Aging, the protection and advocacy agency, the local contact agency for information about returning to the community, the Medicaid Fraud Control Unit and the local Legal Services Program to which residents may address grievances, on the first floor, and on all three clinical nursing units reviewed.

Findings include:

During a group interview conducted on September 28, 2021 at 10:30 a.m. with eight alert and oriented residents (Residents R21, R22, R23, R30, R40, R46, R78 and R84), it was stated by all eight residents that they were not familiar with where to find information posted within the facility of how to and whom to call with filing grievances and/or the state number to file a complaint against the facility

Observations of the nursing unit and bulletin boards throughout the facility, conducted on the days of survey from September 27, 2021, through September 29, 2021, revealed none of the required postings on any of the units. The first and second floors had no postings and was devoid of signage with remodeling in progress. The third and fourth floors had bulletin boards which were hung too high and with small print making it difficult for residents in wheel chairs to read the information, which also did not include the required postings.

During an interview on September 28, 2021, at 2:45 p.m, the Administrator acknowledged that the facility failed to post the required postings on all the floors in a print size and a height that residents in a wheelchair could easily read on every floor of the facility.

The facility failed to ensure that the process for filing a grievance, State Agency's phone number and other required pertinent information was posted as required.


CFR The facility must make information on how to file a grievance or complaint available to the resident.

28 Pa. Code: 201.18(a)(b)(e)(1) Management.

28 Pa. Code 201.29(a)(b)(d)(i) Resident rights

28 Pa. Code 201.29(j) Resident rights

28 Pa. Code 201.29(a) Resident rights



 Plan of Correction - To be completed: 11/05/2021

Social services contacted Pennsylvania Department of Health, office of aging and Ombudsman office to secure adequate postings.
Postings placed in on each unit at appropriate level making it easy for residents to see.
Social services to discuss grievance policy at resident council meetings.
Social services to complete written monthly check of postings and placement.
Written monthly review to be reported to QAPI committee X 3 months

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes: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.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;
Observations:

Based on observations and staff and resident interviews it was determined that the facility failed to follow residents food preferences for 19 of 26 residents reviewed. (Resident R1, R19, R71, R76, R78, R88, R108, R58, R2, R60, R51, R79, R57, R39, R117, R388, R22, R86, and R126).

Findings include:

An observation of the lunch time meal on September 27, 2021, at 12:30 p.m. revealed that the following residents did not receive the items that they requested for lunch. Resident R76 did not receive the eight ounces of milk requested. Resident R1 did not receive the eight ounces of milk, cup of yogurt, and four ounces of magic cup (a fortified supplement.) requested. Resident R108 did not receive the requested eight ounces of skim milk. Resident R71 did not receive the requested eight ounces of whole milk and cup of vanilla ice cream. A review of Resident R19, did not receive the requested eight ounces of whole milk. Resident R88 did not receive eight ounces of whole milk and two containers of four ounces of fruit juice. Resident R78 did not receive the requested eight ounces of whole milk.

An interview with Employee E5, a nursing assistant, on September 27, 2021, at 12:45 p.m. confirmed that the residents did not receive milk on their lunch trays.

An interview with Employee E7, Food Service Director, on September 29, 2021, at 9:40 a.m. revealed that the facility ran out of milk products on September 27, 2021, for the breakfast and lunch time meal.

Interview on September 27, 2021, at 9:44 a.m. Resident R58 stated that he was upset because there was no milk served on the breakfast tray this morning.

Interview on September 27, 2021, at 10:04 a.m. Resident R2 stated that he never receives the menu items that he orders.

Interview on September 27, 2021, at 10:14 a.m. Resident R60 stated that she never receives the menu items that she orders and that the facility does not honor her food preferences.

Interview on September 27, 2021, at 10:39 a.m. Resident R51 stated that menu selections are not followed.

Interview on September 27, 2021, at 11:10 a.m. Resident R126 stated that the kitchen never honors his food preferences and he never receives the menu items that he orders. Continued interview with Resident R126 revealed that over the weekend the kitchen was giving him skim milk, because they ran out of whole milk, and the resident only likes to drink whole milk.

Observations of the luncheon meal on September 27, 2021 at 12:30 p.m. revealed that Resident R86 received chicken for lunch, and did not receive a grilled cheese sandwich, which was listed as her preferred choice on the meal ticket. Interview with Resident R86 revealed that the facility usually does not honor food preferences as listed. Continued interview revealed that Resident R86 was upset because she does not really like meat and is it often what is offered to her.

Observations of the luncheon meal on September 27, 2021, at 12:48 p.m. on the third floor nursing unit revealed the following:

Resident R2 was still upset because there was no milk served on his luncheon tray. Additionally, the resident did not receive coffee, which was listed as a preferred beverage on his meal slip. Interview with nurse aide, Employee E12, revealed that the kitchen was out of milk.

Resident R79 did not receive menu items listed on her meal slip, including salad, diet ginger ale and applesauce. Additionally, the resident received sugar packets instead of a sugar substitute as indicated on her meal slip.

Residents R51 and R57 did not receive salads as listed on their meal slips.

Resident R60 did not receive milk or cranberry juice as listed on her meal slip.

Resident R39 did not receive ginger ale as listed on her meal slip.

An interview with Resident R117 on September 27, 2021, at 10:35 a.m., revealed that all weekend she had not received the peanut butter sandwich with the crust cut off and applesauce that the speech therapist had ordered for her.

An interview with Resident R388 on September 27, 2021, at 10:40 a.m., revealed that she had not received milk for her cereal all weekend.

During a group meeting on September 28, 2021, at 10:30 a.m. Resident R22 stated that she is a vegan and they always send her milk, egg, meat and fish that she cannot eat. She was frustrated and said she should not have to order out all the time.

Observations of the luncheon meal on September 28, 2021, at 1:00 p.m. revealed that Resident R86 was not provided with a grilled cheese for lunch, as indicated on her meal ticket. Interview with Employee E17 confirmed these observations and called down to the kitchen to obtain the resident's correct meal.

The facility failed to follow food preferences.

CFRFood that accommodates resident allergies, intolerances, and preferences

28 Pa. Code: 211.6(b)(d) Dietary services

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: 11/05/2021

Menu items were added, per resident request according to resident council and menu committee meetings. FSD or designee to check meal slip for accuracy and honoring resident request and allergies. Process in place for tickets to be called out to cook on service line and checked at the end line for accuracy, preferences, and allergies. Dietary staff to be in-serviced on importance of meal slip accuracy.
Random audits will be conducted 5X per week to ensure ticket accuracy and resident requests. FSD or designee will update all residents with a current resident preference form. Findings will be reported at monthly QAPI and menu committee meetings for a period of 3 months.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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.
483.60(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 interviews with residents and staff, it was determined that the facility failed to serve food that was attractive, palatable and at appropriate temperature.

Findings include:

Interview with Resident R114 on September 27, 2021, at 10:30 a.m., revealed that the food was terrible, that she had trouble chewing and swallowing the food and she was very upset.

Interview with Resident R117 on September 27, 2021, at 10:35 a.m., revealed that the resident often cannot eat the food that was sent to her and that she had to ask for a peanut butter sandwich.

An interview with Resident R388 on September 27, 2021, at 10:40 a.m., revealed that the resident thought the food was bad, always cold and just plain not good.

During an interview with Resident R114 on September 27, 2021, at 10:45 a.m., revealed that the food was horrible, I hate rice and they serve it all the time, the food is always cold, I have been to a lot of nursing homes and this food is the worst I have ever had, the fish is really bad, I always have to ask for peanut butter and jelly.

Interview on September 27, 2021, at 10:28 a.m. with Resident R131 revealed that the food that was served to him by the facility was bad and wasn't palatable most of times and was cold. The resident stated that he can't even tell what was served to him, because often times the food was all mixed together.

Interview on September 27, 2021 at 11:00 a.m. with Resident R5 revealed that "the food tastes terrible".

Interviews on September 27, 2021 at 11:15 a.m. with Resident R18 and R122 revealed that the food was often served cold and was not palatable to taste.

Observation on the second floor, during meal service, on September 27, 2021, at 12:15 p.m., revealed Resident R388 was trying to cut a breaded meat patty with a stainless-steel knife and was unable to cut it. She then requested a peanut butter and jelly sandwich. Further observation revealed Resident R112 also had difficulty cutting the breaded meat patty and complained about the meat always being overcooked and tough.

A sample tray, for a regular diet, was ordered from the kitchen by Employee E20 at 12:30 p.m. The tray delivered was observed to have a breaded meat patty, which no one could identify, saying that it was probably chicken or turkey. The patty was tough and difficult to cut with the plastic knife delivered with the tray.

An interview with Employee E8, speech therapist, on September 27, 2021, at 1:00 p.m., revealed that the breaded patty was very tough and that she had been asking for these types of meat items be served with gravy to make it easier for the residents to chew and swallow.

An interview with Employee E7, Food Service Director, on September 27, 2021, at 1:15 p.m. confirmed that the kitchen had prepared the breaded chicken patty difficult to cut or chew, and that it should have been served with gravy.

Interview on September 27, 2021, at 9:45 a.m. with Resident R21, revealed that she fills out the menu and the kitchen doesn't follow what she had requested. She further stated that the meals look unappetizing.

Interview on September 27, 2021, at 10:30 a.m. with Resident R48 revealed that the food is disgusting. He stated that he can't even cut the meatloaf and the facility does not serve enough food. He stated that the facility served sour milk yesterday. He doesn't like that cut fruit is served up to six times a week and tastes like its of a cheap quality.

Interview on September 27, 2021, at 9:37 a.m. Resident R118 stated that the food often tastes bad.

Interview on September 27, 2021, at 10:04 a.m. Resident R2 stated that the food always tastes bad and that the facility does not implement any of the suggestions related to food brought up during resident council or resident food committee.

Interview on September 27, 2021, at 10:14 a.m. Resident R60 stated that the food was bad and often overcooked.

Interview on September 27, 2021, at 10:39 a.m. Resident R51 stated that the coffee tasted terrible and that the facility does not implement any of the suggestions from the resident food committee.

Observation of the luncheon meal on September 27, 2021, at 12:48 p.m. on the third floor nursing unit revealed the main entrserved appeared to be broccoli, rice and a breaded meat patty. Residents R79, R57, R51, R60 and R39 were not able to identify what the breaded meat patty was and they all stated that it was hard, overcooked and unappetizing.

During a group interview conducted on September 28, 2021 at 10:30 a.m. with eight alert and oriented residents (Residents R21, R22, R23, R30, R40, R46, R78 and R84), all eight residents stated that the hot foods served are not hot. Resident R21 stated that Sunday's dinner meal looked like someone threw it up on the plate, and when we complain the aide says that's what the kitchen sent up. Resident R84 stated that the food was sometimes too salty, and that there was too much rice and noodles served, and the last week her chef salad was lettuce and some cheese, and that last week she got a bad piece of meat that made her sick to the stomach. Resident R46 stated that he often got things that he did not know what it was. Resident R22 stated that they always send her food that she cannot eat, and she should not have to order out all the time.

Observation on September 28, 2021, at 12:52 p.m. of Resident R131's lunch tray revealed the resident received an unknown meat served with rice, and carrots. The resident's lunch ticket that was on his lunch tray did not identify the meat source, where the resident stated that maybe it was chicken or turkey, but he wasn't sure. The resident stated that the meat was tough and had no nutritive value, as it fell apart when he cut it with a fork.

The facility failed to provide appetizing food that was not overcooked and served at appropriate temperatures.

42 CFR 483.60(d)(2) Food and drink

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(3) Management

28 Pa. Code 201.29 (j) Resident rights



 Plan of Correction - To be completed: 11/05/2021

New menus and menu extensions in place. Staff in serviced on food appearance and food consistency. New menus will be reviewed in monthly menu committee meetings. Random test tray audits to be conducted by FSD or designee to monitor food appearance and consistency, 3X per week. Test tray audits will be reported at monthly QAPI meetings and monthly menu committee meeting for a period of 3 months.
483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed: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.
483.60(c) Menus and nutritional adequacy.
Menus must-

483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

483.60(c)(2) Be prepared in advance;

483.60(c)(3) Be followed;

483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

483.60(c)(5) Be updated periodically;

483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.
Observations:

Based on observation, review of facility documentation, resident and staff interviews, it was determined that the facility failed to ensure menus were posted on all floors, were being followed for therapeutic diets, and that all food items were made available to residents on all living areas.

Findings Include:

A review of the daily menu, as provided by the facility, revealed that milk is offered every day on the breakfast menu.

Interview on September 27, 2021, at 9:44 a.m., with Resident R58 revealed that he was upset because there was no milk served on the breakfast tray that morning. Follow-up interview during the luncheon meal served at 12:48 p.m. with resident R58 revealed that the resident was still upset because there was no milk served on his luncheon tray even though it was on his meal ticket for both meals. Interview with Employee E12, nurse aide, revealed that the kitchen was out of milk.

Interview on September 27, 2021, at 10:04 a.m. Resident R2 stated that the kitchen runs out of food and that there was no milk available for breakfast that morning.

Interview on September 27, 2021 at 11:45 a.m. with Resident R86, rvealed that the resident was upset because she could not have cereal for breakfast since the kitchen was out of milk.

Observation of the luncheon meal on September 27, 2021, at 12:48 p.m. on the third floor nursing unit revealed that there were no menus posted. Residents and staff on the unit did not know what was being served for the meal or if there were alternate menu items available. The main entrserved appeared to be broccoli, rice and a breaded meat patty. Residents R79, R57, R51, R60 and R39 were not able to identify what the breaded meat patty was and they all stated that it was hard, overcooked and unappetizing.

Interview with Resident R117 on September 27, 2021, at 10:30 a.m. revealed that the resident has been working with the speech therapist and was supposed to get a peanut butter sandwich with the crust cut off and applesauce to dip the sandwich in so that she could swallow it. She said that she had not received the sandwich or applesauce all weekend. Interview with the Employee E8, speech therapist, on September 28, 2021, at 12:30 p.m. confirmed that Resident R117 was supposed to be receiving the peanut butter sandwich with the crust cut off and applesauce because some of the meals are difficult for the resident to eat and this would be safe for her.

Interview with Employee E7, Food Service Director, on September 27, 2021 at 1:00 p.m. confirmed that the facility ran out of milk for meal service and that a new shipment would not be in until the next day.

During a group interview conducted on September 28, 2021, at 10:30 a.m. with eight alert and oriented residents (Residents R21, R22, R23, R30, R40, R46, R78 and R84), the residents all agreed that the menus were not posted on the floors and that they filled out menus, but did not always get what they selected. Resident R21 and R30 stated that they have not been getting their menus.

Observations of the luncheon meal on September 28, 2021, at 12:30 p.m. revealed that no menus were posted.

During an interview with Employee E7, food services Director, on September 29, 2021 at 10:30 a.m., copies of the facility's "menu extensions" for therapeutic diets were requested.

Continued interview with Employee E7 on September 29, 2021 at 11:00 a.m. revealed the facility was not able to provide the menu's that are followed for therapeutic diets including: cardiac, consistent carb, and renal diet. Interview with Employee E18, Assistant Food Service Director, revealed that when the previous food service company left about a month ago they also took the menu extensions for the therapeutic diets.

Interview with Employee E7, Food Service Director, on September 29, 2021 at 11:00 a.m. confirmed that the facility is not following a menu for therapeutic diets.

28 Pa. Code: 201.18(a)(b)(1) Management
28 Pa. Code: 201.14(a)(b) Responsibility of Licensee
28 Pa. Code: 201.29(a) Resident rights



 Plan of Correction - To be completed: 11/05/2021

New menus and menu extensions in place. Staff in service on new menus, proper diets, and proper textures. Menus are hung on all 3 floors daily, and there is an always available menu posted. Milk was ordered immediately. FSD or designee to review order guides weekly, to ensure proper food and beverage par level for residents. Random audits for diet and texture accuracy to be completed 3x per week by food service director or designee. Findings will be reported in monthly QAPI meetings for a period of 3 months.
483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.21(b) Comprehensive Care Plans
483.21(b)(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 observation, review of the clinical record and interviews with residents and staff, it was determined that the facility did not ensure that a comprehensive person-centered care plan with measurable objectives and goals were developed and implemented for four of 26 residents related to hearing, constipation, fluid restriction, oxygen and a resident's use of respiratory requirement (Resident R44, R18, R80 and R117).

Findings include:

Review of Resident R44's clinical record revealed the resident was admitted to the facility on August 25, 2020, with a diagnosis to include gastro-esophageal reflux disease (A digestive disease in which stomach acid or bile irritates the food pipe lining) and aphasia (A language disorder that affects a person's ability to communicate).

During the initial tour of the facility on September 27, 2021, Resident R44 stated that his bowel movements are hard as a rock and he has had trouble going to the bathroom for years. The resident stated that he typically has a bowel movement once every five days.

Review of a physician progress note dated February 4, 2021, revealed: Physician's Progress Note Late Entry: Note Text: House NP: CC/HPI: Seen today again for constipation. He was recently started on miralax [Laxative used for constipation] every other day, he is reporting difficulty with bowel movements still and has been requesting MOM [Milk of Magnesia - used for constipation]. He is not having any discomfort or nausea/vomiting. ... Assessment/plan: constipation-will make miralax daily. If continued issues, may need to add additional medications.

Review of a physician progress note dated March 1, 2021, revealed: ... Assessment/plan: constipation-improved with daily miralax, continue plan and monitor. ...

Review of Resident R44's clinical record revealed a record of bowel movements, which revealed the resident had no documented bowel movement from August 29, 2021, through September 2, 2021; no documented bowel movement from September 4, 2021, through September 9, 2021; and no documented bowel movement from September 11, 2021, through September 20, 2021.

Review of the resident's clinical record revealed no documented evidence that a comprehensive care plan had been developed related to the resident's constipation.

During the initial tour of the facility on September 27, 2021, Resident R44 was interviewed where he stated that he was hard of hearing to the point, where questions had to be written out for the resident to answer the questions. The resident stated that he has had insurance issues, so he hasn't received his hearing aides yet. The resident stated that his hearing issues interferes with activities, where he can't play bingo because he can't hear the numbers being called. The resident stated that its embarrassing because he can't hear people so he sits in his room.

Review of Resident R44's clinical record revealed an Ear Nose & Throat consultation report dated June 18, 2021, revealed: Purpose of Consultation / Chief Complaint: Difficulty Hearing. ... Treatment and Recommendations: Audiology Evaluation and Testing OAE [Otoacoustic Emissions] ...

Review of an Audiology Consultation dated June 23, 2021, which revealed: Summary of Test Results: Rt Ear - Sensori-neural Hearing Loss ... Lt Ear - Sensori-neural Hearing Loss ... Recommendations: Hearing Aid Evaluation / Assistive Device - Resident Agrees.

Review of the resident's clinical record revealed no documented evidence that a comprehensive care plan had been developed related to the resident's hearing difficulties.

Review of Resident R18's clinical record revealed the resident was admitted to the facility on July 27, 2021 with diagnoses including hypo-osmolality (levels of electrolytes in the blood are lower than normal) and hyponatremia (low sodium levels).

Review of Resident R18's clinical record revealed a nursing admission assessment, dated July 27, 2021, revealing the resident was admitted to the facility with diet recommendations for a 1400ml fluid restriction.

Continued review of Resident R18's clinical record revealed progress notes by the nurse practitioner, Employee E19, dated July 28, August 9, August 13, August 17, August 30, and September 28, 2021 revealing the fluid restriction should be continued secondary to hyponatremia.

Review of Resident R18's comprehensive care plan revealed no documented evidence that a care plan had been developed related to the resident ' s fluid restriction.

Review of the clinical record for Resident R80 revealed that the resident was admitted to the facility on April 12, 2021, with diagnoses including, chronic obstructive pulmonary disease (COPD, a common, disease characterized by persistent respiratory symptoms like progressive breathlessness and cough) and obstructive sleep apnea (sleep-related breathing disorder which causes you to repeatedly stop and start breathing while you sleep). A review of Resident R80's quarterly Minimum Data Set assessment (MDS-periodic assessment of needs) dated August 22, 2021, revealed that resident was cognitively intact, being alert and oriented.

An interview with Resident R80 on September 27, 2021, at 11:15 a.m., revealed that she had been using the BiPap Machine (is a form of non-invasive ventilation (NIV) therapy used to facilitate breathing) some nights to help her sleep. She pointed to the machine at her bedside which was set up with tubing and a mask and indicated that it was a BiPap machine. During the interview the resident was wearing a nasal canula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help). She indicated that she had to wear it all the time. The oxygen tubing was connected to an oxygen concentrator which was set at 4 liters per minute.

A review of Resident R80's physician's orders, revealed an order dated July, 31, 2021, for continuous oxygen at four liters per minute via a nasal canula. Further review of the physician's order did not reveal an order for the BiPap machine.

A review of Resident R80's care plan revealed no documentation that a plan of care was developed related to the resident's need for supplemental oxygen to facilitate breathing or the use of a BiPap machine to facilitate breathing while sleeping.

Interview with the Unit Manager, Employee E16, on September 29, 2021, at 11:20 a.m., confirmed that no care plan was developed for Resident R80 related to the resident's need for supplemental oxygen or the use of a BiPap machine.

Review of the clinical record for Resident R117 revealed that the resident was admitted to the facility on February 25, 2021, with diagnoses including, heart failure (progressive heart disease that affects pumping action of the heart muscles which causes fatigue, shortness of breath). A review of Resident R117's significant change Minimum Data Set assessment (MDS-periodic assessment of needs) dated June 18, 2021, revealed that resident was cognitively intact, being alert and oriented.

An interview with Resident R117 on September 27, 2021, 10:45 a.m., revealed that she had been using the oxygen to help her breathe. During the interview the resident was wearing a nasal canula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help). She indicated that she was supposed to wear it all the time, but would take it off if it bothered her. The oxygen tubing was connected to an oxygen concentrator which was set at one liter per minute.

A review of Resident R117's physician's orders dated April 27, 2021, revealed an order for continuous oxygen at one liter per minute via a nasal canula and to document her oxygen saturation every shift.

A review of Resident R117's care plan revealed no documentation that a plan of care was developed related to the resident's need for supplemental oxygen to facilitate breathing.

Interview with the Unit Manager, Employee E16, on September 29, 2021, at approximately 11:20 a.m., confirmed that no care plan was developed for Resident R117 related to the resident's need for supplemental oxygen.


CFR Comprehensive Care Plans

28 Pa Code 211.5(f) Clinical records.

28 Pa. Code 211.11(a)(b)(c) Resident care plan

28 Pa. Code 211.11(d) Resident care plan



 Plan of Correction - To be completed: 11/05/2021

1.A care plan for constipation has been initiated for R44.
A care plan for difficulty hearing has been initiated for R44.
A fluid restriction care plan has been initiated for R18.
A care plan for oxygen use and BiPap use has been initiated for R80.
A care plan for supplemental oxygen use has been initiated for R117.
2.Care plans for residents with constipation, hearing difficulties, fluid restrictions, supplemental oxygen and BiPap use have been reviewed to ensure care plans in place for these problems.
3.Education will be provided to nursing staff regarding the importance and requirement of initiating a comprehensive care plan addressing resident diagnosis and care.
4.Random audits will be completed weekly to ensure care plans are updated with constipation, hearing difficulties, fluid restrictions, supplemental oxygen and BiPap problems. Audits will be reviewed during monthly QA meeting x 3 months.

483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:

Based on observation and resident and staff interviews, it was determined that the facility failed to make information regarding the facility's grievance/complaint process and the residents' rights to file a grievance readily available in prominent locations on the nursing units.

Findings include:

During a group interview conducted on September 28, 2021 at 10:30 a.m. with eight alert and oriented residents (Residents R21, R22, R23, R30, R40, R46, R78 and R84), the residents stated that they were not aware of how to file a grievance with the facility anonymously. The residents were also unaware of who was the Grievance Official in the facility. All eight residents in attendance stated that they were unaware of any postings in the facility, which was comprised of four floors, regarding how to file a grievance.

Observations of the nursing unit and bulletin boards throughout the facility, conducted on the days of survey from September 27, 2021, through September 29, 2021, revealed only one posting, titled Grievance Procedure printed on 8 x 11" copy paper in a small print and posted about five feet off the ground on a crowded bulletin board on the third floor. There were no postings on the first, second or fourth floors related to how to file a grievance.

During an interview on September 28, 2021, at approximately 2:45 p.m, the Administrator acknowledged that the facility failed to post the grievance process in a print size and a height that residents in a wheel chair could easily read on every floor of the facility.

The facility failed to make information regarding the facility's grievance/complaint process and the residents' rights to file a grievance readily available in prominent locations on the nursing units.


CFR The facility must make information on how to file a grievance or complaint available to the resident.

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

28 Pa. Code 201.29(a) Resident rights

28 Pa. Code 201.29(c)(d)(e) Resident rights



 Plan of Correction - To be completed: 11/05/2021

Grievance information is posted on all units including grievance coordinator information. Anonymous grievances boxes are placed in accessible locations on each unit for residents.
Resident council meeting is attended by grievance coordinator, and will be recorded in meeting minutes
Social services to complete written monthly check of grievance information posting and check boxes.
Written monthly review to be reported to QAPI committee X3 months

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 a review of clinical records and staff and resident interviews, it was determined that the facility failed to follow physician's orders for two of 26 residents reviewed (Residents R44 and R78).

Findings include:

Review of Resident R44's clinical record revealed the resident was admitted to the facility on August 25, 2020, with a diagnosis to include gastro-esophageal reflux disease (A digestive disease in which stomach acid or bile irritates the food pipe lining) and aphasia (A language disorder that affects a person's ability to communicate).

Futher review of R44's clinical record revealed an order for Magnesium Hydroxide Suspension 400 MG/5ML Give 30 ml by mouth as needed for Constipation If no BM after 3 days with a start date of August 25, 2020.

During the initial tour of the facility on September 27, 2021, Resident R44 stated that his bowel movements are hard as a rock and he has had trouble going to the bathroom for years. The resident stated that he typically has a bowel movement once every five days.

Review of a physician progress note dated February 4, 2021, revealed: Physician's Progress Note Late Entry: Note Text: House NP: CC/HPI: Seen today again for constipation. He was recently started on miralax [Laxative used for constipation] every other day, he is reporting difficulty with bowel movements still and has been requesting MOM [Milk of Magnesia - used for constipation]. He is not having any discomfort or nausea/vomiting. ... Assessment/plan: constipation-will make miralax daily. If continued issues, may need to add additional medications.

Review of a physician progress note dated March 1, 2021, revealed: ... Assessment/plan: constipation-improved with daily miralax, continue plan and monitor. ...

Review of Resident R44's clinical record revealed a record of bowel movements, which revealed the resident had no documented bowel movement from August 29, 2021, through September 2, 2021; no documented bowel movement from September 4, 2021, through September 9, 2021; and no documented bowel movement from September 11, 2021, through September 20, 2021.

Further, review of Resident R44's clinical record revealed the Magnesium Hydroxide Suspension had not been administered to the resident, for the above mentioned days, when the resident did not have a documented bowel movement in three days.


A review of Resident R78's physician orders dated January 9, 2021, revealed the physician ordered a regular diet with regular texture and thin liquids. Observation of Resident R78's lunch tray on September 27, 2021, at 12:30 p.m. revealed that he received a mechanical soft diet. It consisted of chopped up chicken patty, chopped carrots and mashed potatoes.

Interview with the resident on September 27, 2021, at 12:30 p.m. revealed that he stated "look at this" and lifted his dome cover off his plate and it revealed a mechanical soft diet. The resident also stated "what is this?" The resident also did not receive the requested eight ounces of whole milk. A review of the dietary ticket that accompanied the lunch meal tray indicated that the resident was to receive a regular diet and eight ounces of whole milk.

Interview with the Director of Dietary on September 29, 2021, at 9:40 a.m. revealed he was not aware and could not determine why Resident R78 received a mechanical soft diet on September 27, 2021, for the 12:30 p.m. lunch meal. He also confirmed that the facility ran out of milk products for the lunch time meal on September 27, 2021.

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



















 Plan of Correction - To be completed: 11/05/2021

1.R44 bowel movement documentation was reviewed and has not required laxative.
Staff on 2nd floor have been educated to compare meal and meal ticket to ensure accurate diet served to R78.
2.A bowel movement report has been pulled from PCC to determine if any residents have not had a BM for 3 days.
3.Education will be provided to nursing staff that a bowel movement report will be pulled daily to determine if any resident has not had a BM x 3 days and require a bowel medication intervention.
Education will be provided to nursing staff to check that diet on meal ticket is diet being served.
4.Random audits will be completed weekly to ensure bowel medication is given if no bowel movement x 3 days and that residents are being served accurate diet. Audits will be reviewed during monthly QA meeting x 3 months.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on observation, review of facility documentation and interviews with staff and residents, it was determined that the facility failed to provide continence care in a timely manner for two of 26 residents reviewed. (Resident R5 and R126)

Findings Include:

Review of clinical record revealed Resident R5 was admitted to the facility on March 21, 2021 with diagnoses including muscle weakness and difficulty in walking. Review of Resident R5 Admission Minimum Data Set (MDS-assessment of care needs) dated July 1, 202, revealed the resident was cognitively intact, able to make needs known, always incontinent of bowel and bladder, and needed extensive assistance with personal hygiene.

A review of clinical record for Resident R5 revealed a care plan dated March 31, 2021, indicating that the resident was at risk for skin breakdown related to limited mobility. Interventions include providing peri care/incontinence care as needed.

Interview and observation with Resident R5 on September 27, 2021, at 11:00 a.m. revealed that the resident did not receive any morning care yet. Resident R5 revealed they just finished receiving speech therapy and sat in a wet brief throughout the session.

Interview with Employee 9, nurse aide, on September 27, 2021, at 11:05 a.m. confirmed that Resident R5 did not yet receive morning care and went in to assist the resident at that time.

Review of clinical record revealed Resident R126 was admitted to the facility on September 1, 2021, with diagnoses including muscle weakness, and difficulty in walking. Review of Resident R126 Admission Minimum Data Set (MDS-assessment of care needs) dated September 6, 2021, revealed the resident was cognitively intact, able to make needs known, frequently incontinent of bowel and needed extensive assistance with personal hygiene.

A review of clinical record for Resident R126 revealed a care plan revised September 23, 202,which indicated the resident had actual skin breakdown of MASD (Moisture Associated Skin disorder) to the right buttock related to lose stools from use of intravenous antibiotic.

Interview and observation with Resident R126 on September 27, 2021, at 11:10 a.m. revealed that the resident was complaining of diarrhea secondary to the use of antibiotics and has been waiting since 9:00 a.m. to receive morning care. During the interview Resident R126 expressed they were sitting in a soiled brief and had discomfort to the sacrum.

An interview with Employee E17, nurse aide, on September 27, 2021, at 11:15 a.m., confirmed that Resident R126 did not yet receive morning care. Employee E17 stated that they were assisting other resident's and did not have the chance to assist Resident R126 yet.

The facility failed to provide incontinence care in a timely manner, resulting in two residents sitting in soiled briefs.

CFR(s): 483.25(e)(1)-(3)

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




 Plan of Correction - To be completed: 11/05/2021


1.Interviewed R5 regarding her recent incontinence care.
R126 no longer resides at facility.
2.Random interviews with other residents from each unit were completed to determine if residents were receiving incontinence care in a timely manner. A skin sweep of residents in the facility showed no new or unidentified skin breakdown which could result from lack of incontinence care.
3.Education will be provided to nursing staff regarding timely incontinence care.
4.Random audits will be completed weekly to ensure residents are receiving timely incontinence care. Audits will be reviewed during monthly QA meeting x 3 months.

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 review of facility policy, facility documentation, clinical record review and staff and resident interviews, it was determined that the facility failed to implement and monitor a fluid restriction to address a resident's clinical condition to maintain recommended parameters of hydration related to electrolyte balance for one of 2 residents reviewed (R18).

Findings Include:

Review of undated facility policy titled "Encouraging and Restricting Fluids" revealed the purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include restricting fluids.

Review of Resident R18's clinical record revealed the resident was admitted to the facility on July 27, 2021, with diagnoses including hypo-osmolality (levels of electrolytes in the blood are lower than normal) and hyponatremia (low sodium levels).

Review of Resident R18's clinical record revealed a nursing admission assessment, dated July 27, 2021, revealed that the resident was admitted to the facility with diet recommendations to restrict fluid intake to 1400ml per day.

Continued review of Resident R18's clinical record revealed progress notes by Employee E19, nurse practitioner, dated July 28, August 9, August 13, August 17, August 30, and September 28, 2021, which revealed that the fluid restriction should be continued secondary to hyponatremia.

Review of clinical record for Resident R18 revealed no documented evidence of a physician order or that there was any monitoring/enforcement for the fluid restriction.

Review of Resident R18's nutrition admission assessment and nutrition care plan dated July 28, 2021, revealed no documented evidence that the resident's hydration status was addressed related to electrolyte imbalance and fluid restriction. There was no documented evidence that interventions were implemented for a fluid restriction or that any education was provided.

Continued review of Resident R18 clinical record revealed labs dated September 9, 2021, which indicated that the resident's sodium levels were still below recommended parameters.

Interview with Resident R18 on September 27, 2021, at 11:30 a.m. revealed the resident was confused about the fluid restriction recommended by the Nurse Practitioner. Resident R18 revealed they were unaware how to monitor fluid intake and did not know why they needed to be on a fluid restriction.

An interview with Employee E23, Registered Dietitian, on September 28, 2021, at 12:30 p.m. revealed that the employee was unaware of the fluid restriction.

Review of clinical documentation for Resident R18 revealed Employee E20, nursing assistant, did not implement interventions for a fluid restriction and provide education until September 28, 2021.

Continued review of clinical documentation for Resident R18 revealed a physician order for fluid restriction was not placed until September 28, 2021.

A follow-up interview with Employee E23, registered Dietitian, on September 29, 2021 at 1:00 p.m. confirmed that the resident should have been on a fluid restriction since admission.

The facility failed to ensure a fluid restriction was implemented and monitored to address a resident's clinical condition to maintain acceptable hydration parameters related to electrolyte balance.







 Plan of Correction - To be completed: 11/05/2021

1.An order for fluid restrictions has been placed for R18.
2.Residents that require a fluid restriction have been reviewed to ensure an order is in place for fluid restriction.
3.Education will be provided to nursing staff regarding the need to have a fluid restriction order written and implemented if required.
4.Random audits will be completed weekly to ensure an order for fluid restrictions have been entered for residents requiring fluid restrictions. Audits will be reviewed during monthly QA meeting x 3 months.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on observations, interviews with residents and staff, it was determined that the facility failed to ensure that resident respiratory care needs were met related to respiratory equipment for one of 26 residents reviewed (Resident R80)

Finding include:

Review of the clinical record for Resident R80 revealed that the resident was admitted to the facility on April 12, 2021, with diagnoses including, chronic obstructive pulmonary disease (COPD, a common disease characterized by persistent respiratory symptoms like progressive breathlessness and cough) and obstructive sleep apnea (sleep-related breathing disorder which causes you to repeatedly stop and start breathing while you sleep). A review of Resident R80's quarterly Minimum Data Set assessment (MDS-periodic assessment of needs) dated August 22, 2021, revealed that resident was cognitively intact, being alert and oriented.

Interview with Resident R80 on September 27, 2021, at 11:15 a.m., revealed that she had been using the BiPAP Machine (a non-invasive ventilation (NIV) therapy used to facilitate breathing) some nights to help her sleep. She pointed to the machine at her bedside which was set up with tubing and a mask and indicated that it was a BiPAP machine. During the interview the resident was wearing a nasal canula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help). She indicated that she had to wear it all the time. The oxygen tubing was connected to an oxygen concentrator which was set at 4 liters per minute.

A review of Resident R80's physician's orders, revealed an order dated July, 31, 2021, for continuous oxygen at four liters per minute via a nasal canula. Further review of the physician's order did not reveal an order for the BiPAP machine.

A review of Resident R80's care plan revealed no documentation that a plan of care was developed related to the resident's need for supplemental oxygen to facilitate breathing or the use of a BiPAP machine to facilitate breathing while sleeping.

Interview with Employee E16, Unit Manager, on September 29, 2021, at 11:20 a.m., confirmed that no order for the BiPAP machine had been obtained. Additionally, the interview revealed that Employee E16 was unaware of the manufacturer's recommended maintenance for the BiPAP machine or the settings. Further interview revealed that there was no care plan developed for Resident R80 related to the resident's need for supplemental oxygen or the use of a BiPAP machine.

The facility failed to ensure that a resident's respiratory care needs were met related to the use and maintenance of respiratory equipment including an oxygen concentrator and BiPAP machine.


CFR Respiratory care, including tracheostomy care and tracheal suctioning.

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

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



 Plan of Correction - To be completed: 11/05/2021

1.An order for R80 has been written for BiPAP use. A care plan has been entered for R80 for BiPAP use and supplemental oxygen.
2.Records for residents who require BiPAP use and supplemental O2 use have been reviewed to determine orders and care plans are written.
3.Education will be provided to nursing staff regarding the need to enter and order and a care plan for residents who utilize a BiPAP and supplemental oxygen.
4.Random audits will be completed weekly to ensure care plans and orders are in place for residents who utilize BiPAP and supplemental oxygen. Audits will be reviewed during monthly QA meeting x 3 months.

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

483.45(h) Storage of Drugs and Biologicals

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

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

Based on observations, review of manufacturer guidelines for safe medication storage, and staff interviews, it was determined that the facility failed to label and discard multi-dose medications in accordance with currently accepted professional principles, including necessary use by/discard dates, on two of five medication carts (Second and Third floor medication carts).

Findings include:

Review of the following manufacturer guidelines for the safe storage of insulins revealed the following:
Insulin Lispro storage conditions for vial .... once opened, discard after 28 days.
Insulin Lantus ... vial must be discarded after 28 days after being opened.
Insulin Novolog storage conditions for vial .... once opened, discard after 28 days.

Observation on September 28, 2021, at 8:50 a.m. of the third floor medication storage cart revealed the following: two 10 ml opened vials of Insulin Lispro; a 10 ml opened vial of Insulin Lantus; and a 10 ml opened vial of Insulin Novolog; where all the insulins were dated August 10, 2021, which was more than 28 day of when the insulins should have been discarded.

Interview on September 28, 2021, with Employee E13, LPN, confirmed that the above mentioned insulins should have been discarded because the medications were past the 28 days the manufacturers recommended for safe use.

Observation on September 28, 2021, at 9:10 a.m. of the second floor medication storage cart revealed a 10 ml opened vial of Insulin Novolog; where the insulin was not dated when the vial was opened.

Interview on September 28, 2021, with Employee E14, LPN, confirmed that the above mentioned insulin should have been discarded because it was not known if the medication was past the 28 days the manufacturers recommended for safe use.


28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services






 Plan of Correction - To be completed: 11/05/2021

1.Second and third floor medication carts were check for expired multi dose insulin vials and discarded.
2.Remaining medication carts were check for expired multi dose insulin vials and discarded.
3.Education will be provided for nursing staff requiring multi dose insulin vials to be dated upon opening with discard date of 28 days after opening.
4.Random audits will be completed weekly to determine if there are expired multi dose insulin vials in the medication carts and will be discarded if found. Audits will be reviewed during monthly QA meeting x 3 months.

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime: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(f) Frequency of Meals
483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.
Observations:

Based on interviews with residents and staff, it was determined that the facility has failed to provide a nutritious snack at bedtime for four of eight resident council members (Resident R40, R84, R21 and R22), and two of 26 sampled residents (Resident R388 and R117).

Findings include:

During the confidential resident group meeting held on September 28, 2021, at 10:30 a.m. there were concerns expressed by several residents about not regularly receiving an evening snack. Resident R21 stated that they did not send any snacks last night. Resident R22 confirmed that the snack cart did not even come to her floor last night, and that this is not the first time, and that she has also gone two days without fresh ice water. Resident R84 stated that she is not always offered a snack at night, and that they do not have ice on the second floor. Resident R40 said that she is not regularly offered an evening snack.

An interview with Resident R388 on September 27, 2021, at 10:30 a.m., revealed that she often did not receive an evening snack.

An interview with Resident R117 on September 27, 2021, at 11:00 a.m., revealed that she was not always offered an evening snack.

Interview on September 28, 2021, at 1:15 p.m. with the Food Service Director revealed that evening snacks are prepared in the kitchen and sent to the floors, but he did not indicate if they were offered to the residents.


28 Pa. Code: 211.6(b) Dietary Services.



 Plan of Correction - To be completed: 11/05/2021

Resident snacks are being offered at 7pm. A new process will be put into place for a daily sign off sheet for 7pm snacks. Sign off sheets that will require signatures upon delivery to ensure snacks are being delivered. Staff will be in serviced regarding the importance of evening snacks and the new process. Random reviews will be conducted by FSD or designee 1x weekly. Findings will be reported at monthly QAPI and menu (food) committee meetings for a period of 3 months.
211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. 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 2.7 hours of direct resident care for each resident.
Observations:

Based on a review of facility documentation and interview with staff, it was determined that the facility failed to meet the state minimum requirement of direct nursing care hours per resident per day, for three of 21 days reviewed.

Findings include:

Calculation of direct nursing care hours per resident per day revealed that the facility provided:

2.58 nursing hours per resident on December 27, 2020
2.62 nursing hours per resident on June 4, 2021
2.43 nursing hours per resident on June 5, 2021

Interview with the Administrator on September 28, 2021, at 1:30 p.m., confirmed that the facility failed to meet the State minimum requirement of 2.7 direct nursing care hours per resident per day.




 Plan of Correction - To be completed: 11/05/2021

Facility continues to recruit and advertise for all nursing positions.

The facility has contracted with 8 staffing agencies to provide additional staffing to address statewide nursing shortage.

Incentives and sign on bonuses are reviewed weekly.

Recruiting efforts and incentives to be reviewed at QAPI meeting monthly X 6 months


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