Nursing Investigation Results -

Pennsylvania Department of Health
NEWPORT MEADOWS HEALTH AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

NEWPORT MEADOWS HEALTH AND REHABILITATION CENTER
Inspection Results For:
There are 125 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.


NEWPORT MEADOWS HEALTH 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 completed on January 31, 2020, it was determined that Newport Meadows Health 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 as it relates to the health portion of the survey process.

Plan of Correction:

483.25(k) REQUIREMENT Pain Management:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Plan of Correction - To be completed: 03/16/2020

Resident 45 was admitted to acute care on 12/25/19 and returned to the facility on 12/27/2020.

The facility is auditing resident falls that occurred in the last 30 days to ensure that pain was assessed and managed appropriately.

Licensed nursing staff were educated on February 13 and 14, 2020 on assessing and addressing pain in residents. Education was also provided on the necessity of timely informing the physician of a fall, even if no injury is assessed.
The facility has implemented a policy under the guidance and approval of the Medical Director permitting supervising RN's to send a resident out for emergency care, in the resident's best interest, if a physician does not respond to a nurse's call within 2 hours, or sooner if resident's condition warrants.

A weekly audit of pain management for residents who have sustained a fall will be completed for 4 weeks then monthly for 2 months.
Results of these audits will be report to the QA committee monthly until compliance is met.

483.10(j)(1)-(4) REQUIREMENT Grievances:

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(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

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

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

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

Observations:

Based on a review of facility policy and residents group interview, it was determined that the facility failed to ensure that residents were notified of the procedure for filing grievances anonymously.

Findings include:

Review of the facility policy dated October 2019, titled, "Filing Grievances/Complaints" provided to residents on admission indicated that residents have the right to file a grievance or concern without fear of reprisal. The policy also indicated that the grievance form must be signed by the resident or representative.

During a residents group interview conducted on January 28, 2020, at 1:00 p.m., with eight alert and orientated residents, residents were asked by the surveyor if they knew how to file a grievance or a concern and how they would file anonymously. All eight residents were unclear on how to file anonymously and they were unaware of the location of the grievance/concern forms.

During an observation on all nursing units, including the facility entrance and auditorium, on January 28, 2020, at approximately 1:30 p.m., it was noted that the process of filing a grievance anonymously was not displayed nor identified and no grievance/concern forms were visibly available.

An interview on January 28, 2020, at 2:30 p.m. with the Nursing Home Administrator revealed that the forms were only located at the auditorium and the resident/representative would have to hand the grievance form to an employee. It was also confirmed that the policy states that the resident/representative must sign the form. The Nursing Home Administrator confirmed that the current policy and procedure does not allow for an anonymous grievance to be filed.

Pa. 28 Code: 201.29(i) Resident Rights.

Pa. 28 Code: 201.18(e)(4) Management.

Plan of Correction - To be completed: 03/16/2020

A secure box was mounted to the wall outside the auditorium for residents to file anonymous grievances. The facility Complaint/Concern form receptacle that had been removed was replaced and forms replenished in it as well as on all the nursing units.

An explanation of how to file a grievance anonymously was reviewed with residents in the February 13th Resident Council Meeting including the location of forms and the box where they may file their concerns anonymously. The facility policy regarding filing grievances was revised to indicate they do not need to be signed by the resident or their representative.

The licensed administrator or designee will audit weekly to ensure box and forms remain available; weekly for four weeks then monthly for 2 months or until compliance is reached.

Resident concern forms will continue to be reviewed by the administrator and compiled and trended monthly by the social worker and reported to the facility QAPI committee.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:

§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).

Observations:

Based on review of personnel records and staff interview, it was determined that the facility failed to ensure that five of five nurse aides received a timely, yearly performance evaluation (Employees 5, 6, 7, 8, 9).

Findings include:

Review of Employee E5's personnel record revealed a hire date of November 1, 2005. Review of E5's annual performance review revealed that the review due on November 1, 2019, was not completed until December 30, 2019.

Review of Employee E6's personnel record revealed a hire date of December 18, 1995. Review of E6's annual performance review revealed that the review due on December 18, 2018, was not completed until April 4, 2019.

Review of Employee E7's personnel record revealed a hire date of January 15, 2007. Review of E7's annual performance review revealed that the review due on January 15, 2019, was not completed until April 1, 2019.

Review of Employee E8's personnel record revealed a hire date of June 10, 2004. Review of E8's annual performance review revealed that the review due on June 10, 2019, was not completed until June 13, 2019.

Review of Employee E9's personnel record revealed a hire date of May 21, 2002. Review of E9's annual performance review revealed that the review due on May 21, 2019, was not completed until May 23, 2019.

The late performance reviews of Employees 5, 6, 7, 8, and 9 were discussed and confirmed with the Nursing Home Administrator on January 31, 2020, at 11:27 a.m.

28 Pa. Code 201.20(a)(c) Staff development.

Plan of Correction - To be completed: 03/16/2020

The facility cannot change previously documented employee performance evaluations.

The facility has implemented a procedure effective February 14, 2020 whereby nurse aide performance reviews will be distributed 45 to 60 days in advance of their anniversary date.

Human Resources, Nursing staff and managers will be educated on the procedure and the requirement for completion of nurse aide performance evaluations by the anniversary date indicated on the evaluation.

The Human Resources Director will audit the completion of nurse aide performance evaluations by anniversary date and report it at the facility's monthly QAPI committee until compliance is met.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

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

§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Observations:

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to notify the physician of a significant change of condition for two of 18 residents reviewed (Residents 47 and 110).

Findings include:

Review of facility policy titled Change in a Resident's Condition or Status, last revised May 2017, revealed that the nurse will notify the physician when there has been a "significant change in the resident's physical/emotional/mental condition."

Review of facility policy Suicide Threats, last revised December 2007, revealed that when a resident makes a suicidal threat, "the Nurse Supervisor/Charge Nurse shall notify the resident's Attending Physician ...and shall seek further direction from the physician."

Review of Resident 47's progress notes revealed a nurse's note dated November 18, 2019, which stated "around approx. 10:15 a.m. this writer was walking by the nurses station and noticed resident was shaking more then usual, seemed restless and kept pulling at his waist band on his pants, both hands were ashy blue in color, his face looked ashen, eye sockets blueish in color and he was diaphoretic (sweating). Resident was on 4L (liters) O2 (oxygen) via nasal cannula (tube that provides oxygen through the nose) at the time, this writer and the nurse checked residents SpO2 (pulse oximetry - measures the amount of oxygen in the blood) and he was at 80% (normal is 95-100%). We switched the nasal cannula and applied a face mask and rechecked in a couple [minutes]. His SpO2 then went up to 90%. Blood sugar checked and he was 268. [Respirations] 22 (normal is 12-20), [Heartrate] 126 (normal is 60-100). Notified unit manager of issues. Resident readjusted in his geri chair, Vitals monitored and seemed to return to a more accepting level. SpO2 ranging between 90-96%, heart rate returning to 80's. At no time did resident become unresponsive. around 11 am this writer left the resident in the care of the nurse and unit manager."

Further review of Resident 47's progress notes revealed that the physician was not notified of the resident's change in condition until approximately 3:11 p.m.

The approximate five hour delay in notifying Resident 47's physician of the significant change in the resident's condition was discussed with the Nursing Home Administrator and Director of Nursing on January 31, 2020, at 8:10 a.m.

Review of Resident 110's clinical record revealed the resident was admitted to the facility on January 8, 2020, with diagnoses including, but not limited to, major depressive disorder, anxiety disorder, and suicide attempt.

Review of Resident 110's progress notes revealed a nurse's note on January 14, 2020, at 9:39 p.m. stating "resident expressed to [nurse aide] that she just wants to kill herself because she feels like that's the best thing to do. Resident does not have a plan. She also thinks that the police are after her. She was assured that she is safe here and no one was looking for her. She was encouraged to sit at nurses station and offered fluids and snacks. Will continue to monitor."

Further review of Resident 110's progress notes failed to reveal evidence that the physician was made aware of the resident's suicidal ideation.

Interview with licensed nurse Employee E3 on January 30, 2020, at 10:55 a.m., revealed that Employee E3 was Resident 110's nurse the night of January 14, 2020. Employee E3 remembered putting the resident on 15 minute checks and checking the resident's room for safety, but Employee E3 stated that she did not remember calling the physician regarding Resident 110's suicidal ideation.

The facility's failure to contact the physician after Resident 110's statement of suicidal ideation was discussed and confirmed with the Director of Nursing on January 31, 2020 at 12:53 p.m.

28 Pa. Code: 211.5(f) Clinical recordsPreviously cited 5/1/19, 2/15/19, 11/27/18, 1/24/18

28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services
Previously cited 1/24/18, 2/15/19

Plan of Correction - To be completed: 03/16/2020

The physician for residents 47 and 110 were notified of the change in condition. Resident 47 as noted in the deficiency, and resident 110 on January 30, 2020.
The Director of Nursing will audit resident progress notes daily for documented changes in condition and physician notification to ensure no other residents are similarly affected.

Licensed nursing staff will be educated to notify the physician as soon as they are able, taking into consideration the safety of leaving the resident. Education will include accurate documentation of the time the physician was notified.

Monitoring of resident condition changes through progress note audits completed by the Director of Nursing will be documented weekly for 4 weeks then monthly for two months. Results will be reported to the facilities QAPI committee at the monthly meetings until compliance is reached.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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

Observations:

Based on observation, it was determined that the facility failed to maintain proper infection control practices during a wound treatment for one of 18 residents reviewed (Resident 96).

Findings include:

Observation of Resident 96's wound treatment on January 31, 2020, at 11:20 a.m. revealed that licensed nurse Employee E4 left a trash bag on the resident's bed to dispose of the supplies used during the resident's wound treatment.

The above was discussed with the Director of Nursing on January 31, 2020 at approximately 2:00 p.m.

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services
Previously cited 1/24/18, 2/15/19

Plan of Correction - To be completed: 03/16/2020

Resident 96's treatment was reviewed with the nurse providing it and a clean garbage bag, pulled off the roll, was utilized for disposal of the supplies.

All licensed nurses were immediately educated to not place a garbage bag on the bed but to use the garbage can placed closely to where the treatment is administered or tape the bag to the bedside stand as per procedure.

An audit of 2 treatments per week for four weeks then monthly for 2 months to ensure the garbage bag is not placed on the bed will be completed.
A report of these audits will be provided monthly at the Facility's QAPI committee until compliance is met.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.

Observations:

Based upon clinical record review, it was determined that the facility failed to ensure residents were free from significant medication errors for one of twenty-four residents reviewed (Resident #45).

Findings include:

Review of Resident #45's diagnosis list revealed diagnoses including non-alzheimer's dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), depression (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and/or daily routine) and anxiety disorder.

Review of Resident #45's MedOptions Medication Management Assessment dated November 18, 2019, revealed "staff reports adequate appetite and sleep, no suicidal or homicidal ideations reported. Nursing reports no behaviors/concerns. Recommend adding an anxiolytic (anti-anxiety medication) to target anxiety. Consider starting Buspar (medication used to treat anxiety) 7.5 milligrams (mg) two times per day to target anxiety/agitation."

Review of Resident #45's MedOptions Medication Management Assessment dated December 12, 2019, revealed "Staff report increased agitation and irritability throughout the day. Throwing objects including walker. Increased with care. Cursing at staff. Recommend discontinuing Buspar as may have increased agitation. Increase Zoloft to target depression and anxiety."

Review of Resident #45's November 2019 Medication Administration Record (MAR) revealed a physician's order dated November 18, 2019 for Buspar 7.5 milligrams (mg) to be administered two times per day.

Review of Resident #45's December 2019 MAR revealed that Resident #45 continued to receive Buspar 7.5 mg two times per day up to and including December 31, 2019.

Review of Resident #45's January 2020 MAR revealed Resident #45 continued to receive Buspar 7.5 mg two times per day up to and including January 27, 2020.

Review of Resident #45's physician orders revealed Buspar 7.5 mg was not discontinued until January 27, 2020.

Interview with the Nursing Home Administrator and Director of Nursing confirmed that Resident #45 continued to receive Buspar 7.5 mg two times per day from December 12, 2019, until January 27, 2020, resulting in a significant medication error.

28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services
Previously cited 1/24/18, 2/15/19

Plan of Correction - To be completed: 03/16/2020

The Med Options recommendations for resident 45 were reviewed and confirmed with the resident's attending physician and the medication discontinued on January 27th, 2020. Behavioral monitoring continues for this resident.

An audit of Med Options consultation recommendations from December 12th to present was completed to ensure no other residents have been similarly affected.

Effective February 3, 2020 Med Options recommendations are brought to the daily clinical meeting for review and to monitor follow-up with the residents attending physician.
Licensed nursing staff are being educated on the requirement to review and document Med Options recommendations with the attending physician and secure their approval/order upon receipt of the recommendation.

An audit of Med Options recommendations follow-up will be completed weekly for four weeks then monthly for 2 months.
Results of these audits will be reported at the facility QAPA meeting monthly until compliance is reached.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:

§483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

§483.45(d)(1) In excessive dose (including duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its use; or

§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

Observations:

Based on clinical record review, it was determined that the facility failed to ensure residents were free from unnecessary medication for one of five residents reviewed (Resident #45).

Findings include:

Review of Resident #45's diagnosis list revealed diagnoses including non-alzheimer's dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), depression (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and/or daily routine) and anxiety disorder.

Review of Resident #45's MedOptions Medication Management Assessment dated November 18, 2019, revealed "staff reports adequate appetite and sleep, no suicidal or homicidal ideations reported. Nursing reports no behaviors/concerns. Recommend adding an anxiolytic (anti-anxiety medication) to target anxiety. Consider starting Buspar (medication used to treat anxiety) 7.5 milligrams (mg) two times per day to target anxiety/agitation."

Review of Resident #45's MedOptions Medication Management Assessment dated December 12, 2019, revealed "Staff report increased agitation and irritability throughout the day. Throwing objects including walker. Increased with care. Cursing at staff. Recommend discontinuing Buspar as may have increased agitation. Increase Zoloft to target depression and anxiety."

Review of Resident #45's November, 2019 Medication Administration Record (MAR), revealed a physician's order dated November 18, 2019 for Buspar 7.5 milligrams (mg) to be administered two times per day.

Review of Resident #45's December, 2019 MAR, revealed that Resident #45 continued to receive Buspar 7.5 mg two times per day up to and including December 31, 2019.

Review of Resident #45's January, 2020 MAR, revealed Resident #45 continued to receive Buspar 7.5 mg two times per day up to and including January 27, 2020.

Review of Resident #45's physician orders revealed Buspar 7.5 mg was not discontinued until January 27, 2020.

Interview with the Nursing Home Administrator and Director of Nursing confirmed that Resident #45 continued to receive Buspar 7.5 mg two times per day from December 12, 2019, until January 27, 2020, resulting in administration of unnecessary medications from December 12, 2019, until January 27, 2020.

28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services
Previously cited 1/24/18, 2/15/19

Plan of Correction - To be completed: 03/16/2020

The Med Options recommendations for resident 45 were reviewed and confirmed with the resident's attending physician and the medication discontinued on January 27th,2020. Behavioral monitoring continues for this resident.

An audit of Med Options consultation recommendations from December 12th to present was completed to ensure no other residents have been similarly affected.

Effective February 3, 2020 Med Options recommendations are brought to the daily clinical meeting for review and to monitor follow-up by the resident's attending physician.

Licensed nursing staff are being educated on the requirement to review and document Med Options recommendations with the attending physician and secure their approval/order with receipt of the recommendation.

An audit of Med Options recommendations follow-up will be completed weekly for four weeks then monthly for 2 months.
Results of these audits will be reported to the facility QAPI committee monthly until compliance is reached.

483.25 REQUIREMENT Quality of Care:

§ 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.

Plan of Correction - To be completed: 03/16/2020

Resident 45 received care in an acute care setting and was returned to the facility on 12/27/10.
Resident 48 had the CT rescheduled and it was performed on 2/4/2020.

To identify residents who may have been similarly effected and review that services were delivered in a timely manner, the facility will perform an audit of residents who in the last 30 days were discharged to the hospital urgently, and those residents who had outside the facility physician appointments and the follow-up orders from those appointments.

The facility has implemented a policy under the guidance and approval of the Medical Director permitting supervising RN's to send a resident out for emergency care, in the resident's best interest, if a physician does not respond to a nurse's call within 2 hours or sooner if resident's condition warrants.

Nursing staff will be educated on the new policy beginning 2/17/2020.
The Director of Nursing is daily auditing resident appointments out of the facility to determine if orders were returned with the resident and then followed through in a timely manner.
These audits will continue weekly for four weeks then monthly for two months.
Results of these audits and the policy change will be reported at the facilities monthly QAPI committee until compliance is reached.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§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 resident interview, clinical record review, and staff interview, it was found that the facility failed to update and revise resident's plans of care for one of 24 residents reviewed (Resident 98).

Findings include:

Interview with Resident 98 on January 28, 2020, at 9:19 a.m. revealed the resident was currently being treated for a urinary tract infection.

Review of Resident 98's clinical record revealed a diagnosis of benign prostatic hyperplasia (BPH - an enlarged prostate which can cause urinary retention in the bladder).

Review of Resident 98's care plan created on August 4, 2019, identified the resident as at risk for urinary retention with an intervention to utilize a straight catheter (a tube inserted into the bladder through the urethra to drain urine from the bladder) on the resident every 8 hours if the resident did not urinate. Further review of Resident 98's care plan created on August 5, 2019 identified the resident as being incontinent of bladder, again with an intervention to use the straight catheter for the resident every 8 hours if the resident did not urinate.

Review of Resident 98's clinical record failed to reveal evidence that staff were monitoring the resident for the need to utilize the straight catheter if needed.

Interview with the Director of Nursing on January 31, 2020, at 11:04 a.m., confirmed that Resident 98's order to use a straight catheter every 8 hours if the resident did not urinate, was discontinued on October 16, 2019, and the care plan was not updated to reflect the discontinued order.

28 Pa. Code 211.11(d) Resident Care PlanPreviously cited 2/15/19

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 2/15/19, 11/27/18, 1/24/18

Plan of Correction - To be completed: 03/16/2020

Resident 98 had the care plan updated to remove the discontinued straight catheter order. An audit of twelve (12) resident care plans including those with straight catheter orders will be completed to identify and correct any out of date care plans.

Nursing staff will be re-educated on the requirements of review and revision of care plans in a timely manner beginning 2/17/2020.

A weekly audit of five (5) resident care plans will be completed by the DON or designee for four weeks then monthly for 2 months or until compliance is reached. The results of these audits will be reported at the facility's monthly QAPI committee until compliance is reached

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

§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 observations, and clinical record and care plan review, it was determined the facility failed to develop a baseline care plan for history of suicide attempt for one of eight residents reviewed. (Resident 110)

Findings include:

Review of Resident 110's clinical record revealed the resident was admitted to the facility on January 8, 2020, with diagnoses including but not limited to dementia with behavioral disturbances (a chronic disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), anxiety disorder (a condition that causes worry or fear of future or current events), major depressive disorder, (a condition that is characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts), and suicide attempt.

Review of nursing progress note dated January 14, 2020, at 9:39 p.m. reveals Resident 110 was having suicidal thoughts on January 14, 2020, and expressed to nursing staff that she wants to kill herself but did not have a plan.

Review of Resident 110's care plan on January 30, 2020, revealed there was no base line care plan developed for the history of suicide attempt listed in Resident 110 ' s diagnoses or the suicidal ideation expressed on January 14, 2020.

Interview with Director of Nursing January 31, 2020, at 12:50 p.m. confirmed that the resident's baseline care plan did not include a care plan for the history of suicide attempt.

28 Pa. Code 211.10(a) Resident care plan
Previously cited 2/15/19

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 2/15/19, 11/27/18, 1/24/18

Plan of Correction - To be completed: 03/16/2020

Resident 110 had their care plan updated to reflect her verbalized ideations on February 13, 2020. The interdisciplinary team will review the care plans of residents admitted in the last 30 days to ensure the baseline or comprehensive care plan includes the minimum healthcare information necessary to properly care for a resident including but not limited to Physician and dietary orders, Therapy services, Social Services, and PASARR recommendations if applicable.

Nursing staff will be re-educated on the requirements of the baseline care plan beginning 2/17/2020.

Effective February 13, 2020, the Interdisciplinary team will review baseline care plans on newly admitted residents

The DON or designee will audit new admissions weekly for 4 weeks then monthly for 2 months. The results of these audits will be reviewed at the facility's monthly QAPI meeting until compliance is reached.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:

§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 select facility policies and procedures, closed financial record review, and staff interview, it was determined that the facility failed to ensure the understanding of required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage for two of three records reviewed (Residents #27 and Resident #92).

Findings include:

Review of the form title "Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN)" states that this notice is given to make residents aware of care that no longer meets Medicare coverage requirements and they may have to pay out of pocket for the care listed. The provider must ensure that the beneficiary or their representative signs and dates the SNFABN to demonstrate that the beneficiary or their representative received the notice of possible out of pocket costs.

Review of the facility's list of residents discharged from a Medicare covered Part A stay with benefit days remaining in the past six months, revealed that Resident #27 and Resident #92 did not have the form NOMC CMS-10055 given to them and no further documentation stating why it was not provided.

Interview with Nursing Home Administrator on January 29, 2020, at 10:40 a.m. confirmed that the facility could not find documented evidence that Resident #27 and Resident #92's or their representatives received or signed the advanced beneficiary notice.

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

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

28 Pa. Code 201.29(a) Resident rights
Previously cited 8/9/2019

Plan of Correction - To be completed: 03/16/2020

The Skilled Nursing Facility Advanced Beneficiary Notice (ABN) was provided to residents 27 and 92 and all other residents who received a Notice of Medicare Non-coverage of Services (NOMNC) in the preceding 30 days.

On January 30, 2020 the Registered Nurse Assessment Coordinator and the Licensed Practical Nurse Assessment Coordinator were educated on the requirement to provide the ABN notice in addition to the NOMNC when Medicare Services are no longer covered. A copy of the forms is maintained with proof of notification by certified mail.

The Nursing Home Administrator will audit weekly NOMNCs issued for four weeks then monthly for 2 months and report monthly on the completion of the required notices to the facility's QAPI committee until compliance is reached.

483.10(g)(4)(i)-(vi) REQUIREMENT Required Notices and Contact Information:

Least serious 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 has the potential for causing no more than a minor negative impact on the resident.

§483.10(g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including:
(i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes -
(A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section;
(B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act.
(C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and
(D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.
(ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.)
(iii) Information regarding Medicare and Medicaid eligibility and coverage;
(iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program;
(v) Contact information for the Medicaid Fraud Control Unit; and
(vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.

Observations:

Based on a group interview, observations, and staff interview, it was determined that the facility did not ensure that a list of State Agencies including the State Department of Health was posted in a form and manner accessible and understandable to residents and or their representatives, or was provided during the admission process.

Findings include:

During the resident council group meeting conducted on January 28, 2020, at 1:00 p.m., residents expressed they were unaware of how to file a complaint with the State Department of Health. Residents stated they did not recall a sign with the State Agency's information posted in the facility, including information on how to file a complaint with the State Agency, Area Agency on Aging or Medicare/Medicaid Fraud.

Observations conducted on January 28, 2020, at approximately 2:15 p.m., revealed that the State Department of Health's complaint hotline information was posted on a bulletin board, high on the left-hand corner, not at eye level for those in wheel chairs.

Further review of the admission packet given to residents and/or the representatives on January 28, 2020, at 2:30 p.m. revealed that the phone numbers to file a grievance with the State Agency, Area Agency on Aging and Medicare/Medicaid Fraud was not included in the information given.

An interview was conducted with the Nursing Home Administrator on January 29, 2020, at 1:55 p.m., and confirmed that the phone numbers to file a grievance with the State Agency, Area Agency on Aging and Medicare/Medicaid Fraud was not included in admission packet.

The facility failed to ensure that the State Agency's phone number for grievances was posted for residents or their representatives and that the information to file a grievance with the State Agency, Area Agency on Aging and Medicare/Medicaid Fraud was provided.

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

28 Pa. Code 201.29(a) Resident rights
Previously cited 08/09/2019

Plan of Correction - To be completed: 03/16/2020

The facility developed the notice of required contact information for State and local advocacy groups including phone numbers and mailing addresses and email when available, for the state survey agency, the state licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services, the Area Agency on Aging and the Medicaid Fraud Control Unit.
The notice will be mailed to the resident or the resident representative for all residents in the building admitted after November 28,2017.

All residents admitted since January 31, 2020 have received the notice in their admission agreement. In the resident council meeting scheduled for February 13, 2020 the notice will be reviewed as well as the location of contact information posted in the entry corridor bulletin board. There is a second eye level posting of required contacts on that bulletin board.

The admissions coordinator will audit to ensure that each admission receives the required notice upon admission and will report monthly to the facility QAPI committee until compliance is reached.

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