Pennsylvania Department of Health
CLARION HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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CLARION HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  85 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.
CLARION HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on April 12, 2024, it was determined that Clarion Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of rights of medication administration, facility policy, observation, and staff interview, it was determined that the facility failed to provide nursing services consistent with professional standards of practice for medication administration during observation of one of three resident units (Unit C).

Findings include:

Review of "Eight Rights of Medication Administration" published by Lippincott (a prominent medical publisher that provides essential health information for practitioners, faculty, residents, students and healthcare institutions) on 5/28/2011, rights of medication administration include: Right Patient, Right Medication (includes checking label and checking physician order), Right Dose (includes checking order), Right Route, Right Time, Right Documentation (after administration), Right Reason, and Right Response.

Review of facility policy entitled "Administering Medications" dated 1/2/24, indicated "The individual administering the medication checked the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication." and "The individual administering the medication initials the resident's MAR (medication administration record) on the appropriate line after giving each medication and before administering the next ones."

Observation of medication administration pass on 4/9/24, at approximately 3:50 p.m. revealed Licensed Practical Nurse (LPN) Employee E1 logged onto his/her computer located on the top of the medication cart bringing up a list of residents names. The LPN proceeded to obtain medications for Resident R60 that included Buspar (medication to treat anxiety) 15 mg, Gabapentin (medication to treat seizures and/or pain) 100 mg, and Tylenol Extra Strength 500mg, he/she then proceeded to the unit lounge and administer Resident R60's medication. Upon returning to the medication cart, LPN Employee E1 proceeded to obtain medications for Resident R5 that included Duoneb (solution administered via nebulizer for individual with lung disease), he/she then proceeded to Resident R5's room and administer Resident R5's medication. Upon returning to the medication cart, LPN Employee E1 proceeded to move the medication cart down the hallway and then obtained medications for Resident R45 that included Potassium 10 meq (milliequivalent), he/she then proceeded to Resident R45's room and administered Resident R45's medication. Upon returning to the medication cart, LPN Employee E1 was going to proceed to the next resident.

During an interview, the surveyor asked LPN Employee E1 if he/she normally completes their medication pass without looking at the resident's MAR and without signing for administration after each resident. LPN Employee E1 stated he/she is always on this hall so they know what the residents get. When asked what they do if there were medication changes, LPN Employee E1 stated he/she gets report and they would find out that way. When asked what they would do if they were not informed of changes in report, LPN Employee E1 stated he/she knows some residents have routine changes, so he/she would look at their MARs first. LPN Employee E1 stated the last place he/she worked he/she was taught to save time he/she could give all the medications and then when he/she was done he/she could go back and sign the MAR and if he/she noticed anything was missed he/she could then go back and give it. LPN Employee E1 then stated if it would make the surveyor feel better he/she would look at their MAR and sign off for medication administration like he/she should.

During interview on 4/9/24, at approximately 4:00 p.m. LPN Employee E1 confirmed he/she did not reference the MAR record for Residents R60, R5, and R28 prior to administering the medication nor did he/she document the administration of the medications after each resident.

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

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





 Plan of Correction - To be completed: 05/16/2024

1. Director of Nursing reviewed R60, R5, and R45 MARs to ensure correct medication received during med pass.
2. E1 was not permitted to pass medication until completion of 1:1 education and med pass competency.
3. Education provided to licensed staff on the policy administering medication and administering oral medication and documentation of medication administration.
4. Director of nursing or designee will perform random med pass observation three times weekly x 2 weeks, weekly x 2 weeks.
5. Audits will be reviewed and presented by the Director of nursing or designee at Quality Assurance and Performance Improvement (QAPI) meeting to ensure systemic change has been made.

483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination: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(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:


Based on observation, review of clinical records and facility policy, and resident and staff interviews, it was determined that the facility failed to allow residents the right to make choices about aspects of his or her life in the facility that are significant to the resident for one of 20 residents reviewed (Resident R17).

Findings include:

Resident R17's clinical record revealed an admission date of 11/10/20, with diagnoses that included diabetes (condition of improper blood sugar control), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and Crohn's disease (a chronic inflammation of the digestive tract that leads to abdominal pain and severe diarrhea).

Review of facility policy entitled "Resident Rights" dated 1/2/24, revealed "Federal and state laws guarantee certain rights to all residents ... These rights include the residents right to, self-determination."

Review of Resident R17's Minimum Data Set (MDS- periodic assessment of resident care needs) assessment dated 2/15/24, indicated that Resident R17 had a Brief Interview for Mental Status (BIMS-tool used to assess cognitive status) of 15 (a score from 13 to 15 indicates intact cognition, or mental status).

Review of Resident R17's care plans revealed a care plan focus for activities with interventions that included encourage resident out of room for activities. Further review of care plans revealed a care plan focus for depression with interventions that included involve resident in making his/her own schedule of activities.

Review of Resident R17's MDS Section F 0500 dated 8/16/23, indicated that participating in religious services or practices, attending favorite activities, and doing things with a group of people is very important to Resident R17.

During an interview with Resident R17 on 4/9/24, at 12:00 p.m. resident shared that he/she wanted to be out of bed for meals including breakfast and that he/she would like to be up in his/her wheelchair to eat. He/she also shared that he/she wants to attend bible study, and other activities but staff does not always have him/her up to attend on a regular basis.

Observation on 4/9/24, at 12:00 p.m. revealed Resident R17 was laying in his/her bed dressed in his/her pajamas. Further observations at 2:10 p.m. revealed resident was laying in his/her bed and remained dressed in his/her pajamas, and at 2:13 p.m. resident was observed being assisted by staff getting ready for the day.

Observation on 4/10/24, at 10:00 a.m. revealed Resident R17 was laying in his/her bed dressed in his/her pajamas, further observations at 11:34 a.m. revealed resident was laying in his/her bed and remained dressed in his/her pajamas, with further observations on 4/10/24, revealed that at 12:30 p.m. resident was up in his/her wheelchair appropriately dressed.

Observation on 4/10/24, at 12:37 p.m. revealed Resident R17 was being assisted to the dining room for lunch when a staff member approached Resident R17 with his/her lunch tray. At the time of observation, Resident R17 was observed being taken back to his/her room to eat his/her lunch.

During an interview with Resident R17 on 4/10/24, at 12:45 p.m. he/she shared that he/she was eating in her room because the staff told him/her that lunch was done in the dining room. He/she shared that she eats in the dining room for lunch.

Observation on 4/10/24, at 12:55 p.m. of the seating chart in the dining room revealed Resident R17's name on the seating chart posted on the wall in the dining room.

Observation on 4/11/24, at 9:35 a.m. Resident R17 was laying in his/her bed dressed in his/her pajamas, further observation on 4/11/24, at 10:35 a.m. revealed resident was up in his/her wheelchair.

Interview with Resident R17 on 4/11/24, at 10:40 a.m. revealed he/she shared that he/she wanted to be at a resident council meeting that was scheduled at 10:00 a.m. but he/she had just got out of bed. He/she shared that not getting out of bed in a timely manner happens often.

During an interview on 4/12/24, at 11:25 a.m. the Nursing Home Administrator and the Director of Nursing confirmed that residents have the right to be out of bed for meals and activities. They also confirmed that it is not appropriate for staff to not get a resident out of bed per the resident's wishes.

28 Pa. Code 201.29 (a) Resident rights

28 Pa. Code 201.18 (b)(1)(3) Management

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






 Plan of Correction - To be completed: 05/16/2024

1. R17 interviewed for preferences. Care plan updated with new preference to be up for breakfast. R17 has since changed her mind and no longer wishes to be up for breakfast. Care plan again updated.
2. Education provided to current staff regarding Resident Rights
3. Activities director or designee will interview current residents regarding preference to be out of bed for activities and meals
4. Resident preferences will be documented in Care plan and Kardex
5. Director of nursing or designee will interview random selection of residents to ensure preferences are honored for activity and meal attendance 3x weekly x2 weeks, weekly x 2 weeks.
6. Audits will be reviewed and presented by the Director of nursing or designee at Quality Assurance and Performance Improvement (QAPI) meeting to ensure systemic change has been made

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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(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 review of a facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of two refrigerators reviewed (first floor pantry).

Findings include:

Review of a facility policy entitled "Food Receiving and Storage" dated 1/2/24, indicated "Beverages are dated when open and discarded after twenty-four (24) hours."

Observation on 4/11/24, at approximately 1:35 p.m. revealed a refrigerator in the pantry used for residents on the first floor with two open containers of Imperial Butter Pecan 2.0 Cal Med Pass (a supplement that helps increased calorie intake) with no open date.

During an interview on 4/11/24, at the time of observation with Registered Nurse Employee E2, he/she confirmed that the two open containers of Imperial 2.0 Cal Med Pass in the refrigerator should have been dated when opened. He/she also confirmed that the Imperial 2.0 Cal Med Pass should have been discarded due to no open date.

28 Pa. Code 201.14(a) Responsibility of licensee







 Plan of Correction - To be completed: 05/16/2024

1. Undated Med Pass supplement discarded. Refrigerators checked for any undated or expired items.
2. Education provided to licensed staff regarding Food Receiving and Storage
3. Med Pass supplement will be dated upon opening with date opened and used by date written on carton.
4. Director of nursing or designee will audit pantry refrigerators to ensure the date is written legibly on the container and discarded when outdated. Audits will occur 3 x weekly for 2 weeks, then twice weekly x 2 weeks
5. Audits will be reviewed and presented by the Director of nursing or designee at Quality Assurance and Performance Improvement (QAPI) meeting to ensure systemic change has been made

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:


Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to administration of a PRN (as needed) psychotropic (affecting the mind) medication for two of six residents reviewed for unnecessary medications (Residents R39 and R60).

Findings include:

Review of a facility policy entitled "Psychotropic Medication Use" dated 1/2/24, indicated that "Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible."

Resident R39's clinical record revealed an admission date of 10/19/22, with diagnoses that included dementia (brain disorder that affects memory, thinking, and social abilities), anxiety, and depression.

Resident R39's clinical record revealed a physician's order dated 1/12/24, that identified to administer Haldol (medication to treat mental/mood disorders) injection 1 milligram (mg) intramuscular (IM) times one for agitation, combativeness, and anxiety.

Resident R39's Medication Administration Record (MAR) for January 2024 revealed that the Haldol was administered on 1/12/24, at 2:41 p.m. Review of the January 2024 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the Haldol.

Resident R39's clinical record revealed a physician's order dated 4/6/24, that identified to administer Lorazepam (medication to treat anxiety) 0.5 mg by mouth every 12 hours PRN for anxiety / agitation for 14-days.

Resident R39's MAR for April 2024 revealed that the Lorazepam was used twice between 4/6/24, and 4/20/24. Review of April 2024 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the PRN Lorazepam two of the two times the Lorazepam was utilized in April 2024.


Resident R60's clinical record revealed an admission date of 10/13/23, with diagnoses that included dementia, anxiety, and depression.

Resident R60's clinical record revealed a physician's order dated 10/21/23, that identified to administer Vistaril (medication to treat anxiety) 25 mg by mouth every 6 hours PRN for anxiety / agitation. A physician's order dated 10/27/23, identified to administer Vistaril 25 mg by mouth every 6 hours PRN for restlessness. A physician's order dated 12/21/23, identified to administer Vistaril 25 --mg po every 8 hours PRN for anxiety / agitation. A physician's order dated 1/25/24, identified to administer Vistaril 25 mg po every 6 hours PRN for restlessness.

Resident R60's MAR for October 2023 revealed that the Vistaril was used 12 times between 10/21/23, and 10/31/23. Review of October 2023 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the PRN Vistaril nine of the 12 times the Vistaril was utilized in October 2023.

Resident R60's MAR for November 2023 revealed that the Vistaril was used eight times between 11/1/23, and 11/16/23. Review of November 2023 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the PRN Vistaril five of the eight times the Vistaril was utilized in November 2023.

Resident R60's MAR for December 2023 revealed that the Vistaril was used four times between 12/21/23, and 12/31/23. Review of December 2023 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the PRN Vistaril two of the four time the Vistaril was utilized in December 2023.

Resident R60's MAR for January 2024 revealed that the Vistaril was used seven times between 1/1/24, and 1/4/24, and 1/25/24, and 1/31/24. Review of January 2024 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the PRN Vistaril five of the seven times the Vistaril was utilized in January 2024.

Resident R60's MAR for February 2024 revealed that the Vistaril was used five times between 2/1/24, and 2/29/24. Review of the February 2024 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the PRN Vistaril five of the five times the Vistaril was utilized in February 2024.

Resident R60's MAR for March 2024 revealed that the Vistaril was used four times between 3/1/24, and 3/17/24. Review of the March 2024 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the PRN Vistaril four of the four times the Vistaril was utilized in March 2024.

During an interview on 4/11/24, at 2:08 p.m. the Director of Nursing confirmed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Haldol and the PRN Lorazepam administered for Resident R39 and for the PRN Vistaril administered for Resident R60.

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

28 Pa. Code 201.18(b)(1)(3) Management






 Plan of Correction - To be completed: 05/16/2024

R39 and R60 orders updated to include supplemental documentation of non-pharmacological interventions
2. Orders for current residents receiving as needed anti-anxiety medication were updated to include supplemental documentation of non-pharmacological interventions
3. Education provided to licensed nursing staff regarding policy Psychotropic Medication Use
including documentation of non-pharmacological interventions (NPIs) prior to administration of as needed antianxiety medication.
4. Education provided to Registered Nurses to utilize Point Click Care template that provides order sentence to include supplementary documentation of non-pharmacological interventions .
5. Director of nursing or designee will audit current as needed antianxiety order to ensure that non-pharmacological interventions are completed upon administration of PRN anti-anxiety medications. Daily x 1 week, 3 times weekly x 1 week, and then weekly x 2 week.
6. Audits will be reviewed and presented by the Director of nursing or designee at Quality Assurance and Performance Improvement (QAPI) meeting to ensure systemic change has been made.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

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

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

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

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

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


Based on a review of facility policy and closed clinical records, and staff interview, it was determined that the facility failed to implement procedures to promote accurate and safe disposition of controlled medication records for one of three closed records reviewed (Resident CR68).

Findings include:

Review of the facility policy, entitled "Disposal of Medications and Medication related Supplies," dated 1/02/24, indicated, "Schedule II-V medications remaining in the facility after a resident has been discharged, or the order discontinued, are disposed of in the facility by two licensed nurses or a licensed nurse and a licensed pharmacist as directed by state laws, regulations, and/or the DEA."

Review of Resident CR68's closed clinical record revealed admission to the facility on 4/02/13. Resident CR68 ceased to breathe on 2/18/24.

Review of Resident CR68's closed clinical record revealed a lack of evidence that two licensed nurses were present and signed on 2/18/24, when 12.5 milliliters of Morphine (a controlled schedule II drug used for pain management and to help with breathing) and 29.75 milliliters of Lorazepam (a controlled schedule IV drug used for anxiety) were transferred to a Federally approved waste container.

During an interview on 4/12/24, at 12:40 p.m. the Director of Nursing confirmed that the disposition of medications documentation lacked evidence that two licensed nurses were present and signed on 2/18/24, when 12.5 milliliters of Morphine and 29.75 milliliters of Lorazepam for Resident CR68 were transferred to a Federally approved waste container and that two licensed nurses should always be present and sign when disposing of a controlled drug.

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

28 Pa. Code 211.9(j.1)(3) Pharmacy services

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







 Plan of Correction - To be completed: 05/16/2024

1. CR 68 record is closed because resident CR 68 ceased to breathe
2. Director of nursing or designee completed audit of closed records from 03/15/2024-04/15/2024 to ensure disposed controlled medication had two signatures.
3. Education provided to licensed staff regarding policy Controlled medication disposal.
4. Director of nursing or designee will perform Audits of narcotic control sheets of discharged residents 3 times weekly x 2 weeks, then weekly x 2 weeks
5. Audits will be reviewed and presented by the director of nursing or designee at Quality Assurance and Performance Improvement (QAPI) meeting to ensure systemic change has been made.

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 review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment for one of two residents reviewed for respiratory services (Resident R22).

Findings include:

Review of the facility policy entitled "Departmental (Respiratory Therapy) - Prevention of Infection" dated 1/2/24, indicated to "Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry."

Resident R22's clinical record revealed an admission date of 1/20/21, with diagnoses that included Diabetes, High Blood Pressure, and Alzheimer's Disease (brain disorder that destroys memory and thinking skills and eventually, the ability to carry out simple tasks).

Resident R22's physician's order dated 7/12/23, revealed that oxygen was ordered at two liters per minute for shortness of breath via nasal cannula (tubing that enters into the nostrils to administer oxygen) every shift.

Observations on 4/9/24, at 11:21 a.m. and on 4/10/24, at 9:38 a.m. revealed that Resident R22's oxygen concentrator had two filters, one on each side of the concentrator, that contained a gray dusty substance.

During an interview on 4/10/23, at 9:56 a.m. Registered Nurse Employee E2 confirmed that the oxygen concentrator filters contained a gray dusty substance and are to be cleaned on a weekly basis.

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








 Plan of Correction - To be completed: 05/16/2024

R22 oxygen filter was cleaned.
2. Current Oxygen concentrator filters were checked for cleanliness and cleaned if needed
3. Residents with oxygen orders were reviewed to ensure orders were placed to clean oxygen filter weekly.
4. Licensed staff were educated on Departmental (Respiratory Therapy) Prevention of Infection policy
5. Director of Nursing or designee will audit residents with oxygen to ensure clean filter applied as ordered 3 x weekly for 2 weeks then 1 x weekly for 2 weeks.
6. Audits will be reviewed and presented by the Director of nursing or designee at Quality Assurance and Performance Improvement (QAPI) meeting to ensure systemic change has been made

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at 483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:


Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain privacy of confidential information during medication administration for one of three resident units (Unit C).

Findings include:

Review of a facility policy entitled "Confidentiality of Information and Personal Privacy" dated 1/2/24, indicated "The facility will safeguard the personal privacy and confidentiality of all Resident personal and medical records."

Observation on 4/9/24, between 3:50 p.m. and 4:20 p.m. revealed Licensed Practical Nurse (LPN) Employee E1 performing resident medication administration to Residents R5, R10, R26, R28, R45, R47, and R60. The medication cart was parked in the hallway against the wall with the computer screen unlocked and open, sitting on top of the medication cart facing into the hallway with resident information accessible to anyone passing by in the corridor. On each occasion, the LPN proceeded into the resident's room to administer medication where the medication cart / computer screen was out of his/her view and did not cover resident information that was on the computer screen accessible to anyone passing by.

During an interview on 4/9/24, at 4:20 p.m. LPN Employee E1 confirmed that he/she left the medication cart unattended and out of his/ her view the computer open and resident information accessible to anyone passing by.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.5(b) Medical records

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



 Plan of Correction - To be completed: 05/16/2024

1. E1 was not permitted to pass medication until completion of 1:1 education and med pass competency.
2. Education provided to licensed staff regarding confidentiality of resident records, specifically, the right to privacy and confidentiality locking med cart/computer screen when out of view to ensure confidentiality.
3. Director of nursing or designee will perform random observation during medication pass to ensure resident right to privacy and confidentially maintained by locking computer privacy screen3 times weekly x 2 weeks , weekly x 2 weeks
4. Audits will be reviewed and presented by the Director of nursing or designee at Quality Assurance and Performance Improvement (QAPI) meeting to ensure systemic change has been made

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

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

Based on review of facility policy and documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of 20 residents reviewed was free of neglect during care. (Resident R8)

Findings include:

Review of facility policy entitled, "Identifying Types of Abuse," dated 1/2/24, revealed that "Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them, and this has resulted in (or may result in) physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference to or disregard for resident care, comfort, or safety results in (or could have resulted in) physical harm, pain, mental anguish, or emotional distress."

Review of facility policy entitled, "Safe Lifting and Movement of Residents" dated 1/2/24, revealed that "Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents."

Review of Resident R8's clinical record revealed an admission date of 7/10/08, with diagnoses that included multiple sclerosis (a disease where the body's immune system attacks the nerves which can cause vision problems, muscle weakness, numbness, feeling tired, difficulty thinking and bowel and bladder dysfunction), dementia (a disease that affects short term memory and the ability to think logically), and chronic obstructive pulmonary disease (when your lungs do not have adequate air flow).

Review of Resident R8's Quarterly Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated 3/7/24, revealed under section GG 0170 E, that Resident R8 is dependent on staff for transfers from chair to bed.

Review of Resident R8's Kardex (an easy reference of resident care needs for the nursing assistants to reference), revealed under "transferring" that Resident R8 transfers with mechanical lift (Sara lift-type of mechanical lift) and required two staff members.

Review of Resident R8's "Task" (section of the clinical record where nursing assistants document in the resident record for care provided), documentation under "transfer support provided" revealed the resident was a two person physical assist.

Review of Resident R8's revision of care plan dated 4/1/24, for transfers revealed that Resident R8 transfers with a mechanical lift (Sara lift) and two staff.

Review of Resident R8's active physician orders as of 4/7/24, revealed an order for a Sara lift for all transfers.

Review of information submitted by facility dated 4/8/24, and interview with the Nursing Home Administrator and Director of Nursing revealed that Resident R8 was transferred from his/her wheelchair with the Sara lift to his/her bed with assist of one staff member resulting in Resident R8 being lowered to the floor.

Review of facility's investigation revealed that NA Employee E3 confirmed on 4/7/24, he/she transferred Resident R8 with the Sara lift without the two staff members as required. NA Employee E3's statement revealed that he/she transferred Resident R8 using the Sara lift without another staff member. NA Employee E3 had Resident R8 sitting on the edge of the bed with the Sara lift still attached to Resident R8 when Resident R8 started to slide off the bed. NA Employee E3 grabbed Resident R8 under the arms and lowered Resident R8 to the floor.

Review of documentation submitted by the facility dated 4/8/24, revealed that the facility initiated an investigation, regarding resident neglect on 4/8/24. The investigation revealed that NA Employee E3 was suspended pending investigation.

During an interview on 4/12/24, at 11:45 a.m. the Nursing Home Administrator and Director of Nursing confirmed that NA Employee E3 did not get another staff member to assist in the transfer of Resident R8 that required assist of two staff with transfers. They also confirmed that all mechanical lifts must have two staff when in use with a resident.

28 Pa. Code 201.14(a) Responsibility of licensee

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

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

28 Pa. Code 211.12(c) Nursing services

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







 Plan of Correction - To be completed: 05/16/2024

1. R8 was assessed at time of fall; no injury.
2. E3 was educated on Abuse/neglect and requirement of 2 staff being present for lift transfers
3. E3 completed 1:1 lift competency
4. Education provided to current staff regarding Abuse Policy, and new staff complete as a part of orientation.
5. Education provided to current nursing staff on how to access KARDEX and the requirement of 2 staff being present during transfer using a lift and new nursing staff are educated during orientation.
6. DON or designee will audit safe transfer of resident and proper transfer status usage daily x 1 week, 2 times weekly x 2 weeks, 1-time weekly x 1 week
7. Audits will be reviewed and presented by the Director of nursing or designee at Quality Assurance and Performance Improvement (QAPI) meeting to ensure systemic change has been made

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.21 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:


Based on review of facility policy and clinical record and staff interview, it was determined that the facility failed to provide a resident and/or his/her representative with a summary of the baseline care plan for one of 20 residents (Resident R9).

Findings include:

Review of facility policy entitled "Care Plans Baseline" dated 1/2/24, revealed "The resident and their representative will be provided a summary of the baseline care plan ..."

Review of Resident R9's clinical record revealed an admission date of 2/3/24, with diagnoses that included pneumonia (an illness that causes respiratory distress, congestion, and cough), hypertension (high blood pressure), and urinary retention (a condition where your bladder doesn't empty all the way or at all when you urinate).

Review of Resident R9's Minimum Data Set (MDS-a periodic assessment of resident care needs) assessment section A entry/discharge reporting with dates of 12/29/23, 1/20/24, and 1/30/24, revealed Resident R9 was discharged.

Review of Resident R9's clinical record lacked evidence that a summary of the baseline care plan that includes goals, treatments, and services, and a summary of medications and dietary instructions was provided to Resident R9 and/or his/her representative.

During an interview on 4/12/24, at 12:15 p.m. the Director of Nursing confirmed that there was no evidence that Resident R9 and/or his/her representative was provided a summary of the baseline care plan that included goals, treatments and services, and a summary of medications and dietary instructions.

28 Pa. Code 201.14 (a) Responsibility of Licensee

28 Pa. Code 211.10 (c) Resident care policies

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








 Plan of Correction - To be completed: 05/03/2024

I hereby acknowledge the CMS 2567-A, issued to CLARION HEALTHCARE AND REHABILITATION CENTER for the survey ending 04/12/2024, AND attest that all deficiencies listed on the form will be corrected in a timely manner.

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