Pennsylvania Department of Health
HILLTOP HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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HILLTOP HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  156 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.
HILLTOP HEALTHCARE 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 February 1, 2024, it was determined that Hilltop Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(i) Food safety requirements.
The facility must -

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

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


Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to serve and store food in accordance with professional standards for food service safety by failing to ensure that outdated or expired food was removed from the refrigerator and failing to ensure that dietary staff wore hair coverings that completely covered their hair during food handling.

Findings include:

Observations in the main cooler on January 29, 2024, at 9:09 a.m. revealed a container of strawberries with a white substance (mold) all over them.

Interview with the Dietary Director on January 29, 2024, at 9:09 a.m. confirmed that the strawberries had white mold all over them and then removed them from the cooler.

The facility's dietary policy regarding personal hygiene, dated November 30, 2023, revealed that staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.

Observations in the kitchen on February 1, 2024, at 12:21 p.m. revealed dietary staff preparing meal trays for delivery to the units for the resident's lunch. Cook/Server 6 had hair exposed on both sides of her face as well as the back of her head.

Interview with the Dietary Director on February 1, 2024, at 1:45 p.m. confirmed that Cook/Server 6 did not have all her hair covered with a restraint and that she should have.

28 Pa. Code 211.6(f) Dietary services.



 Plan of Correction - To be completed: 03/14/2024

The Dietary Manager verified that there were no other fresh fruits in the kitchen cooler containing mold and that all staff had hair nets on correctly with all hair contained.
Registered Dietician and/or designee will educate dietary staff including any newly hired staff during orientation process on hygiene/properly securing hair within hairnets and on facility Food Receiving and Storage Policy.
Registered Dietician and/or designee will audit fresh fruits upon receiving prior to placing in refrigeration/storage for signs of mold and daily by AM cook 2 x week for 4 weeks and monthly x 2 months. Audits will also be completed on all staff within the food preparation area to ensure hair is contained per facility policy. Audit will be completed 2xweek for 4 weeks, monthly x 2 months and randomly to ensure and maintain compliance.
Date of compliance 3/14/2024

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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.
§483.10(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 81°F; and

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


Based on observations and staff interviews, it was determined that the facility failed to ensure that the resident environment was maintained in a homelike manner in two of four resident lounge/activity/dining areas (B and C Hall lounge/activity/dining areas).

Findings include:

Observations in the B Hall resident lounge/activity/dining area on January 29, 2024, at 12:10 p.m. revealed that there were three residents being fed by staff, and there were 10 wheelchairs and two rollators stored in the corner by the windows. Observations on January 30, 2024, at 12:15 p.m. revealed that there were five residents in the dining area eating lunch, and there were six wheelchairs and two rollators stored in the corner by the windows.

Interview with Licensed Practical Nurse 1 on January 30, 2024, at 12:30 p.m. confirmed the wheelchairs and rollators were stored in the dining room and the staff did not know where else to store them when not in use.

Observations in the C Hall resident lounge/activity/dining area on January 29, 2024, at 12:07 p.m. revealed that there were three residents in the room watching TV, and there were six wheelchairs stored in the corner by the windows. There was also a set of wheelchair leg rests stored on a wooden chair. At 12:40 p.m there were five residents in the room waiting to receive their lunch meal and the wheelchairs in the corner by the windows and the set of wheelchair leg rests stored on a wooden chair were still there. Observations on January 30, 2024, at 12:40 p.m. revealed that there were four wheelchairs stored in the corner by the windows and one stored under the TV. There was also a set of wheelchair leg rests stored on a wooden chair. There were five residents in the room waiting to receive their lunch meal. Observations on January 31, 2024, at 10:07 a.m. revealed that there was four wheelchairs stored in the corner by the windows and one stored under the TV. There was also a set of wheelchair leg rests stored on a wooden chair. There was one resident in the room at that time.

Interview with Licensed Practical Nurse 2 on January 31, 2024, 10:07 a.m. confirmed that the wheelchairs and wheelchair leg rests were stored in the C Hall resident lounge/activity/dining area and were wheelchairs that belonged to residents who were not out of bed yet.

Interview with the Nursing Home Administrator on January 31, 2024, at 3:38 p.m. revealed that staff store the resident's wheelchairs in those areas when they are in bed because there is not a lot of room in their rooms to keep their wheelchairs.

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

28 Pa. Code 207.2(a) Administrator's Responsibility.



 Plan of Correction - To be completed: 03/14/2024

1. Wheelchairs that were in the solariums on B and C wing were removed
2. A walk-through of the solariums on all wings was completed to ensure no further wheelchairs are being put into any of the facility solariums while not being used.
3. Education with all nursing staff completed on the storing of wheelchairs when not in use.
4. Audits of the solarium will be completed twice a week for two weeks and monthly for 2 months to main by the Administrator or designee to maintain compliance. Results will be reported and trended through the facility's Quality Assurance Committee.
5. Date of compliance: 3/14/2024

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.
Observations:


Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of correction for the State Survey and Certification (Department of Health) survey ending February 24, 2023, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 1, 2024, identified repeated deficiencies related to a failure to complete Minimum Data Set (MDS) assessments (mandated assessments of residents' abilities and care needs) accurately, to develop comprehensive care plans, following physician's orders, and to prepare and store food under sanitary conditions.

The facility's plan of correction for a deficiency regarding completing accurate MDS assessments, cited during the survey ending February 24, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding completing accurate MDS assessments.

The facility's plan of correction for a deficiency regarding developing comprehensive care plans, cited during the survey ending February 24, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding the development of comprehensive care plans.

The facility's plan of correction for a deficiency regarding a failure to follow physician's orders, cited during the survey ending on February 24, 2023, revealed that audits would be conducted, and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F684, revealed that the QAPI committee was ineffective in correcting deficient practices related to following physician's orders.

The facility's plan of correction for a deficiency regarding labeling and storing food under sanitary conditions, cited during the survey ending February 24, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding preparing and storing food under sanitary conditions.

Refer to F641, F656, F684, F812.

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

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




 Plan of Correction - To be completed: 03/14/2024

1. The facility Quality Assurance Performance Improvement committee will continue to be held monthly. The committee will meet the expectations of the facility policy to ensure follow-up on repeat deficiencies.
2. The Administrator will provide re-education on the Quality Assurance Performance Improvement committee process and the expectations to active committee participants as outlined in the above-mentioned policy.
3. The committee failed to successfully implement plan of corrections for previously identified areas by not reviewing audit findings and making any corrective recommendations. To assure compliance of the plan of correction, department head committee members will present their specified areas at the committee meetings for discussion, committee recommendations, effectiveness and implementation of corrective actions. These presentations will include audit tools utilized to address areas of the plan of correction and will be reported on a monthly basis. Committee members will implement recommendations as discussed and detailed by the committee. Participating committee members will follow up on recommendations to assure continued compliance. Any outlying findings will be corrected and reported back to the committee for further discussion/ recommendations.
4. Monthly minutes from the Quality Assurance Performance Improvement committee will be forwarded to the Regional Clinical Nurse for review and recommendations.
5. Date of compliance 3/14/2023

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of 48 residents reviewed (Resident 71).

Findings include:

Physician's orders for Resident 71, dated January 4, 2024, included an order for the resident to receive one 10 milligram (mg) tablet of Midodrine (used to treat low blood pressure) three times per day for hypotension (low blood pressure) and staff was to hold the medication if the systolic blood pressure (the top number of the blood pressure) was greater than 120 millimeters of mercury (mmHg).

Medication Administration Records (MAR's) for Resident 71, dated January 2024, revealed that Licensed Practical Nurse 7 documented as administering the 10 mg of Midodrine to the resident on January 12, 2024, at 8:00 a.m. for a blood pressure reading of 138/72 mmHg, and at 1:00 p.m. for a blood pressure reading of 138/78 mmHg; on January 15, 2024, at 1:00 p.m. for a blood pressure reading of 126/62 mmHg; on Janaury 24, 2024, at 1:00 p.m. for a blood pressure reading of 122/64 mmHg; and on January 26, 2024, at 1:00 p.m. for a blood pressure reading of 142/78 mmHg.

Interview with Licensed Practical Nurse 7 on February 1, 2024, at 3:10 p.m. confirmed that Resident 71's MAR's revealed that she documented as administering the 10 mg of Midodrine to the resident on the above dates and times. She indicated that she did not administer the 10 mg of Midodrine to the resident on the above dates and times because the blood pressures were above the physician-ordered parameter. She indicated that when this was brought to her attention the registered nurse supervisor showed her how to chart that the medication was not administered in a supplemental charting area on the MARs.

28 Pa. Code 211.5(f) Clinical Records.

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




 Plan of Correction - To be completed: 03/14/2024

1. Resident #71 no longer resides in the facility
2. A baseline audit was completed on all residents currently receiving the medication Midodrine to check for error in documentation.
3. All licensed nursing staff were educated on the process of documenting medications not given due resident being outside of parameters.
4. Audits on residents receiving medications with parameters will be completed weekly x2 weeks and monthly x 2 months to ensure compliance. Results will be reported and trended through the facility's Quality Assurance Committee.
5. Date of compliance 3/14/2024

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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(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 review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at palatable temperatures.

Findings include:

The facility's policy regarding hot foods, dated November 30, 2023, revealed that dietary staff will serve all hot foods at 135 degrees Fahrenheit (F) or above and ensure that the food is palatable.

An interview with a group of residents on January 30, 2024, at 3:30 p.m. revealed that the food served by the facility was sometimes bland and was sometimes served cold.

Observations of the lunch meal service in the main kitchen on February 1, 2024, revealed that the C-Wing cart containing a test tray left the main kitchen at 12:36 p.m. and arrived on C-Wing at 12:38 p.m. Trays were passed to the residents that were in their rooms and in the common area at the end of the hall. The last resident was served at 12:56 a.m. The test tray was removed from the cart at 12:56 a.m. and the temperature of the milk was 45.1 degrees F, the coffee was 140 degrees F, the zucchini was 129.3 degrees F, the stuffing was 134 degrees F, the turkey was 128.6 degrees F. The Zucchini and milk were lukewarm and not at a palatable or appetizing temperature.

Interview with the Dietary Director on February 1, 2024, at 12:56 p.m. confirmed that the food on the test tray was not at an appetizing temperature.

28 Pa. Code 201.18(b)(1)(2)(e) Management.

28 Pa. Code 211.6(c) Dietary services.



 Plan of Correction - To be completed: 03/14/2024

The policy on palatable food temperatures was reviewed with all members of the dietary department by the Registered Dietician and/or designee.
Test trays will be completed by the Registered Dietician dietary manager twice weekly x 4 weeks then monthly x 2 months and at random afterwards to ensure that served foods are within facility policy temperatures and palatable.
Results for test trays will be reviewed during facilities Quality Assurance committee meetings.
Date of compliance 3/14/2024

483.25(m) REQUIREMENT Trauma Informed Care: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.
§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.
Observations:


Based on review of facility policies and clinical records, as well as staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for three of 48 residents reviewed (Residents 65, 80, 84)

Findings include:

The facility's policy regarding Trauma Informed Care, dated November 30, 2023, revealed the facility will complete an assessment that involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 65, dated December 5, 2023, revealed that the resident was was cognitively impaired and had a diagnosis which included Parkinson's disease and Post Traumatic Stress Disorder (PTSD a real disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event). A care plan for the resident, dated September 19, 2023, revealed that the resident has a mood problem related to depression/anxiety and PTSD.

However, there was no documented evidence the facility completed an assessment for a history of trauma for Resident 65 to identify specific triggers that could re-traumatize the resident.


An admission MDS assessment for Resident 80, dated November 7, 2023, revealed that the resident was cognitively impaired and had a diagnosis which included dementia. A care plan, dated November 3, 2023, revealed that the resident had a past traumatic event of exposure to combat or warzone.

A psychiatry note, dated December 16, 2023, revealed that Resident 80 had a history of dementia and severe PTSD in which he was followed by psychiatry for management.

However, there was no documented evidence the facility completed an assessment for a history of trauma for Resident 80 to identify specific triggers that could re-traumatize the resident.


An admission MDS assessment for Resident 84, dated January 10, 2024, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnosis that included heart failure, diabetes, and PTSD.

There was no documented evidence the facility completed an assessment for a history of trauma for Resident 84 to identify specific triggers that could re-traumatize the resident.

Interview with the Director of Nursing on January 30, 2024, at 11:46 a.m. confirmed that there was no documented evidence of an assessment for a history of trauma being completed for Residents 65, 80, and 84.

28 Pa. Code 211.12(a)(d)(3)(5) Nursing Services.

28 Pa. Code 211.16(a) Social Services.




 Plan of Correction - To be completed: 03/14/2024

1. Trauma assessments were completed for resident #65 and resident #80 resident #84 no longer resides at the facility.
2. The Social Service Director or designee will review resident assessments for all residents who have a diagnosis of PDSD. Any identified residents not having a trauma assessment will be updated upon discovery for specific triggers.
3. Administrator has provided education to the Director of Social Service on the facilities policy on trauma informed care/assessments
4. Audits on all new admissions/current residents with new diagnosis of PTSD will be conducted 2 x week for 2 weeks then monthly for 2 months by the Nursing Home Administrator or designee to ensure any residents with PTSD have the Trauma assessment completed and documented.
5. Date of compliance 3/14/2024

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address resident care needs for four of 48 residents reviewed (Residents 61, 65, 80, 84).

Findings include:

The facility's policy regarding care plans, dated November 30, 2023, revealed that a comprehensive care plan for each resident will be developed within seven days of completion of the MDS and be individualized to the resident's care needs.

A nursing note, dated September 14, 2023, at 1:50 p.m. revealed that Resident 61 was admitted from the hospital and had a pacemaker (a small medical device implanted under the skin that delivers electrical impulses to the heart to help control abnormal heart rhythms) inserted.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated January 6, 2024, revealed that the resident was cognitively impaired and had a pacemaker.

As of February 1, 2024, there was no documented evidence that Resident 61's care plan included any information or interventions related to the pacemaker.

Interview with Director of Nursing 1 on February 1, 2024, at 3:46 p.m. confirmed that there was no care plan developed to address Resident 61's pacemaker.


The facility policy regarding informed trauma care, dated November 30, 2023, revealed that the facility would develop individualized care plans that address past trauma in collaboration with the resident and family as appropriate. The facility would identify and decrease exposure to triggers that may re-traumatize the resident.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 65, dated December 5, 2023, revealed that the resident was cognitively impaired and had a diagnosis which included Parkinson's disease and Post Traumatic Stress Disorder (PTSD a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event). A care plan for the resident, dated September 19, 2023, revealed that the resident has a mood problem related to depression/anxiety and PTSD. However, there was no documented evidence the facility developed individualized interventions to identify and/or prevent specific triggers that could re-traumatize the resident.


An admission MDS assessment for Resident 80, dated November 7, 2023, revealed that the resident was cognitively impaired and had a diagnosis of dementia. A care plan, dated November 3, 2023, revealed that the resident had a past traumatic event or exposure to combat or warzone.

A psychiatry note for Resident 80, dated December 16, 2023, revealed that Resident 80 had a history of dementia and severe PTSD in which he was followed by psychiatry for management.

There was no documented evidence that the facility developed individualized interventions to identify and/or prevent specific triggers that could re-traumatize the resident.


An admission MDS assessment for Resident 84, dated January 10, 2024, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included heart failure, diabetes and PTSD.

A review of Resident 84's plan of care revealed that there was no documented evidence that a care plan was developed to address Resident 84's triggers related to PTSD.

Interview with the Director of Social Services on January 30, 2024, at 11:53 a.m. confirmed that she is responsible for behavior care plans and also confirmed that Residents 65, 80, and 84 do not have individualized care plans for PTSD triggers.

Interview with the Director of Nursing on January 30, 2024, at 11:46 a.m. confirmed that Resident 65's, 80's, and 84's care plans should have included triggers related to their diagnosis of PTSD.

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




 Plan of Correction - To be completed: 03/14/2024

1. Care plans for residents 61,65,80 and 84 were reviewed and updated to ensure they contain specific and individualized interventions for care of PTSD diagnosis and pacemaker.
2. An audit of all residents with a diagnosis of PTSD and all residents who currently have pacemakers was conducted and all care plans were updated to ensure specific and individualized interventions are in place for both PTSD and pacemakers.
3. Director of Nursing/designee will educate social service department/licensed staff on responsibilities of care plan specific individualized interventions for residents with a PTSD diagnosis and for all residents having a pacemaker, education will also include the creating of care plans for any new diagnosis of PTSD or resident getting pacemaker inserted on current residents.
4. The Director of Nursing/designee will complete audits of new residents' care plans who have a diagnosis of PTSD or who have a pacemaker to ensure their care plan is individualized and specific to their needs and order summary report to ensure no new PTSD diagnosis or pacemaker for current residents. Audits will be completed weekly times 2 weeks then monthly for two (2) months.
Results will be reported and trended through the facility's Quality Assurance Committee.
5. Date of compliance: 3/14/2024

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


Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for nine of 48 residents reviewed (Residents 23, 31, 56, 63, 65, 80, 83, 84, 86).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that Section O0110K (b) (Hospice Care) was to be coded if hospice services were provided while a resident of the facility and within the last 14 days.

Physician's orders for Resident 23, dated August 20, 2021, included an order for the resident to receive hospice Care Services. A current care plan for Resident 23 included a plan of care to provide hospice care to the resident.

A quarterly MDS assessment for Resident 23, dated November 30, 2023, revealed that Section O0110K (b) was coded (0), indicating that the resident did not receive any hospice care within the last 14 days of the assessment period.

Interview with the Registered Nurse Assessment Coordinator (RNAC) on January 31, 2024, at 3:28 p.m. confirmed that Section O0110K(b) was coded incorrectly on Resident 23's quarterly MDS assessment dated November 30, 2023.


The RAI User's Manual, dated October 2023, revealed that section H0300 should be coded (0), always continent when the resident has been continent of urine, without any episodes of incontinence during the seven-day look-back period.

A quarterly MDS assessment for Resident 31, dated December 23, 2023, revealed that the resident was cognitively intact, required moderate assist with toileting and transfers, and was always continent of bladder. A care plan for Resident 31, dated August 7, 2023, revealed that she was incontinent of urine due to impaired mobility.

A nurse aide documentation report for December 2023 revealed that Resident 31 was incontinent of bladder six times during the seven-day look back period.

Interview with the RNAC on February 1, 2024, at 10:05 a.m. confirmed that Resident 31's MDS Section H0300 for bladder continence was coded inaccurately.


The RAI User's Manual, dated October 2023, revealed that Section N0415E Anticoagulant (a blood thinning medication) was to be coded if the resident took the medication during the seven-day look-back period.

Physician's orders for Resident 56, dated October 26, 2023, included an order for the resident to receive 5 milligrams of Apixaban (anticoagulant medication) twice a day for a pulmonary embolus (blood clot in the lung).

Resident 56's Medication Administration Record for October 2023 revealed that the resident was administered Apixaban during the seven-day look-back assessment period.

An admission MDS assessment for Resident 56, dated November 1, 2023, revealed that N0415E was not coded, indicating he did not receive an anticoagulant medication during the seven-day look-back assessment period.

Interview with the RNAC on February 1, 2024, at 4:04 p.m. confirmed that Resident 56's MDS section N0415E for anticoagulant medication was coded inaccurately.


The RAI Manual, dated October 2023, revealed that Section H0100A was to be checked if the resident had an indwelling urinary catheter (a tube held in the bladder for the continuous drainage of urine) any time during the seven-day assessment period. If the resident had an indwelling catheter in use during the entire seven-day assessment period, then Section H0300 (Urinary Continence) was to be coded nine (9), indicating that the resident's urinary continence was not rated due to the presence of the catheter.

Physician's orders for Resident 63, dated January 16, 2024, included an order for staff to connect the urostomy (a surgically-created opening in the abdominal wall through which urine passes) to the foley drainage bag every shift and to change the urostomy bag every day shift and as needed.

A quarterly MDS assessment, dated December 6, 2023, revealed that Section H0100A was checked, indicating that the resident had an indwelling urinary catheter, and Section H0100C was checked, indicating that the resident had an ostomy (is surgery to create an opening from an area inside the body to the outside); however, Section H0300 (Urinary Continence) was coded with a zero (0), indicating that the resident was always continent of urine.

Interview with the RNAC on January 31, 2024, at 2:05 p.m. confirmed that Section H0300 was coded incorrectly on Resident 63's quarterly MDS assessment dated December 6, 2023.


The RAI User's Manual, dated October 2023, revealed that if the influenza (flu) vaccine was not received, Section O0250C (influenza vaccine) was to be coded with the reason the flu vaccine was not received. The section was to be coded with a one (1) if the resident was not in the facility during this year's influenza vaccination season; two (2) if the resident received the vaccination outside of the facility; three (3) if the resident was not eligible for the vaccine due to a medical contraindication; (4) if the vaccine was offered and declined; or (5) if the vaccine was not offered.

Review of Resident 65's Immunization record revealed that the resident received the influenza vaccination on September 29, 2023.

A quarterly MDS assessment for Resident 65, dated December 5, 2023, revealed that Section O0250A was coded with no, indicating that the resident did not receive the influenza vaccination in the facility for this year's influenza vaccination season, and Section O0250C was coded with a five (5), indicating that the influenza vaccine was not offered to the resident.

Interview with the RNAC on January 31, 2024, at 2:05 p.m. confirmed that Section O0250A and Section O0250C were coded incorrectly on Resident 65's quarterly MDS assessment dated December 5, 2023.


The RAI User's Manual, dated October 2023, revealed that Section N0415J hypoglycemic medication (lowers blood sugar - including insulin) was to be coded if the resident took the medication during the seven-day look-back period.

Physician's orders for Resident 80, dated November 1, 2023, included an order for the resident to receive 6.25 mg (milligrams) of alogliptin benzoate (a hypoglycemic medication) daily for diabetes. The resident's Medication Administration Record (MAR) for November 2023 revealed that the resident received alogliptin benzoate daily during the seven-day look-back assessment period.

An admission MDS assessment for Resident 80, dated November 7, 2023, revealed that Sections N0415J was not coded, indicating that the resident did not receive a hypoglycemic medication during the seven-day look-back assessment period.

Interview with the RNAC on January 31, 2024, at 3:28 p.m. confirmed that Section N0415J was coded incorrectly on Resident 80's admission MDS assessment dated November 7, 2023.


The RAI User's Manual, dated October, 2023, revealed that if a wander/elopement alarm was used, then Section P0200E was to be coded as (0) not used, (1) used less than daily, or (2) used daily.

Physician's orders for Resident 83, dated December 4, 2023, included orders for the resident to use a Wanderguard (device that alarms when close to exit doors) and to check the placement/function every shift. The resident's Treatment Administration Record (TAR) for December 2023 revealed that the resident used a Wanderguard from December 4 through December 8, 2023.

An admission MDS assessment for Resident 83, dated December 8, 2023, revealed that Section P0200E was coded with a (0), indicating that the resident did not use a wander/elopement alarm.

Interview with the RNAC on February 1, 2024, at 4:05 p.m. confirmed that Section P0200E of Resident 83's December 8, 2023, MDS assessment should have been coded (2) for daily use of a wander/elopement alarm.


The RAI Manual, dated October 2023, revealed that Section H0100A was to be checked if the resident had an indwelling urinary catheter (a tube held in the bladder for the continuous drainage of urine) any time during the seven-day assessment period. If the resident had an indwelling catheter in use during the entire seven-day assessment period, then Section H0300 (Urinary Continence) was to be coded nine (9), indicating that the resident's urinary continence was not rated due to the presence of the catheter. Section N0415F Antibiotic (medication used for infection) and Section N0415I Antiplatelet (a medication used to prevent clots) was to be coded if the resident took the medication during the seven-day look-back period.

Physician's orders for Resident 84, dated January 5, 2024, included an order for the resident to have an indwelling foley catheter (a tube inserted into the bladder for urine), to receive 125 mg (milligrams) of Vancomycin (an antibiotic medication) four times a day, and to receive 81 mg of aspirin (an antiplatelet medication) every day.

The resident's Medication Administration Record (MAR) for January 2024 revealed that the resident received Vancomycin and aspirin daily during the seven-day look-back assessment period.

An admission MDS assessment for Resident 84, dated January 10, 2024, revealed that Section H0300 was coded with a zero (0), indicating that the resident was always continent of urine. Sections N0401F and N0401I was not coded, indicating that the resident did not receive an antibiotic and antiplatelet medication during the seven-day look-back assessment period.

Interview with the RNAC on January 31, 2024, at 12:58 p.m. confirmed that Sections H0300, N0401F and N0401I on Resident 84's admission MDS were coded inaccurately.


The RAI User's Manual, dated October 2023, indicated that the intent of Section A was to record the discharge status of the resident. Section A2105 was to be coded with the location of the resident's discharge.

A nursing note for Resident 86, dated November 6, 2023, indicated that the resident was discharged to home on that date. However, a discharge tracking MDS for Resident 86, dated November 6, 2023, indicated that Resident 86 was discharged to the hospital.

An interview with the Registered Nurse Assessment Coordinator on February 1, 2024, at 10:05 a.m. confirmed that Resident 86's discharge tracking MDS was coded incorrectly.

28 Pa. Code 211.5(f) Clinical Records.



 Plan of Correction - To be completed: 03/14/2024

1. The Minimum Data Set assessments for residents #23, 31, 63, 56, 65, 80 and 83 have been reviewed and modified to correctly reflect the residents' condition at the time of the assessment periods. Modifications have been completed and submitted to MDS. Residents #84 and #86 have been modified but no longer reside in the facility.
2. Sections O, H, N, P along with the discharge tracking in section A reviewed for accuracy on current residents most recent Minimum Data Set based on his/her most recent Assessment Reference Date (ARD) and corrected where applicable.
3. The Registered Nurse Assessment Coordinator was educated by the Director of Nursing on assessment accuracy.
4. Registered Nurse Assessment Coordinator(s) and/or designee will audit 15% or a minimum of 5 completed Minimum Data Set(s) section O, H, N and P weekly for 2 weeks and then monthly for 2 months - The results of the audits will be addressed at the Quality Assurance and Performance Improvement Committee for further analysis and corrective actions.
5. Date of compliance 3/14/2024

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.
Observations:


Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that staff followed the facility's policy regarding reporting an allegation of physical abuse in a timely manner for one of 48 residents reviewed (Resident 65).

Findings include:

The facility's policy regarding abuse, dated November 30, 2023, indicated that employees, facility consultants and/or attending physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing. In the absence of the Director of Nursing such reports may be made to the nurse supervisor on duty. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Nursing Home Administrator, Director of Nursing, or charge nurse.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 65, dated December 5, 2023, revealed that the resident was was cognitively impaired and had a diagnosis which included Parkinson's disease, and Post Traumatic Stress Disorder (PTSD a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event).

Facility investigation documents, dated January 22, 2024, revealed that Nurse Aide 3 reported to staff that yesterday January 21, 2024, at approximately 5:30 p.m. to 6:00 p.m. she witnessed Nurse Aide 4 punch Resident 65 in the stomach. The resident is unable to give a description.

A witness statement completed by Nurse Aide 3, dated January 22, 2024, revealed that on January 21, 2024, at approximately 5:00 p.m. Nurse Aide 4 asked her to assist with toileting Resident 65. Nurse Aide 3 pushed the resident into the bathroom in his wheelchair and while Nurse Aide 4 was getting his clothes the resident reached for grab bar and attempted to stand up to get on the toilet, but the resident sat back down in the wheelchair. She said to Nurse Aide 4 to just give the resident a minute, and Nurse Aide 4 stated just let me do it, it will be faster. Nurse Aide 4 stood in front of the resident, lifted him around the waist, and pulled his pants down. She then directed the resident to the toilet. Nurse Aide 4 wiped his face off and the resident swatted at Nurse Aide 4. Nurse Aide 4 pushed the resident back on the toilet with an open hand to his left shoulder. Nurse Aide 3 then grabbed Nurse Aide 4 and told her to stop. Nurse Aide 4 placed a gown on the resident and the resident attempted to punch Nurse Aide 4. Nurse Aide 4 then punched the resident in the stomach with a closed fist and stated, "Don't even think you can hit me." The resident appeared startled and did not appear in pain. Nurse Aide 3 then separated Nurse Aide 4 from the resident and Nurse Aide 4 stated "whatever," and she left the resident's bathroom. Nurse Aide 3 then assisted the resident with care, assisted him back into his wheelchair, and took him out into the hall where he always sits. Nurse Aide 3 did not report this immediately because she did not want to tell the wrong person that would spread gossip. She indicated that she thought about it all night and knows she should have reported it immediately.

An interdisciplinary team (IDT) note, dated, January 23, 2024, revealed that the incident was reviewed by IDT. Nurse Aide 3 reported that she witnessed Nurse Aide 4 punch Resident 65 in the stomach. The resident is confused and unable to confirm or deny that this occurred. Interviews were completed with both nurse aides, other nursing staff assigned on that unit when the alleged incident occurred, and the resident's roommate who is alert and oriented. The alleged incident was not substantiated by any witness or other residents. Corrective action was completed with Nurse Aide 3 for not reporting the allegation of abuse timely, and education was completed with Nurse Aide 4 regarding dealing with resident behaviors and dementia.

Interview with the Director of Nursing on January 30, 2024, at 2:30 p.m. confirmed that Nurse Aide 3 did not report the alleged allegation of abuse immediately as per the facility's policy. She indicated that they provided education to Nurse Aide 3 and Nurse Aide 4, as well as to the whole facility.

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

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



 Plan of Correction - To be completed: 03/14/2024

1. Incident involving resident number 65 was reported on 1/22/2024.
2. An initial audit of all reportable incidents filed in the last 30 days was completed to ensure there were no other incidents of late reporting occurred.
3. Education with all nursing staff on the facilities policy and procedure for reporting abuse was completed. Written education was completed with the nurse aide who did not report the incident timely.
4. Audits will be completed checking timeliness of all reportable incidents 2 x week for 2 weeks and monthly x 2 months. Results will be reported and trended through the facility's Quality Assurance Committee.
5. Date of compliance: 3/14/2024

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


Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice by failing to ensure that physician's orders were followed for two of 48 residents reviewed (Residents 23, 83).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated November 30, 2023, revealed that the resident was cognitively impaired, was dependent on staff for toileting hygiene, was always incontinent of bowel, and had diagnoses that included dementia. A care plan for Resident 23, dated July 29, 2022, revealed that the resident was to receive incontinent care every two to three hours and as needed.

Physician's orders for Resident 23, dated April 2, 2021, included orders for the resident to receive 30 milliliters (ml) of Milk of Magnesia (MOM - an oral laxative) as needed for constipation if no bowel movement by the third day (9 shifts); one Dulcolax suppository (a laxative inserted rectally) as needed if no bowel movement within 24 hours after administration of Milk of Magnesia; and one Fleets enema (a liquid inserted rectally to stimulate a bowel movement) as needed for constipation if no bowel movement by the end of the following shift after administration of the suppository, and the physician was to be notified if it was ineffective.

Resident 23's bowel records for December 2023 revealed that the resident had a bowel movement on December 24, 2023, and did not have a bowel movement from December 25 through December 28, 2023. The Medication Administration Records (MAR's) for December 2023 revealed that staff did not administer Milk of Magnesia on December 27, 2023, as ordered, which was the third day without a bowel movement. The resident's MAR revealed that there was no laxative administered on December 28, 2023, which would have been the fourth day without a bowel movement.

Resident 23's bowel records for January 2024 revealed that the resident had a bowel movement on January 7, 2024, and did not have a bowel movement from January 8 through January 11, 2024. The Medication Administration Records (MAR's) for January 2024 revealed that staff did not administer Milk of Magnesia on January 10, 2024, as ordered, which was the third day without a bowel movement. The resident's MAR revealed that there was no laxative administered on January 11, 2024, which would have been the fourth day without a bowel movement.

Interview with Registered Nurse 5 on February 1, 2024, at 3:09 p.m. confirmed that Resident 23's physician's orders for constipation were not followed on the above days.


An admission MDS assessment for Resident 83, dated December 8, 2023, revealed that the resident was cognitively impaired, had diagnoses that included diabetes, and received insulin (medication that lowers blood sugar levels).

Physician's orders for Resident 83, dated December 11, 2023, included an order for the resident's blood sugar to be checked before meals and at bedtime. If the resident's blood sugar was less than 70 milligrams/deciliter (mg/dL) or greater than 400 mg/dL the physician or registered nurse supervisor was to be notified.

Resident 83's Medication Administration Record (MAR's) for December 2023 revealed that the resident's blood sugar result on December 24, 2023, was 499 mg/dL at 8:00 p.m. There was no documented evidence that the physician or registered nurse supervisor was notified that the resident's blood sugar was greater than 400 mg/dL.

Interview with the Director of Nursing on February 1, 2024, at 12:28 p.m. confirmed that there was no documented evidence that Resident 83's physician or the registered nurse supervisor was notified of the high blood sugar on December 24, 2023, at 8:00 p.m. as ordered.

28 Pa. Code 211.12(d)(1)(5) Nursing Services.



 Plan of Correction - To be completed: 03/14/2024

1. Resident 23 nor resident 83 suffered any ill effects. The Medical Director was notified of resident 83's high blood sugar reading from 12/24/2023 and not following the bowel protocol for resident 23. No new orders were given.
2.An audit of all residents within the facility who have had their blood sugars monitored for the past 30 days and residents who have required the use of the facilities bowel protocol was completed with any findings addressed.
3. Licensed staff including agency staff educated on the facility's guidelines/policy for doctor notification when a blood sugar is outside of parameters. Education was also completed on the facilities bowel protocol. Any new facility licensed staff or agency staff will be educated on the facility's guidelines for doctor notification and bowel protocol as part of the orientation to the facility.
4. Director of nursing/designee will randomly audit at a minimum 10% of residents who have their blood sugar monitored to ensure the physician is being notified when a high blood sugar is obtained and residents who trigger for no BM as per bowel protocol to ensure it is being followed as ordered. The audit will be completed 2 times a week for 2 weeks, then monthly for two (2) months. Results will be reported and trended through the facility's Quality Assurance Committee.
5. Date of compliance 3/14/2024

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 clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 48 residents reviewed (Residents 3, 26).

Findings include:

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 16, 2023, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included high blood pressure and dementia. A care plan, dated January 26, 2023, revealed that the resident and her family preferred that she receive showers twice a week.

A review of the December 2023 and January 2024 shower record revealed that the resident was receiving bed baths.

A nursing note, dated January 30, 2024, revealed that the nurse spoke with the resident's daughter, and she stated she told staff to bed bath the resident whenever they needed to.

An interview with Director of Nursing on January 30, 2024, at 9:05 a.m. confirmed that the care plan developed for Resident 3 was incorrect and should have included a plan of care for a preference on bathing.

A quarterly MDS for Resident 26, dated November 22, 2023, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included stroke. A care plan, dated September 26, 2022, revealed that the resident had a nutritional concern with dysphagia (difficulty swallowing food and liquids) management, and the facility was to provide a controlled-carbohydrate pureed diet with thin liquids.

Physician's orders for Resident 26, dated January 8, 2024, included an order for the resident to receive a controlled- carbohydrate mechanical soft, ground texture diet with thin liquids.

Observations of Resident 26's lunch meal on February 1, 2024, at 12:30 p.m. revealed that she received ground turkey with pureed vegetables, mashed potatoes, gravy, and pureed cake.

Interview with the Director of Nursing on February 1, 2024, at 1:04 p.m. revealed that Resident 26's care plan was not updated to reflect her current ordered diet.

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




 Plan of Correction - To be completed: 03/14/2024

1. Care plans for resident # 3 and resident # 26 were reviewed and updated by the Director of Nursing. Neither resident suffered any adverse effects.
2. The Director of Nursing or designee will review the care plans for all current residents for accuracy in bathing preference and diet. Any identified care plans will be updated upon discovery.
3. The Director of Nursing or designee will educate all staff completing sections in the care plan so that to reflect a resident's new orders, treatments, and interventions.
4. The Director of Nursing or designee will audit all comprehensive care plans 2 times a week for 2 weeks then monthly for 2 months to assure the resident's new diet orders/ changes in bathing preferences are reflected. The Director of Nursing or designee will report the results of the audit to the facility's Quality Assurance Committee.
5. Date of Compliance 3/14/2024

483.21(a)(1)-(3) REQUIREMENT Baseline 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 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:


Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed for one of 48 residents reviewed (Resident 94) who was a recent admission.

Findings include:

A nursing note for Resident 94, dated January 23, 2024, revealed that the resident was admitted from a hospital setting and was alert and oriented to person, place and time.

Physician's orders for Resident 94, dated January 23, 2024, included an order for the resident to receive four liters of oxygen via nasal cannula (a tube that is inserted into the nares to delivery oxygen).

Observations and an interview with Resident 94 on January 29, 2024, at 12:02 p.m. revealed that the resident was sitting in his wheelchair watching television and was receiving oxygen by nasal canula. The resident was admitted for a short-term stay to receive therapy services. He said he was admitted from the hospital after being in another facility for respite care.

The baseline care plan for Resident 94, initiated on January 23, 2024, was incomplete and not signed off in the electronic record.

An interview with Director of Nursing on February 1, 2024, at 12:10 p.m. confirmed that the baseline care plan was incomplete, and there was no documented evidence that a copy of the baseline care plan was given to the resident.




 Plan of Correction - To be completed: 03/14/2024

1. Resident #94 no longer resides in the facility.
2. Current residents admitted in the last 30 days will be reviewed to ensure that the residents and/or responsible parties have received a copy of the Baseline Care Plan.
3. All Licensed Nursing Staff completing Baseline Care Plans educated on the Baseline Care Plan Policy and ensuring resident and/or responsible party receives a copy.
4. The DON or designee will complete an audit on all new admissions weekly x2 weeks and monthly x 2 months to ensure Baseline Care Plans are being provided to residents or responsible parties. This audit will be discussed during the Clinical Start Up meeting weekly to ensure that Baseline Care Plans are being provided, any areas of concern will be brought to the Quality Assurance Committee Meetings for review and discussion.
5. Date of compliance: 3/14/2024

51.3 (f) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.
Observations:


Based on observations, staff interviews, and review of facility records, it was determined that the facility failed to notify the Department of Health about events that could seriously compromise quality assurance and/or resident safety.

Findings include:

A nursing note for Resident 26, dated November 3, 2023, revealed that the resident's sister notified staff that Resident 26 was choking on a strawberry in her room. Nursing staff entered the room to find the resident sitting in her wheelchair holding her throat, lips cyanotic, and no airway movement. The nurse completed the Heimlich Maneuver and the resident expelled a whole strawberry.

Observations of Resident 26's lunch meal revealed she received ground turkey with pureed vegetables, mashed potatoes, gravy, and pureed cake.

Interview with the Director of Nursing on February 1, 2024, at 1:23 p.m. revealed that management reviewed the incident, but since Resident 26 was not transferred to the hospital, the incident was not reported.



 Plan of Correction - To be completed: 03/14/2024

1. Resident 26 suffered no ill effects from alleged deficiency
2. audit from last 30 days of all residents was completed to look for other incidents of any residents having chocking episodes that were not reported.
3. the facilities management team is know aware that any choking incident regardless of whether or not a resident gets sent to the hospital needs reported.
4. Audits will be completed 2 x week for 2 weeks and monthly for 2 months to ensure any resident having a similar episode is reported within the required time frame.
5. date of compliance 3/14/2024


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