Nursing Investigation Results -

Pennsylvania Department of Health
GARDEN SPRING NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDEN SPRING NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  119 surveys for this facility. Please select a date to view the survey results.

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GARDEN SPRING NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on October 9, 2019, it was determined that Garden Spring Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirments for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.






















































 Plan of Correction:


483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition: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(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.
Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain ice machines in safe operating condition on one of four nursing units (Nursing unit four) and in the kitchen.

Findings include:

The 2009 International Plumbing Code, Sections 802.2.1 and 802.2.2 indicates, "The air gap between the indirect waste pipe and the flood level rim of the waste receptor shall be a minimum of twice the effective opening of the indirect waste pipe." "An air break shall be provided between the indirect waste pipe and the trap seal of the waste receptor or stand pipe."

Observations conducted on October 6, 2019, between 12:30 p.m., and 1:00 p.m., revealed ice machines located on nursing unit four and in the kitchen to be soiled with a black substance on the inside of the ice machines.

Additionally, the ice machine located in the kitchen lacked the required two inch air gap above the waste water drain and the drain piping on each ice machine appeared soiled.

In an interview on October 6, 2019, at 1:15 p.m., the Administrator and Director of Maintenance confirmed that the facility failed to maintain ice machines in safe operating condition.

28 Pa. Code 207.2(a) Administrator's responsibility.
Previously cited 9/17/19, 12/13/19

28 Pa. Code 201.18(a)(b)(1)(3) Management.
Previously cited 9/17/19, 12/13/19

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 9/17/18
















 Plan of Correction - To be completed: 10/11/2019

The ice machines were cleaned Immediately, the pipe was adjusted to make sure there was a two-inch gap, the drain piping was cleaned.
Maintenance was re-educated on proper care of the ice machines.
The Administrator/designee will do an audit once a month x 3.
Findings will be presented to the quarterly quality assurance committee.

483.21(b)(1) 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.
Observations:

Based on clinical record review, observation and staff interview, it was determined that the facility failed to implement a care planned intervention for one of 27 residents sampled. (Resident 96)

Findings include:

Clinical record review revealed that Resident 96 had diagnoses that included cerebral infarction (a bleed on the brain), epilepsy (seizures), and hemiplegia (one sided paralysis). A current physician order and the care plan identified that the resident pulls at her tracheostomy tube (tube in a surgical opening in the neck to breath) and this could potentially dislodge making it difficult to breathe. An intervention was to place a soft hand mitt to her right hand and that staff were to remove the right hand mitt restraint every two hours for ten minutes to check range of motion and skin integrity.

Observations on October 6, 2019, from 10:20 a.m., to 12:43 p.m., revealed that staff had not entered the resident room to remove the hand mitt to perform range of motion and check skin integrity. The Treatment Administration Record (TAR) for October 6, 2019, revealed that there was no documentation to support that the staff removed the mitt and checked the resident's skin integrity and range of motion in accordance with the care plan.
Further review of the TAR for September 2019, revealed a lack of documentation to support that the interventions were completed ten times during September and two times in October 2019.

In an interview on October 9, 2019, at 09:45 a.m., the Director of Nursing stated that there was no documentation to support the care plan was implemented.

28 Pa. Code 211.10(c)(d) Resident care policies.
Previously cited 9/17/18

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 6/24/19, 9/17/18







 Plan of Correction - To be completed: 11/11/2019

R96 care plan and documentation were reviewed and modified to ensure proper documentation is being obtained and care being provided according to plan of care and restraint policy.
DON/Designee will conduct review of residents currently utilizing restraints to ensure that proper documentation and care are being provided according to plan of care and restraint policy.
DON/Designee will educate licensed staff on documentation and restraint policy and guidelines for following the comprehensive person-centered care plan that is consistent with the resident rights regarding the use of restraints.
DON/Designee will conduct audits restraint documentation and care plan weekly x 4 weeks then monthly x 2 months to ensure is in accordance to facilities policy and results reviewed at Quality Assurance Performance Improvement meeting.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based policy review, clinical record review and observation, it was determined the facility failed to ensure staff performed hand hygiene to prevent the possible spread of infection for one of one sampled residents during a dressing change (Resident 120). The facility also failed to ensure that staff emptied and cleaned a suction canister daily for one of one sampled residents with respiratory equipment. (Resident 13).

Findings include:

Review of facility policy entitled, "Handwashing/Hand Hygiene", dated July 31, 2019, revealed that the facility considered hand hygiene the primary means to prevent the spread of infections. Staff were to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents; before and after handling an invasive device (e.g.., urinary catheters); and after removing gloves.

Clinical record review for Resident 120 revealed that the resident had a diagnosis of neuromuscular bladder dysfunction (dysfunctional urinary bladder due to disease or injury of the central nervous system or peripheral nerves that are involved in the control of urination). The Minimum Data Set (MDS), dated September 16, 2019, indicated that the resident had urinary incontinence (inability to control flow of urine). Observation revealed that staff had applied a condom catheter over the resident's penis. The condom catheter was connected to a urinary collection bag. The MDS also reflected that the resident had an indwelling catheter of a left nephrostomy ( A nephrostomy is an artificial opening created between the kidney and the skin which allows for the urinary diversion directly from the upper part of the urinary system through a tube). Observation revealed that the resident's Nephrostomy tube was connected to a urinary drainage bag.

Observation on October 7, 2019, at 11:49 a.m., revealed that Resident 120 was lying in his bed, while the nurse LPN1 and the nursing aide CNA 1 prepared for a dressing change procedure. CNA 1 put on a pair of non-sterile gloves, and pulled the sheets down that were covering the resident, she began to reposition the resident by touching his lower legs, touching and repositioning tubing that was connected to the nephrostomy urinary collection bag and the tubing that was connected to condom catheter urinary collection bag. She proceeded to empty this collection bag and failed to hand sanitize by either using alcohol based hand rub or wash with soap and water before and after touching the urinary catheter collection bags. She also failed to perform hand hygiene before apply new non-sterile gloves.

Review of facility policy entitled, "Suctioning", dated July 31, 2019, revealed that a suction collection canister was to be emptied and cleaned daily and changed or decontaminated as necessary.

Clinical record review for Resident 13 revealed that the resident had a diagnosis of respiratory failure. The MDS assessment dated June 26, 2019, indicated the resident had a tracheostomy (surgical opening to create an airway in the windpipe) and the tracheostomy required treatment which included suctioning.

Observation on October 9, 2019, at 12:40 p.m., revealed the suction collection canister was 3/4 full of secretions with a date of October 7, 2019 written on the canister. This suction canister had not been emptied and cleaned for two days.

CFR 483.80 Infection Prevention and Control
Previously cited 9/17/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 9/17/18 and 6/24/19
























 Plan of Correction - To be completed: 11/11/2019

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

CNA 1 was immediately re-educated on proper handwashing and infection control.
Resident 13 suction collection canister was discarded, and new equipment placed.

DON/Designee conducted audit of residents with suction equipment and collection canisters were replaced to ensure proper infection control practices. Infection Preventionist/Designee conducting ongoing surveillance of appropriate handwashing throughout facility.

DON/Designee will re-educate current nursing staff on handwashing and suction equipment replacement.

DON/Designee will conduct audits on handwashing and suction equipment weekly
x 4 weeks then monthly for two months. Results will be
reviewed at Quality Assurance Performance Improvement meeting.

483.60(g) REQUIREMENT Assistive Devices - Eating Equipment/Utensils: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(g) Assistive devices
The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.
Observations:

Based on clinical record review and observation it was determined that the facility failed to ensure that adaptive equipment was provided to one of one sampled residents that required adaptive equipment. (Resident 41)

Findings include

Clinical record review revealed that Resident 41 had diagnoses that included rheumatoid arthritis. The Minimum Data Set assessment dated August 3, 2019, indicated that the resident was able to eat independently; however, she needed help setting up her meal. Review of the current care plan revealed that resident had limited physical mobility related to her rheumatoid arthritis. The care plan included an intervention that staff provide a two handled mug for all liquids during meals.

An observation in the dining room on October 6, 2019, at 12:25 p.m., revealed that the resident was not provided the two handled mug to drink her beverage. The resident was observed in her room on October 7, 2019, at 12:31 p.m., for lunch. The resident was not provided the two handled mug do drink her beverage.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 6/24/19, 12/13/18, 9/17/18





 Plan of Correction - To be completed: 11/11/2019

Resident 41 is being provided assistive device at each meal.
Residents utilizing assistive devices for eating were audited by Registered Dietitian/Designee to ensure devices were being provided.
Registered Dietitian/Designee to inservice dietary and nursing staff on importance of adaptive devices for eating to be used during each meal.
Registered Dietitian/Designee to conduct adaptive devices for eating audit weekly x 4 weeks and then monthly for 2 months. Audits will be reviewed and discussed with the Quality Assurance Performance Improvement meeting.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to properly store medications on two of four nursing units. (First floor and Fourth floor).

Findings include:

Review of facility policy entitled "Discarding and Destroying Medications", dated July 31, 2019, revealed that medications were to be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous phamaceuticals, hazardous waste and controlled substances.

Observation of the first floor medication cart on October 7, 2019 at 9:30 a.m., revealed that a controlled substance medication named Lorazepam with an expiration date of April 30, 2019 was stored in the locked drawer of the medication cart. In an interview on October 7, 2019, at 9:48 a.m., LPN2 and LPN3, confirmed that the medication was past the expiration date and should have been discarded.

Observation of the fourth floor medication storage room on October 7, 2019 at 11:32 a.m., revealed that a bottle of expired Gevravite Liquid (multivitamin liquid) was stored in the cabinet with an expiration date of February 28, 2019. In an interview on October 7, 2019 at 11:33 a.m., LPN4 confirmed that the bottle of multivitamin liquid was expired and should have been discarded.

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


















 Plan of Correction - To be completed: 11/11/2019

Expired medications were destroyed and disposed of per policy.
Current medications in carts were reviewed and checked for expiration dates. No expired medications were found.
Licensed nurses will be re-educated on proper storage, discarding, and destruction of medications related to expiration dates.
DON/Designee will complete audits of medications to ensure medications that expire are returned to pharmacy and/or destroyed per policy. Audits will be completed weekly x 4 weeks then monthly for two months. Results will be reviewed at Quality Assurance Performance Improvement meetings.

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More: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(f) Medication Errors.
The facility must ensure that its-

483.45(f)(1) Medication error rates are not 5 percent or greater;
Observations:

Based on clinical record review and policy review as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate of less than five percent.

Findings include:

Review of the policy entitled "Adverse Consequences and Medication Errors," dated July 31, 2019, revealed that a "medication error" was defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Further, the policy cites that an example of a medication error would include the omission of a drug if it is ordered but not administered.

Observations during medication administration on October 6, 2019, and October 7, 2019, revealed that two medication administration errors were made during 31 opportunities for error, resulting in a medication administration error rate of 6.45 percent.

Observation of medication administration on October 6, 2019, at approximately 12:30 p.m., revealed LPN5 preparing to administer medications to Resident 106. A medication, Tylenol Arthritis Extended Release was to be administered. LPN5 stated that she did not have the medication available to administer to the resident.

Observation of medication administration on October 7, 2019, at approximately 10:30 p.m., revealed LPN6 preparing to administer medications to Resident 14. A medication, amlodipine besylate was to be administered. LPN6 stated that he did not have the medication available to administer to the resident.

In an interview October 8, 2019, at 9:25 a.m., the Director of Nursing stated that the medications should have been available for administration.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 6/24/19, 9/18/18.







 Plan of Correction - To be completed: 11/11/2019

R14 medication orders were reviewed physician to ensure all orders were accurate and implemented as indicated as per physicians' orders. Medication received and administered per orders. Resident 106 medication was obtained. Physician was notified and new orders received. Medication administered per orders.
DON/Designee conducted audit of current in-house prescribed medications to ensure availability.
DON/Designee to provide education on policy and procedure of obtaining medications in a timely manner.
DON/Designee will conduct audits of current prescribed medications weekly x 4 weeks then monthly for 2 months. Results will be reviewed at Quality Assurance Performance Improvement meeting.

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 clinical record review and staff interview, it was determined that the facility failed to ensure that a physician's order was implemented for one of 27 sampled residents. (Resident 13)

Findings include:

Clinical record review revealed that Resident 13 was admitted on March 1, 2016, with diagnoses that included respiratory failure and chronic obstructive pulmonary disease. Review of ongoing physician orders revealed that the resident was to have her tracheostomy (a surgical hole placed in the throat to help a person breath) tie (a collar type of tie to keep the tracheostomy tube in place) changed twice a week and as needed and that staff was to date and initial the tie prior to applying it to the tracheostomy tube. Observation on October 7, 2019, 1:20 p.m., and October 8, 2019, at 11:52 p.m., revealed that the tracheostomy tie was dated September 15, 2019. The tracheostomy tie was to be changed on Tuesdays and Fridays.

In an interview on October 9, 2019, at 9:45 a.m., the Director of Nursing confirmed that the physician orders were not followed.

CFR 483.25 Quality of Care
Previously cited 9/17/18

28 Pa. Code 211.12 (d)(5) Nursing services.
Previously cited 6/24/19, 12/13/18, 9/17/18





 Plan of Correction - To be completed: 11/11/2019

Resident 13 treatment documentation for tracheostomy care was modified on treatment administration record to ensure detailed documentation of treatment provided including change of ties.
DON/Designee conducted audit of current residents with tracheostomy to ensure documentation of care is specific with all care that was provided.
DON/Designee to receive in-service on standards for tracheostomy tie changes in accordance with physician orders and documentation of acceptance/refusal of care in the Administration Record.
DON/Designee will audit tracheostomy changes and documentation weekly x 4 weeks then monthly x 2 months. Audits will be reviewed with the Quality Assurance Performance Improvement meeting.

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 observation, clinical record review, and interview, it was determined that the facility failed to ensure that a resident's preference of a shower was provided consistently to one of 27 sampled residents. (Resident 77)

Findings include:

Clinical record review revealed that Resident 77 was admitted on May 15, 2019, and had a diagnosis of diabetes and weakness. Review of the Minimum Data Set assessment dated August 15, 2019, revealed that the resident required extensive assistance from staff for bathing. Review of the shower schedule revealed a lack of documented evidence to support that staff offered the resident a shower. The resident should have had a shower on September 30, 2019, October 3, 2019, and October 7, 2019.

In an interview on October 9, 2019, at 12:50 p.m., the Director of Nursing stated that the resident was to be offered a shower twice a week.

28 Pa. Code 211.10(d) Care policies.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 6/24/19, 9/17/18







 Plan of Correction - To be completed: 11/11/2019

Resident 77 received shower.
DON/Designee conducted review of current in-house residents to ensure showers were received.
DON/Designee to educate Nursing Staff on appropriate documentation and reporting of resident bath/shower, refusals of bath/shower, and providing bath/shower per resident preference.
DON/Designee will conduct audit of bath/showers completion x 4 weeks and then monthly for 2 months. Results will be reviewed at Quality Assurance Performance Improvement meeting.

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

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure that a registered nurse maintained professional standards of quality care in the documentation of administration of medications set forth in the Pennsylvania Code Title 49, Professional and Vocational Standards for one of four residents sampled. (Resident 14)

Findings include:

Review of the facility's policy entitled "Administering Medications," dated July 31, 2019, revealed that medications were to be prepared, adminstered, and recorded only by licensed nurses. Only the licensed nurse who prepared the medication was to administer the medication and document in the resident's Medication Administration Record on the appropriate line after giving each medication and before preparing the next resident's medications.

Clinical record review revealed that Resident 14 had diagnoses that included hypertension (high blood pressure) and dementia. Observation of medication administration on October 7, 2019, at approximately 10:30 a.m., revealed LPN6 prepared and administered Resident 14's medications to include a multivitamin, Zoloft, bupropion hydrochloride, lastacaft eye drops, Baclofen and Pepto-Bismol. LPN6 stated that he did not have the medication amlodipine besylate available to administer to the resident. Review of the Medication Administration Record (MAR) revealed that the unit manager, RN1, had documented that she had given all of the aformentioned medications to include the amlodipine besylate that was unavailable. In an interview on October 8, 2019, at 11:22 a.m., RN1 stated that she did not actually prepare and administer the medications to the resident.

Licensed staff failed to observe standards of clinical practice as referenced in section 21.11(d) General functions, section 21.14(a) Administration of drugs and section 21.18(a)(5) Standards of nursing conduct.

28 Pa. Code 211.10(c) Resident care policies.
Previously cited 9/17/18

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 6/24/19, 12/13/18, 9/17/18








 Plan of Correction - To be completed: 11/11/2019

R14 medication administration record was reviewed with her physician and nursing staff to ensure all medications were administered as documented and per physician's orders.
DON/Designee will review medication administration records of current residents to ensure medications are being administered per physician orders and documented appropriately.
DON/Designee will educate licensed nursing staff on medication administration and documentation to meet professional standards.
DON/Designee will conduct audits to ensure medication administration and documentation is meeting professional standards. Audits will be conducted weekly x 4 weeks and monthly for two months. Results will be reviewed at Quality Assurance and Performance Improvement meeting.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
483.15(d) Notice of bed-hold policy and return-

483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:

Based on a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed hold policy, (an agreement for the facility to hold a bed for an agreed rate during a hospitalization), to the resident, family member, or legal representative at the time of the transfer out of the facility for six of six sampled residents transferred to the hospital. (Residents 13, 41, 75, 99, 102, 238)

Findings include:

Review of the facility's policy entitled "Bed Hold Policy", dated July 31, 2019, revealed that residents that were transferred or discharged to the hospital may have their beds held for them in accordance with federal, state, and facility policy.

Clinical record review revealed that Resident 13 was transferred and admitted to the hospital on June 17, 2019, due to a change in condition. There was no documented evidence that the resident or responsible party was provided written information about the facility's bed hold policy at the time of the transfer.

Clinical record review revealed that Resident 41 was transferred and admitted to the hospital on July 21, 2019, and again on August 29, 2019, due to a change in condition. There was no documented evidence that the resident or responsible party was provided written information about the facility's bed hold policy at the time of the transfer.

Clinical record review revealed that Resident 75 was transferred and admitted to the hospital on September 30, 2019, due to a change in condition. There was no documented evidence that the resident or responsible party was provided written information about the facility's bed hold policy at the time of the transfer.

Clinical record review revealed that Resident 99 was transferred and admitted to the hospital on July 26, 2019, due to a change in condition. There was no documented evidence that the resident or responsible party was provided written information about the facility's bed hold policy at the time of the transfer.

Clinical record review revealed that Resident 102, was transferred and admitted to the hospital on September 14, 2019, and again on October 5, 2019, due to a change in condition. There was no documented evidence that the resident or responsible party was provided written information about the facility's bed hold policy at the time of the transfer.

Clinical record review revealed that Resident 238 was transferred and admitted to the hospital on September 25, 2019, due to a change in condition. There was no documented evidence that the resident or responsible party was provided written information about the facility's bed hold policy at the time of the transfer.

In an interview on October 9, 2019, at 9:27 a.m., the Director of Nursing confirmed that there was no documented evidence that the residents or responsible parties had been provided written information about the facility's bed hold policy at the time of the transfers as per facility policy.




 Plan of Correction - To be completed: 11/11/2019

The facility cannot retroactively correct the missing Bed hold forms, and documentation. The facility will give bed hold policy in writing to residents when they transfer out.
The facility will review current residents transferred from the facility to ensure written bed-hold notifications were provided.
In-servicing will be provided to licensed staff by the Administrator/Designee on the need to provide written bed-hold policy notification.
Audits of residents' transfers and notifications will be completed by Administrator/designee monthly for 3 months.
Findings will be submitted to the facility QAPI Committee for review and further recommendations.

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
Observations:

Based on observation, it was determined that the facility failed to provide a comfortable environment on three of four nursing units. (Nursing units one, two and three)

Findings include:

Observation of nursing units one, two and three on October 6, 2019, revealed carpeting throughout the nursing unit corridors to be stained/soiled.

28 Pa. Code 207.2(a) Administrator's responsibility.
Previously cited 6/24/19, 12/13/19

28 Pa. Code 201.18(a)(b)(1)(3) Management.
Previously cited 9/17/18, 12/13/18

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 9/17/18

















 Plan of Correction - To be completed: 11/11/2019

The facility cleaned the carpets. For carpets that have permanent stains, the facility is pursuing options regarding replacing the flooring.

Other Units carpets will be checked and cleaned appropriately.

Housekeeping was re-educated on proper care of the carpets.

The administrator/designee will audit progress monthly x 3.
Updates will be presented to the quarterly quality assurance committee.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:

Based on observation, it was determined that the facility failed to properly dispose of garbage and refuse properly.

Findings include:

Observation of the dumpster area during the initial environmental tour conducted on October 6, 2019, at 9: 35 a.m., revealed three dumpsters located approximately 30 feet from the left lower entrance of the facility to be littered with trash that included tube feeding supplies, food wrappers and disposable gloves.

28 Pa. Code 207.2(a) Administrator's responsibility.
Previously cited 9/17/18, 12/13/19

28 Pa. Code 201.18(a)(b)(1)(3) Management.
Previously cited 9/17/18, 12/13/19

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












 Plan of Correction - To be completed: 11/11/2019

The trash was removed immediately.
Dumpster area was checked for proper waste disposal.
The dietary and housekeeping department were re-inserviced regarding proper waste disposal.
The food service director/designee will conduct monthly audits x 3.
All findings will be given to the quarterly quality assurance committee.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observation, it was determined that the facility failed to provide a safe, clean, comfortable and home-like environment on three of four nursing units. (Nursing units one, two, and three)

Findings include:

Observations during environment tours conducted on October 6, 2019, through October 9, 2019, revealed the following:

On October 6, 2019, at 10:33 a.m., in room 220, there was a brown liquid substance on the floor at the foot of the resident's bed.

On October 6, 2019, between 12:04 p.m. and 12:04 p.m., in rooms 101, 102, 103, 104, 105, 108, 107, 109, and 115 the base-board heating shields were detached from the walls.

On October 6, 2019, at 12:41 p.m., in room 406 there was a pervasive smell of urine in and in the area outside of the room.

On October 6, 2019, at 12:58 p.m., in the resident recreation room, located adjacent to the resident personal laundry room, there were two window sills and two air conditioning units with a heavy accumulation of dust/dirt.

On October 6, 2019, at 1:04 p.m., in the resident personal laundry room, the top-loading washing machine had an excess build-up of lint under the lid and around the rim of the washing machine.

On October 6, 2019, at 1:34 p.m., on the unit four central bath room, the floor was soiled and the several areas of the wall were heavily marred.

On October 6, 2019 at 1:40 p.m., the common area on nursing unit four, there was a love seat and two chairs with stains.

On October 6, 2019, at 10:50 a.m., the over bed lights for both beds were non functioning. Additionally, the cords for the lights were broken. Several areas of wall throughout the room were found to be heavily marred.

On October 6, 2019, at 2:00 p.m., in room 311 there were four stained ceiling tiles. The light cover had what what appeared to be a water stain. There were two stained ceiling tiles in the hallway outside of the room.

28 Pa. Code 207.2(a)(1) Administrator's responsibility.
Previously cited 9/17/18, 12/13/19
























 Plan of Correction - To be completed: 11/11/2019

Brown liquid substance on the floor at the foot of the resident's bed was cleaned.
Heating shields in rooms 101, 102, 103, 104, 105, 108, 107, 109 and 115 were properly placed.
Urine smell in room 406 and in the area outside was properly cleaned and treated.
The windowsills and ac units in the resident recreation room located adjacent to the resident personal laundry room were cleaned of the heavy accumulation of dust/dirt.
The top loading washing machine in the resident personal laundry room had the excess of lint under the lid and around the rim of the washing machine cleaned.
The unit four central bathroom floor was cleaned and walls with heavy marring were repaired
The love seat and two chairs with stains in the common area on nursing unit four were cleaned.
Room 305 Overbed lights were fixed. The cords were fixed as well.
Walls that were heavily marred were corrected.
The stained ceiling tiles in room 311 were replaced. The light cover was cleaned. The two stained ceiling tiles in the hallway outside were replaced.

Heating shields in resident rooms on unit 1 will be checked.
Unit 5 will be checked for urine odors and will be cleaned as needed.
The windowsills and ac units in the resident recreation rooms and personal laundry rooms will be checked for heavy accumulation of dust/dirt.
Resident personal laundry washing machines will be checked.
Central bathroom floors and walls will be checked.
Furniture in common areas will be replaced when full facility renovations are completed.
Unit 3 overbed lights will be checked.
Unit 3 ceiling tiles will be checked.
Housekeeping and Maintenance will be re-educated, on proper environmental conditions.
The Administrator/designee will audit monthly x 3.
Audit findings will be presented to Quarterly QA


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