Nursing Investigation Results -

Pennsylvania Department of Health
SPIRITRUST LUTHERAN THE VILLAGE AT SHREWSBURY
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SPIRITRUST LUTHERAN THE VILLAGE AT SHREWSBURY
Inspection Results For:

There are  84 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.
SPIRITRUST LUTHERAN THE VILLAGE AT SHREWSBURY - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid, State Licensure and Civil Rights survey and an abbreviated complaint survey which ended on April 21, 2022, it was determined that Spiritrust Lutheran Village At Shrewsbury 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:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:

Based on clinical record review, policy review, and facility provided documentation review, it was determined that the facility displayed past noncompliance in that it failed to ensure each resident the right to be free from neglect, resulting in harm for one of twenty-one residents reviewed (Resident 217).

Findings Include:

Review of Resident 217's clinical record revealed diagnoses including Myasthenia Gravis (a chronic autoimmune, neuromuscular disease characterized by weakness and rapid fatigue of any of the muscles under your voluntary control. It's caused by a breakdown in the normal communication between nerves and muscles) and hypertension (elevated blood pressure).

Review of the facility's document titled "Corporate Standard of Practice...Abuse", recently revised October 4, 2017, describes Neglect as "failure to provide goods and services necessary to avoid physical harm." Also, "... the deprivation by a caretaker of goods or services which are necessary to maintain physical or mental health."

Review of a facility reported incident, dated January 28, 2022, revealed Resident 217's "care plan was not followed during a transfer. [Resident 217's] care plan indicated a transfer status of 2 assist." "Caregiver [licensed practical nurse- Employee 1] transferred the resident alone." Resident 217 was transferred to the emergency room and "received 13 sutures."

Review of the facility's investigation revealed Employee 1's statement to read "[Resident 217] sitting up in wheelchair." Also, Resident 217 was "transferred from the w/c [wheelchair] to bed upon removing resident's pants blood noted coming down leg. Skin tear to leg noted."

Employee 1's statement continues "wasn't aware of looking at care plan before providing care."

Review of the facility's interdisciplinary progress notes revealed "Resident with a 4 x 4 cm L shaped skin tear to left lateral calf area...wound is significantly deep with active bleeding and unable to stop bleeding."

Review of documentation revealed that Employee 1 received training, including abuse/neglect, on January 3, 2022. Review of Employee 1's personnel record revealed a final warning of corrective/disciplinary action dated February 11, 2022. Employee 1 was terminated due to neglecting to follow the care plan.

Review of facility documentation revealed that all nursing staff were educated on following the resident interdisciplinary plan of care. The education was complete with all nursing staff on February 1, 2022.

Review of the facility's documentation revealed random weekly audits initiated on February 9, 2022 for a period of four weeks to ensure compliance.

An interview with the Nursing Home Administrator, on April 20, 2022, at 1:53 PM, revealed the facility's investigation found the incident to be a confirmed instance of staff neglect, resulting in harm to Resident 217. The interview also revealed Employee 1 is no longer working as a nurse in the state of Pennsylvania and the incident was reported to the state licensing board for further investigation.

Prior to the Full Health Survey, the facility failed to provide the appropriate transfer for Resident 217, resulting in harm to the resident.

The facility reported the incident timely, investigated the incident thoroughly, and initiated interventions in an effort to prevent a future incident. During the Full Health Survey, audits, staff education and resident care plans were reviewed. Resident record reviews and observations failed to reveal continued or additional concerns regarding appropriate transfer status.

483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition

28 Pa. Code 201.14 Responsibility of licensee
28 Pa. Code 201.18 (b) (1) Management
28 Pa. Code 211.11 (d) Resident care plan
28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services




 Plan of Correction - To be completed: 05/06/2022

Past noncompliance: no plan of correction required.
483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on clinical record review, staff interviews and facility provided documentation review, it was determined that the facility displayed past noncompliance in that it failed to ensure each resident recieves adequate supervision and assistance to prevent accidents resulting in a skin tear and 13 sutures for one of twenty-one residents reviewed (Resident 217).

Findings Include:

Review of Resident 217's clinical record revealed diagnoses including Myasthenia Gravis (a chronic autoimmune, neuromuscular disease characterized by weakness and rapid fatigue of any of the muscles under your voluntary control. It's caused by a breakdown in the normal communication between nerves and muscles) and hypertension (elevated blood pressure).

Review of a facility reported incident, dated January 28, 2022, revealed Resident 217's "care plan was not followed during a transfer. [Resident 217's] care plan indicated a transfer status of 2 assist." "Caregiver [licensed practical nurse- Employee 1] transferred the resident alone." Resident 217 was transferred to the emergency room and "received 13 sutures."

Review of the facility's investigation revealed Employee 1's statement to read "[Resident 217] sitting up in wheelchair." Also, Resident 217 was "transferred from the w/c [wheelchair] to bed upon removing resident's pants blood noted coming down leg. Skin tear to leg noted."

Employee 1's statement continues "wasn't aware of looking at care plan before providing care."

Review of the facility's interdisciplinary progress notes revealed "Resident with a 4 x 4 cm L shaped skin tear to left lateral calf area...wound is significantly deep with active bleeding and unable to stop bleeding."

Review of facility documentation revealed staff education related to following the resident interdisciplinary plan of care completed with all nursing staff on February 1, 2022.

Review of the facility's documentation revealed random weekly audits initiated on February 9, 2022 for a period of four weeks to ensure compliance.

Review of documentation revealed that Employee 1 received training, including abuse/neglect, on January 3, 2022. Review of Employee 1's personnel record revealed a final warning of corrective/disciplinary action dated February 11, 2022. Employee 1 was terminated due to neglecting to follow the care plan.

An interview with the Nursing Home Administrator, on April 20, 2022, at 1:53 PM, revealed the facility's investigation found the incident to be a confirmed instance of staff neglect, resulting in harm to Resident 217.

Prior to the Full Health Survey the facility failed to provide the appropriate transfer for Resident 217, resulting in harm to the resident. The facility reported the incident timely, investigated the incident thoroughly, and initiated interventions in an effort to prevent a future incident. During the Full Health Survey, audits, staff education, incident reports and resident care plans were reviewed. Resident record review and observations revealed no concerns with transfer status for the sampled residents.

483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition

28 Pa. Code 201.14 Responsibility of licensee
28 Pa. Code 201.18 (b) (1) Management
28 Pa. Code 211.11 (d) Resident care plan
28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services



 Plan of Correction - To be completed: 05/06/2022

Past noncompliance: no plan of correction required.
483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on clinical record review and staff and staff interview, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of twenty-five residents reviewed (Resident 1, 9, 35, and 54).

Findings include:

Review of Resident 1's clinical record revealed diagnoses that included heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should) and muscle weakness (muscle weakness is commonly due to lack of exercise, aging, muscle injury, or pregnancy).

Observation of Resident 1 on April 18, 2022, at 10:45 AM, revealed that the resident had bilateral enabler bars.

Review of Resident 1's Bed Rail Data Collection Tool, provided by the facility and signed on January 27, 2022, revealed that Resident 1 was appropriate to have bilateral enabler bars.

Review of Resident 1's care plan on April 20, 2022, failed to reveal a care plan including enabler bars.

During an interview with the Nursing Home Administrator (NHA) on April 20, 2022, at 1:36 PM, revealed that Resident 1's care plan did not include enabler bars.

Review of Resident 9's clinical record revealed diagnoses of cerebral infarction (stroke), Type II Diabetes Mellitus ((DM- a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and a history of falls.

Observation of Resident 9 on April 18, 2022, at approximately 10:00 AM, revealed bilateral enabler bars present on the bed.

Review of Resident 9's Bed Rail Data Collection Tool, provided by the facility and signed on May 11, 2021, revealed that Resident 9 was appropriate to have bilateral enabler bars.

Review of Resident 9's care plan dated April 2022, failed to reveal a care plan including enabler bars.

During an interview with the Nursing Home Administrator (NHA) on April 19, 2022, at 1:30 PM, revealed that Resident 9's care plan did not include enabler bars.

Review of Resident 35's clinical record revealed diagnoses including shortness of breath and anxiety disorder (a group of mental illnesses that cause constant fear and worry).

Review of Resident 35's April 2022 physician orders revealed oxygen treatment PRN (pro re nata- translated loosely to mean "as needed") related to shortness of breath.

Review of Resident 35's interdisciplinary plan of care revealed none developed to address the Resident's need for PRN oxygen use.

An interview with the NHA on April 21, 2022, at 8:46 AM, confirmed no care plan in place related to Resident 35's need for the as needed use of oxygen therapy and the care plan has now been updated to reflect the oxygen order.

Review of Resident 54's clinical record revealed diagnoses that included contracture of left hand (A permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) and congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should).

Review of Resident 54's physician orders on April 19, 2022, revealed a current physician order for supplemental oxygen at two liters per minute for shortness of breath, ordered on November 15, 2019. Further review revealed a current physician's order for a palm guard for Resident 54's left hand to be on for four hours during day shift, every day.

Review of Resident 54's care plan revealed a care plan, initiated, and last revised in July 2018, for supplemental oxygen at two liters running continuously. Further review of Resident 54's care plan revealed a care plan for a left palm guard to be applied six hours during dayshift and on at night, initiated April 24, 2019, and last revised on May 6, 2020.

Interview with the Nursing Home Administrator on April 20, 2022, at 1:30 PM, revealed that Resident 54's care plan should have been updated to reflect the current physician's orders.


42 CFR 483.21(b) Comprehensive Care Plans.

28 Pa. Code 211.11(d)(e) Resident care plan.

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


 Plan of Correction - To be completed: 05/30/2022

1. Resident #1's care plan has been reviewed and revised to include the enabler bars.
Resident #9's care plan has been reviewed and revised to include the enabler bars.
Resident #35's care plan has been reviewed and revised to include the need for oxygen therapy.
Resident #54's care plan has been reviewed and revised to reflect the current orders for oxygen therapy and for use of the palm guard.

2.Audit of current resident to be conducted of resident's with orders for enabler bars, oxygen therapy and/or palm guards to ascertain those resident's care plans are reflected of the current physician orders.

3.Licensed team members (RN, LPN) will be re-educated on the inclusion of physician orders in the care plan process.
The Interdisciplinary team will include review of care plans when reviewing new physician orders at stand-up meeting.

4.RNAC/designee will conduct 5 random care plan audits weekly x4 weeks then 3 random care plan audits weekly x 2 months for those who have oxygen, enabler bars or palm guards to ensure care plans are revised,. Findings will be reported monthly to the Quality Assurance Performance Improvement Committee for review and recommendations.


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 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 on observation, interview, and facility policy review, it was determined the facility failed to maintain an accurate data collection system of surveillance from June 2021 through December 2021.

Findings include:

Review of the facility policy titled, "Infection Control Plan Standards," last reviewed March 2022, states, "The following forms/standards/programs are used to facilitate based on CDC (Centers for Disease Control) recommendations:
Infection Line List MDRO Form # 879NSG
Infection Line List Monthly Form 878NSG
Infection Line List GI Form # 877NSG
Infection Control Line List Influenza Form # 876NSG
Infection Control Line List Conjunctivitis Form # 8-071A

Review of the facility's infection control logs on April 19, 2022, failed to provide any of the above forms with data from June 2021 through December 2021.

Based on the infection control logs reviewed prior to June 2021 and after December 2021, data to be collected and documented included the resident's name, room location, infection site, type of infection, signs and symptoms, treatment, and indicated those infections that required reporting to the Department of Health and Patient Safety Authority.

During an interview with the Nursing Home Administrator (NHA) on April 19, 2022, the NHA stated that the facility had previous issues with reporting to NHSN (National Healthcare Safety Network) and now all submissions are up to date.

A review of NHSN COVID 19 reports submitted by the facility were reviewed for the dates of January 24, 2022, through April 18, 2022, and were submitted timely to NHSN, as required.

During an interview with the NHA and the Director of Nursing (DON) on April 21, 2022, at approximately 10:45 AM, the infection control data was still unable to be located after a thorough search and contacting previous employees. The NHA and DON informed the surveyor that neither one of them were employed at the facility from June 2021 through December 2021. By not having documentation, it appears that the facility failed to maintain a program of tracking to identify infections, determine outbreaks for specific infections, and monitor for the care that was provided by staff to residents with infections.

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

28 Pa Code 211.1(a)(c)Reportable diseases.


 Plan of Correction - To be completed: 05/04/2022

1.No residents were identified as being affected.

2.An audit of Infection Control logs from January 2022 through April 2022 has been completed to ascertain compliance with data collection surveillance.

3. The recently hired DON?ADON/Clinical/Quality Manager has been in-serviced on the facility's Infection Control Plan including data collection and completion of Infection Control logs.

4.Director of Nursing / designee will monitor completion of infection control surveillance weekly x4 weeks, biweekly x2 weeks, then monthly x1. Findings will be reported monthly to the Quality Assurance and Performance Improvement Committee for review and recommendations.
483.60(a)(3)(b) REQUIREMENT Sufficient Dietary Support Personnel: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(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.60(a)(3) Support staff.
The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in 483.21(b)(2)(ii).
Observations:

Based on observation, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to ensure that residents were afforded the opportunity to be served their meals in a communal setting, for three of three meals observed.

Findings include:

During entrance conference meeting with the Nursing Home Administrator (NHA) on April 18, 2022, at approximately 9:30 AM, it was revealed that the facility was serving meals in resident rooms and the the main dining room was not in use.

Multiple resident interviews on April 18, 2022, revealed residents voiced concerns with the temperature of the food during meal service.

Observation of meal service on April 18, 2022 at approximately 12:00 PM, on April 19, 2022 at approximately 11:30 AM, and on April 20, 2022 at approximately 11:30 AM during the lunch meal revealed the following; meals were served via tray service to resident rooms, meal trays were brought to the units on an open metal racks, main meal was served on ceramic plate covered with an insulated plastic thermal lid, and a heated pellet or liner was not in use. Also several residents were observed eating their lunch meal in the hallway on 300 and 500 hallways.

During resident group meeting on April 20, 2022 at approximately 1:00 PM, several residents questioned when they would be able to eat meals in the dining room.

Review of the facility's submitted data to National Healthcare Safety Network, the facility hasn't had a COVID-19 positive resident since the week of January 23, 2022.

Observations on April 18th through 21st, 2022, group activities occurred in the activities room.

During an interview with the Nursing Home Administrator on April 20, 2022, at approximately 2:30 PM, it was revealed that the dining room was not utilized to serve meals because there was insufficient staff in the Dietary Department. It was also revealed that the Dietary Department had six positions that were vacant, and the aforementioned positions have been vacant since September 2021. It was not known if the contract Food Service Company considered the use of agency staff to fill the vacant positions.

28 Pa code 211.6(b)(d) Dietary Services
Previously cited: 8/2/18, 7/25/19, 4/15/21

28 Pa code 201.18(b)(6) Management


 Plan of Correction - To be completed: 05/30/2022

1.No specific residents have been identified.

2.Plan of correction will include all residents who desire to eat in the dining room. Audit of current residents to see who prefers to eat in communal dining for the lunch meal (main meal).

3.Dining room will open for main meal at Lunch time to allow for communal dining. The facility does have sufficient nursing staff to support the dining room. The facility will be utilizing ancillary team members to support dining staff during meal time.

4.General manager/designee will audit the dining room daily x4 weeks to make sure it is open and weekly time 2 months. Findings of the audit will be brought to Qapi for further recommendations
483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination: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(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:

Based on clinical record review, facility policy review, and staff interview it was determined that the facility failed to promote and facilitate the resident's right to self-determination through support, including choice in health care services and health care providers for two of five residents reviewed for hospice care and services (Resident 6 and 35).

Findings Include:

Review of the facility's standard titled "Hospice Program", recently revised January 2021, reads, in part, "Social Worker(s) are the designated liaison with the Hospice provider."

The standard continues "when a resident has been diagnosed as terminally ill, the Resident Care Supervisor/Charge Nurse will contact Social Services and request that a visit/interview with the resident/family be conducted to determine the resident's wishes relative to participation in the hospice program."

Review of Resident 6's clinical record revealed diagnoses including alzheimer's disease (A type of brain disorder that causes problems with memory, thinking, and behavior. This is a gradually progressive condition) and chronic kidney disease (A condition characterized by a gradual loss of kidney function. Early stages can be asymptomatic. Disease progression occurs slowly over a period of time).

Continued review of Resident 6's clinical record revealed documentation dated July 30, 2021 that reads "The physician spoke with the resident's family in regards to hospice services and the SW [social worker] spoke with the family on this date to verify and confirm that family is agreeable to hospice services."

Further review of the clinical record revealed the facility referred the resident for hospice care and services with its own hospice provider. The clinical record revelaed no documentation of the facility staff discussing a choice of providers with the resident and/or family members.

Review of Resident 35's clinical record revealed diagnoses including aphasia (a comprehension and communication [reading, speaking, or writing] disorder resulting from damage or injury to the specific area in the brain) and hemiplegia (paralysis of one side of the body).

Continued review of Resident 35's clinical record revealed a provider note dated March 3, 2022, reading in part, "I discussed...with son and recommended hospice. Wife is in agreement with hospice."

Further review of the clinical record revealed no documentation by the facility social worker discussing with the family/resident the various contracted hospice providers.

An interview with the Nursing Home Administrator, on April 20, 2022, at 9:51 AM, confirmed no documentation in the clinical records related to staff discussion of hospice provider choice with the aformentioned Residents or their family members.

28 Pa. Code 211.5 (f) Clinical records
28 Pa. Code 201.29 (a) (j) Resident rights


 Plan of Correction - To be completed: 05/30/2022

"Preparation and submission of this plan is required by state and federal law. This plan of correction does not constitute an admission for the purposes of general liability, professional malpractice or other court proceedings."

1.Resident #6 and resident #35 no longer reside at the facility.

2.Audit of current residents will be conducted of documentation of current hospice participants to confirm they were offered a choice of hospice services. If no documentation is found stating the resident was offered choice the families will be offered a choice of provider.

3.The Director of Social Services and social worker will be in-serviced on the Hospice Program Standard.

Review of new hospice orders will be reviewed at the clinical meeting along with SW documentation of discussion with the resident and their family and offer of choice of providers.

4.The Nursing Home Administrator/designee will audit hospice charts for documentation of resident choice of provider weekly x4 then monthly x2. Findings of the audit will be reported monthly to the Quality Assurance Performance Improvement Committee for review and recommendations.
483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(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 and staff interview it was determined that the facility failed to ensure each resident the right to a homelike environment and the necessary maintenance services to maintain a comfortable interior for one of twenty-one residents reviewed (Resident 36).

Findings Include:

Observations in Resident 36's room, on April 15, 2022, at approximately 10:00 AM, revealed a hole in the wall behind the head of the Resident's bed.

An interview with the Nursing Home Administrator (NHA), on April 20, 2022, at 9:55 AM, revealed all staff are responsible for reporting maintenance concerns to the appropriate personnel in order to submit a work order.

The interview also revealed a work order to address the hole in the wall in Resident 36's room was submitted and a house audit of the condition of all resident rooms had been completed.

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


 Plan of Correction - To be completed: 05/30/2022

1. Resident #36: A maintenance work order was submitted and the repair has been completed.

2. At the time of the survey Environmental rounds were completed by the Director of Buildings & Grounds and team to identify and address any other needed repairs.

3.Team members from all departments will be in-serviced on identification and reporting of environmental concerns.

4. Executive Director/designee and the Director of Buildings and Grounds will conduct environmental rounds weekly x 4 and monthly x2. Findings of the audit will be reported monthly to the Quality Assurance and Performance Improvement Committee for review and recommendations.
483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:

Based on observations, resident group response interview, and staff interview it was determined that the facility failed to ensure each resident the right to anonymously file a grievance/concern based on interviews held with the resident council group participants during the onsite survey.

Findings Include:

Review of the facility's corporate standard of practice titled "Grievances/Concerns", recently revised February 7, 2017, reads "The resident and/or his/her interested party have the right to voice grievances regarding treatment and/or services, which have been provided or not provided."

The standard continues "The resident or interested party may voice a concern to any team member or may report a concern anonymously."

An interview with members of the facility's Resident Council, during a meeting held on April 20, 2022, at 1:00 PM, revealed residents are instructed to request the grievance/concern form from the Life Enrichment Coordinator, complete the grievance/concern form, and return.

The interview also revealed there are no areas within the facility to obtain a grievance/concern form anonymously or without the assistance or participation of other staff.

Observations during the onsite survey confirmed no areas within the facility providing access to residents and/or family members to obtain the forms anonymously.

An interview with the Nursing Home Administrator, on April 21, 2022, at 8:45 AM, revealed grievance forms are now available in resident areas in order to file a grievance/concern in an anonymous fashion.

28 Pa. Code 201.29 (a) Resident rights


 Plan of Correction - To be completed: 05/30/2022

1.At the next Resident Council meeting the resident will be informed on how to file an anonymously.

2.Residents will be educated at the Resident Council Meetings of their right to file an anonymous grievance or concern and of the process to do so.

3.A new office door file has been hung in a common area with grievance forms and a new lock box for resident to file of grievance/concern forms has been hung and labeled for grievances. IDT will be re-education on the residents right to file an anonymous grievances and location of the new lock box for placement of grievances.

4.The Director of Social Services/designee will make rounds 2x/week x1 month, then weekly x2 months to ensure forms are available. Findings will be reported monthly to the Quality Assurance Performance Improvement Committee for review and recommendations.
483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff: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.
483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:


Based on observation, clinical record review, resident and staff interview it was determined that the facility failed to ensure sufficient staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being by ensuring call bells were responded to within reasonable amount of time for two of twenty-two residents reviewed (Resident 23 and 36).


Findings include:

Review of facility provide policy; Call Light, Use of; Revised May 18, 2018, states "Answer ALL call lights promptly (with little or no delay; immediately)".

An interview with members of the facility's Resident Council, during a meeting held on April 20, 2022, at 1:00 PM, revealed residents had concern with the amount of time it takes for the staff to answer their call bell.

Review of Resident 23's clinical record revealed diagnoses that included congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should) and vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain).

Review of facility provided call bell audits on April 20, 2022, revealed that on April 15, 2022, at 4:34 PM Resident 23 activated her call bell and it was not answered for one hour and forty-seven minutes.

Interview with Resident 23 on April 18, 2022, revealed that she felt it sometimes took too long for facility staff to answer the call light when help was needed.

Review of Resident 36's clinical record revealed diagnoses that included cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body) and muscle weakness (muscle weakness is commonly due to lack of exercise, aging, muscle injury or pregnancy).

Review of facility provided call bell audits, on April 20, 2022, revealed that on April 10, 2022 at 6:51 AM Resident 36 activated her call bell and it was not answered for one hour and five minutes; on April 10, 2022 at 8:07 AM Resident 36 activated her call bell and it was not answered for one hour and five minutes; on April 10, 2022 at 9:36 AM Resident 36 activated her call bell and it was not answered for one hour and thirty-nine minutes; on April 11, 2022 at 1:37 PM Resident 36 activated her call bell and it was not answered for one hour and six minutes; and on April 12, 2022 at 7:00 AM Resident 36 activated her call bell and it was not answered for one hour and forty-two minutes.

Interview with Nursing Home Administrator on April 20, 2022, at 1:36 PM, revealed that the call bells mentioned above should have been answered in a timely manner.

Pa. Code 211.12(d)(1) Nursing Services


 Plan of Correction - To be completed: 05/30/2022

1. Resident #23 will be interviewed to ensure the resident didn't have any current needs that were not met. Resident #36 is no longer in the facility. Audit of Nursing home hours per day was completed for the dates listed in the 2567. No dates list were below a 3.2 which is above the required nursing staffing hours for Pennsylvania.

2.Grievance logs for the last 3 months were reviewed to determine if any there were any call bell grievances and if so was the grievance resolved.

3.Team members from all departments will be re-educated to answer call bells in a reasonable amount of time. NHA/designee weekly will review daily staffing sheets with the DON/designee to ensure sufficient staffing.

4.The DON/designee will audit five random rooms 3 times a week x 4 weeks and then five rooms weekly times 4 weeks to ensure call balls were answered in a reasonable amount of time. Findings and results of the audits will be brought to QAPI for further recommendation.
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, clinical record review, and staff interview it was determined that the facility failed to ensure that the pharmacy regimen review was accurately completed, and that the physician responded to and provided an appropriate rationale to the recommended changes for one of twenty-two residents reviewed (Resident 44).

Findings include:

Review of facility policy titled, Drug Regimen Review Standard, last revised November 28, 2017, revealed, "Arrangements shall be made through pharmacy contract to assure a licensed pharmacist will perform a drug regimen review for each resident no less than monthly."

Review of Resident 44's clinical record revealed diagnoses that included diabetes mellitus (to a group of diseases that affect how your body uses blood sugar [glucose]) and major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).

Review of facility provided documents failed to reveal any evidence that a pharmacist reviewed Resident 44's drug regimen for the months of June 2021, July 2021, August 2021, and March 2022.

Interview with the Nursing Home Administrator on April 20, 2022, at 1:30 PM, revealed that the facility and pharmacist should be reviewing the medications monthly per facility policy and regulation.

28 Pa. Code 211.2(a) Physician services.
28 Pa. Code 211.5(f) Clinical records.
28 Pa. Code 211.10(c) Resident care policies.


 Plan of Correction - To be completed: 05/30/2022

1.Resident #44 has had a completed pharmacy regimen review this month with no recommendations. This was reviewed by the residents physician.

2.Audit of current residents has been conducted to ensure all current residents have had a drug regimen review completed in the month of April.

3. The Consulting Pharmacist will use the "Missing Entries" report in PCC to scan for any residents who do not have a med regimen review noted at the conclusion of the current month's review. The DON and Adon were in-service of the drug regimen process and the DON/designee will run a detailed census report and compare this to the pharmacy recommendation report.

4.Director of Nursing/designee will compare monthly pharmacy reports to the resident roster to monitor compliance with the pharmacy regimen reviews x3 months. Findings will be reported monthly to the Quality Assurance Performance Improvement Committee for review and recommendations.
483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:

Based on observations and interviews, it was determined the facility failed to provide food at appetizing temperatures for one observed meal.

Findings

Review of facility policy, Holding/Serving Temperatures Standard, last revised February 4, 2019, revealed that hot foods should be served at 135 degrees or above.

Multiple resident interviews on April 18, 2022, revealed residents voiced concerns with the temperature of the food during meal service.

Observation of meal service for the lunch meal on April 19, 2022, at 11:32 AM, revealed a tray being served that included: ground ham, potato and green bean casserole, coffee, and ginger ale. Temperatures taken revealed the potato and green bean casserole was 131.8 degrees Fahrenheit (a unit of measure), and coffee was 130.2 degrees Fahrenheit.

Interview with the Nursing Home Administrator on April 20, 2022, at 1:35 PM, revealed the foods should have been served at a temperature greater than 135 degrees Fahrenheit, as stated in the facility policy

28 Pa. Code 211.6 (d) Dietary services


 Plan of Correction - To be completed: 05/30/2022

1.No residents were identified for the tray that the temperature was taken.

2.The Dining Services Director and/or designee will complete an audit on kitchen equipment to ensure optimal performance on all components.

3. The Dining Services Director will re-educate the dining services department on the HACCP and Food Handling Principles Standard outlining safe food temperatures. Dining services will limit the number of trays distributed at a time. And once the Kitchen project is completed the pellet system will be implemented.

4.The Dining Services Director and/or designee will complete 5 test trays per week x8 weeks to ensure food temperatures achieve compliance. The test temperatures will be taken on the tray line and at the time of meal delivery. Audits will be reviewed at the QAPI meeting for follow up and additional recommendations.
483.90(e)(1)(ii) REQUIREMENT Bedrooms Measure at Least 80 Sq Ft/Resident: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.
483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms;
Observations:

Based on observations and documentation provided by the facility, it was determined that the facility failed to provide the regulatory required minimum square footage in one of 51 resident rooms.

Findings include:

Review of the facility documentation and observation revealed that room 319 has two beds and measures 150 square feet. Room 319 multi-bedroom failed to provide the minimum square footage requirement of 80 square feet per bed.

42 CFR 483.70(d)(1)(ii)
Previously cited 9/24/2012, 9/12/2013, 8/7/2014, 9/3/2015, 8/5/2016, 7/27/2017, 8/2/18, 4/15/21

28 Pa. Code 2015.20 Euro(f) Resident Bedrooms
Previously cited 9/24/2012, 9/12/2013, 8/7/2014, 9/3/2015, 8/5/2016, 7/27/2017, 8/2/18, 4/15/21


 Plan of Correction - To be completed: 05/30/2022

1.The residents who reside in this room are aware that the square footage is less than other resident rooms and do not express any concerns with comfort of the room.

2.This room is the only room in the facility that doesn't meet square footage requirements. Anyone new moving into the room is made aware of the square footage variance and is permitted to choose not to accept the room.

3.The facility will re-apply annually for the federal waiver for the room that does not meet the federal requirement for square footage. A waiver has been in place for PA.
The application process will be reviewed with the facilities Quality Assurance and Improvement Program, and reported at the meeting.
201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:

Based on interview, infection control monitoring logs, and facility policy, it was determined the facility failed to maintain an accurate data collection system of surveillance for the required reports to the Patient Safety Authority from June 2021 through December 2021.

Findings include:

Review of the facility policy titled, "Infection Control Plan Standards," last reviewed March 2022, states, "Reporting of Healthcare Associated Infections (HAI): Reportable Diseases will be electronically submitted to the Department of Health in accordance with the Reportable Diseases Standard #8-002 and according to Act 52 reporting requirements for confirmed infections. McGreer criteria is used to confirm infections (criteria for infections to be reported)."

During the COVID 19 pandemic, NHSN reporting requirement was completed by the Nursing Home Administrator (NHA)/designee.
HAIs are considered serious events: Resident/responsible party notified in 7 days of identification.

During an interview with the NHA on April 19, 2022, the NHA stated that the facility had previous issues with reporting to NHSN (National Healthcare Safety Network) and now all submissions are up to date. A review of NHSN COVID 19 reports submitted by the facility were reviewed for the dates of January 24, 2022, through April 18, 2022, and were submitted timely to NHSN, as required.

Review of the facility's infection control logs failed to provide any data from June 2021 through December 2021. Based on the infection control logs reviewed prior to June 2021 and after December 2021, data to be collected and documented included the resident's name, room location, infection site, type of infection, signs and symptoms, treatment, and indicated those infections that required reporting to the Department of Health and Patient Safety Authority.

During an interview with the NHA and the Director of Nursing (DON) on April 21, 2022, at approximately 10:45 AM, the data was unable to be located after a thorough search and contacting previous employees. The NHA and DON informed the surveyor that neither one of them were employed at the facility from June 2021 through December 2021.


 Plan of Correction - To be completed: 05/30/2022

1.No residents were identified as being effected.

2.Audit has been completed to ascertain reports to the Patient Safety Authority reporting System have been completed from January 2022 through April 2022.

3.The recently hired Clinical/Quality Manager has been in-serviced on the data collection surveillance and required reporting to the Patient Safety Authority Reporting System.


4.Director of Nursing /designee will monitor completion of the data collection and reporting to the Patient Safety Authority Reporting System monthly x3. Findings will be reported monthly to the Quality Assurance and Performance Improvement Committee for review and recommendations.

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