Pennsylvania Department of Health
LECOM AT ELMWOOD GARDENS, LLC
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LECOM AT ELMWOOD GARDENS, LLC
Inspection Results For:

There are  54 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.
LECOM AT ELMWOOD GARDENS, LLC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on March 29, 2024, it was determined that LECOM at Elmwood Gardens, LLC, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on review of facility policy and clinical records, and staff interview it was determined that the facility failed to develop a comprehensive care plan for one of 13 residents reviewed (Resident R27).

Findings include:

A facility policy dated 3/20/24, entitled "Care Plans" indicated that the facility will develop a comprehensive care plan for each resident that includes measurable objectives, and timetables to meet residents medical, nursing, and mental / psychosocial needs of the resident.

Resident R27's clinical record revealed an admission date of 7/1/21, with diagnoses that included diabetes, transient ischemic attack (TIA - minor stroke or mini-stroke with noticeable symptoms going away) and obstructive sleep apnea (a disorder that makes you stop breathing repeatedly during sleep).

Resident R27's clinical record revealed a physician's order 1/15/24, for Seroquel (psychotropic medication - affects the mind) 25 milligram (mg) by mouth at bedtime for depression and anxiety. Another physician's order dated 3/6/24, indicated the Seroquel dosage was increased to 50 mg at bedtime for delusions.

The clinical record lacked evidence that a care plan had been developed to address Resident R27's behaviors and use of Seroquel.

During an interview on 3/28/24, at 11:14 a.m. confirmed that a care plan had not been developed to address Resident R27's behaviors and use of Seroquel.

28 Pa. Code 201.14(a) Responsibility of licensee

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









 Plan of Correction - To be completed: 05/18/2024

R 27's care plan was updated to include the use of Seroquel.

All residents who are on psychotropic medications will be audited by the Director of Nursing/designee to ensure they have a care plan addressing the medication. Care plans will be updated as needed.

Director of Nursing/designee will provide education to the Interdisciplinary Team and the nurses on proper completion/updating of care plans for any changes in psychotropic medications.

Director of Nursing/designee will audit the new physician orders for psychotropic medications and ensure care plans are updated for five (5) days a week for two (2) weeks, weekly for two (2) weeks and monthly for two (2) months.

Nursing Home Administrator will audit Director of Nursing designee to ensure completion of audits.

Ongoing audits will be completed by the pharmacy consultant during monthly reviews and reviewed at the quality assurance meeting.

Results of audit will be reviewed at quality assurance meeting.


483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

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

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

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

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

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

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

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN (as needed) psychotropic (affecting the mind) medication for one of five residents reviewed for unnecessary medications (Resident R158).

Findings include:

A facility policy dated 3/20/24, entitled "Unnecessary Drugs" indicated that non-pharmacological interventions are considered and used when indicated.

Review of Resident R158's clinical record revealed an admission date of 3/19/24, with diagnoses that included anxiety, depression, and gastro-esophageal reflux disease (a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]).

Review of Resident R158's clinical record revealed a physician's order dated 3/19/24, that identified to administer Clonazepam (medication to treat anxiety) 1 milligram (mg) by mouth every 8 hours as needed for anxiety until 4/2/24.

Review of Resident R158's Medication Administration Record (MAR) for March 2024 revealed that the PRN Clonazepam was used 18 times between 3/19/24, and 3/28/24. Review of the March 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions were attempted prior to the administration of the PRN Clonazepam 18 of the 18 times the Clonazepam was utilized in March 2024.

During an interview on 3/28/24, at approximately 2:22 p.m. the Director of Nursing confirmed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Clonazepam 18 of the 18 times it was administered to Resident R158 between 3/19/24, and 3/28/24.

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

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





 Plan of Correction - To be completed: 05/18/2024

R 158's prn psychotropic medication order was updated to include non-pharmacological interventions.

Director of Nursing/designee will review and update all physician orders for all residents receiving prn psychotropic medications to ensure non-pharmacological interventions are completed and documented before the medication is given.

The Assistant Director of Nursing/designee will educate nurses on offering and documenting non-pharmacological interventions before prn psychotropic are given

Director of Nursing/designee will audit the new physician orders for prn psychotropic medications for five (5) days a week for two (2) weeks, weekly for two (2) weeks and monthly for two (2) months to ensure non-pharmacological interventions are documented before giving the medication.

Nursing Home Administrator will audit Director of Nursing/designee to ensure completion of audits.

Ongoing audits will be completed by the pharmacy consultant during monthly reviews and reviewed at the quality assurance meeting.

Results of audit will be reviewed at quality assurance meeting.


483.20(f)(1)-(4) REQUIREMENT Encoding/Transmitting Resident Assessments:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.20(f) Automated data processing requirement-
483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:
(i) Admission assessment.
(ii) Annual assessment updates.
(iii) Significant change in status assessments.
(iv) Quarterly review assessments.
(v) A subset of items upon a resident's transfer, reentry, discharge, and death.
(vi) Background (face-sheet) information, if there is no admission assessment.

483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.

483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:
(i)Admission assessment.
(ii) Annual assessment.
(iii) Significant change in status assessment.
(iv) Significant correction of prior full assessment.
(v) Significant correction of prior quarterly assessment.
(vi) Quarterly review.
(vii) A subset of items upon a resident's transfer, reentry, discharge, and death.
(viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment.

483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.
Observations:

Based on review of the Long-Term Care Resident Assessment Instrument (RAI - provides instructions and guidelines for the completion of Minimum Data Sets [MDS - federally mandated standardized assessments of resident abilities and care, conducted at specific intervals to plan resident care] User's Manual and clinical records and staff interview, it was determined that the facility failed to transmit MDS's to the required electronic system within the mandated time frame for one of 17 residents reviewed (Resident R17).

Findings include:

The RAI User's Manual indicated that Entry, Death and Facility and Discharge tracking MDS's must be completed and transmitted within 14 days of the event date.

Review of Resident R17's closed clinical record revealed an admission date of 10/3/23, with diagnoses that included diabetes, high blood pressure, and congestive heart failure (progressive heart disease that affects the pumping action of the heart resulting in difficulty breathing and tiredness).

Resident R17's clinical record progress note dated 10/17/23, indicated Resident R17 was discharged from the facility to a senior living community.

Review of Resident R17's submitted MDS's included an entry MDS dated 10/3/23, and a state optional / admission MDS dated 10/10/23. The records lacked evidence that a Discharge, Return Not Anticipated MDS was submitted within 14-days of Resident R17's discharge on 10/17/23.

During an interview on 3/18/24, at approximately 11:26 a.m. Registered Nurse Assessment Coordinator confirmed that Resident R17's Discharge, Return Not Anticipated MDS was not submitted within the required timeframe.

28 Pa. Code 211.5(d) Medical records







 Plan of Correction - To be completed: 04/24/2024

I hereby acknowledge the CMS 2567-A, issued to LECOM at Elmwood Gardens for the survey ending March 29, 2024, AND attest that all deficiencies listed on the form will be corrected in a timely manner.


211.12(e) LICENSURE Nursing services.:State only Deficiency.
(e) The facility shall designate a charge nurse who is responsible for overseeing total nursing activities within the facility on each tour of duty each day of the week.

Observations:

Based on review of the facility provided staffing documents and staff interview, it was determined that the facility failed to ensure a charge nurse who is responsible for overseeing total nursing activities within the facility was on each tour of duty each day of the week for 21 of 21 days reviewed (11/5/23, 11/6/23, 11/7/23, 11/8/23, 11/9/23, 11/10/23, 11/11/23, 1/1/24, 1/2/24, 1/3/24, 1/4/24, 1/5/24, 1/6/24, 1/7/24, 3/21/24, 3/22/24, 3/23/24, 3/24/24, 3/25/24, 3/26/24, and 3/27/24).

Findings include:

Review of facility provided staffing information for 11/5/23, 11/6/23, 11/7/23, 11/8/23, 11/9/23, 11/10/23, 11/11/23, 1/1/24, 1/2/24, 1/3/24, 1/4/24, 1/5/24, 1/6/24, 1/7/24, 3/21/24, 3/22/24, 3/23/24, 3/24/24, 3/25/24, 3/26/24, and 3/27/24, revealed the overnight shift lacked a charge nurse to oversee total nursing activities within the facility.

During an interview on 3/29/24, at approximately 11:20 a.m. the Scheduling Coordinator confirmed that the facility failed to meet the required charge nurse staffing on each tour of duty each day of the week.



 Plan of Correction - To be completed: 05/18/2024

Nursing Home Administrator provided education to the Director of Nursing, staffing coordinator and the Supervisors on the requirement for a charge nurse to be on tour for all shifts.

If a call off occurs that results in not meeting the state mandate, the Supervisor on duty will call staff in to work to meet the mandate. A staffing log will be kept reflecting the replace of the Supervisor as needed.

Director of Nursing/designee will audit the daily schedule and staffing log for five (5) days a week for two (2) weeks, weekly for two (2) weeks and monthly for two (2) months to ensure compliance with staffing requirements.

Ongoing audits will be completed by the Nursing Home Administrator during the quality assurance meeting.

Results of audits will be discussed at the Quality Assurance meeting.




Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port