Pennsylvania Department of Health
CHESTNUT HILL LODGE HEALTH AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations

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CHESTNUT HILL LODGE HEALTH AND REHABILITATION CENTER
Inspection Results For:

There are  221 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.
CHESTNUT HILL LODGE HEALTH AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated Survey in response to a complaint, completed on February 28, 2024, it was determined that Chestnut Hill Lodge Health and Rehabilitation Center, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.




 Plan of Correction:


483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly: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)(4)- Dispose of garbage and refuse properly.
Observations:

Based on observations and staff interviews, it was determined that the facility failed to ensure that garbage and refuse was disposed of properly.

Findings Include:

An initial tour of the Food Service Department was conducted on February 25, 2024, at 9:15 a.m. with the Assistant Food Service Director, Employee E4, which revealed the following:

Observations of the trash area revealed a large trash compactor. Continued observations revealed a significant build-up of trash, food, and debris surrounding and along the perimeter of the trash compactor.

Interview with the Assistant Food Service Director, Employee E4, on February 24, 2024, at 9:20 a.m. confirmed the observations.

28 Pa. Code: 201.14(a) Responsibility of licensee.

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







 Plan of Correction - To be completed: 04/17/2024

This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrong doing, nor does it- reflect agreement with the facts and conclusions stated in the statement of deficiencies.
1.] The area around the compactor has been cleaned.
2.] All residents have the potential to be affected if the compactor area is not kept clean.
3.] The Maintenance, Housekeeping and Dietary Staff will be educated on the importance of keeping the compactor area clean.
4.] NHA or designee will conduct audits, weekly x 4 weeks then monthly x 2 months of the dumpster/compactor area to ensure that the area around it is being kept clean. Results of audits will be brought to QAPI to determine if there is need for further action.


483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on observations, resident and staff interview, it was determined that the facility failed accommodate the residents' needs by failing to provide proper bedding for sleeping for one of 34 residents reviewed (Resident R83).

Findings include:

Review of the clinical record revealed that Resident R83 revealed that the resident was admitted to the facility on February 10, 2024 with the diagnoses of chronic obstructive pulmonary disease with respiratory infection (a lung infection), high blood pressure, and muscle weakness.

It was observed on February 25, 2024, at 10:00 a.m. Resident R83 appeared cold as he laid in bed using his coat as a blanket. The resident explained last night his blanket got wet and the aides told him there were none left. The resident said he used his coat as a blanket all night through the morning and was cold.

At the time of the observation and interview with Resident R83 nurse aide Employee E15 confirmed that the resident was without a blanket.


28 Pa. Code: 201.29(j) Resident rights




 Plan of Correction - To be completed: 04/17/2024

This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrong doing, nor does it- reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1.] Resident R83 was provided a blanket
2.] All residents have the potential to be affected if linens/blankets are not available on units.
3.] Nursing staff will be educated on where to find blankets/linens on their unit and in the facility should their unit run out of blankets/linens.
4.] Director of Environmental Services, or designee will conduct audits weekly x 4 weeks then monthly x 2 months to ensure an adequate supply of linens/blankets are available on the nursing unit. Results of audits will be brought to QAPI to determine if there is need for further action.

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, review of clinical records, observations, and staff interviews, it was determined that the facility did not complete a comprehensive care plan for one of 35 residents reviewed (Resident R128).

Findings include:

Review of Resident R128's clinical record revealed that the resident was admitted to the facility on September 14, 2022 with the diagnoses of Colostomy Status (an operation that creates an opening for the large intestine, through the abdomen, to treat disease or to relieve an obstruction or to prevent the remaining bowel from contamination by fecal matter), and Dysphagia (difficulty swallowing) .

Review of physician order dated March 31, 2023, for Residnet R128, indicated an order stating, "Resident has a colostomy on the Right Upper Quadrant".

On February 27, 2024, at 12:23 p.m. Resident R128 was observed having his colostomy bag attached to his colostomy site.

Review of the care plan for Resident R128, on February 27, 2024, at 2:12 p.m., revealed that there were no focus, interventions, and outcomes (goals) care- planned for Colostomy care.

On February 27, 2024, at 2:12 p.m., interview with Employee E9, a Licensed Nurse, confirmed the above findings.

28 Pa Code 211.10 (c)(d) Resident care policies

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



 Plan of Correction - To be completed: 04/17/2024

This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrong doing, nor does it- reflect agreement with the facts and conclusions stated in the statement of deficiencies.
1.] Facility has care planned the colostomy care for resident R 128
2.] All residents with an colostomy have the potential to be affected. Nursing will conduct an audit of all residents with an ostomy to ensure the ostomy is care planned.
3.] Professional Nurses will be educated on the need to care plan for colostomy care.
4.] DON or designee will conduct audits of all new admissions and new colostomy orders of existing residents to ensure ostomy care s care planned in the resident's medical record. Audits will be conducted weekly x 4 weeks then monthly x 2 months. Results of audits will be brought to QAPI to determine if there is need for further action.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on review of facility policy, review of clinical record, observations, and staff and resident interviews, it was determined that the facility failed to ensure a dependent resident received assistance with activities of daily living for one of 34 residents reviewed (Resident R40).

Findings Include:

Review of facility policy "ADL (Activities of Daily Living) Care - Supporting Resident" revised 01/31/2023 revealed residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Review of Resident R40's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 25, 2024, revealed the resident was cognitively intact and had diagnoses of muscle weakness and abnormalities of gait and mobility.

Continued review of the MDS revealed Resident R40 had impairment in functional range of motion to the lower extremities and was dependent on staff for transfers to and from bed, rolling left and right, toileting hygiene, and lower body dressing. Resident R40 required supervision/touching assistance with personal hygiene.

Review of Resident R40's comprehensive care plan dated February 23, 2024, revealed the resident was at risk for decline in functional mobility, strength, balance, and endurance.

Interview and observation on February 26, 2024, at 1:03 p.m. with Resident R40 revealed the resident was still in bed and the resident reported to not have received morning care yet.

Interview on February 26, 2024, at 1:45 p.m. with nurse aide, Employee E3, confirmed this employee did not assist Resident R40 with morning care. Further interview revealed that the staff member assigned to provide care for Resident R40 was late and therefore did not provide care in a timely manner.

Interview on February 27, 2024, at 12:45 p.m. with Resident R40 revealed on February 26, 2024, the resident wanted to be assisted out of bed and into the chair to have dinner. Further interview revealed staff did not assist resident out of bed until after dinner at 8:15 p.m. and subsequently was not put back into bed until 11:30 p.m.

Review of Resident R40's clinical record revealed a nursing note dated February 26, 2024, at 6:00 p.m. by Registered Nurse, Employee E6, that confirmed staff failed to assist the resident out of bed in a timely manner. Registered Nurse, Employee E6, stated in the nursing note that R40 kept ringing the call bell to get out of bed prior to the dinner trays coming to the floor. Registered Nurse, Employee E6, told Resident R40 that staff could get the resident up after dinner trays were delivered and subsequently collected.

Continued review of the nursing note by Registered Nurse, Employee E6, revealed "the resident [Resident R40] continued to ring the bell ... [Resident R40] was asked what time she normally gets OOB (out of bed) and said 2 pm. I told her she can't blame the current shift for not getting her OOB earlier, and she didn't ask on 3-11 shift until right before dinner. [Resident R40] continues to ring her call bell as soon as it's turned off and her light has been answered multiple times to tell her they will get her out of bed right after dinner."


28 Pa. Code 211.10 (d) Resident Care Policies

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





 Plan of Correction - To be completed: 04/17/2024

This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrong doing, nor does it- reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1.] ADL's on resident R40 were done.
2.] All residents on B Wing requiring care with ADLs have the potential of being affected.
3.] Nursing Staff will be educated on performing ADL care in a timely manner.
4.] DON or designee will conduct audits weekly x 4 weeks then monthly x 2 months to ensure residents on B Wing who require assistance with ADL are receiving ADL care timely. Results of audits will be brought to QAPI to determine if there is need for further action.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to clarify physician orders related to insulin, for one of two residents reviewed related to insulin (Resident R14).

Findings include:

Review of facility policy, "Guidelines for Diabetes Mellitus" dated reviewed June 2023, revealed that glucose monitoring guidelines include to "check blood sugar level and frequency" as ordered and for "facility protocol in place for physician notification with specific parameters for notification."

Review of Resident R14's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated January 19, 2024, revealed that the resident was admitted to the facility on September 20, 2021, and had diagnoses including diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose) and schizophrenia (mental illness associated with loss of reality contact, delusions and hallucinations). Continued review revealed that the resident received insulin (medication used to lower blood sugar levels) injections every day. Further review revealed that the resident had a BIMS (Brief Interview for Mental Status) of seven, indicating that the resident was severely cognitively impaired.

Review of Resident R14's care plan, dated initiated September 23, 2021, revealed that the resident was at risk for alteration in nutrition/hydration related to diabetes and to monitor for symptoms of hyper or hypoglycemia (high or low blood sugar levels).

Review of physician orders for Resident R14 revealed an order, dated October 28, 2021, for insulin lispro (type of insulin that is fast acting) inject eight units with meals. Continued review of the physician's order revealed that no additional instructions were provided.

Review of Medication Administration Records (MARs) for Resident R14 for February 2024 revealed the following:
On February 1, 2024, at 8:00 a.m. the resident's blood sugar was 98 and the insulin was not administered, documented as "no insulin due;"
On February 1, 2024, at 12:00 p.m. the resident's blood sugar was 99 and the insulin was not administered, documented as "no insulin due;"
On February 2, 2024, at 12:00 p.m. the resident's blood sugar was 78 and the insulin was not administered, documented as "no insulin due;"
On February 3, 2024, at 8:00 a.m. the resident's blood sugar was 128 and the insulin was not administered, documented as "no insulin due;"
On February 3, 2024, at 5:00 p.m. the resident's blood sugar was 61 and the insulin was administered;
On February 4, 2024, at 5:00 p.m. the resident's blood sugar was 77 and the insulin was administered;
On February 5, 2024, at 8:00 a.m. the resident's blood sugar was 77 and the insulin was administered;
On February 5, 2024, at 12:00 p.m. the resident's blood sugar was 71 and the insulin was administered;
On February 5, 2024, at 5:00 p.m. the resident's blood sugar was 98 and the insulin was not administered, documented as "held-below parameters;"
On February 8, 2024, at 5:00 p.m. the resident's blood sugar was 73 and the insulin was not administered, documented as "hold - see nurses note;"
On February 9, 2024, at 8:00 a.m. the resident's blood sugar was 88 and the insulin was not administered, documented as "no insulin due;"
On February 9, 2024, at 12:00 p.m. the resident's blood sugar was 90 and the insulin was not administered, documented as "no insulin due;"
On February 11, 2024, at 12:00 p.m. the resident's blood sugar was 97 and the insulin was not administered, documented as "held-below parameters;"
On February 12, 2024, at 8:00 a.m. the resident's blood sugar was 84 and the insulin was administered;
On February 12, 2024, at 12:00 p.m. the resident's blood sugar was 79 and the insulin was administered;
On February 13, 2024, at 8:00 a.m. the resident's blood sugar was 78 and the insulin was administered;
On February 13, 2024, at 12:00 p.m. the resident's blood sugar was 83 and the insulin was administered;
On February 13, 2024, at 5:00 p.m. the resident's blood sugar was 78 and the insulin was not administered, documented as "no insulin due;"
On February 14, 2024, at 12:00 p.m. the resident's blood sugar was 74 and the insulin was administered;
On February 14, 2024, at 5:00 p.m. the resident's blood sugar was 101 and the insulin was not administered, documented as "held-below parameters;"
On February 16, 2024, at 5:00 p.m. the resident's blood sugar was 105 and the insulin was not administered, documented as "held-below parameters;"
On February 18, 2024, at 5:00 p.m. the resident's blood sugar was 79 and the insulin was administered;
On February 19, 2024, at 8:00 a.m. the resident's blood sugar was 79 and the insulin was administered;
On February 19, 2024, at 12:00 p.m. the resident's blood sugar was 65 and the insulin was administered;
On February 22, 2024, at 8:00 a.m. the resident's blood sugar was 95 and the insulin was not administered, documented as "hold - see nurses note;"
On February 24, 2024, at 8:00 a.m. the resident's blood sugar was 100 and the insulin was not administered, documented as "held-below parameters;"
On February 24, 2024, at 5:00 p.m. the resident's blood sugar was 86 and the insulin was not administered, documented as "held-below parameters;"
On February 25, 2024, at 12:00 p.m. the resident's blood sugar was 98 and the insulin was not administered, documented as "hold - see nurses note."

Review of progress notes, nurses notes and electronic MAR (eMAR) notes for February 2024 for Resident R14 revealed that there was no indication that the physician was notified of the resident's blood sugar levels or that the insulin was not administered on the above dates.

Further review of Resident R14's clinical record revealed that there were no prescribed parameters related to when to notify the physician or when to hold the prescribed insulin.

Interview on February 27, 2024, at 1:37 p.m. the Director of Nursing confirmed that the physician should have been notified when Resident R14's insulin was held/not administered. In addition, the Director of Nursing stated that the resident's insulin order needed to be clarified to include hold and physician notification parameters.

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

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












 Plan of Correction - To be completed: 04/17/2024

This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrong doing, nor does it- reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. R14's insulin orders were clarified with the Physician and parameters are in place.
2. Audits will be completed for all residents with insulin orders to make sure that hold parameters are present for any insulin held.
3. The Nursing staff will be educated on following Physician orders for the administration of insulin and to notify the Physician if the insulin is not administered.
4. DON or designee will conduct audits, weekly x4 weeks and then monthly x2 months of resident's ordered to receive insulin to ensure that their insulin is being administered and Physician is notified of any instances when insulin is not administered. Results of audits will be brought to QAPI to determine if there is need for further action.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

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

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

Based upon interview with resident and staff, review of clinical records and facility policy and procedures, it was revealed the facility failed to ensure that residents who were continent of bladder and bowel on admission received services and assistance to maintain continence for one of 34 resident records reviewed (Resident R122).

Findings include:

Review of the facility's policy titled, "Bladder Incontinence Management Program, last revised October 2023 states the facility policy is to identify residents with urinary incontinence and provide an appropriate incontinence program based on incontinence status, 3-day elimination tracking and competition of a Comprehensive Bowel and Bladder assessment. The same policy instructs to consult therapy if applicable for evaluation of functional needs, develop and implement individualized interventions, discuss goals and interventions with resident and educate staff on toileting plan.

Review of Resident R122's clinical record revealed that the resident was was admitted to the facility on January 13, 2024, with the diagnoses of Type Two Diabetes with ketoacidosis ( a life-threatening complication of diabetes) without coma, malnutrition, unspecified infection of the skin and subcutaneous tissue, and end stage renal (kidney) disease needing hemodialysis (acting as an artificial kidney).

During an interview on February 25, 2024, at 10:12 a.m. with Resident R122, the resident complained about wearing an adult brief and stated, "I do not wear a diaper at home, in the hospital they gave me a commode or a bed pan, but not here, they give me a diaper. They (nursing staff) want me to go in my diaper when I have a BM (bowel movement) and don't want me to use the call bell until I soil myself."

Review of Resident R122's care plan dated January 22, 2024, revealed he was continent of bowel and bladder and indicated the resident was able to let the staff know when he needed to use the toilet. Interventions included meeting his toileting needs with dignity, nursing to check every two hours if the resident needed assistants.

Review of Resident R122's Admission Bowel and Bladder assessment dated January 16, 2024, revealed the prescreening questions asked, "Based on a three- day bowel and bladder pattern observation, if the resident has had any episodes of incontinence, then a "full" assessment must be completed." The resident was documented as not continent of bowel or bladder (incontinent). Further review of the assessment revealed no documented evidence the full assessment was completed.

Interview conducated on February 27, 2024, at 10:30 a.m. with the Infection Control/Nurse Educator, Employee E11 revealed that Resident R122 was incontinent but when shown the care plan the nurse could not explain the discrepancy and confirmed the bowel and bladder assessment was not complete. The nurse also recommended contacting therapy for Resident R122's toileting status needs.

Interview with the Director of Therapy on February 27, 2024, at 1:00 p.m. stated on admission would recommend Resident R122 be a hoyer lifted (mechanical lift) due to his limited functional needs. The therapist also noted the resident had been making great progress in therapy since admission and was able to ambulate with therapy. When the surveyor asked what the requirements would be for using a bed pan it was explained therapy would not have to assess Resident R122 if he chose to use one.

Interview with Nursing aide (NA), Employee E12 on February 27, 2:00 p.m. revealed that she was not aware Resident R122 was continent of bowel and bladder as indicated on the care plan. When asked why he was given a brief not a bed pan, she explained, "He was in a lot of pain when he first came here. I think he was in too much pain. The NA was informed of the resident stating in the hospital they offered him a bed pan or a commode, only here does he wear an adult brief. The aide agreed that she could see him using a bedpan now but was unaware he was continent.

28 Pa. Code 211.10(d) Resident care policies

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




 Plan of Correction - To be completed: 04/17/2024

This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrong doing, nor does it- reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. A Bowel and Bladder Assessment was completed for Resident R122 to identify his toileting needs to promote his continence
2. The DON/designee conducted An audit of new admissions in the past 2 weeks to ensure that their Bowel and Bladder assessments are completed and residents deemed continent will continue to be encouraged to maintain continence with regular toileting , and or use of urinal or bedpan.
3. The nursing staff will be educated by the educator to ensure that Bowel and Bladder Assessments are to be completed in entirety and residents that are continent will be encouraged to maintain continence with regular toileting, and or use of urinal or bedpan.
4. DON/Designee will audit records of a new admissions weekly x4 weeks and then monthly x2 months to make sure that bowel and bladder assessments have been completed and residents that are continent have appropriate care plans to maintain continence . Results of the audits will be submitted to the quality assurance committee to determine if further action is required

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

Based on review of facility policy, review of clinical record, observations, and staff and resident interviews, it was determined that the facility failed to provide residents with respiratory therapy per physician orders for two of two residents reviewed (Residents R40 and R2).

Findings Include:

Review of facility policy "BIPAP (bilevel positive airway pressure - a type of ventilator that helps with breathing by delivering different levels of air pressure to the lungs) and CPAP (continuous positive airway pressure) Policy and Procedure" revised May 2021, revealed BIPAP and CPAP is administered by licensed nurses with a physician's order. BIPAP and CPAP may be prescribed for some residents to augment resident breathing when they have difficulty maintaining adequate ventilation.

Review of Resident R40's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 25, 2024, revealed the resident was cognitively intact and had a diagnosis of obstructive sleep apnea (a condition when your breathing is interrupted or stopped during sleep).

Review of Resident R40's comprehensive care plan revised January 24, 2024, revealed the resident had altered respiratory status/difficulty breathing related to sleep apnea. Interventions dated January 19, 2024, included use of BIPAP.

Review of Resident R40's clinical record revealed a physician order dated February 1, 2024, to apply BIPAP nightly and with naps.

Review of Resident R2's annual MDS dated February 3, 2024, revealed the resident was cognitively intact and had a diagnosis of chronic respiratory failure (a condition where the lungs cannot supply enough oxygen or remove enough carbon dioxide from the blood) with hypoxia (below-normal level of oxygen in your blood).

Review of Resident R2's clinical record revealed a physician order dated February 1, 2024, to apply BIPAP at bedtime and remove in the morning.

Interview on February 25, 2024, at 11:39 a.m. with alert and oriented Resident R27 revealed nursing staff did not apply BIPAP for roommate Resident R2.

Interview on February 25, 2024, at 11:46 a.m. with Licensed Nurse, Employee E14, confirmed Resident R2 reported nursing staff did not apply BIPAP at night on February 24, 2024, and that this was not the first time that has happened.

Interview on February 25, 2024, at 12:04 p.m. with Resident R2 revealed the nurse did not apply BIPAP at night on February 24, 2024. Resident R2 reported using the call bell but the nurse never came.

Interview on February 26, 2024, at 1:30 p.m. with Resident R40 revealed nursing staff did not apply BIPAP machine at night on February 25, 2024.

Interview and observations on February 26, 2024, at 1:36 p.m. with the Director of Nursing, Employee E2, revealed the usage log history on Resident R2's and R40's BIPAP machines confirmed the residents did not have BIPAPs applied on alleged dates.


28 Pa. Code 211.10 (d) Resident Care Policies

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





 Plan of Correction - To be completed: 04/17/2024

This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrong doing, nor does it- reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Facility is unable to retroactively correct this deficiency.
2. The DON/designee conducted an audit of residents with Bipap machines to ensure the BIPAP is being applied as ordered unless the resident refuses the Bipap
3. The nursing staff will be educated by the staff educator on the importance of applying BIPAPs on residents that require them.
4. DON/Designee will conduct random nightly audits of residents using bipaps to ensure that the residents bipap is on as ordered. Audits will be done weekly x4 weeks and monthly x2 months. Results of the audits will be submitted to the quality assurance committee to determine if further action is required

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 observation, interviews with resident and staff and review of clinical records and facility policy, it was determined that the facility failed to ensure pain management was provided to a resident consistent with professional standards of practice, the comprehensive care plan and the resident's preferences for one of 34 resident records reviewed (Resident R230).

Findings include:

Review of facility policy titled "Pain" revised September 2022, stated the facility is committed to reducing physical and psychosocial symptoms associated with pain to assist the resident in achieving their highest practicable level of functioning.

Review of Resident R230 clinical record revealed he was admitted to the facility on February 22, 2024, post discharge from the hospital where he was being treated after experiencing a seizure episode. Resident was noted as awake alert and oriented able to voice his needs and concerns.

Review of Resident R230's current care plan revealed that the resident was care plan for pain related to subdural hemorrhage initiated on February 23, 2024. Goals and interventions included to be pain free targeted date May 27, 2024 . Interventions included the resident communicate with the nursing staff when experiencing pain and to say what works to alleviate pain.

On February 25, 2024, at 1:00 pm surveyor observed resident in bed tearful and upset complaining of severe pain of 9/10 (10 being the most severe). The resident indicated a nurse gave him something for his pain "a while ago" but it never worked. Review of Resident R230 electronic administration record (EMAR) revealed an order for Tylenol, to be given for mild pain, was given at 8:45am for pain documented as 8 out of 10 administered by Licensed Practical Nurse (LPN) Employee E8 . The LPN was immediately interviewed at 1:09 p.m. and explained she had not re-assessed the resident since 8:45 a.m. when she initially administered the Tylenol. "I was busy, and I am getting to it now." The surveyor questioned why the nurse administered Tylenol specified for mild pain when it was documented as severe. The nurse replied she did not know he was in pain.

Interview with the Director of Nursing on February 25, 2025 at 2:00 p.m. stated the nurse should have informed the doctor about his level of pain to provide him comfort and to ease the pain.


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





 Plan of Correction - To be completed: 04/17/2024

This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrong doing, nor does it- reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Resident R230 was assessed by the Physician and he was ordered alternate treatment for his pain.
2. An initial audit of residents receiving pain medication will be completed to ensure that nurses are following up timely after administering pain medication and appropriate follow through is completed if pain is not relieved.
3. The nursing staff will be educated on the importance of timely reassessment of residents that have received pain medication to ensure effectiveness. If there is no relief the nurse should contact the Physician for alternate orders.
4. DON/Designee will conduct random audits of resident's that receive pain medication to ensure that timely reassessment is done for those residents, and that appropriate follow up is done if pain is not relieved. Audits will be done weekly x4 weeks and then monthly x2 months. Results of the audits will be submitted to the QA committee to determine if further action is required.

483.60(e)(1)(2) REQUIREMENT Therapeutic Diet Prescribed by Physician:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(e) Therapeutic Diets
483.60(e)(1) Therapeutic diets must be prescribed by the attending physician.

483.60(e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law.
Observations:

Based on review of facility policy, review of clinical record, observations, and staff and resident interviews it was determined that the facility failed provide food items consistent with the prescribed diet order for one of five residents observed during dining (Resident R40).

Findings Include:

Review of facility diet guide sheet revealed Sunday lunch offerings on February 25, 2024, was breaded chicken, beef chopped steak, baked fish, mashed potatoes, steamed rice, yellow squash, carrots, and tropical fruit. Per the diet guide sheet, a resident on a Renal (a specialized diet for people with kidney problems)/CCD (carbohydrate controlled) diet should receive steamed rice instead of mashed potatoes.

Review of Resident R40's physician orders revealed the resident was ordered a Carbohydrate Controlled/Renal diet dated January 23, 2024.

Review of Resident R40's nutrition assessment dated January 24, 2024, confirmed to continue CCD/Renal diet as ordered by the physician.

Observations on February 25, 2024, at 12:46 p.m. revealed Resident R40's meal ticket confirmed the resident was ordered a Renal, CCD Diet. Further review of the meal ticket indicated the resident was to receive 4 ounces of steamed rice. Further observations of Resident R40's lunch time meal tray revealed the resident was served mashed potatoes.

Interview on February 25, 2024, at 1:00 p.m. with Registered Nurse, Employee E5, confirmed Resident R40 received mashed potatoes instead of rice.

28 Pa. Code 211.6 (a) Dietary Services







 Plan of Correction - To be completed: 04/17/2024

This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrong doing, nor does it- reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1.] Regarding Resident R40; The facility is unable to retroactively correct this deficiency.
2.] All residents on therapeutic diets have the potential to be affected.
3.] Kitchen staff will be educated on the importance of following resident's therapeutic diet orders.
4.] Registered Dietician or designee will conduct audits weekly x 4 weeks then monthly x 2 months of resident's meal trays to ensure therapeutic diets are being followed. Results of audits will be brought to QAPI to determine if there is need for further action.


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