Pennsylvania Department of Health
 GRANDVIEW NURSING AND REHABILITATION
Patient Care Inspection Results

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GRANDVIEW NURSING AND REHABILITATION
Inspection Results For:

There are  132 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.
GRANDVIEW NURSING AND REHABILITATION - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on March 12, 2024, it was determined that Grandview Nursing and Rehabilitation 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:


483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
§483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:

Based on a review of clinical records and facility investigative reports and staff and family interviews it was determined the facility failed to provide nursing staff with the appropriate competencies and skills sets necessary to promptly identify and act upon ongoing signs and symptoms of a change in resident condition, and evaluating current resident care needs, which resulted in a delay in treatment of a serious injury, a comminuted impacted hip fracture for one resident (Resident B1), and to maintain the safety of one cognitively impaired resident with behavioral symptoms (Resident A8) out of 22 residents reviewed.

Findings include:

A review of Resident B1's clinical record revealed that the resident was admitted to the facility on September 18, 2023, with diagnoses to include, osteoarthritis, spinal chronic kidney disease, dementia and a history of falling. The resident was cognitively intact with a BIMS score of 14 (brief interview for mental status - a tool to assess cognitive function, a score of 13 to 15 indicates the resident is cognitively intact) according to a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 23, 2023. The resident required the assistance of staff for activities of daily living, including bathing, toileting, bed mobility and transfers and ambulated with assistance with a rollator walker.

The resident had current physician orders, initially dated September 18, 2023, for Acetaminophen ER (extended release,Tylenol, a non narcotic pain medication) 650 mg, take 1 by mouth every 12 hours for pain management and Tylenol 325 mg, give 2 tabs by mouth every 4 hours as needed for mild to severe pain level 1-10.

A facility investigation report and nursing documentation dated January 1, 2024, at 1:41 PM revealed that staff found Resident B1 on the floor in her room, between her bed and the wheelchair, after the resident attempted to self transfer. Nursing noted that the resident sustained no apparent injury, denied discomfort and was able to move all extremities without discomfort. It was noted that the resident's non-skid socks had been applied incorrectly. Staff reapplied the socks. The resident was referred to therapy for evaluation and treatment.

A physical therapy evaluation dated January 2, 2024, revealed that the resident had unspecified abnormalities of gait and mobility, muscle weakness and pain. The assessment summary noted that the resident was evaluated and treated after a fall on January 1, 2024. It was noted that the resident presented with a decline in functional ability, increased low back pain and was at risk for falls.

A review of a physical therapy service note dated January 12, 2024, indicated that nurse aides alerted therapy that they were having difficulty transferring Resident B1 off the toilet. Therapy assisted the nurse aides into the wheelchair with the assistance of another therapy staff member. The task was completed with dycem (a non-slip surface) placed under the resident's feet to ensure that her feet remained on the floor. The resident's transfer status was changed to transfer assistance of two staff with a rollator walker and the use of a hoyer (mechanical lift) lift as needed. The resident's care plan was updated at this time with this change in transfer status.

A facility investigation report and nursing documentation dated January 15, 2024 at 6:45 AM revealed that staff lowered the resident to floor during a transfer to the bathroom. The resident was then seated on the floor with her legs extended in front of her. She was able to move all extremities without pain or limiting range of motion. Resident B1 stated that her knees gave out. The nurse practioner was notified. The resident was placed into her wheelchair via a mechanical lift. A request for another physical therapy screen was sent to therapy for evaluation and treatment. The report indicated that the resident's transfer status was changed on January 12, 2024, indicating that the resident required the assistance of two staff with transfers, and, as needed, use of the hoyer lift for transfers. Employee 12, a nurse aide admitted that she did not review the resident's care card (kardex) prior to starting her shift and transferred the resident by herself.

A review of an employee witness statement dated January 15, 2024, revealed that Employee 12 stated, "I was walking Resident B1 to the bathroom and had to lower her to the floor so I slid her down my legs. She didn't hit anything."

Physical therapy was notified after this fall for an additional evaluation. The evaluation, dated January 17, 2024, indicated that the resident needs extensive assistance for sit to stands from the wheelchair. The resident tends to have extensive toe out of the right lower extremity, unable to weight shift to correct.

A review of an "interviewer statement" (between nursing administration and Employee 12) dated January 15, 2024 revealed, Resident B1 is an assist for transfers/ambulation. On January 15, 2024, approximately 6:45 AM Employee 12, nurse aide, stated that she lowered the resident to the floor. Employee 12 transferred Resident B1 as a one assist. Employee 12 stated that she did not check the communication book at the beginning of the shift to see if there were any changes for the resident's ADL status.

During an interview March 12, 2024, at approximately 3 PM the Director of Nursing (DON) confirmed that Resident B1 required the assistance of two staff members for transfers and on January 15, 2024, Employee 12 transferred the resident by herself The DON stated that Employee 12 was interviewed regarding the incident, and Employee 12 stated that she did not check Resident 2's care card to ascertain the resident's transfer status prior to transferring her. Employee 12 was suspended pending investigation.

A review of an employee disciplinary record dated January 18, 2024 revealed that Employee 12's work performance was not up to established professional standards. The employee was reeducated and returned to work.

A facility incident report dated February 4, 2024 at 12:45 AM revealed that staff identified a dark purple bruise was on the resident's left inner thigh measuring 10 cm x 5 cm. Resident B1 reported pain rated at a 4 out of 10 pain scale rating. The intervention planned was to monitor the site until resolved. The resident was also noted to be receiving daily anticoagulant therapy, Coumadin (dose dependent on lab results).

A review of nursing documentation dated February 4, 2024 at 05:40 AM "Dark purplish bruise remains to mid left thigh inner aspect. Denies pain at this time. No further bruising noted at this time."

A review of a therapy progress note dated February 5, 2024, revealed that the resident was seen on this date, seated in her wheelchair complaining of pain rated at an 8 out of 10 pain in her "hernia" (a hernia usually happens in your abdomen or groin, when one of your organs pushes through the muscle or tissue that contains it. It may look like an odd bulge that comes and goes during different activities or in different positions. It may or may not cause symptoms, such as discomfort or pain) area, the left lower quadrant. Therapy noted that the medical team was made aware. Seated bilateral lower exercises were limited due to the resident's left lower quadrant pain which also affected her lower back. The resident was returned to her room.

Therapy notes dated February 8, 2024, revealed that "the resident was hesitant to participate in physical therapy session, repeatedly stating that she does not "feel like herself", unable to tolerate activity to be able to pivot and walk."

Physical therapy notes dated February 12, 2024, revealed "the resident is reluctant to trial stands from the wheelchair due to overall decreased motivation and complaints of back pain stating, "it hurts pretty bad."

A review of physical therapy notes dated February 13, 2024 revealed that the "resident requires maximum assistance for toileting. The resident not appearing appropriate for consistent transfers with assistance of 2 staff. Nursing staff was educated on orders for the use of the hoyer lift for all transfers."

Physical therapy notes dated February 14, 2024 revealed that "due to complaints of pain, fear of falling and overall muscle weakness, \ was unable to complete therapy session. She reports pain in her back area as an 8 out of 10 scale."

A nursing note dated February 18, 2024 at 6:15 P.M. revealed that the "resident complaining of left knee pain stated she bumped it while at an activity yesterday, resident does not want to move it or allow nursing staff to move it, resident requested a warm compress for her knee and nursing staff provided the compress, resident stated it was feeling better with the warmth. asked resident if she would like to elevate it and she said no it hurts to move, offered resident Tylenol and she wanted to see if the warm compress would work or not before taking Tylenol. resident also refused to get into bed at this time. RN supervisors notified and RN supervisor assessed knee. The nurse practioner was notified and ordered a left knee x-ray."

The x-ray of the knee was completed February 19, 2024 and negative for a fracture.

A review of physical therapy notes dated February 20, 2024, revealed that the resident had limited standing tolerance due to complaints of left knee pain.

Physical therapy notes dated February 21, 2024, revealed that Resident B1 remained in bed throughout the morning, declining to get out of bed due to fatigue and left extremity pain. Bed exercises were attempted. The resident was not helping during mobility, and was described as anxious and resistive due to complaints of lower extremity pain and fatigue. The resident did not give specific description of the pain and then begins to state she was not felling well.

Physical therapy notes dated February 23, 2024, revealed that "The resident was approached in the morning and again in the afternoon for PT services. She is hesitant and resistive to PT services, complaining of fatigue and left extremity pain at rest. She is becoming behavioral with even the attempt to move the wheelchair. She begins to yell that she is having pain in her left extremity. The resident was yelling in pain when the therapist was moving her feet on the wheelchair rests. Therapy services were discontinued at this time due to not making progress."

A review of the resident's February 2024 medication administration record (MAR) revealed that staff administered the prn (as needed) Tylenol 325 mg, two tabs, to Resident B1 on February 4, 2024, at 11:22 AM and 6:05 PM and February 17, 2024, at 5:11 PM for complaints of pain.

A review of the resident's March 2024 MAR revealed that staff administered the as needed Tylenol 325 mg tabs, to Resident B1 on March 6, 2024 at 2:32 PM

A review of nursing documentation dated March 7, 2024 at 11:33 AM revealed a physician order for x-ray of left hip due to the resident's complaints of left hip pain.

Prior to the notation of this physician order for an x-ray of the resident's left hip, there was no documented evidence in the clinical record of an assessment of the resident's ongoing pain by licensed professional nursing staff. Since the resident's falls on January 1, 2024, and January 15, 2024, the resident had been complaining of pain in left side and left extremity and decreased participation in physical therapy and ADLs. According to the resident's January 2024 and February 2024 MAR nursing was medicating the resident with Tylenol for complaints of left sided pain. However, there was no documented evidence that the facility's licensed professional nursing staff had consulted with the physician regarding the resident's ongoing signs and symptoms of potential injury and the potential need for further diagnostics and treatment.

A review of an x-ray report of the resident's left hip and pelvis dated March 7, 2024 for Resident B1 revealed an acute fracture of the femoral neck. The physician was contacted and the resident was sent to the hospital for evaluation and treatment.

A review of hospital documentation dated March 7, 2024 revealed that "\ presented to the emergency department after she was found to have a left femoral neck fracture at her nursing home. Resident reportedly had her last known fall in January and had been complaining of significant left leg pain since that time. They had previously only x-rayed her femur and knee and did not x-ray of the left hip. This is a 93-year-old woman presenting with several weeks of left leg pain and difficulty ambulating patient has had multiple falls in the month of January \ and has been having left leg pain and requiring a Hoyer lift. Physical exam did not show any other obvious injuries or tenderness does have significant tenderness of the left hip. X-rays confirmed the left femoral neck fracture. Orthopedics and Trauma Surgery consulted Trauma Surgery admitted the patient plan for likely operative intervention of the hip by Orthopedics."

A review of a CT (computed tomography scan is a medical imaging technique used to obtain detailed internal images of the body) dated March 8, 2024 revealed the following:

1. A mildly comminuted fracture (a comminuted fracture refers to a bone that is broken in at least two places. Comminuted fractures are caused by severe traumas) of the left femoral neck is present with 1/2 bone width lateral displacement, impaction and various angulation.

2. Focal hematoma (A collection of blood outside the blood vessels) in the left iliacus (The iliacus is a flat, triangular muscle which fills the iliac fossa) to the fracture, measuring up to 3.6 cm.

Orthopedics was consulted by the emergency department and the resident was to proceed to OR (operating room) within 24 hours. Left leg held in shortened and externally rotation position compared to contralateral leg, (+) pain with log roll.

The resident had surgery March 8, 2024. The orthopedic surgical report revealed that
"\ with several months of decline in ambulatory status and ongoing pain. She was found to have a chronic left femoral neck fracture. It was believed that this occurred approximately 3 months ago. Prior to her decline in ambulation she was a limited ambulator
with the use of a walker. Options which include nonoperative treatment as well as Girdlestone (Girdlestone procedure, the orthopedic surgeon removes the hip bone and ball, leaving patients without a hip joint) and close. versus hemiarthroplasty. We discussed
that due to this being a chronic fracture as well as her health status both cognitively and physically she may do better with a Girdlestone procedure. After discussion with the family the decision was made to proceed to a Girdlestone they are aware that she will not have a hip but we will be able to be a limited ambulator with bed-to-chair transfers and short ambulation with the help of her walker."

During a telephone interview March 12, 2024 at 12 PM, the resident's representative stated that her mother has had a steady decline in her health since her first fall on January 1, 2024. She stated that her mother was in constant pain that was not addressed by the facility. By the time of the second fall on January 15, 2024, the resident's ambulation and transfer abilities had decreased. The resident's representative stated that she reported her concerns regarding her mother's ongoing pain to the facility nursing staff, but those reports were most mostly ignored by the facility.

During a telephone interview March 14, 2024 at 10 A.M. the resident's other daughter stated that she lives locally and visited her mother daily. She stated that since her mother's falls in January 2024 her mother's ADL abilities declined. She stated that after the falls her mother could no longer stand and ambulate by herself. The resident's daughter stated that her mother complained about pain and nursing staff said "they could not do anything about it."

The facility failed to ensure that Employee 12, a nurse aide, demonstrated knowledge of the resident's individual needs and used techniques and skills to maintain resident safety identified on the resident's care plan for providing assistance with transferring.

The facility failed to ensure that licensed professional nursing staff consistently assessed the resident's health status, including her ongoing complaints of pain and declines in functional status and ADL abilities, after two falls, to timely identify potential signs and symptoms of injury, and coordinate with other members of the interdisciplinary team, including the physician, to ensure that the resident received timely treatment at the level required for the resident's serious injury.

A review of the clinical record of Resident A8 revealed admission to the facility on October 1, 2018, with diagnoses of a psychotic disorder (conditions that affect the mind, where there has been some loss of contact with reality) with delusions (a false belief or judgment about external reality) dysphagia (difficulty swallowing food or liquid), and dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) with agitation.

A review of the resident's quarterly MDS dated December 6, 2023, revealed that the resident was severely cognitively impaired with a BIMS score of 3.

A review of the resident's current comprehensive plan of care, which was not dated when reviewed during the survey ending March 12, 2024, indicated that Resident A8 was at risk for elopement due to wandering behaviors. The resident self-propelled in the wheelchair was noted to display fidgety and restless behaviors. The resident had a history of wandering into other resident rooms. The care plan noted that if the resident wanders into other resident rooms she is to be assisted toward her room and placed back to bed and provided an activity bag that contained magazines and word search books.

A review of Resident A8's clinical record revealed nursing note dated March 3, 2024, at 9:53 PM written by Employee 15, LPN, indicating that staff witnessed the resident drinking from a bottle of aloe peri wash while in the hallway of the West wing.

A written report entitled Unusual Event, written by Employee 15, indicated Employee 16, an LPN, witnessed the resident drinking aloe peri wash. The resident was sucking at the end of the container like a bottle. The peri wash was taken from the resident. The physician assistant was made aware and poison control was contacted. Poison control advised to have resident drink water and observe the resident for any nausea or vomiting.

A review of the MSDS (material safety data sheet) for the periwash indicated that if swallowed call physician immediately and rinse mouth and throat with water.

A statement written by Employee 16, LPN indicated "This nurse was walking towards the nurses station when witnessing resident attempting to drink out of a peri wash bottle. This nurse immediately took bottle from resident. The spray mechanism on the bottle was missing but screw on cap was on the bottle. A nurse aide provided the resident with water to drink. This nurse provided the LPN assigned to the resident with information and immediately alerted the RN supervisor."

A telephone interview conducted with Employee 16, LPN, on March 12, 2024, at 5:30 PM revealed that Employee 16 stated that the resident obtained the peri wash bottle from the linen cart that was located in the hallway. She stated they looked but never found the spray mechanism from the bottle.

Clinical record documentation from the facility's behavior management team dated March 4, 2024, revealed a note written by the DON which indicated the new intervention developed in response to this incident, was to attach a cup holder to the resident's wheelchair so the resident may have access to drinking while self-propelling in the hallway. A note written by Employee 17, LPN, also indicated that a cup holder would be added to the resident's wheelchair to provide more beverages.

It was determined through interview with the facility's DON and corporate nurse on March 12, 2024, at 6:30 PM that nursing staff had left the personal care item, periwash on the linen cart, where it was accessible to the resident self-propelling in the corridor. Following the incident, the facility provided education to nursing staff, on March 5, 2024, to ensure that personal care items are stored in the resident's room and not on the linen cart where they may be accessible to residents and mishandled or consumed.

The facility was aware that Resident A8 self-propelled about the facility and displayed restless and figidity behavioral symptoms but nursing staff failed to secure personal care supplies to prevent this cognitively impaired wandering resident from accessing and drinking periwash.



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

28 Pa. Code 211.5 (f) Medical records






























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

1. The facility is unable to retroactively correct this deficiency.
2. a. Facility residents have the ability to be affected.
b. Environmental audit and care plan review of identified cognitively impaired wandering residents.
3. a. An in-service education program was conducted by the DON for nursing staff on identifying and addressing a resident's change in condition, the importance and expectation of communicating changes to a resident's care plan or transfer status at shift change for interdisciplinary team.
b. Audit of current staff training programming to ensure nursing competencies. Identified gaps in education corrected.
c. Alert charting implemented to facilitate increased communication and awareness of potential resident changes.
d. Personal care items removed from linen carts.
e. Linen carts stored out of the hallway when active care is not occurring.
4. a. The DON or designee will review nursing documentation and alert charting during am clinical meeting to ensure that any trends or possible changes of condition are presented to the IDT team, including the medical provider, to ensure that the resident receives timely treatment five times per week x 3 weeks, weekly x 3 weeks, and monthly x 3 months.
b. QI department will conduct audit of linen carts to ensure no personal items are kept on carts and they are out of the hallways when not in use twice weekly x 3 weeks, monthly x 3 months.
c. The RNAC, or designee will audit 4 care plans to ensure accurate transfer status weekly x 3 weeks, monthly x 3 months.
5. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed: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(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 observations, review of the facility's planned written menus, menu extensions, and select facility policy, and staff interviews, it was determined that the facility failed to follow planned menus, failed to ensure that the facility's dietitian periodically updated the planned menus to reflect variety, the preferences of the current resident population and nutritional adequacy and failed to assure consistent availability of food to serve the emergency menu in the event of an emergency.

Findings included:

A review of the current facility census at the time of the survey on March 12, 2024, revealed 165 residents were currently residing in the facility.

Review of the facility's Week 3 lunch menu for Tuesday March 12, 2024, revealed that the planned menu included breaded baked fish, rice pilaf, buttered carrots, broth, and red white and blue poke cake.

However, the observation of the lunch meal on March 12, 2024, at 12:00 PM revealed that unbreaded pollock (fish filet) was served in place of the breaded baked fish.

Further observation of the lunch tray line revealed a steam table pan of water with individual prepackaged single units of pureed turkey floating in the water in the pan. When a puree consistency diet was needed, the dietary employee removed the plastic packaging and emptied the contents onto the residents plate.

Further Review of the facility's Week 3 lunch menu extension for "puree consistency" for Tuesday March 12, 2024 revealed that the planned menu did not include an extension for pureed diets for portion sizes and nutritional content.

Interview with the dietary manager at this time confirmed that the substitution of unbreaded pollock for the lunch meal was made because the original entree item, breaded fish, was not received in the weekly food order. She stated that she orders food, based on the weekly menu, but the food order gets changed at the corporate level and she does not know about the changes until the food order arrives at the the facility. She further stated that she received several cases of prepackaged single portion premade puree protein, assorted meats, from a local hospital. She was unable to provide the preparation instructions or serving size planned for the product and the reason for the substitution of puree turkey, for the fish.

The dietary manager stated that the facility does not maintain a current a substitution log despite making frequent substitutions to the menu because the facility does not have the food planned on the menu.

Review of the facility's Substitution Record for March 2024 revealed that today's lunch planned menu entree, baked breaded fish, was not on the substitution log.

A review of a facility dietary policy for "emergency feeding plan", dated April 17, 2020, and noted as revised "2023" revealed that the dietary department shall be able to meet the nutritional needs of the residents during a disaster. Menus shall be established for residents that can be prepared with or without pre-preparation or cooking equipment. A sufficient food, 3 day supply of emergency food is located in the disaster inventory.

A review of the facility's disaster plan included 3 days of menus and a list of "disaster food inventory" to include all the foods to be in storage to manage the noted menus for the facility residents.

An observation of the dietary department dry storage areas as well as the freezers on March 12, 2024, revealed the three day emergency food supply for the 165 residents included two cases of canned ravioli, a case of grape jelly and 3 cans of kidney beans. There was no frozen food designated as emergency food supply.

During an interview with the CDM at the time of the observation, she confirmed that the facility does not current have a 3 day emergency food supply. She stated that the emergency food supply is frequently used when dietary staff does not have enough food to prepare resident meals routinely. She stated that she has not been able to replace the designated emergency food supply from the food ordered and received at the facility.

Interview with the registered dietitian on March 12, 2024, at 1:00 PM the RD confirmed that she did not approve the menu changes for March 12, 2024, lunch meal. She stated that she preforms only clinical dietary duties and the CDM runs the kitchen. The menu changes were completed by the food service director and she was unable to confirm that the menu/recipes were reviewed for nutritional adequacy, portion sizes, variety, and appropriate combinations for each therapeutic and mechanically altered diet provided to residents at the facility. She further could not provide the nutritional data for the donated pre-packaged puree protein portions or the preparation directions .

Interview with the administrator on March 12, 2024, at 1:00 PM confirmed that the facility was unable to provide evidence that the facility's registered dietitian periodically reviewed and updated the menus, that the facility followed the planned menus as written, that the facility maintained a 3-day emergency food supply and that the facility prepared pureed foods to maintain nutritive value and appearance and served portion sizes of pureed foods to meet nutritional needs of residents.


28 Pa. Code 211.6 (a) Dietary services.

28 Pa. Code 201.18 (e)(2)(3) Management





























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

Breaded fish was added to the facility substitution log upon discovery on 3/12/24. Menu extensions for the current menu cycle will be reviewed and revised as necessary by the facility RD. Emergency food supply will be replenished and the RD will review the emergency menu.

Facility residents have the potential to be affected by this practice.

Food Service Managers will be re-educated concerning documenting substitutions, complete menu extensions and emergency menu/food supply by the NHA or designee. RD or designee will audit substitution log weekly to validate compliance with nutritional adequacy of substitution and documentation of same. RD or designee will audit menu extensions for completion prior to the beginning of each new menu cycle. Food Service Director or designee will audit emergency food supply weekly to validate adequacy and maintain par levels through the ordering process. Audit results will be reported to the NHA. Concerns will be corrected upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.90(g)(1)(2) REQUIREMENT Resident Call System: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.
§483.90(g) Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from-

§483.90(g)(1) Each resident's bedside; and
§483.90(g)(2) Toilet and bathing facilities.
Observations:

Based on observation, resident and staff interviews and a review of select facility policy, it was determined the facility failed to consistently provide a fully functioning call system to maintain direct communication from the resident to the caregivers for six of 22 residents sampled (Residents A1, A2, A3, A4, A5, and A6)

Findings include:

A review of facility protocol regarding Call Light Response/Purposeful Rounding Expectations dated February 16, 2024, indicated the following:

All call bells must be answered in a timely manner. 15 minutes or less is the facilities. Goal as expressed by the Resident Council in order to promote quality of life to the residents.

All facility staff are responsible to answer call bells. Anyone out on the unit walking by a room can stick their head and ask what the resident needs. Social service activities, dietary maintenance, office staff etc.

Do not turn off a call bell until the resident's need is being met. This means the call bell cannot be turned off and staff say they will be back. Staff are to go into a room and ask what the need is, even if the staff members on their way to do something else. It is encouraged that staff lets the residents know they care and they are working to get the need met.

Call bells must be placed within reach at all times. This means when in bed or in a wheelchair.
All nurse aides, LPN's and RN's are responsible to carry pagers and answer call bells in a timely manner. Additional pages are carried by ancillary staff and auditing will occur more frequently on all shifts.

Charge nurses and RN's MUST be responsible for ensuring call bells are answered in a timely manner. This means assisting the nurse aids and ensuring they are not extended call bells.
Accountability is key. The RNS must make sure the LPNS accountable and the LPNS must make the nurse aids accountable.

Those that are assigned must have pagers on, the pagers must be audible, not on vibrate or silent and staff must look at them and answer them.

Those who do not carry pages should be looking at the marquis every time they step on to a unit and assist with any resident's needs if able.

Upon arrival on the Pavilion unit at approximately 8:45 AM resident room numbers were scrolling across the marquis indicating call bell were activated and residents required/requested assistance.

At that time, Resident A2 was heard yelling for help from her room.

Nursing employees 1, 2, 3, 4, 5, 6, 7, and 8 were present on the unit and when interviewed and observed, none of these staff was in possession of a pager. Interviews with these employees at this time, these nursing staff members stated that they become aware that a resident's call bell is ringing by looking at the marquis, but confirmed that they are not able to see if a call bell is ringing, when when they are not in the hallway to see the marquis. Employees 6 and 7 stated that there are not enough functioning pagers for nursing staff.

Interview with Resident A2 on March 12, 2024, at approximately 1:30 PM revealed that she sometimes has to wait for over an hour for nursing staff to answer her call bell.

Interviews with Residents A3, A4, A5 and A6 throughout the day of the survey on March 12, 2024, revealed that these residents stated at times it takes a quite while for nursing staff to answer their call bells.

Interview with Employee 9, a nurse aide, at 5:00 PM on March 12, 2024, a nursing employee who wished to remain anonymous, confirmed that the facility does not ensure that all nurse aides have pagers. She did not have one in her possession at the time of the interview. The employee stated that very few licensed nurses assist nurse aides with answering the call bells. This nursing employee also stated that it would make things more efficient if they were able to see and hear the call bells when a resident activated their call bell and required assistance.

Observation on the West unit at 2:30 PM revealed that nursing Employees 10, 11, 12, 13, and 14 did not have their pagers in their possession to respond to call bells.

Upon request at the time of the survey ending March 12, 2024, the facility provided random call bell audits to the survey team which revealed no concerns will call bell wait times, despite multiple residents reporting concerns regarding long wait times.

A review of the facility regulatory compliance history, revealed that the same deficient practice was cited by the State Survey Agency during a survey on October 22, 2022, whereas the call bell system was not properly utilized by failing to ensure staff were aware of the requirement of using a pager to respond to residents' requests for assistance via the nurse call bell system. At that time, the facility reported that the problem was corrected by audits to ensure staff were wearing the pagers and had use of Walkie talkies. The same concern was again identified by the State Survey Agency on August 11, 2023, when the facility failed to ensure the nursing staff were in possession of pagers to be alerted to the call bells. The facility reported correction by ensuring the pagers were properly charged and functioning and they would contact a vendor to evaluate the call bell system.

During interview with the administrative staff at 7:00 PM on March 12, 2024, the NHA was unable to demonstrate that the facility provides pagers to all nursing staff to ensure that the facility consistently maintained a functioning system to maintain direct communication between residents and their caregivers. The NHA also stated that the facility's call bell system no longer has the ability to generate a report of call bell response and wait times, and a repair of the call bell system is not in the facility's capital budget.


28 Pa. Code 205.28 (c)(1) Nurses' station

28 Pa. Code 211.12 (c) Nursing services

28 Pa. Code 201.18 (b)(1)(3)(e)(2.1)(3) Management







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

Facility cannot retroactively correct the observation.

Facility residents have the potential to be affected by this practice.

Maintenance Director or designee will complete an audit of call system pagers to validate an adequate supply of functioning pagers is available to staff. Nursing staff will be re-educated by the Director of Nursing or designee concerning the expectation to a) wear pagers while on duty and b) report issues related to function or availability promptly to the nursing supervisor for resolution. RN Shift Supervisor or designee will conduct a random audit of staff pager compliance five times weekly for three weeks and monthly for three months to validate compliance with pager utilization. Social Services Director will conduct five random resident interviews weekly for three weeks and monthly for three months to validate response time satisfaction. Concerns will be corrected upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

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 observation, staff interview and a review of CMS guidelines, it was determined that the facility failed to maintain acceptable practices for the storage, preparation, and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness on the Pavilion Unit Resident Pantry and West Nursing Care Unit (two of three resident units) and the facility's kitchen and in the service of unpasteurized eggs to residents.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

During observations of the Pavilion Unit resident pantry room on March 12, 2024, at 11 AM, revealed that inside of the refrigerator, the shelves and door storage units, were dirty with food debris and were sticky to touch. There were two opened water bottles, an open soda bottle that were unlabeled as to whom they belonged on the door. There was a tray with 3 sandwiches dated March 10, 2024, on top of second tray of food on the top shelf that were not labeled to identify to whom they belonged. On the second shelf there was an unlabeled/undated personal covered plastic food container of a red/brown food, an unlabeled/undated plastic container of macaroni salad, a plastic grocery bag with an uncovered plate of lasagna, unlabeled and undated, and an undated opened bottle of prune juice.

In the freezer section there was a unlabeled/undated, large styrofoam container with food, 4 unlabeled/undated frozen dinner meals and a small container of ice cream undated/unlabeled on the door of the freezer. There was a large therapeutic ice pack, used for resident care stored under the shelf in the freezer.

During observations of the West unit resident pantry the seal on the refrigerator door was observed to broken and did not seal fully. There were multiple sandwiches in the vegetable crisper drawer with dated March 10 and March 11, 2024, that were not labeled to whom they belonged. There were 2 plastic bags as well as a zipped lunch tote containing unlabeled and undated foods in the refrigerator.

There was a sheath for a thermometer noted on top of the microwave but no thermometer located on top or around the microwave in the room to take temperatures of reheated/heated foods for safety.

According to the Center for Clinical Standards and Quality/Survey & Certification Group
Survey and Certification Memo dated May 20, 2014 CMS provided interpretive guidance and Procedures for Sanitary Conditions, Preparation of Eggs in Nursing Homes.

CMS guidance for Nursing Homes: Skilled nursing and nursing facilities should use pasteurized shell eggs or liquid pasteurized eggs to eliminate the risk of residents contracting Salmonella Enteritidis (SE). The use of pasteurized eggs allows for resident preference for soft-cooked, undercooked or sunny-side up eggs while maintaining food safety.

In accordance with the Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA) standards, skilled nursing and nursing facilities should not prepare nor serve soft-cooked, undercooked or sunny-side up eggs from unpasteurized eggs. Signed health release agreements between the resident (or the resident ' s representative) and the facility that acknowledges the resident's acceptance of the risk of eating undercooked unpasteurized eggs are not permitted. Pasteurized eggs are commercially available and allow the safe consumption of eggs.

(1) unpasteurized eggs must be cooked until both the yolk and white are completely firm; For all other forms of egg preparation, including hot holding of eggs, and pooling (combining) of eggs for recipes where more than one egg is broken and the eggs are pooled and used as an ingredient immediately before baking, such as in a meat loaf mixture, muffins or cake, the eggs must be pasteurized or thoroughly cooked to an internal temperature of 160(71

Observation of the facility refrigerator March 12, 2024 at 10 AM revealed a box containing 15 dozen unpasteurized eggs.

During an interview with the facility CDM at the time of the observation confirmed that the facility does not purchase pasteurized eggs. She state that the unpasteurized eggs are used to make fried eggs for residents and was unable to state that the CMS guidelines for thorough cooking were consistent met while preparing or cooking with unpasteurized eggs.

Observation of the freezer in the facility kitchen revealed a large build up of ice on the ceiling around the light as well as on the ceiling light. There was a large build up of ice on a plastic bench/shelf unit under the fan.

An interview with the Nursing Home Administrator (NHA) on March 12, 2024, at 2:15 PM, confirmed that the resident pantries should be maintained in a sanitary manner and freezer should be free from ice buildup to maintain appropriate temperatures.



28 Pa. Code 201.18 (e)(2.1) Management

28 Pa. Code 211.6 (f) Dietary Services










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

Pavilion refrigerator was cleaned and unlabeled food items were discarded, ice pack was removed upon discovery. West wing refrigerator seal was repaired, unlabeled food items were discarded and thermometer was replaced upon discovery. Walk-in freezer ice was removed by the maintenance department upon discovery.

Facility residents have the potential to be affected by this practice.

Facility staff will be re-educated concerning these requirements, and the need for food items contained in unit pantries to be labeled and dated. Dietary staff designated to deliver snacks to the units nightly will monitor unit refrigerators, log temperatures and discard any unlabeled or undated items. Food Service Director or designee will audit unit pantries weekly for three weeks and monthly for three months to verify compliance with labeling/dating or items. Maintenance Director will audit walk-in freezer for ice buildup/defrost need weekly as a preventative maintenance task/. Concerns will be corrected upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

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 observation and staff and resident interview it was determined that the facility failed to ensure that each resident received food prepared by methods that conserve flavor and appearance for one resident out of 22 sampled (Resident B2).

Findings included:


Clinical record review revealed that Resident B2 was admitted to the facility on May 23, 2023 with diagnosis to include diabetes. The resident was receiveing dialysis treatments and had a current physician order, dated May 23, 2023, for a renal diet.

A review of the resident's current care plan in effect at the time of the survey revealed that the resident attends dialysis treatments on Tuesdays, Thursdays and Saturdays, leaving the facility at 5:30 AM

During an observation of the refrigerator in the facility's dietary department, on March 12, 2024 at 9:15 AM revealed a breakfast tray containing scrambled eggs, apple sauce and apple juice.

During an interview at the time of the observation, the CDM (certified dietary manager) stated that Resident B2 leaves the facility at 5:30 AM for dialysis treatments and her breakfast is cooked and left in the refrigerator. When she returns to the facility much later in the morning, the resident's breakfast tray is heated up in the microwave and served to the resident. The CDM confirmed that the facility does not prepare a fresh meal for the resident upon the resident's return from dialysis to ensure the palatability of the food, regardless of the foods served that may not be palatable after reheating, particularly in the microwave. The CDM also stated that the facility does not serve the resident an early breakfast to allow the resident to eat breakfast before leaving for dialysis.

During an interview with this resident upon return the resident's return from hemodialysis on March 12, 2024, at approximately 1:30 PM the resident stated that the reheated food items served "taste awful." The resident stated that the facility does not provide her anything to eat before she leaves the building at 5:30 AM, and the dialysis center does not allow food. She resident stated that she does not return to the facility until 11:30 AM and then finally gets breakfast, sometimes just a little before lunch is served.

The facility failed to consistently serve the resident palatable, attractive, and appetizing food, at appropriate times, to encourage optimal intake and meal satisfaction.





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

Resident B2 was interviewed for preferences related to breakfast meal times and types of food. Resident B2's care plan was updated concerning these preferences.

Residents receiving dialysis services with chair times requiring a breakfast meal time modification will be interviewed to determine their preference of accommodation. Preferences will be care planned and communicated to dietary for implementation.

Dietary staff will be re-educated by the Food Service Director or designee concerning implementing accommodation for dialysis resident meal times based on their expressed preferences. Continental breakfast prior to dialysis and prepared meal upon return will be made available. CDM or designee will audit dialysis meal administration weekly for three weeks and monthly for three months to validate compliance with preferences. Concerns will be corrected upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

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

Based on a review of clinical records and medication error reports and staff interview, it was determined that the facility failed to timely notify the resident's interested representative of a fall for one out of 22 residents sampled (Resident B1).

Findings include:

A review of Resident B1's clinical record revealed that the resident was admitted to the facility on September 18, 2023, with diagnoses to include, osteoarthritis, spinal chronic kidney disease, dementia and a history of falling.

A facility investigation report and nursing documentation dated January 1, 2024, at 1:41 PM revealed that staff found Resident B1 on the floor in her room, between her bed and the wheelchair, after the resident attempted to self transfer. Nursing noted that the resident sustained no apparent injury, denied discomfort and was able to move all extremities without discomfort. It was noted that the resident's non-skid socks had been applied incorrectly. Staff reapplied the socks. The resident was referred to therapy for evaluation and treatment.

There was no documented evidence a the time of the survey ending March 12, 2024, that the designated representative was timely notified of this fall.


Refer F726


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

28 Pa. Code 201.29 (a) Resident rights



















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

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Grandview Nursing & Rehabilitation agrees with the allegations and citations listed on the statement of deficiencies.

Grandview Nursing & Rehabilitation maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Grandview Nursing & Rehabilitation's written credible allegation of compliance.

By submitting this plan of correction, Grandview Nursing & Rehabilitation does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Grandview Nursing & Rehabilitation reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

1. Resident B1's POA/RP was notified of the fall which occurred by LPN on 1/1/24 at 1456 as documented in the incident record.
2. Facility wide audit of incidents from 3/17/24 completed to ensure resident representatives were notified consistent with his or her authority as indicated by 483.10(g)(14)(i)-(iv)(15).
3. Licensed nursing staff were educated on §483.10(g)(14) Notification of Changes. Clinical follow up tracking developed to facilitate increased communication of resident incidents.
4. The DON or designee will review previous days incidents during AM clinical meeting to ensure resident representatives were notified five times per week x 3 weeks, weekly x 3 weeks, monthly x 3 months.
5. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met

483.40(d) REQUIREMENT Provision of Medically Related Social Service: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.
§483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.
Observations:

Based on clinical record review and staff interviews, it was determined the facility failed to provide therapeutic social services to promote the highest practicable mental and psychosocial well-being of one of the 22 residents reviewed (Residents A7).

Findings include:

A review of the clinical record of Resident A7 revealed admission to the facility on March 4, 2024, with diagnoses of cancer of the face and neck, for which the resident was receiving
radiation treatments, a tracheostomy tube due to tracheostomy (a surgical procedure where a surgeon creates a hole through the neck and into the windpipe in order to deliver oxygen to the lungs safely. A tracheostomy tube is placed into the windpipe to deliver oxygen), adjustment disorder with depressed mood and history of substance abuse with opioid dependency.

During an interview with a facility staff member, who did not wish to be identified for fear of retaliation, on March 12, 2024, at approximately 10 AM the employee stated that Resident A7 had expressed thoughts of wanting to kill himself. The resident reportedly made this statement, to the occupational therapist, Employee 13, on March 6, 2024, but staff were told not to report this concern because the resident did not have a plan to harm himself.

Further review of Resident A7's clinical record during the survey ending March 12, 2024, revealed no documented evidence that the resident had expressed thoughts or feelings of wanting to kill or harm himself.

Interviews with the facility nursing home administrator and director of nursing on March 12, 2024, at 10:00 AM revealed they had no knowledge of any resident who expressed thoughts of wanting to kill or harm themselves at that time.

Following survey inquiry, the NHA reported via telephone on March 13, 2024, that Resident A7 did convey thoughts of self harm to an employee on March 6, 2024. According to an interview with the NHA on March 13, 2024, the NHA verified, that Employee 13, the occupational therapist, was evaluating Resident A7 on March 6, 2024, and administered the PHQ-9 (patient health questionnaire - a validated interview that screens for symptoms of depression. It provides a standardized severity score and a rating for evidence of a depressive disorder assessment, used to address mood distress).

A statement written by Employee 13 dated March 13, 2024, following surveyor inquiry during the survey ending March 12, 2024, indicated she was evaluating Resident A7 on March 6, 2024 and administered the PHQ-9 assessment, which usually involves the Social Worker according to the RAI Process (resident assessment instrument). The resident informed Employee 13 that he had thoughts that he "would be better off dead" but reported no plans or thoughts of self harm. Employee 13's late statement indicated that she attempted to call Social Service staff on March 6, 2024, to report the results of the assessment but she was unable to reach her. Employee 13 indicted that called the resident's unit and Employee 7 a licensed practical nurse (LPN) indicated she would tell the Social Worker about the resident's statement.

The NHA stated during interview via telephone at 12:30 PM on March 13, 2024, that the Social Worker reportedly completed and documented the results of the PHQ-9 on March 6, 2024, however, when the resident's record was reviewed during the survey on March 12, 2024, there was no documented evidence to support this.

The Social Worker placed an entry in the PHQ-9 on March 13, 2024, which read "Resident reports feeling frustrated over his medical diagnosis. He reports this being new to him and feeling ugly with the trach. The resident reports no pain or intent of suicidal ideation. Resident was referred to PGS (PsychoGeriatric Services) for medication management and the physician assistant was notified." This was confirmed in the clinical record as a late entry. The social worker signed that she completed the assesment on March 13, 2024, follow surveyor inquiry, and planned on March 14, 2024, to refer the resident to psychiatric services for an evaluation.

The resident made statements of psychosocial/emotional distress on March 6, 2024, but there was no documented evidence of timely assessment of the resident's psychosocial status and needs and the provision of therapeutic social services to promote the resident's psychosocial well being by assisting the resident in coping with his distress and feelings of frustration regarding this medical condition and physical appearance.



28 Pa. Code 211.5(f) Medical records

28 Pa. Code 211.16 (a) Social Services.










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

Resident A7 was seen by psychiatric Nurse Practitioner on 3/14/24, reaffirming that resident remains without thoughts of self-harm and his diagnosis is being managed through an interdisciplinary behavior support approach.

Director of Nursing or designee will audit PHQ-9 completions since 3/12/24 to identify any residents requiring behavioral intervention or counseling and validate that those services have been initiated. Concerns will be corrected upon discovery.

Facility Social Worker will be re-educated concerning these requirements and the expectation to provide therapeutic social services to residents assessed as requiring them. PHQ-9 scores of 10 or above will be referred to contracted counseling provider. Nurse Assessment Coordinator or designee will audit PHQ-9 completions weekly for three weeks and monthly for three months to identify need and validate documented evidence of therapeutic social services intervention. Concerns will be corrected upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.25(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on review of clinical records, select facility policy and reports, and staff and family interviews it was determined that the facility failed to timely evaluate increased pain and evaluate potential underlying causes and potential etiology for one resident out of 22 sampled (Resident B1).


Findings include:

A review of the facility policy for pain assessment and management reviewed January 2024 revealed that the purpose of this procedure is to help the staff identify pain in the resident, and to develop interventions that are consistanet with the resident's goals and needs and that address the underlying causes of pain. Pain management is a multidisciplinary care process that includes the following: assessing the potential for pain; effectively recognizing the presence of pain; identifying the characteristics of pain; addressing the underlying causes of pain; developing and implementing approaches to pain management; identifying and using specific strategies for different levels and sources of pain; monitoring for the effectiveness of interventions; and modifying approaches as necessary. Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition and when there is onset of new pain or worsening of existing pain.


A review of Resident B1's clinical record revealed that the resident was admitted to the facility on September 18, 2023, with diagnoses to include, osteoarthritis, spinal chronic kidney disease, dementia and a history of falling.

The resident was cognitively intact with a BIMS score of 14 (brief interview for mental status - a tool to assess cognitive function, a score of 13 to 15 indicates the resident is cognitively intact) according a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 23, 2023. The resident required the assistance of staff with activities of daily living, including bathing, bed mobility and transfers, ambulated with assistance with a rollator walker and had no pain and was receiving non-narcotic pain medication.

The resident had a current physician order dated September 18, 2023, for Tylenol ER 650 mg (a non narcotic pain medication) one by mouth every 12 hours for chronic pain management.

The resident's care plan noted identified that the resident had knee pain, dated September 18, 2023, with a goal that the Resident B1 will be as pain free/comfortable as possible. Interventions planned were the use of the facility's pain Obseravtion tool per facility policy, monitor location of pain, duration, intensity and quality of pain, monitor what makes the pain better or worse, notify the physician of any unrelieved pain, pain medications as ordered, utilize pain scale, offer non-pharmacological intervention prior to as needed pain meds. These non-pharmacological interventions included repositioning the resident and pillows under calves,

An incident investigative report and nursing documentation dated January 1, 2024, at 1:41 PM revealed that staff found Resident B1 on the floor in her room, between her bed and the wheelchair, after attempting to self transfer. Nursing identified no apparent injury, the resident denied discomfort, and was able to move all extremities without discomfort. The resident was referred to therapy for evaluation and treatment.

A pain assessment dated January 9, 2024, indicated that Resident B1 had no pain.

An investigative report and nursing documentation dated January 15, 2024, at 6:45 AM revealed that nursing staff lowered Resident B1 to the floor during a transfer to the bathroom. The resident was sitting on the floor with her legs extended in front of her. She was able to move all extremities without pain or limiting range of motion. Resident B1 stated that her knees gave out. The nurse practioner was notified. Staff placed the resident into her wheelchair via a mechanical lift. A request for a physical therapy screen was sent for evaluation and treatment.

A review of a therapy progress note dated February 5, 2024, revealed that Resident B1 was seen seated in her wheelchair, complaining of pain rated at an 8 out of 10 on the pain scale. The resident indicated that the pain was in her "hernia" area, her left lower quadrant. Therapy made the medical team aware. Seated bilateral lower exercises were limited due to the resident's left lower quadrant pain which also affected her lower back. Staff returned to the resident to her room.

Therapy notes dated February 8, 2024, revealed that "the resident was hesitant to participate in physical therapy session, repeatedly stating that she does not "feel like herself", unable to tolerate activity to be able to pivot and walk."

Physical therapy notes dated February 12, 2024, revealed that the "resident is reluctant to trial stands from the wheelchair due to overall decreased motivation and complaints of back pain stating, "it hurts pretty bad."

A review of physical therapy notes dated February 13, 2024, revealed "resident requires maximum assistance for toileting. The resident not appearing appropriate for consistent transfers with assistance of 2 staff. Nursing staff was educated on orders for the use of the hoyer lift for all transfers."

Physical therapy notes dated February 14, 2024, reveled that "due to complaints of pain, fear of falling and overall muscle weakness, \ was unable to complete therapy session. She reports pain in her back area as an 8 out of 10 scale."

A nursing note dated February 18, 2024 at 6:15 P.M. revealed "resident complaining of left knee pain stated she bumped it while at an activity yesterday, resident does not want to move it or allow nursing staff to move it, resident requested a warm compress for her knee and nursing staff provided the compress, resident stated it was feeling better with the warmth. asked resident if she would like to elevate it and she said no it hurts to move to move, offered resident Tylenol and she wanted to see if the warm compress would work or not before taking Tylenol. resident also refused to get into bed at this time. RN supervisors notified and RN supervisor assessed knee. The nurse practioner was notified and ordered a left knee x-ray."

The x-ray of the left knee completed February 19, 2024, was negative for a fracture.

Physical therapy notes dated February 20, 2024, revealed that the resident had limited standing tolerance due to complaints of left knee pain.

A review of physical therapy notes dated February 21, 2024, revealed that "\ remained in bed throughout the morning, declining to get out of bed due to fatigue and left extremity pain. Bed exercises were attempted. The resident not helping during mobility, anxious and resistive due to complaints of lower extremity pain and fatigue. The resident not giving specific description of pain and then begins to state she is not felling well."

Physical therapy notes dated February 23, 2024, revealed "The resident was approached in the morning and again in the afternoon for PT services. She is hesitant and resistive to PT services, complaining of fatigue and left extremity pain at rest. She is becoming behavioral with even the attempt to move the wheelchair. She begins to yell that she is having pain in her left extremity. The resident was yelling in pain when the therapist was moving her feet on the wheelchair rests. Therapy services were discontinued at this time due to not making progress."

There was no documented evidence that nursing timely conducted a comprehensive pain assessment of the resident due to the resident's ongoing complaints of left sided extremity pain, inability to participate in therapy due to pain, decreased functional abilities and a decline in activities of daily living to and conduct appropriate monitoring for effectiveness of the resident's current pain relieving regimen, to identify how and when to monitor the resident's symptoms and degree of pain relief and assure timely consultation with the physician regarding the adequacy and continued appropriateness of the resident's pain management.

A review of nursing documentation dated March 7, 2024 at 11:33 AM revealed a physician order for x-ray of left hip due to complaints of left hip pain.

The results of the resident's x-ray of the left hip and pelvis dated March 7, 2024, revealed an acute fracture of the femoral neck. The physician was contacted and she was sent to the hospital for evaluation and treatment.

During a telephone interview March 12, 2024 at 12 PM, the resident's representative stated that her mother had a steady decline in her health since her first fall on January 1, 2024. She stated that her mother has been in constant pain that was not addressed by the facility. By the time of her mother's second fall on January 15, 2024, her mother's ambulation and transfer abilities had decreased. The resident's representative stated that her reports of her mother's pain made to the facility were mostly ignored by nursing staff.

During a telephone interview March 14, 2024, at 10 AM with the resident's other interested representative, another daughter, who visits daily, the resident's daughter stated since her mothers falls in January 2024, her mother's ADL abilities have declined. She stated that after these falls, her mother could no longer stand and ambulate by herself. The resident's daughter stated that her mother complained about her pain to the staff, but nursing staff said "they could not do anything about it."

The facility failed to promptly recognize the resident's increased pain and the negative affect it was having on the resident's functional abilities and failed to address the pain promptly.

Refer F726


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

28 Pa. Code 211.10 (a)(d) Resident care policies

28 Pa. Code 211.5 (f) Medical records









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

1. The facility is unable to retroactively medicate a resident for pain.
2. Facility wide audit of MDS Section J for residents identified as being at risk for pain. Pain assessments are complete and interventions currently in place are appropriate.
3. An in-service education program was conducted by the DON and Therapy Director with nursing department staff and therapy department staff on the facility's Pain Management policy/procedure, identification of possible causes and communication to ensure resident's pain needs are met inter-departmentally.
4. The DON, or designee will complete 5 random pain assessment audits to verify possible causes are identified and appropriate pain interventions are in place weekly x 3 weeks, monthly x 3 months.
5. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.

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 clinical records and staff and family interview, it was determined that the facility failed to consistently monitor resident weights to timely identify and act upon a resident's weight loss, and implement necessary nutritional support to promote acceptable nutritional parameters for one resident out of 22 sampled (Resident B1).

Findings include:

A review of Resident B1's clinical record revealed that the resident was admitted to the facility on September 18, 2023, with diagnoses to include, osteoarthritis, spinal chronic kidney disease, dementia and a history of falling.

The resident was cognitively intact with a BIMS score of 14 (brief interview for mental status - a tool to assess cognitive function, a score of 13 to 15 indicates the resident is cognitively intact) according a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 23, 2023. The resident required the assistance of staff for activities of daily living, including bathing, bed mobility, transfers and eating.

The resident's of care for nutrition initiated September 18, 2023, and revised January 5, 2024, and March 7, 2024, revealed the goal that Resident B1's meal intake will be >75% and the resident's weight will be stable between 165-175 lbs. Interventions planned dated September 18, 2023, were to assist with meals as needed, monitor intake as needed, monitor weights and labs as available, notify MD of any significant weight changes as needed, offer menu alternates/ selective menus/ always available menu, provide with food/beverage preferences as available, and provide with diet as ordered.

A review of the resident's weight record revealed that an admission weight, September 18, 2023, the resident's weight was 172 pounds. On February 5, 2024, the resident's weight was 173.2 pounds. On February 27, 2024, the resident's weight declined to 157.6, reflecting 15.6 lb, or 9.01% loss of body weight in approximately 22 days. A reweight was obtained March 2, 2024, and the resident's weight had declined to 156.4, an additional 1.2 lbs weight loss, a total of 16.8 lbs or 9.7 lbs weight loss in loss in approximately one month.

A review of the resident's meal intakes for January 2024 indicated that Resident B1 consumed 51% to 75% with multiple meal intakes not recorded by staff.

A review of Resident B1's documented meal intakes for February 1, 2024 through February 27, 2024, revealed documented meal intakes of 0% to 50 % on most days with multiple meal intakes not recorded by staff. The resident refused meals on several days according to the documentation.

A review of nutritional assessment and note dated February 7, 2024 at 2:34 P.M. revealed that
Resident B1 was assessed for a Quarterly Nutrition assessment revealing no nausea, vomiting, or diarrhea was noted. The resident had fair to good oral intakes and consumes greater than 50% of most meals. The resident's current Body Weight was 173 lbs; Jan: 176 lbs (-1.7% loss /3 pounds #); Nov: 175# (-1.1%/2#). The entry noted that the resident had no significant weight change x 30, 90 days. Goal remains to provide adequate nutrition to maintain overall health. Will follow up as needed. The resident was not meeting the care planned goal of more than 75% meal consumption, but there was no revision to the resident's plan of care at that time.

At the time of the survey ending March 12, 2024, there were no further nutritional assessments conducted or documentation from the dietitian regarding the resident's weight loss noted on February 27, 2024, and again on March 2, 2024. There was no documented evidence that the physician was notified of the weight loss. The resident's weight dropped below the goal range of 165-175 lbs but there was no evidence of reassessment by the dietitian or revision of the resident's care plan.

There was no evidence at the time of the survey ending March 12, 2024, that the facility had timely acted upon the resident's weight loss and developed and implemented nutritional support measures to maintain acceptable nutritional parameters and deter progressive weight loss.

During a telephone interview on March 14, 2024, at 10 AM the resident's daughter stated that she visited her mother daily. She stated that since her mother's falls, her ADL abilities have been declining. She stated that early in January 2024 Resident B1 was feeding herself, but after the falls, the resident was in a lot of pain and did not want to feed herself. The resident's daughter stated that, at that time she came into the facility daily and assisted her mother with some meals. The residents daughter stated that facility staff knew about her mother's decreased meal intake decline and abilities to feed herself, but did not put interventions in place to address these declines.

Interview with the Director of Nursing on March 12, 2024, at 2 P.M. confirmed that the facility was unable to demonstrate timely response to the resident's weight loss.


28 Pa Code 211.10 (c) Resident care policies.

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








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

1. The facility is unable to retroactively assess resident weight loss due to resident's discharge.
2. Facility wide audit from 3/12/24 conducted to identify like residents. Concerns addressed upon discovery.
3. a. Dietitian and IDT will review weight triggers during morning clinical meeting to prompt the need for a dietary assessment
b. Weekly weight meeting with IDT team, including the dietitian created to identify at-risk residents, review weights from previous week for weight changes, ensure nutritional interventions were implemented as indicated, care plans are updated and MD and RP are notified.
c. Direct care staff were educated on obtaining re-weights within 24-48 hours of being notified.
d. Maintenance ensured scales were calibrated appropriately.
4. The DON, or designee, review weight reports and residents with weight change to ensure that changes are identified and appropriate interventions have been put in place weekly x 3 weeks, monthly x 3 months.
5. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.


483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on a review of clinical records, select incident reports and the facility's abuse prohibition policy it was determined that the facility failed to thoroughly investigate an injury of unknown source to rule out abuse, neglect or mistreatment as a potential cause of the injury presented by one resident out of 22 sampled (Resident B1).


Findings include:

Resident B1 was admitted to the facility on September 18, 2023, with diagnoses of chronic kidney disease, osteoarthritis (when cartilage of the joint is worn down) of right shoulder, unsteadiness on feet, unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) without behaviors and psychotic mood disturbance (conditions that affect the mind, where there has been some loss of contact with reality).

A review of a quarterly MDS (minimum data set- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 9, 2024, indicated the resident was cognitively intact with a BIMS of 14 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact).

A review of the facility's policy titled "Abuse Prevention" dated January 27, 2024, revealed that "physical abuse- includes hitting, slapping, punching, kicking." and "verbal abuse- any use of oral, written, or gestured language that includes willfully disparaging and derogatory terms to residents or their families." The policy also indicates that "allegations of abuse or neglect which are uncovered by investigation and tracking of incident reports will be investigated further and corrective actions taken according to the facility's abuse policies and procedures."

A review of a facility report dated February 4, 2024, at 12:45 AM revealed that the resident presented a "Dark purple bruise to inner aspect of left thigh. The resident reports 4/10 pain around bruise site. Hardened tissue noted to medial aspect of bruise. Bruise measures 10 cm long x 5 cm wide. Current treatment: Monitor bruising to left inner thigh until resolved. Immediate Action Taken was to monitor bruising to left inner thigh until resolved. Coumadin (medication to prevent blood clots) was on hold related to high laboratory value."

Nursing progress notes dated February 5, 2024, at 8:42 AM revealed that the resident complained of left lower quadrant pain resulting in a pain level of 8 out of 10, with 10 being the worst pain. At the time of this complaint the resident was seated in her wheelchair eating breakfast. Although the bruise was identified on February 4, 2024, there was no documented evidence of an evaluation or IDT discussion of the affect the bruise and its relationship to the resident's continued complaints of left lower quadrant pain.

Nursing documentation later in the day on February 5, 2024 at 1:16 PM indicated the RN spoke to the resident about the bruise on her thigh and the resident denied staff misconduct when questioned by the RN, but there was no documented evidence that the facility had asked the resident about staff transfer and/or care techniques or other incidents that may have occurred that could have caused the injury.

A review of therapy documentation dated throughout the month of February 2024 revealed that the resident continued to complain of left sided pain and displayed decreased functional abilities and ability to participate in activities of daily living declined. Therapy was discontinued February 23, 2024, due to lack of progress and the resident's inability to participate.

A review of an x-ray report of the resident's left hip and pelvis dated March 7, 2024, revealed Resident B1 had an acute fracture of the femoral neck. The physician was contacted and the resident was sent to the hospital for evaluation and treatment.

At the time of the survey ending March 12, 2024, there was no documented evidence that the facility had timely conducted a thorough investigation into the resident's injury of unknown source. The facility did not interview staff to determine the possible cause of the bruising. facility did not conduct an investigation to determine the causative factor of this bruise to determine if the bruise was caused by injury or potential abuse. The facility did not conduct interviews with facility staff to possibly determine the cause of the bruising and rule out abuse, neglect or mistreatment as a potential cause of the resident's injury.

An interview March 12, 2024 at 3 P.M., the Director of Nursing confirmed that Resident B1's injury of unknown origin was not investigated to rule out abuse, neglect or mistreatment as the potential cause.


28 Pa. Code 201.14(a) Responsibility of licensee

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

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

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












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

1. The facility reported the incidence of an injury of unknown origin after completing a thorough investigation to rule out abuse, neglect or mistreatment.
2. The facility has determined that all residents have the potential to be affected.
3. An in-service education program was conducted by the DON and the NHA with direct care staff on reporting injuries, investigation initiation to rule out abuse, neglect, or staff mistreatment. When the facility is made aware of an injury of unknown origin an investigation will begin immediately.
4. The DON or designee will review nursing documentation and alert charting during AM clinical meeting to ensure that any injuries are identified, properly investigated and reported to the appropriate people five times per week x 3 weeks, weekly x 3 weeks, and monthly x 3 months.
5. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.

51.3 (f) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.
Observations:

Based on a review clinical records and select facility policy and interviews with residents and facility staff it was determined the facility failed to include accurate and sufficient detail in reporting situations, which could compromise quality assurance or resident safety to the State Licensing Agency, PA Department of Health, Division of Nursing Care Facilities for one out of 22 residents reviewed. (Resident A1)

Findings included:

A review of the clinical record revealed Resident A1 was admitted to the facility on January 17, 2024, with diagnoses diabetes mellitus (commonly referred to as diabetes, is a group of metabolic diseases in which there are high blood sugar levels over a prolonged period), end stage renal disease (is a medical condition in which the kidneys fail to adequately filter waste products from the blood and a transplant or dialysis is required) dependent on renal dialysis (procedure is used to remove toxic wastes from the blood), difficulty walking and anxiety disorder.

A review of an admission MDS (Minimum Data Set Assessment a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 22, 2024, revealed that the resident was cognitively intact with a BIMS score of 14 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact).

A review Resident A1's clinical record revealed a nursing progress note dated March 9, 2024, at 2:40 PM written by the nursing supervisor, Employee 1, which read, "Aides were in room making bed, when pulling up the sheets, a bag of what looked like marijuana was noted. Bag was brought to nurse, RN Supervisor was notified, Director of Nursing (DON) was notified. Currently baggie locked in medication room."

A review of the facility policy entitled Suspicion of Crime (no review date) revealed that the facility will report to the State Survey Agencies (SAs) and Law Enforcement (LE) within 24 hours if the events that cause reasonable suspicion do not result in serious bodily injury to a resident, the covered individual shall report the suspicion not later than 24 hours after forming reasonable suspicion. A crime is defined by law of the applicable political subdivision where a long term care facility is located. Applicable facilities must coordinate with their local law enforcement entities to determine what actions are considered crimes within their political subdivision.

Interview with Resident A1 on March 12, 2024 at 4:00 PM revealed that the resident was concerned that she was receiving a police citation for the possession of an illegal substance. She was concerned that the police were notified about the bag of marijuana and asked if that was necessary. Resident 97 was made aware facility policy regarding suspicion of a crime occurring in a long term care facility. .

Interview with the DON on March 12, 2024 at 4:30 PM revealed she was in he facility on the day the bag, suspected to be marijuana, was found and stated that she locked the bag in the medication room. The DON stated that she did not contact the police as noted in the facility policy.

Interview with the NHA on March 12, 2024, revealed that the NHA stated that he contacted the police on March 11, 2024, but confirmed that the facility did not report the event to the State Survey Agency. He also confirmed that the facility did not notify the police within 24 hours as noted in the policy.

The facility failed to timely contact law enforcement upon finding and suspicion of an illegal substance according to facility policy and failed to notify the State Survey Agency of the incident and of the facility's actions to rectify the situation.




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

Event was reported to local authorities on 3/11/24 as indicated, and to the Department of Health on 3/12/24.

Facility residents have the potential to be affected by this practice.

Leadership team will be re-educated by the NHA or designee concerning the Suspicion of Crime policy. DON or designee will audit 24 hour report and events during daily clinical meeting to identify situations that may require further investigation and reporting. Events meeting reporting criteria will be reported to appropriate agencies in accordance with regulation.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

§ 201.18(d) LICENSURE Management.:State only Deficiency.
(d) The governing body shall adopt effective administrative and resident care policies and bylaws governing the operation of the facility in accordance with legal requirements. The administrative and resident care policies and bylaws shall be in writing; shall be dated; and shall be reviewed and revised, in writing, as often as necessary but at least annually. The policies and bylaws shall be available upon request, to residents, resident representatives and for review by members of the public.

Observations:

Based on a review of the facility's diet manual and staff interviews it was determined the facility failed to review and revise, in writing, the facility's diet manual and corresponding food and nutrition department policies and procedures, at least annually.

Findings include:

During an interview March 12, 2024 at 11 A.M., the facility Registered Dietitian confirmed that the facility's diet manual (a manual which establishes and promulgates the administrative and operation procedures governing the provision of therapeutic diets and provide guidance and direction to the health care providers and food service personnel in requesting and providing therapeutic diets), has not been reviewed/updated in the past 12 months.




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

Annual facility policy and procedure review occurred through QAPI/Governing body on 3/23/23 and 1/16/24. Facility RD reviewed the diet manual on 3/25/24.

Facility residents have the potential to be affected by this practice.

Leadership team will be re-educated by the NHA or designee concerning annual policy review and ensuring department manuals contain signature sheets from that review. NHA or designee will audit policy review verification during Q4 annually to validate compliance and schedule annual review.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.


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