Pennsylvania Department of Health
NURSING AND REHABILITATION AT THE MANSION
Patient Care Inspection Results

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NURSING AND REHABILITATION AT THE MANSION
Inspection Results For:

There are  60 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.
NURSING AND REHABILITATION AT THE MANSION - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey completed on January 19, 2024, it was determined that Nursing and Rehabilitation at the Mansion was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to implement interventions and provide adequate supervision to prevent a fall for one of three residents reviewed for falls that resulted in harm (Resident 5).
This deficiency is cited as past non-compliance.

Findings include:

Clinical record review revealed the facility admitted Resident 5 on March 26, 2015. Review of Resident 5's plan of care initiated on March 26, 2015, indicated that Resident 5 is at risk for falls related to her diagnosis of Alzheimer's dementia, history of falls, syncope, and noncompliance with assistance with transfers.

Nursing documentation dated October 5, 2023, at 2:45 PM revealed the Director of Nursing was called to the front porch by staff asking for nursing assistance. Documentation revealed that upon reaching the porch the Director of Nursing was notified that Resident 5 had wheeled herself off the porch and down the steps. Resident 5 was noted to be lying on the ground on her left side with blood from the left side of her head. Nursing documentation noted Resident 5 complained of head and right arm pain. Documentation further revealed that 911 was called and EMS staff reported that Resident 5 would be transferred to the emergency room under a trauma alert.

Further review of Resident 5's clinical record revealed she was admitted and remained in the hospital from October 5 to 9, 2023.

Review of the hospital discharge summary from October 9, 2023, revealed Resident 5 was admitted with a large forehead laceration with exposed bone, as well as a large hematoma of the left upper extremity extending from the elbow to the hand, along with swelling and a hematoma to the right knee. The summary indicated that "sutures were used to close the head laceration" and she was diagnosed with a fracture of her left ring finger.

Nursing documentation dated October 11, 2023, at 11:48 AM revealed the physician's assistant was made aware of Resident 5's increased right leg pain and the facility requested an x-ray, as only her knee was x-rayed at the hospital.

Nursing documentation dated October 12, 2023, at 10:05 AM revealed the physician's assistant and physician reviewed Resident 5's x-ray and noted she needed to be evaluated at the emergency room for a nondisplaced fracture of her distal right femur.

Review of the facility's investigation into Resident 5's fall revealed that it occurred while Resident 5 was with other residents outside on a porch activity. Resident 5 was noted to be in her wheelchair approximately 25 feet away from the end of the porch. The investigation indicated Resident 5 self-propelled herself off the end of the porch. The activity aide was assisting another resident when she heard Resident 5's alarm sounding. Resident 5's wheelchair was noted to be at the top of the porch steps tipped over and the activity aide notified nursing staff that Resident 5 had fallen down the steps. The investigation revealed there were 20 residents on the porch with the activity aide. The facility investigation did not determine if Resident 5's wheelchair brakes were engaged at the time of the incident. The activity aide was unable to state if the brakes were engaged or not. Review of the Director of Maintenance's witness statement revealed an inspection was completed on Resident 5's wheelchair and determined all the hardware on the wheelchair worked properly, stating Resident 5's wheelchair would not move forward or backward if the brakes were applied.

Further review of Resident 5's clinical record revealed her most recent MDS (Minimum Data Set, an assessment at specific intervals to determine care needs) dated October 16, 2023, revealed staff assessed Resident 5 as dependent to wheel 50 feet. An interview with the Director of Nursing on January 19, 2024, at 2:40 PM revealed that Resident 5 is physically capable of self-propelling, but due to her cognition, and visual deficits, staff coded her as dependent.

The facility failed to implement interventions and provide adequate supervision to prevent a fall for Resident 5. These findings were reviewed in an interview with the Director of Nursing on January 19, 2023, at 2:52 PM.

The quality assurance team met and developed a safety plan regarding porch activities on October 9, 2023. The plan included the facility will keep a staff/volunteer ratio of one staff to 10 residents while outside, and if at any time more staff is needed to immediately notify staff members in the facility. A retractable gate was placed on the porch on October 9, 2023, and will be closed when residents are attending a porch activity. Education was initiated on October 6, 2023, educating staff regarding brakes being applied to residents' wheelchairs when seated in an area. The Nursing Home Administrator or designee planned to audit porch activities for three months and as needed thereafter to ensure that the safety plan does not need to be updated or revised related to safety concerns.


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




 Plan of Correction - To be completed: 01/31/2024

Past noncompliance: no plan of correction required.
483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on clinical record review and resident and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to maintain the highest practicable care for four of 16 residents reviewed (Residents 2, 44, 5, and 47).

Findings Include:

Interview with Resident 2 on January 17, 2024, at 11:54 AM revealed that he has a broken back and that he gets severe pain at times. He said that he will ask for pain medication when this happens. He also indicated that it is not every day and usually only one or two times a week.

Review of Resident 2's medication administration record (a form used to document medications given to the resident) revealed that he was provided pain medication six times in November 2023, four times in December 2023, and nine times in January 2024.

Review of Resident 2's clinical record revealed that there was no current plan of care for his pain.

Clinical record review for Resident 47 revealed a skin and wound note dated January 12, 2024, at 12:56 PM. The note indicated that Resident 47 had a Stage III sacral pressure ulcer (a sore that is caused by prolonged pressure and extends through the skin into the deeper tissue and fat). The treatment recommendations included to wash the area with soap and water, pat dry, apply Hydrogel (used on the wound to provide moisture and promote healing) to the base of the wound, and secure with bordered gauze daily. Preventative measures were to offload pressure and other recommendations were to use appropriate moisture barrier creams, provide thorough skin care for each incontinence episode, use approved briefs when indicated to manage moisture, assess often, minimize friction and shear, and continue with turning and repositioning schedule per protocol for pressure prevention.

Review of Resident 47's care plan revealed no plan of care for his sacral ulcer.

The Director of Nursing confirmed the above noted findings on January 19, 2024, at 1:35 PM for Residents 2 and 47.

Clinical record review for Resident 44 revealed the facility admitted her on December 13, 2023. Review of the initial nursing evaluation completed on December 13, 2023, revealed Resident 44 had an open area to her right heel and an open area to her sacrum and bilateral buttocks.

Review of Resident 44's admission MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated December 20, 2023, revealed Resident 44 triggered for pressure ulcer/injury and the facility made the decision to proceed to a care plan.

Review of Resident 44's most recent Skin and Wound Note dated January 12, 2024, revealed Resident 44 continued with a pressure area to her right heel.

Review of Resident 44's clinical record on January 19, 2024, revealed there was no plan of care addressing Resident 44's pressure areas.

Interview with the Director of Nursing on January 19, 2024, at 11:38 AM confirmed the facility never developed a care plan to address Resident 44's open areas.

Clinical record review revealed a recent Skin and Wound Note for Resident 5 dated January 12, 2024, noting a deep tissue pressure injury to Resident 5's right heel measuring 7.5 by 4 centimeters. The treatment recommendations included to apply Betadine to the base of the wound, secure with ABD and rolled gauze, and change twice a day. The preventative measures included to offload pressure and elevate Resident 5's heels while in bed.

Review of Resident 5's clinical record revealed the facility initiated a plan of care addressing potential skin breakdown on March 26, 2015, with the latest revision on May 15, 2022. Resident 5's plan of care did not address the pressure injury to Resident 5's right foot.

The facility failed to develop and implement a comprehensive person-centered care plan to maintain the highest practicable care for Residents 2, 5, 44, and 47.


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


 Plan of Correction - To be completed: 03/13/2024

Care plans were updated to reflect the needs of Resident 2, 44, 5, and 47.

Education was completed on completion and accuracy of comprehensive care plans.

A facility audit to be completed to ensure that resident's care plans are updated to reflect pain and skin integrity needs

Audit of care plans for skin and pain needs to be completed weekly X 4 weeks, and then monthly X 2. Findings to be reviewed in QAPI X 3 months.


483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:

Based on observation and staff interview, it was determined that the facility failed to secure medications and biologicals on one of two nursing units (First Floor Nursing Unit).

Findings include:

Observation of the first-floor nursing unit on January 18, 2024, at 8:51 AM revealed the medication room door with keys inserted into the doorknob. This surveyor was able to enter the room using an easy turn of the keys and push the door open. Medications were on the counter to include prescription intravenous antibiotics, two Flonase nasal sprays (treats allergies), Ventolin inhaler (used to treat respiratory problems), Acidophilus (a probiotic) and Alka seltzer.

Above the sink was an unlocked cabinet that contained multiple bottles of over-the-counter medications that including but not limited to Acetaminophen (pain reliever), Melatonin (sleep aid), Magnesium, Vitamin D, Zinc, Iron, Diphenhydramine (treats allergies) and Deep-Sea Nasal Spray (treats nasal dryness).

The medication room continued to be left unattended and accessible to non-licensed staff, residents, and visitors until 9:04 AM, at which time Employee 1, licensed practical nurse, removed the keys from the door. This surveyor was able to be inside the medication room for five minutes without anyone coming in or being aware that anyone was inside.

Observation on January 18, 2024, at 9:10 AM revealed an open treatment cart near the first-floor nursing station. The treatment cart contained wound care supplies to treat skin and wound issues such as Dermasyn wound dressing, hydrocortisone, ketoconazole (antifungal), and Ivermectin (anti-parasitic medication).

Interview with Employee 1 on January 18, 2024, at 9:16 AM confirmed that the medication room should not have the keys in the door, and that the treatment cart should be locked when not attended too.

28 Pa. Code 211.9 (k) Pharmacy services

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


 Plan of Correction - To be completed: 03/13/2024

Facility unable to correct the medication storage not being secured at time of observation.

Education provided to clinical staff regarding properly storing and securing medication.

Random audits to be completed weekly X 4 and then monthly X 2 to ensure medication is properly stored and secured.

Findings to be reviewed in QAPI X 3 months.
483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on clinical record review and resident and staff interview, it was determined that the facility failed to thoroughly investigate and report an allegation of misappropriation of property to the State Survey Agency for one of one resident reviewed (Resident 16).

Findings include:

Clinical record review for Resident 16 revealed a social service progress noted dated November 27, 2023, at 3:31 PM that indicated Resident 16 alleged that a couple of days before her hospitalization a tall man came to her and told her that she did not need her watch anymore and ripped it off her hand and pointed to a resident sitting down in the hallway and stated it was him.

A social service progress note dated November 24, 2023, at 3:21 PM revealed that Resident 16 was missing a watch with a black face and tan strap. Her room was searched, and no watch was found. The note indicated that the hospital had no record of a watch being in her possession during her recent stay. The note also indicated that Resident 16's story changed concerning the missing item. Social Services notified Resident 16's sister of the missing watch and she said that she did not want the facility to reimburse Resident 16 for the watch stating that she had many watches at her house and would replace this one.

Review of Resident 16's personal effects inventory form revealed that she did have two watches.

Review of a grievance form completed by the facility dated November 23, 2023, revealed that Resident 16's room was searched, laundry was notified, and that they contacted the hospital to inquire about the missing watch. The corrective action noted that Resident 16's sister would bring her in another watch from home.

Interview with the Director of Nursing and Nursing Home Administrator on January 18, 2024, at 2:20 PM revealed that the facility did not report or investigate the allegation of misappropriation of resident property because the resident kept changing her story.

The facility failed to thoroughly investigate and report an allegation of misappropriation of property for Resident 16.

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

28 Pa. Code 201.29(a) Resident rights

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


 Plan of Correction - To be completed: 03/13/2024

The facility is unable to correct and report to the appropriate reporting agencies. Resident 16 and family were offered replacement watch at time of incident and declined.

All grievances will be reviewed in morning clinical meeting.

All alleged allegations of misappropriation of property will be investigated and reported to appropriate agencies as required. Education on grievance policy and abuse provided to staff.

Administrator or designee will complete audit of all grievances weekly X 4 weeks, monthly X 2 will be completed. Results to be reviewed monthly at QAPI X 3 months.
483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 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 and staff interviews, it was determined that the facility failed to ensure an environment free from the potential spread of infection on one of two nursing units (First Floor and Residents 41 and 213).

Findings include:

Clinical record review for Resident 41 revealed that she was on transmission-based precautions (TBP) related to a diagnosis of COVID-19.

Observations of Resident 41's room on January 17, 2024, at 11:25 AM revealed a sign indicating that she was on droplet precautions (preventative steps taken by healthcare team members and staff to prevent the spread of an infection that is transmitted by coughing, sneezing, talking or close contacts with an infected person). The sign indicated that an N-95 mask (a mask that protects you from breathing in small particles in the air) is to be worn when entering the room.

Observation of Employee 5 (Housekeeper) at 11:25 AM on January 17, 2024, revealed she was in Resident 41's room with a surgical mask on.

Interview with Employee 6 (Housekeeping supervisor) at 11:35 AM on January 17, 2024, revealed that Employee 5 should have had an N95 mask on when she was in Resident 41's room.

Observation of Employee 7, Licensed Practical Nurse (LPN) on January 18, 2024, at 8:45 AM during medication administration to Resident 213, revealed that she entered the resident's room, placed the oral medications and the topical medication on the overbed table. Employee 7 donned gloves and picked up the medication cup to administer Resident 213's oral medication to her. Resident 213 asked if the medication was extra strength Tylenol (a mild pain reliever), and Employee 7 indicated that it was not but that she would go check to see if there was an order for her to have the extra strength. Employee 7 left the room with gloves still on her hands. She went to her medication cart and used the computer to review Resident 213's orders, with the same gloves still on. Employee 7 then went back into Resident 213's room with the same unclean gloves on, administered her oral medication, repositioned her onto her left side, and applied Voltaren Gel (a gel used for arthritis pain) to her right hip.

Employee 7 failed to prevent the potential spread of infection during medication administration to Resident 213.

Interview with Employee 7 on January 18, 2024, at 9:35 AM confirmed the above noted findings that she failed to prevent the potential spread of infection during medication administration to Resident 213.

The Director of Nursing and Nursing Home Administrator were made aware of the concerns related to infection control with Resident's 41 and 213 during a meeting on January 18, 2024, at 2:11 PM.

28 Pa. Code 201.18 (d) Management

28 Pa. Code 211.10(d) Resident care policies

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


 Plan of Correction - To be completed: 03/13/2024

Facility unable to correct actions that were observed at time of survey.

Education will be provided to facility's staff regarding proper PPE for isolation and proper utilization of gloves.

Random audits to be completed for proper infection control practices weekly X 4, and then monthly X 2.

Findings to be reviewed in QAPI X 3 months.
483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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.
§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of one resident reviewed (Resident 40).

Findings include:

Clinical record review for Resident 40 revealed the facility admitted her on October 25, 2018, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 40's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated March 2, 2023, indicated that the facility assessed Resident 40 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 40's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.

The findings were reviewed with the Director of Nursing on January 19, 2023, at 11:30 AM. The Director of Nursing confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address Resident 40's dementia and cognitive loss.

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


 Plan of Correction - To be completed: 03/13/2024

Resident 40's care plan updated to reflect a person-centered care plan to address resident's dementia and cognitive loss.

Facility sweep of residents with dementia and cognitive loss will be completed to ensure they have a person- centered care plan addressing their dementia and cognitive loss.

Audits to be completed on all newly admitted or diagnosed residents with dementia and cognitive loss to ensure they have a care plan addressing their needs weekly X 4 weeks and then monthly X 2 months.

Findings to be reviewed in QAPI X 3 months.
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 clinical record review and staff interview, it was determined that the facility failed to assess and implement interventions regarding weight gain for one of six residents reviewed (Resident 4).

Findings include:

Review of Resident 4's clinical record revealed he had a diagnosis of congestive heart failure since his admission to the facility in 2019. Documentation indicated that nursing staff weighed him on July 6, 2023, to be 164 pounds. Nursing staff weighed him on January 10, 2023, to be 183 pounds, which would be a 11.59 percent significant weight gain in six months. Resident 4's current body weight would put him into the overweight category for body mass index. There was no documented evidence in Resident 4's clinical record to indicate that nursing staff assessed Resident 4 for edema related to his diagnosis of congestive heart failure.

A nutritional risk assessment dated October 2, 2023, and again on December 6, 2023, indicated that Resident 4's usual body weight was between 172 and 178 pounds. A dietary note dated January 8, 2024, indicated that Resident 4's current body weight is considered a planned and desirable weight gain.

There was no documented evidence in Resident 4's nutritional care plan to indicate that he was on a physician guided weight gain program. Review of Resident 4's nutritional care plan revealed that he was at nutritional risk and that his goals were to not exhibit signs and/or symptoms of dehydration and to eat greater than 50 percent of his meals. There was no mention of weight gain goals or interventions as to how a desired weight gain would be obtained, how much he should gain, or how long it should take.

Review of Resident 4's physician orders and progress notes revealed no physician orders regarding a weight gain program, nor progress notes to indicate he was on a physician involved weight gain program.

Information provided by the Director of Nursing on January 19, 2023, at 11:36 AM could provide no additional documented evidence and confirmed the above findings for Resident 4.

483.25(g)(1) Acceptable Parameters of Nutrition
Previously cited 2/10/23

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


 Plan of Correction - To be completed: 03/13/2024

Dietician reviewed Resident 4. Acceptable Parameters for age 65 and up is a BMI of 25-28. Resident 4's goal target weight was determined to be 180-190 lbs. MD assessment completed and in agreement with beneficial weight gain. Nursing assessment completed with no CHF concerns. Resident will be on weekly weights X 4 weeks or until stable. Care plan updated to reflect changes.


Education provided to dieticians and certified dietary manager regarding procedure for weight gains.


Facility audit to be completed to ensure that proper interventions/plan in place for any residents with recent significant weigh gain.

Audits to be completed for weight gains weekly X 4 and monthly X 2. Findings to be reviewed in QAPI X 3 months.
483.20(g) REQUIREMENT Accuracy of Assessments: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.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two of 16 residents reviewed (Residents 33 and 55).

Findings include:

Review of Resident 33's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated November 7, 2023, and November 20, 2023, that indicated the facility assessed her as having moisture associated skin damage (MASD, inflammation and erosion of the skin caused by excessive moisture).

Review of Resident 33's wound assessments dated October 27, 2023, November 3, 2023, November 10, 2023, November 17, 2023, and November 24, 2023, indicated that the wound care consulting company described Resident 33's wound as being full thickness skin loss, which would be considered a Stage III (wound that involves full thickness loss of the skin potentially extending into the subcutaneous tissue) pressure ulcer according to the MDS coding instructions.

The facility did not complete Resident 33's November 7, 2023, and November 20, 2023, MDS correctly to accurately reflect the status of her pressure ulcer.

Review of Resident 55's clinical record revealed that the facility admitted her on September 26, 2023. Resident 55 entered the facility with a diagnosis of end stage renal disease and was getting dialysis. Review of Resident 55's MDS dated November 9, 2023, revealed that the facility did not accurately code the MDS to include her dialysis treatments.

Documentation provided by the Director of Nursing on January 18, 2024, at 11:45 AM, and again on January 19, 2024, at 1:00 PM, confirmed the above MDS errors for Resident 33 and Resident 55.

28 Pa. Code 211.5(f)(ix) Medical records

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


 Plan of Correction - To be completed: 03/13/2024

Resident 33 and Resident 55's MDS assessments were modified.

Education will be provided on appropriate coding for OBRA and ASA MDS section A0100.

Random audits of OBRA and ASA MDSs section A0100 to ensure accuracy of both assessments weekly X 4, monthly X 2.

Random MDS audit of section M to ensure accurate coding of pressure ulcers as per the RAI manual weekly X 4, and monthly X 2.

Findings to be reviewed in QAPI X 3 months.
483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide a transfer notice that included all the written components to the resident and/or the resident's responsible party upon transfer to the hospital for four of five residents reviewed (Residents 5, 16, 33, and 39).

Findings include:

Review of Resident 33's clinical record revealed that she was transferred to the hospital on December 6, 2023. The transfer notice provided by the facility to Resident 33's responsible party regarding her transfer to the hospital did not include all the required contents: State long term care appeal agency or contact and address information for the Office of the State Long-Term Care Ombudsman including email address. The notice only contained the information for the local county ombudsman office.

Review of Resident 16's clinical record revealed that she was transferred to the hospital on November 12, 2023. The transfer notice provided by the facility to Resident 16's responsible party regarding her transfer to the hospital did not include all the required contents: State long term care appeal agency or contact and address information for the Office of the State Long-Term Care Ombudsman including email address. The notice only contained the information for the local county ombudsman office.

Review of Resident 5's clinical record revealed that she was transferred to the hospital on October 5, 2023. The transfer notice provided by the facility to Resident 5's responsible party regarding her transfer to the hospital did not include all the required contents: State long term care appeal agency or contact and address information for the Office of the State Long-Term Care Ombudsman including email address. The notice only contained the information for the local county ombudsman office.

Review of Resident 39's clinical record revealed that she was transferred to the hospital on July 27, 2023. The transfer notice provided by the facility to Resident 39's responsible party regarding her transfer to the hospital did not include all the required contents: State long term care appeal agency or contact and address information for the Office of the State Long-Term Care Ombudsman including email address. The notice only contained the information for the local county ombudsman office.

Interview with Employee 8, business office manager, on January 18, 2024, at 12:46 PM confirmed the above findings for Residents 33, 16, 5, and 39.

28 Pa. Code 201.14(a) Responsibility of license

28 Pa. Code 201.29(a) Resident rights


 Plan of Correction - To be completed: 03/13/2024

The facility is unable to correct the previous information of county ombudsman on transfer notices

Education provided to business office personnel and social services regarding required contents for the transfer notice.

Audits to be completed on all transfer notices to ensure they contain required contents weekly X 4, monthly X 2. Results to be reviewed monthly at QAPI X 3 months.
483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly: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.
§483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:

Based on observation and staff interview, it was determined that the facility did not ensure that garbage and refuse was disposed of properly.

Findings include:

Observation on January 17, 2024, at 8:50 AM revealed that the facility's two main dumpsters in the parking lot were overfilled, and the lids were not able to close. There were at least four bags of garbage laying on the ground between the two dumpsters.

Interview with Employee 2, dietary manager, on January 17, 2024, at 9:40 AM acknowledged the above observations. Subsequent interview with Employee 3, director of maintenance, on January 17, 2024, at 9:45 AM revealed that the facility does not have an alternate means of proper disposal of garbage if their dumpsters are full.

29 Pa. Code 201.18 (b)(1) Management


 Plan of Correction - To be completed: 03/13/2024

Facility reviewed contract with disposal company and we increased our dumpster storage capacity.
An outside storage shed will be utlized with closed garbage container willif there was the situation of a full dumpster.

Facility will audit dumpster capacity weekly X 4 and monthly X 2.

Finding will be reviewed in QAIP monthly X 3 months.
§ 201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on staff interview and documentation review, it was determined that the facility did not comply with the requirements of the Act 52 Infection Control Plan.

Findings include:

The Act 52 Infection Control Plan, states that a health care facility should develop and implement an internal infection control plan that should be established for improving the health and safety of residents and health care workers and should include a multidisciplinary committee including a representative from each of the following, if applicable, to the specific health care facility:

(i) Medical staff that could include the chief medical officer or the nursing home medical director
(ii) Administration representatives that could include the chief executive officer, the chief financial officer, or the nursing home administrator
(iii) Laboratory personnel
(iv) Nursing staff that could include a director of nursing or a nursing supervisor
(v) Pharmacy staff that could include the chief of pharmacy
(vi) Physical plant personnel
(vii) A patient safety officer
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee, or contractor of the health care facility.

Interview with Employee 4, Infection Control Preventionist, and the Director of Nursing on January 18, at 1:55 PM revealed that the facility had no evidence of attendance of all required committee members at the infection control meetings. Review of attendees' signatures revealed that the facility had no evidence that laboratory personnel or pharmacy attended the meetings.


 Plan of Correction - To be completed: 03/13/2024

Education completed for DON/ADON/Administrator on ACT 52 infection control required committee members.

Committee members will receive reminders of scheduled committee meetings to ensure compliance.

Monthly audits to ensure required members have attended. Finding to be reviewed X 3 months in QAPI
§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 20 residents during the night shift for 11 of the 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following nurse aides (NA) scheduled for the resident census:

Night shift:

August 21, 2023, 3 NAs for a census of 66, requires 3.30 NAs
December 22, 2023, 3 NAs for a census of 65, requires 3.25 NAs
December 23, 2023, 3 NAs for a census of 64, requires 3.20 NAs
December 25, 2023, 3 NAs for a census of 62, requires 3.10 NAs
December 26, 2023, 3 NAs for a census of 62, requires 3.10 NAs
January 12, 2024, 3 NAs for a census of 63, requires 3.15 NAs
January 14, 2024, 3 NAs for a census of 64, requires 3.20 NAs
January 15, 2024, 3 NAs for a census of 64, requires 3.20 NAs
January 16, 2024, 3 NAs for a census of 64, requires 3.20 NAs
January 17, 2024, 3 NAs for a census of 64, requires 3.20 NAs
January 18, 2024, 3 NAs for a census of 65, requires 3.25 NAs

Interview with the Director of Nursing on January 18, 2024, at 12:30 PM confirmed the above findings.


 Plan of Correction - To be completed: 03/13/2024



Education provided to ADON and DON regarding staffing ratios/PPD.



PPD/ratios will be completed and reviewed daily for accuracy by ADON and all efforts will be made to increase PPD and ratios to required levels.



Recruitment of nursing staff will continue via hiring resources. Agency will be utilized for open shifts. Retention efforts made with any resignation.



Daily PPD will be audited weekly X 4, then monthly X 2. Findings to be reviewed in QAPI X 3 months.
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse per 40 residents during the night shift for 16 of the 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following licensed practical nurse (LPN)scheduled for the following resident census:

Night shift:

August 19, 2023, 1 LPN for a census of 67, requires 1.68 LPNs.
August 20, 2023, 1 LPN for a census of 66, requires 1.65 LPNs.
August 21, 2023, 1 LPN for a census of 66, requires 1.65 LPNs.
August 23, 2023, 1 LPN for a census of 65, requires 1.63 LPNs.
August 24, 2023, 1 LPN for a census of 65, requires 1.63 LPNs.

December 23, 2023, 1 LPN for a census of 64, requires 1.60 LPNs.
December 24, 2023, 1 LPN for a census of 64, requires 1.60 LPNs.
December 25, 2023, 1 LPN for a census of 62, requires 1.55 LPNs.
December 26, 2023, 1 LPN for a census of 62, requires 1.55 LPNs.
December 28, 2023, 1 LPN for a census of 60, requires 1.50 LPNs.

January 12, 2024, 1 LPN for a census of 63, requires 1.58 LPNS.
January 14, 2024, 1 LPN for a census of 64, requires 1.60 LPNS.
January 15, 2024, 1 LPN for a census of 64, requires 1.60 LPNS.
January 16, 2024, 1 LPN for a census of 64, requires 1.60 LPNS.
January 17, 2024, 1 LPN for a census of 64, requires 1.60 LPNS.
January 18, 2024, 1 LPN for a census of 65, requires 1.63 LPNS.

Interview with the Director of Nursing on January 18, 2024, at 12:30 PM confirmed the above findings.


 Plan of Correction - To be completed: 03/13/2024



Education provided to ADON and DON regarding staffing ratios/PPD.



PPD/ratios will be completed and reviewed daily for accuracy by ADON and all efforts will be made to increase PPD and ratios to required levels.



Recruitment of nursing staff will continue via hiring resources. Agency will be utilized for open shifts. Retention efforts made with any resignation.



Daily PPD will be audited weekly X 4, then monthly X 2. Findings to be reviewed in QAPI X 3 months.

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