Pennsylvania Department of Health
SARAH REED SENIOR LIVING
Patient Care Inspection Results

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SARAH REED SENIOR LIVING
Inspection Results For:

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SARAH REED SENIOR LIVING - 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 22, 2024, it was determined that Sarah Reed Senior Living 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:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety and sanitation in the walk-in freezer located in the main kitchen.

Findings include:

Review of the facility policy entitled, "Refrigerated And Frozen Storage" dated 2/6/2024, indicated that, "The Food Service Department shall receive all food products in a manner that assures safety and quality of food products. All food items shall be placed on shelves and not on floor of refrigerator or freezer."

Observations made during the initial kitchen tour on 3/19/2024, at approximately 11:00 a.m. revealed that there were several food items on the floor in the walk-in freezer located in the main kitchen.

Interview conducted with the Food Service Director at that time confirmed the food items should not be on the floor in the walk-in freezer.

28 Pa. Code 211.6(f) Dietary services

28 Pa. Code 201.14(a) Responsibility of licensee

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





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

1) The day of deficient practice the food items (individual wrapped muffin, sundae cup, and half a rack of ribs) that had fallen on the freezer floor were picked up and disposed of in the trash immediately.

2) The walk-in freezer was audited/checked for additional food items on the floor.

3) Dietary staff to be educated on facility food storage policy.

4) The walk-in freezer will be audited by the Food Service Director or Designee for items on the floor 1x daily x1 week, 3x weekly x1 week, and 1x monthly for 2 months.

5) Results of audits will be discussed at the Quarterly QA Meeting.

483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary: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(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of 483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
Observations:

Based on review of facility policies, clinical record review and staff interview, it was determined that the facility failed to ensure that a discharge summary, which included a recapitulation of the resident's stay and the resident's discharge status, physician's final diagnosis and prognosis or cause of death was completed for three of three closed clinical records reviewed (Residents CR94, CR95, and CR96).

Findings include:

A facility policy last reviewed 2/15/24, entitled "Discharge Policy and Procedure" indicated that a recapitulation of the resident's stay, a final summary of the resident's status and the disposition of medications would be part of the interdisciplinary summary discharge summary.

A facility policy entitled "Closed Record Policy" dated 2/06/24, indicated that an interdisciplinary discharge summary is to be completed on all discharges from the facility by each member of the interdisciplinary team (IDT) and include: a short summary of resident's stay; final summary of resident status; disposition of medications; IDT on current caseload to sign off with specific instructions; physician's discharge prognosis, discharge diagnosis, cause of death, physician's signature- as applicable; and the summary goes to medical records with the chart.

Resident CR94's closed clinical record revealed an admission date of 12/25/23, with diagnoses that included diabetes (condition related to inadequate insulin and high blood sugars), high blood pressure and heart disease.

Resident CR94's clinical record revealed the resident was discharged from the facility on 1/2/24. Further review of Resident CR94's clinical record, lacked evidence of a discharge summary having been completed which included a recapitulation of the resident's stay and a final summary of the resident's status.

During interview on 3/22/24, at 10:10 a.m. the Director of Nursing (DON) confirmed that Resident CR94's closed clinical records lacked evidence of a discharge summary being completed.


Resident CR96's closed clinical record revealed an admission date of 1/07/24, with diagnoses including a broken rib, altered mental status, cognitive communication deficit, and difficulty speaking.

Departmental progress notes revealed that Resident CR96 ceased to breath on 2/13/24, at the facility.

Resident CR96's closed clinical record revealed that the physician's discharge summary was incomplete and did not include a cause of death.

Resident CR95's closed clinical record revealed an admission date of 2/14/24, with diagnoses including dyspnea (shortness of breath), surgery on the circulatory system, and acquired absence of lung.

Departmental progress notes revealed that Resident CR95 discharged from the facility on 2/14/24.

Resident CR95's closed clinical record revealed that the physician's discharge summary was incomplete and did not include a recapitulation of stay or reason for discharge.

During an interview on 3/22/24, at 11:05 a.m. the DON confirmed that Resident CR96's physician's discharge summary was incomplete and did not include the cause of death and that Resident CR95's discharge summary was incomplete and did not include a recapitulation of stay or reason for discharge from the facility.

28 Pa. Code 211.5(d)(f)(xi) Medical records





 Plan of Correction - To be completed: 05/12/2024

1) CR94 and CR95 have been discharged. CR96 ceased to breath.

2) All residents discharged in the past 30 days will be audited to ensure that a discharge summary has been completed.

3) A new recapitulation of stay form will be created to encompass all discharge information that will be completed by the IDT members.

4) IDT members to be educated on the new form and process.

5) The Administrator and DON or designee will audit 1x weekly for 3 weeks then 1x monthly x2 for completion of discharged summaries/recapitulation of stays. Results will be reviewed at Quarterly QA Meetings.

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 interviews, it was determined that the facility failed to provide a clinical rationale and duration for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for two of five residents reviewed (Residents R34 and R50).

Findings include:

A facility policy entitled " Psychotropic Medication Policy" dated 2/6/24, indicated that, PRN orders for psychotropic drugs are limited to 14 days. The attending physician or prescriber may extend the order beyond 14 days if he/she believes the order is appropriate. The prescriber must document the rational and duration when extending the order. 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.

Review of Resident R34's clinical record revealed an admission date of 2/23/23, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), anxiety disorder (a disorder that causes a person to be nervous, uneasy, or worried about something or someone), and hypertension (high blood pressure).

Review of Resident R34's clinical record revealed a physician's order to administer Lorazepam (anti-anxiety medication), 0.5 milligrams (mg) by mouth every 24 hours PRN for anxiety and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days.

Review of a pharmacy recommendation form revealed an order for Lorazepam 0.5 mg every 24 hours PRN which lacked a rational and a duration for the medication.

Review of Resident R50's clinical record revealed an admission date of 1/22/24, with diagnoses that included, dementia, hypertension, and traumatic brain injury (a serious condition that affects the brain's function because of a sudden impact or penetration to the head).

Review of Resident R50's clinical record revealed a physician's order dated 2/9/24, to administer Lorazepam 0.5 mg by mouth every four hours PRN for anxiety and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days.

Further review of Resident R50's clinical record revealed a physician's order dated 2/9/24, to administer Haloperidol (anti-psychotic) 0.5 mg by mouth every four hours PRN for agitation and lacked evidence that the resident was evaluated by the attending physician or prescribing practitioner. There also lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days.

During an interview on 3/21/24, at 12:54 p.m. the Nursing Home Administrator and Employee E1 confirmed that Resident R34's Lorazepam order and Resident R50's Lorazepam and Haloperidol orders lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. They also confirmed that Resident R50 was not evaluated by the attending physician or prescribing practitioner for the continuation of an anti-psychotic medication.

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: 05/10/2024

1) R50 has been discharged. R34 stop date added to Lorazepam and rationale given for GDR from physician and documented in residents chart.

2) All PRN psychotropic medications will be audited to ensure there is a stop date in place or documentation with rational to continue the medication.

3) The nurses will be trained by the Director of Nursing/designee on ensuring there is a stop date in place for all prn psychotropic medications unless there is documentation with rational to continue the medication.

4) The Director of Nursing/designee will audit all new orders to ensure there are stop dates for all residents on prn psychotropic medications and rationale to support continued use; 1x weekly for 3 weeks then 1x monthly x2.


5)Results of the audits will be discussed at the Quality Assurance Process Improvement.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

483.45(c)(2) This review must include a review of the resident's medical chart.

483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that the contracted pharmacist provided separate, written reports of irregularities identified during the medication regimen review (MRR) for one of five residents reviewed for unnecessary medications (Resident R49).

Findings include:

A facility policy entitled, "Medication Regimen Review and Reporting" dated 2/06/24, indicated that findings/recommendations of interim (routine interval) MRR are communicated to the Director of Nursing (DON) or designee and medical director, and that the findings are documented and filed with other consultant pharmacist recommendations in the resident's chart.

Resident R49's clinical record revealed an admission date of 3/12/18, with diagnoses including left-sided paralysis post stroke, Type 2 Diabetes (condition of improper insulin levels and blood sugar control), heart failure, irregular heartbeat, and dementia.

Resident R49's progress notes revealed MRR's were completed monthly and lacked evidence that documented findings/recommendations/irregularities were communicated to the DON or designee and medical director, and filed with other consultant pharmacist recommendations in the resident's chart.

During an interview on 3/21/24, at 12:38 p.m. the DON confirmed there was no evidence that the pharmacist provided irregularities on a separate, written report sent to the medical director and DON for Resident R49.

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





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

1) R49 recommendations separated and uploaded into medical chart.

2) Pharmacy to be contacted and all future physician recommendations will be sent on separate documents.

3) Physician recommendations within the past 30 days will be separated and uploaded into residents EMR.

4) Process and policy will be reviewed with Medical Director, pharmacy consultant, and contracted physicians.

5) Physician recommendations will be audited by DON or Designee for separate documentation and EMR upload for 1x monthly x3. Results will be reviewed at Quarterly QA Meetings.

483.20(g) REQUIREMENT Accuracy of 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(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on review of clinical records and staff interviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS-periodic assessment of resident care needs) for one of 20 residents reviewed (Resident R69).

Findings include:

Resident R69's admission record revealed an admission date of 10/13/21, with diagnoses that include diabetes (condition of improper insulin levels and blood sugar control), hypertension (high blood pressure), and hyperlipidemia (high cholesterol).

Review of Section N0350 of the RAI (Resident Assessment Instrument-instructions for completion of the MDS) User's Manual, entitled "Insulin," directed staff to document under "A" the number of days insulin injections were received in the previous 7 days, or since admission, or re-entry, if less than 7 days.

Review of manufacturer insert information for Trulicity (an injectable prescription medicine that may improve blood sugar in adults with diabetes) revealed "Trulicity is not a substitute for insulin ..."

Resident R69's clinical record revealed that Trulicity was ordered for Resident R69 as a weekly injection on 8/18/23.

Review of the MDS dated 1/12/24, Medications Section N0350A indicated that Resident R69 received insulin one time during the seven day look back period.

During an interview on 3/21/24, at 1:25 p.m. the Registered Nursed Assessment Coordinator (RNAC) confirmed that Resident R69 was not on insulin. RNAC also confirmed that Section N0350A of the MDS dated 1/12/24, was incorrectly coded for Resident R69 regarding insulin.

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



 Plan of Correction - To be completed: 05/10/2024

I hereby acknowledge the CMS 2567-A, issued to SARAH REED SENIOR LIVING for the survey ending 03/22/2024, AND attest that all deficiencies listed on the form will be corrected in a timely manner.


211.5(d) LICENSURE Medical records.:State only Deficiency.
(d) Records of discharged residents shall be completed within 30 days of discharge. Medical information pertaining to a resident ' s stay shall be centralized in the resident ' s record.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to complete the record within 30 days for one of the three closed records reviewed (Resident CR96).

Findings include:

Resident CR96's clinical record revealed an admission date of 1/07/24, with diagnoses including a broken rib, altered mental status, cognitive communication deficit, and difficulty speaking.

Departmental progress notes revealed that Resident CR96 ceased to breath on 2/13/24. The clinical record lacked evidence of a completed discharge summary and disposition of medications present in the clinical record.

During an interview on 3/22/24, at 11:05 a.m. the Director of Nursing confirmed that Resident CR96's clinical record was not completed within 30 days.







 Plan of Correction - To be completed: 05/10/2024

1) CR96 ceased to breath.

2) A new recapitulation of stay form will be created to encompass all discharge information that will be completed by the IDT members, each member will be educated on the new form and process.

3) All residents discharged in the past 30 days will be audited to ensure that a discharge summary has been completed.

4) The Administrator and DON or designee will audit 1x weekly for 3 weeks then 1x monthly x2 for completion of 10 closed records. Results will be reviewed at Quarterly QA Meetings.


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