Pennsylvania Department of Health
CORNER VIEW NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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CORNER VIEW NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  302 surveys for this facility. Please select a date to view the survey results.

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CORNER VIEW NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey, and an Abbreviated survey in response to six complaints completed on March 10, 2023, it was determined that Corner View Nursing and Rehabilitation Center, was not in compliance with the 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:


483.70(e)(1)-(3) REQUIREMENT Facility Assessment: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.
483.70(e) Facility assessment.
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include:

483.70(e)(1) The facility's resident population, including, but not limited to,
(i) Both the number of residents and the facility's resident capacity;
(ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population;
(iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population;
(iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and
(v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

483.70(e)(2) The facility's resources, including but not limited to,
(i) All buildings and/or other physical structures and vehicles;
(ii) Equipment (medical and non- medical);
(iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies;
(iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;
(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
(vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.
Observations:

Based on review of facility documents and staff interview it was determined that the facility failed to complete the Facility Assessment annually.

Findings include:

A review of the "Facility Assessment Tool," dated 12/15/22, revealed the facility did not individualize the template to indicate accurate information on:

-Ethnic, cultural, or religious factors: no information was provided in this section.
-Care required by the resident population: information was included on ventilator care, which is not provided by the facility.
-Facility Resources: Information was included on respiratory care staff which are not employed by the facility. Information was not included on: staff assignments, policies for the provision of care, working with medical practitioners.
-Physical Environment: No contracts, memorandum of understanding, or third-party agreements provided with Facility Assessment for services not directly provided by the facility or in the instance of emergency.
-Health Information: No information was provided on electronic record management.
-A facility-based and community-based risk assessment was not provided.

During an interview on 3/10/23, at 12:30 p.m. the Nursing Home Administrator confirmed that the facility failed to complete the Facility Assessment document as necessary.

28 Pa. Code 201.18(b)(3)(e)(2) Management.











 Plan of Correction - To be completed: 04/25/2023

Education on how to sufficiently write a facility assessment was provided to the NHA by the Aharon Franco, Coo of the company. Corner View redeveloped its Facility assessment to include aspects that address ethnical, cultural, & religious factors, care required by the resident population i.e. ventilator care, facility resources, physical environment, facility-based health Information and community-based risk assessment.

The Facility Assessment will be reviewed and updated annually or whenever there are plans for any significant change that would require a modification to any part of this assessment.

NHA/Designee will monitor quarterly to determine if modifications need to be made to the facility assessment as to provide the most up to date accurate information.

483.20(b)(2)(ii) REQUIREMENT Comprehensive Assessment After Signifcant Chg: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(b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)
Observations:



Based on review of the Minimum Data Set (MDS-periodic assessment of resident care needs) User's Manual, clinical record, and staff interview, it was determined that the facility failed to complete a comprehensive assessment after a significant change in condition for two of five residents receiving hospice services (Resident R31 and R111).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a significant change in status assessment is required to be performed when a terminally ill resident enrolls in a hospice program and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14-days from effective date of the hospice election.

A review of Resident R31's clinical record revealed an admission date of 11/1/21, with diagnoses that included chronic obstructive pulmonary disease, diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and depression.

A review of Resident R31's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 1/18/23, indicated that diagnoses remain current upon review.

A review of the clinical record revealed a physician's order, dated 2/8/23, indicating that hospice services were initiated for Resident R31.

Further review of the clinical record failed to indicate documented evidence that a significant change MDS with an ARD completed within 14-days from when Resident R31 was admitted to hospice care was completed.

A review of Resident R111's clinical record revealed an admission date of 8/25/21, with diagnoses that included dementia (a group of symptoms that affects memory, thinking and interferes with daily life), high blood pressure, and depression.

A review of Resident R111's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 1/25/23, indicated that diagnoses remain current upon review.

A review of the clinical record revealed a physician's order, dated 2/16/23, indicating that hospice services were initiated for Resident R111.

Further review of the clinical record failed to indicate documented evidence that a significant change MDS with an ARD completed within 14-days from when Resident R11 was admitted to hospice care was completed.

During an interview on 3/10/23, at 1:10 p.m., Director of Nursing (DON) confirmed that the facility failed to complete a comprehensive assessment after a significant change in condition for two of five residents receiving hospice services (Resident R31 and R111).

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.5(f) Clinical Records

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


 Plan of Correction - To be completed: 04/25/2023

F636
- R31 and R111 did not have a significant change MDS (MDS-periodic assessment of resident care needs) The facility has no way to retroactively correct.
- Order report will be run each day prior to morning start up meeting and, in the event, hospice will be started for a resident the Interdisciplinary team will then follow the process for completing a significant change MDS in the timeframe per regulation.
- Education to be provided to the Interdisciplinary Team by the Administrator/Designee on F 636 with a focus on completing a comprehensive assessment after the significant change of beginning to receive hospice services.
- Audits will be completed on new orders for hospice with the following setting of the significant change daily X2weeks, weekly X2, then as needed following.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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

Based on observations, facility document review and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program, which ensured proper cleaning and disinfecting of glucometers (a device used to test the amount of sugar in a person's blood) to prevent the potential for cross-contamination and failed to properly complete dressing changes for three of six residents observed (Resident R18, R13, R65, and R107) as required.

Findings include:

Review of the facility policy titled "Blood Sampling - Capillary (Finger Sticks)" dated 1/15/23, indicated that staff should always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses.

Review of the facility policy "Wound Care" dated 1/15/23, indicated staff will utilize their policy to for the care of wounds to promote healing.

Review of the Centers for Disease Control and Prevention's document titled "Infection Prevention during Blood Glucose Monitoring and Insulin Administration" last reviewed 3/2/11, indicated that if blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents.

Review of admission record indicated the Resident R18 was admitted to the facility on 8/30/22.

Review of Resident R18's Minimum Data Set (MDS- periodic assessment of care needs) dated 2/6/23, indicated the diagnoses of high blood pressure, diabetes (too much sugar in the blood), and traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head).

Observation of Resident R18's blood sugar check on 3/8/23, at 12:02 p.m., Licensed Practical Nurse (LPN) Employee E3 failed to clean the glucometer before or after use with a germicidal wipe.

Review of admission record indicated Resident R13 was admitted to the facility on 12/15/21.

Review of the MDS dated 12/7/22, indicated the diagnoses of heart failure (heart doesn ' t pump blood as well as it should), respiratory failure (a serious condition that makes it difficult to breathe on your own), and tracheostomy (a tube inserted into the windpipe through the neck for breathing).

Observation of Resident R13' blood sugar check on 3/8/23, at 12:12 p.m. LPN Employee E3 failed to clean the glucometer before or after use with a germicidal wipe.

Review of admission record indicated Resident R65 was admitted to the facility on 9/20/22.

Review of Resident R65's MDS dated 2/2/23 indicated the diagnoses of anemia (the blood doesn ' t have enough health red blood cells), high blood pressure, and stroke.

Observation of Resident R65' blood sugar check on 3/8/23, at 12:21 p.m. LPN Employee E3 failed to clean the glucometer before or after use with a germicidal wipe.

During an observation of a dressing change for Resident R107 on 3/9/23, at 12:00 p.m. the following was observed:
-Licensed Practical Nurse (LPN) Employee E1 cleansed the bedside table with gloved hands and placed a disposable cloth on it for a clean field. LPN Employee E1 then proceeded to open and place dressing changes supplies on the field without changing her gloves, touching the sterile gauze with the gloves that had disinfectant on them.
-LPN Employee E1 used the contaminated gauze to clean the wound.
-LPN Employee E1 dated the dressing by writing on the dressing after it had been applied to the resident.
-The wound dressing had been completed with a brief wet with urine folded down, and when the dressing change was completed, the wet brief was refastened, not replaced.

During an interview on 3/8/23, at 2:00 p.m. the Director of Nursing confirmed the facility failed to maintain an infection prevention and control program, which ensured proper cleaning and disinfecting of glucometers to prevent the potential for cross-contamination and failed to properly complete dressing changes for four of six residents observed (Resident R18, R13, R65, and R107) as required.

28 Pa. Code: Resident care policies.

28 Pa. Code: Nursing services.





 Plan of Correction - To be completed: 04/25/2023

- R18, R13 and R65 have shown no ill effects from the glucometer not being cleaned with a germicidal wipe between uses. The facility has no way to retroactively correct.
- R107 no longer resides in the facility. Prior to discharge R107 showed no ill effects from the dressing change completed on 3/9/23. The facility has no way to retroactively correct.
- E3 has been educated by the Director of Nursing/designee on F880 with a focus on the policy Blood Sampling/Capillary(Finger Sticks)
- E1 has been educated on F880 by Director of Nursing/designee with a focus on wound care and infection control.
- Education will be provided to licensed staff by Director of Nursing/designee on F880 with a focus on ensuring properly cleaning and disinfecting of glucometers to prevent the potential for cross contamination and properly cleaning dressing changes (wound care). Observing competencies will be completed on floor nurses.
- Audits to be completed of wound change and "Blood Sampling - Capillary (Finger Sticks)" 5 residents Nursing/Designee weekly X4 weeks

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff: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.
483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:

Based on review of policies and clinical records, observations, and staff interviews it was determined that the facility failed to assure that licensed nurses demonstrated competencies and skills necessary to administer medications for five of 14 residents (Resident R2, R30, R59, R95, and R109).

Review of the facility policy "Administering Medications" dated 1/15/23, indicated that medications are administered in a safe manner.

During an observation of a medication administration on 3/10/23, at 8:05 a.m. LPN Employee E2 was observed with five medication cups stacked, one on top of the other, in her hands. One of the medication cups was labeled with a name, the remaining four were unlabeled.

During an interview on 3/10/23, at 8:06 a.m. LPN Employee E2 stated the medications were for Resident R2, R30, R59, R95, and R109. Only the medication cup for R59 was labeled. When asked why she had pre-poured the medications, she stated that if she moved the medication cart away from the power supply, it would shut off.

During an interview on 3/10/23, at 9:15 a.m. the Director of Nursing confirmed that the facility failed to assure that licensed nurses demonstrated competencies and skills necessary to administer medications for five of 14 residents.






 Plan of Correction - To be completed: 04/25/2023

F726
- E2 has been provided education by Director of Nursing and a medication pass competency for the skills necessary to administer medications.
- Licensed nurses that pass medications staff will have a medication pass observation completed by Director of Nursing/Designee
- Education by Director of Nursing/Designee on F726 with a focus on assuring licensed nurses demonstrating competencies and skills necessary to administer medications.
- Audits of each nurse who administers medications will be observed and/or have a competency completed for medication adminsitration.to be completed by Director of Nursing/designee

483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities: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.
483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

483.24(b)(2) Mobility-transfer and ambulation, including walking,

483.24(b)(3) Elimination-toileting,

483.24(b)(4) Dining-eating, including meals and snacks,

483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
Observations:

Based on observations, clinical record review and staff interview, it was determined that the facility failed to provide proper Activities of Daily Living (ADL) assistance with eating and timely incontinence care for one of 16 residents (Resident R151), assistance with bathing for two of 16 residents (Resident R51 and R92) and lack of fingernail care for one of 16 residents (Resident R65).

Findings include:

Review of the facility policy "Activities of Daily Living (ADLs), Supporting" dated 1/15/23, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including appropriate support and assistance with hygiene (bathing and dressing), elimination (toileting), and dining (meals and snacks).

Review of the admission record indicated Resident R151 was admitted to the facility on 7/2/22.

Review of Resident R151's Minimum Data Set (MDS- periodic review of care needs) dated 12/7/22, indicated the diagnoses of high blood pressure, urinary tract infection, quadriplegia (paralysis of all four limbs).

Review of Resident R151's ADL self-care deficit care plan dated 1/11/23, indicated total dependence required with bathing, bed mobility, dressing, eating, hygiene and grooming, and toileting.

Observation of Resident R151 on 3/6/23, at 1:18 p.m. indicated an uncovered condom catheter (external catheter used for urinary drainage) on the floor beside the bed attached to a urinary drainage bag and a strong odor of urine in the room.

Interview with Resident R151 on 3/6/23, at 1:19 p.m. indicated the catheter came off this morning before 9:00 a.m., that he was wet at the time of the interview and had not been changed since before 9:00 a.m. this morning. He stated the Nursing Assistant (NA) Employee E4 came into the room and he requested to be changed but at the time NA Employee E4 had his lunch tray and proceeded to feed him while he was soiled in urine.

Interview on 3/6/23, at 1:39 p.m. NA Employee E4 indicated resident R151 was washed that morning before 9:00 a.m. and required a complete bed change because the catheter had come off and that at lunch Resident R151 asked to be changed, but NA Employee E4 already had the food, and proceeded to feed resident. Stated "He wasn't soiled when I fed him, just wet".

Review of admission record indicated Resident R51 was admitted to the facility on 4/19/22.

Review of Resident R51's MDS dated 2/10/23 indicated diagnoses of atrial fibrillation (irregular heart rhythm), heart failure (heart doesn't pump blood as well as it should), and high blood pressure. Section
G indicated total dependence for personal hygiene and bathing.

Review of Resident R51's task document titled Bath/Shower - Wednesday/Saturday evenings dated from 2/8/23 - 3/4/23 indicated no evidence of a bath or shower.

Observation on 3/6/21, at 10:25 a.m. indicated Resident R51's hair was unkempt, greasy, and facial hair present on female.

Review of admission record indicated Resident R92 was admitted to the facility on 6/2/22.

Review of Resident R92's MDS dated 12/20/22 indicated diagnoses of Alzheimer's disease (progressive disease that destroys memory), osteoarthritis (brittle bones), and malnutrition (lack of nutrition). Section G indicated total dependence for personal hygiene and bathing.

Review of Resident R92's task document titled Bath/Shower - Tuesday/Friday evenings dated from 2/7/23 - 3/3/23 indicated no evidence of a bath or shower.

Observation on 3/7/23, at 2:05 p.m. indicated Resident R92's mouth was dry with cracked lips and facial hair on a female resident.

Interview on 3/7/23, at 2:06 p.m. NA Employee E5 confirmed Resident R92's lips were dried and cracked and facial hair was present.

Review of admission record indicated Resident R65 was admitted to the facility on 9/20/22.

Review of Resident R65's MDS dated 2/2/23 indicated the diagnoses of anemia (the blood doesn ' t have enough health red blood cells), high blood pressure, and stroke. Section G indicated extensive assistance of one staff for personal hygiene.

Observation on 3/8/23, at 12:21 p.m. indicated long fingernails with debris underneath.

Interview with Resident R65 and Licensed Practical Nurse (LPN) Employee E3 indicated Resident R65would like to have assistance with cutting his nails.

Interview on 3/10/23, at 3:00 p.m. the Director of Nursing confirmed the facility failed to provide proper Activities of Daily Living (ADL) assistance with eating and timely incontinence care for one of 16 residents (Resident R151), assistance with bathing for two of 16 residents (Resident R51 and R92) and lack of fingernail care for one of 16 residents (Resident R65).

28 Pa. Code: 211.10(c)(d) Resident care policies.

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

28 Pa. Code: 201.29(d) Resident rights.








 Plan of Correction - To be completed: 04/25/2023

- R151 did not receive incontinent care prior to the lunch meal on 3/6/22. The facility has no way to retroactively correct.
- At the next resident council meeting the subject of incontinent care will be discussed.
- Nursing staff will be re-educated by ADON/Designee regarding incontinence care with a focus on timely incontinence care for resident's who are not able to carry out incontinence care independently.
- R51 refused all shower and care planned adjusted.
- R92 last shower and hygiene completed on 3/23
- R65 Nail care was provided on by DON on 3/24 resident is care planned for refusal of care.
- Shower schedule reviewed and revised by Director of Nursing/designee and placed in the task area of Point Click Care and care plans updated.
- Education provided by Director of Nursing/Designee with nursing staff on F676 with a focus on providing appropriate care and services provided to residents who are unable to carry out ADLs independently, including appropriate support and assistance with hygiene (bathing and dressing), elimination (toileting), and lack of fingernail care.
- Audits will be completed on 10 residents a dayon shower, hygiene and incontinent care daily 5 days a week X2 weeks, weekly x2, then monthly following.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(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 review of facility policy, clinical record review, weight documentation, and staff interview it was determined that the facility failed to obtain weight monitoring documentation for one of five sampled residents (Resident R27).

Findings include:

Review of facility policy "Weight Assessment and Intervention, dated 10/29/21, indicated weights will be measured on admission, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Weights will be recorded in the resident's medical record by the 15th of every month. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation.

Review of Resident R27's admission record indicated that she was admitted 10/27/22, with diagnoses that included epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), schizophrenia (a serious mental disorder in which people interpret reality abnormally), and high blood pressure.

A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 1/30/23, indicated that diagnosis remain current upon review.

A review of Resident R27's care plan dated 11/16/22, indicated to monitor weights.

Review of Resident R27's Weight Summary report indicated the following:
10/31/22 - 149.6#
11/28/22 - 150#
12/13/22 - 194.1#

Review of Resident R27's nutrition note dated 12/28/22, indicated that Resident R27 had a significant weight gain of 29.4% (44.1#) in a month. Nutrition note further indicated that the resident's physician was notified, questioned the accuracy of the weight, and that a reweight was needed to confirm.

Review of clinical records, Nurse Practioner note, dated 1/6/23, indicated that Resident R27's appetite is good, weight gain of 41#, and dietitian is requesting a reweigh.

Review of Resident R27's nutrition note dated 2/9/23, indicated no new weight, referencing 12/13/22, weight of 194.1# as most recent weight available.

Review of clinical records, Nurse Practioner note, dated 2/3/23, and 3/3/23, indicated no recent weight available.

During an interview on 3/10/23, at 11:30 p.m., Registered Dietitian (RD) Employee E6 confirmed that the facility failed to obtain weight monitoring documentation for Resident R27 as required.

28 Pa Code: 211.10 (c )(d) Resident care policies

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






 Plan of Correction - To be completed: 04/25/2023

- R27 has been weighed on 3/21/22 with a reweight on 3/22/23. No new orders at this time on the resident's weight gain.
-House audit was completed, and all abnormalities addressed
- Dietician will monitor weights and in conjunction with nursing administration will identify residents that require a reweight and will be discussed at morning stand up meeting.
- Weight meetings, Q week meeting to review increase or decrease in weights to add in interventions.
- Nursing staff will be educated by the DON or dietician on weights with a focus on weight monitoring documentation.
- Audits will be completed by the dietician/designee on 10 residents weekly X4 weeks then random following.


483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:



Based on review of facility policy, observation and resident and staff interview, it was determined that the facility failed to provide tracheostomy (a tube surgically placed in the windpipe for breathing) care and services consistent with professional standards of practice for one of seven newly admitted residents (Resident R13).

Findings include:

Review of admission record indicated Resident R13 was re-admitted to the facility on 3/2/23.

Review of facility policy "Tracheostomy Care" dated 1/15/23, indicated the tracheostomy care should be provided as often as needed and at least once daily for established tracheostomies.

Review of Resident R13's Minimum Data Set (MDS - periodic assessment of care needs) dated 12/7/22, indicated the diagnoses of heart failure (heart doesn ' t pump blood as well as it should) , respiratory failure (lungs are not getting enough oxygen), and tracheostomy.

Review of Resident R13's physician orders dated 3/2/23, the day of re-admission to the facility, indicated no order for tracheostomy care.

Review of Resident R13's care plan dated 3/8/23, failed to reveal required interventions related to inner cannula replacement and changes.

Observation on 3/8/23, at 10:31 a.m. indicated Resident R13 in bed with tracheostomy tube in place.

Interview on 3/8/23, at 10:32 a.m. Resident R13 indicated staff had not changed her disposable inner cannula since return from the hospital on 3/2/23, and not daily as required.

Interview with the Director of Nursing on 3/8/23, at 11:00 a.m. stated, "You caught us, she re-admitted at the end of last week and we haven't had a chance to triple check her chart" and confirmed
the facility failed to provide tracheostomy care and services consistent with professional standards of practice for one of seven newly admitted residents (Resident R13).


28 Pa. Code: 211.10(c)(d) Resident care policies.

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









 Plan of Correction - To be completed: 04/24/2023

- R13 has had tracheostomy care provided per order beginning 3/8/23.
- Other residents that are receiving tracheostomy care orders reviewed to verify orders are present and correct.
- New orders to be reviewed at the morning start up meeting to review, correct and determine if changes need to be completed.
- R13's care plan has been reviewed and revised.
-The Director of nursing, or designee will provide Education with licensed RN/LPN on F695 with a focus on providing tracheostomy and services consistent with professional standards of practice.
- Audits of all tracheostomy resident will be completed weekly by Director of Nursing/Designee weekly X4 weeks then random following.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:



Based on review of facility documentation and staff interview, it was determined that the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - a form provided to residents when the facility identifies that services may not be covered by Medicare which includes choices for continuation or discontinuation of services) that included sufficient information to make an informed decision for two of three residents reviewed (Resident R147 and Closed Record CR1).

Findings include:

Review of instructions for the completion of an SNFABN indicated that the form was to be provided to residents by the facility when services provided may not be covered by Medicare. The instructions indicated that the SNFABN provided "information to the beneficiary (resident receiving services) so that he/she can decide whether or not to get the care that may not be paid for by Medicare and assume the financial responsibility." All sections are to be completed including the specific service/care in question, the reason why the service/care may not be covered, and the estimated cost of the care.

A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form completed by the facility revealed that Resident R147's last covered day of Medicare coverage was 9/9/22. The SNF ABN form indicated that Medicare would probably not pay for therapy services; however, there was no documented evidence that Resident R147 was provided with specific service/care in question, the reason why the service/care may not be covered, and the estimated cost of the care to continue therapy services.

A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form completed by the facility revealed that Resident CR1's last covered day of Medicare coverage was 12/5/22. The SNF ABN form indicated that Medicare would probably not pay for therapy services; however, there was no documented evidence that Resident R42 was provided with specific service/care in question, the reason why the service/care may not be covered, and the estimated cost of the care to continue therapy services.

During an interview on 3/8/23, at 9:30 a.m., Nursing Home Administrator confirmed that the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - a form provided to residents when the facility identifies that services may not be covered by Medicare which includes choices for continuation or discontinuation of services) that included sufficient information to make an informed decision for two of three residents reviewed (Resident R147 and Closed Record CR1).

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



 Plan of Correction - To be completed: 04/25/2023

- R 147 and CR1 no longer resident in the facility.
-30 day look back was completed and no other SNF-ABN's have been missed?
- The Registered Nurse Assessment Coordinator, or designee, will review current residents receiving Medicare Part A coverage and issue an Advanced Beneficiary Notice of Non-Coverage, as appropriate.
- The interdisciplinary team will review upcoming discontinuations from Medicare Part A coverage and the need to issue an Advanced Beneficiary Notice of Non-Coverage at the morning start up meetings.
- The Administrator, or designee, will provide education to the Registered Nurse Assessment Coordinator and Social Service Department on F582 with a focus on providing an Advanced Beneficiary Notice of Non-Coverage (SNFABN- a form provided to residents when the facility identifies that services may not be covered by Medicare which includes choices for continuation or discontinuation of services) to ensure that sufficient information to make an informed decision was provided.
- The Administrator, or designee, will conduct a weekly audit of all residents receiving Medicare Part A coverage weekly for four (4) consecutive weeks to verify that notices were issued timely and appropriately. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.


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