Pennsylvania Department of Health
CHAPEL MANOR
Patient Care Inspection Results

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CHAPEL MANOR
Inspection Results For:

There are  165 surveys for this facility. Please select a date to view the survey results.

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CHAPEL MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to one complaint completed February 7, 2024 , it was determined that Chapel Manor 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 related to the health portion of the survey process.



 Plan of Correction:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on review of facility policy, review of clinical records, observations, and staff and resident interviews, it was determined that the facility failed to maintain resident dignity for two of five residents reviewed (Resident R2 and R4).

Findings Include:

Review of facility policy "Resident Rights", effective November 2016, revealed the resident has a right to a dignified existence inside the facility. Further review of facility policy revealed the facility must treat each resident with respect and dignity, and care for each resident in a manner, and in an environment, that promotes maintenance, or enhancement, of quality of life, recognizing each resident's individuality.

Review of Resident R2's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated November 4, 2023, revealed the resident was cognitively intact and was dependent on staff for upper and lower body dressing.

Review of Resident R4's comprehensive MDS dated January 25, 2024, revealed the resident was cognitively intact and required partial/moderate assistance with upper body dressing.

Observations from the hallway on February 7, 2024, at 1:15 p.m. revealed Resident R2 was laying in the bed closest to the door. Resident R2 was observed to be dressed in a hospital gown with brief exposed. Interview with Resident R2 revealed the resident had personal clothing in the dresser.

Interview on February 7, 2024, at 1:20 p.m. with nurse aide, Employee E3, confirmed observations of Resident R2. Further interview with nurse aide, Employee E3, confirmed Resident R2 had personal clothing in the dresser and would assist the resident with getting dressed.

Observations from the hallway on February 7, 2024, at 1:35 p.m. revealed Resident R4 walking around the room in a hospital gown and brief exposed. Interview with Resident R4 revealed the resident had personal clothing in the closet and would prefer to be dressed in personal clothing.

Interview on February 7, 2024, at 1:40 p.m. with licensed nurse, Employee E4, confirmed observations of Resident R4 and confirmed the resident had personal clothing in the closet.


211.10 (d) Resident care policies.





 Plan of Correction - To be completed: 04/07/2024

Residents R2 and R4 were reviewed and care planned for dressed preferences.

Staff has been educated on following residents' preferences and maintaining proper hygiene.

Unit Managers or designee will complete a random daily audit for 4 weeks to ensure residents' preferences and hygiene needs are met. Findings will be reviewed in QAPI.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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)(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 review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that each resident was involved in developing the care plan and making decisions about his or her care for two of five records reviewed (Resident R1 and R3).

Findings Include:

Review of facility policy "Person-Centered Care Plan", revised October 24, 2022, revealed person-centered care means to focus on the resident as the point of control and support the resident in making their own choices and having control over their daily life. The policy states that the resident has the right to participate in the development and implementation of the person-centered care plan.

Further review of facility policy revealed that a person-centered care plan must be developed for each resident and, in consultation with the patient, must include preference and potential for future discharge. The facility has the responsibility to assist residents to participate by facilitating the inclusion of the resident to attend. Care plan meetings will be documented by use of the Care Plan Meeting note.

Review of facility policy "Resident Rights", effective November 28, 2016, revealed the resident has the right to participate in the development and implementation of his/her person-centered plan of care,

Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated December 21, 2023, revealed the resident was cognitively intact.

Review of Resident R3's quarterly MDS dated December 12, 2023, revealed the resident was cognitively intact.

Review of Resident R1 and Resident R3's comprehensive care plans revealed it did not include preference and potential for future discharge.

Interview on February 7, 2024, at 12:45 p.m. with Resident R1 revealed the resident would like to transfer to a different facility and is not receiving any assistance to do so. Continued interview with Resident R1 revealed the resident has not been invited to or participated in the development of the person-centered care planning process.

Interview on February 7, 2024, at 1:00 p.m. with Resident R3 revealed the resident denied being invited to or the opportunity to participate in the development of the person-centered care planning process. Resident R2 voiced that, if given the opportunity, would be interested in transferring to a different facility.

Review of Resident R1's and R3's entire clinical record revealed no documented evidence that the residents were routinely invited to participate in care planning.

Interview on February 7, 2024, at 3:00 p.m. with the Director of Nursing, Employee E2, confirmed there was no documented evidence that each resident was invited to participate in care planning.

201.29 (a) Resident Rights.




 Plan of Correction - To be completed: 04/07/2024

Residents R1 and R3 requests for transfer were sent to the facility of their choice.
Residents R1 and R3 have had care conference meetings.

Social workers have been educated on the importance of timely completion of Care conferences.

Social workers will ensure that all residents participate and have timely documented care conferences.

NHA or designee will complete random weekly audits to ensure compliance. Findings will be reviewed in QAPI.


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