Pennsylvania Department of Health
LAURELDALE SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LAURELDALE SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

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LAURELDALE SKILLED NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated survey in response to a complaint completed on March 13, 2024, it was determined that Laureldale Skilled Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

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

Findings include:

Clinical record review revealed that Resident 1 was admitted to the facility on January 10, 2024, and had diagnoses that included diabetes and an altered mental state. The Minimum Data Set Care Area Assessment summary dated January 20, 2024, noted that the resident was at risk for impaired nutrition and that it was to be addressed in the care plan. There was no evidence that interventions to address Resident 1's nutritional needs were included in the current care plan.

In an interview on March 13, 2024, at 2:21 p.m., the Nursing Home Administrator confirmed that the identified care area was not addressed in the resident's care plan.

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

Plan of Correction - To be completed: 04/16/2024

1. Resident 1 will have a care plan to address their nutritional needs.

2. All residents will have a care plan to address nutritional needs.

3. Licensed nurses and dietitian will be educated on having a nutritional care plan for each resident.

4. Random audits of 10 patients will be completed weekly to ensure care plans are in place. Results of the audits will be present to the QAA committee and any issues will be addressed.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Observations:

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to timely assess nutritional status for two of seven sampled residents. (Residents 1, 6)

Findings include:

Review of the facility policy entitled, "Weights and Heights," dated August 1, 2023, revealed that residents were to be weighed upon admission and then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the interdisciplinary care team.

Review of the facility policy entitled, "Change in Condition" dated August 1, 2023, revealed that a facility must immediately inform the resident, the physician, and responsible party (RP) of a significant change in the resident's physical status (deterioration in health).

Clinical record review revealed that Resident 1 was admitted to the facility on January 10, 2024, and had diagnoses that included diabetes and altered mental state. Review of the Minimum Data Set (MDS) assessment, dated February 7, 2024, revealed the resident had cognitive impairment. Review of the weight record revealed that the resident weighed 147 pounds on January 12, 2024. There was no further weights recorded until March 5, 2024, when he weighed 128.65 pounds, a significant (12.5 percent) loss of 18.35 pounds. Documentation revealed that the resident was only eating about 25 percent of his meals from February 27, to March 8, 2024. There was no evidence to support that the facility had assessed or addressed the significant weight loss and/or had immediately notified the physician and responsible party of Resident 1's change in condition.

Clinical record review revealed that Resident 6 had diagnoses that included spastic paraplegia and anemia. Review of the MDS assessment, dated February 2, 2024, revealed the resident had no memory impairment. Review of the weight record revealed the resident weighed 122.4 pounds on January 5, 2024. There was no further weights recorded until March 8, 2024, when the resident weighed 110 pounds, a significant (10.13 percent) loss of 12.4 pounds. There was no evidence to support that the facility had assessed or addressed the significant weight loss and/or had immediately notified the physician and responsible party of Resident 6's change in condition.

In an interview on March 13, 2024, at 2:21 p.m., the Nursing Home Administrator stated there was no documented evidence that staff obtained the weights according to the facility policy or that staff immediately notified the physician and RP of the significant weight losses.

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

Plan of Correction - To be completed: 04/16/2024

1. Resident 1 and 6 will be weighed according to policy and will inform the resident, physician and responsible party of any significant changes in weight.

2. A sweep of residents will be completed and residents will be weighed according to physician orders. MD and RP will be made aware of any significant changes in weight as appropriate.

3. CNAs and licensed nurses will be educated on the policy of monitoring weights and notifying the physician and responsible party of any changes.

4. A random audit of 10 residents will be completed weekly and the physician and responsible party will be updated with any changes. Results of audits will be presented to the QAA committee and any issues will be addressed.

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