PRINTED: 01/25/2008 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L (X2) MULTIPLE CONSTRUCTION STREET ADDRESS, CITY, STATE, ZIP CODE

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1 S FOR MEDICARE & MEDICA SERVICES 2567-L NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D (X4) PROVER'S PLAN OF CORRECTION F 000 INITIAL COMMENTS F 000 No Plan of Correction is required Based on a State Licensure Survey and Federal Monitoring Survey completed on 1/10/08, it was determined that Laurel Crest Rehabilitation and Special Care 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. F (a) DIGNITY F 241 SS=B The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Completion Date: 02/06/2008 This REQUIREMENT is not met as evidenced by: Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to enhance each resident's dignity by serving all residents in the dining room at the same time, providing a homelike dining experience with dining tables or in an uncrowded environment that maintained or enhanced each resident's dignity for 12 of 34 residents reviewed (Residents R19, R21, R22, R23, R24, R25, R26, R29, R31, R32, R33, R34). Findings include: Observations of the fifth floor east hall kitchenette on 1/7/08 at 5:00 p.m. and 1/9/08 at 5:00 p.m. revealed that Residents R19, R21, R22, R23, R24, R25, and R26 were seated in geriatric chairs, which were lined up against the walls. Other residents were seated at the dining room table eating their meals, which Preparation and/or evaluation of the plan of correction set forth in this document does not constitute admission or agreement by the provider of the facts, allegations, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because provisions of federal and state law require it. Resident s R18, R19, R21, R22, R23, R24, R25, R26, R29, R31, R32, R33, and R34 will be served at a table when served their meals in a lounge. The tray delivery schedule for the fifth floor was reviewed by Nursing Administration and the Director of Dietary, and the tray delivery times for the residents on the fifth floor have Approved: 01/23/2008 LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) Any deficiency statement ending with an asterisk (*) denotes a deficiency which may be excused from correction providing it is determined that other safeguards provide sufficient protection to the patients. The findings stated above are disclosable whether or not a plan of correction is provided. The findings are disclosable within 14 days after such information is made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. If continuation sheet 1 of 8

2 S FOR MEDICARE & MEDICA SERVICES 2567-L NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D (X4) PROVER'S PLAN OF CORRECTION F 241 Continued From page 1 F 241 created a crowded dining experience. On 1/9/08 at 5:00 p.m., there were 16 residents at the dining table, which was crowded. Interview on 1/9/08 at 5:50 p.m. with Registered Nurse 11 and Nurse Aide 10 revealed that they routinely served the residents meals in the kitchenette because it was larger and they could place all the residents in one room, which saved the staff time and from having to walk to different rooms. Observations of the fifth floor west hall dining room on 1/9/08 at 12:00 p.m. through 12:30 p.m. revealed that five of the seven residents in the dining room required complete nursing assistance for eating. Resident R29 was alert and seated at the dining table with his tray in front of him from 12:05 p.m. until 12:25 p.m. (20 minutes) while the other residents at the table were being fed. Observations of the fifth floor dining room across from the nursing station on 1/9/08 at 5:35 p.m. revealed that there was only one dining table in the room which seated four residents in wheelchairs. Resident R31 was served her meal on an over bed table and she was seated in a wheelchair that was placed in a small alcove within the dining room. Resident R32 were seated in a chair with her meal served on an over bed table. Residents R33 and R34 were seated in geriatric chairs in an alcove on the right side of the dining room with their meal trays on over bed tables. been staggered into two groups for each meal to allow residents on the unit to be able to eat at a lounge table without overcrowding for the afternoon and evening meals, unless care planned otherwise. Tray delivery schedules to the floor were reviewed by Nursing Administration and the Director of Dietary and an adequate time frame for tray delivery pass for each meal is present to ensure that residents who have their dining experience in a lounge are served at a table, unless care planned otherwise. The facility policy on meals has been revised to include that residents who have their dining experience in a lounge are served at a table. Nursing staff will be in-serviced on this policy and system revision by February 1, 2008 by the facility Staff Development Department. A quality assurance audit has been developed to monitor and ensure compliance and will be conducted by a licensed staff member on each floor with each meal for one month and then three times weekly. The Quality Assurance Committee reviews results, monitors data collection, and will make recommendations. Interview on 1/9/08 with Licensed Practical Nurse 6 and Nurse Aide 7 at 5:35 p.m. and 5:40 p.m., respectively, indicated that the same residents routinely ate in this dining area and the over bed tables were used routinely due to the limited space in the room for tables. If continuation sheet 2 of 8

3 S FOR MEDICARE & MEDICA SERVICES 2567-L NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D (X4) PROVER'S PLAN OF CORRECTION F 241 Continued From page 2 F CFR (a) Dignity. Previously cited 7/16/ Pa. Code (j) Resident rights. Previously cited 7/16/07. F QUALITY OF CARE F 309 SS=D Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Completion Date: 02/06/2008 This REQUIREMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined that the facility failed to implement physician orders timely for three of 34 residents reviewed (Residents R3, R9, R14). Findings include: A laboratory test result, dated 12/28/07, for Resident R3 revealed that the resident's stool was positive for giardia lamblia (a parasite that causes an intestinal infection). Physician orders, dated 12/28/07, included an order for an antibiotic and a repeat stool specimen in one week (1/4/08). A review of the laboratory testing records reflected that the tests were not done until 1/8/08, four days after the order was to be implemented. Interview with the director of nursing and Registered Nurse 4 on 1/9/08 at 12:21 p.m. revealed that the laboratory testing was to be done on 1/4/08 when the Resident s R3, R9, R14 had their physicians notified of their particular laboratory testing that was not completed, then the residents cited had their ordered laboratory testing completed with the results reported to the physician. Physicians orders for laboratory testing have been reviewed by licensed nursing staff to ensure that any ordered laboratory testing was completed as ordered by the physician. The facility policy regarding Laboratory Reports and the completion of laboratory requisition forms has been revised and now includes a new system that has been put into place to ensure the timely and accurate implementation of physician ordered laboratory testing. The licensed nurse who takes off the physician order will now Approved: 01/23/2008 If continuation sheet 3 of 8

4 S FOR MEDICARE & MEDICA SERVICES 2567-L NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D (X4) PROVER'S PLAN OF CORRECTION F 309 Continued From page 3 F 309 resident had a bowel movement, but the staff were not aware that they were to do it. A comprehensive resident assessment, dated 12/3/07, for Resident R9 revealed that the resident had a diagnosis of seizure disorder and was given Dilantin (a medication used to prevent seizures). Physician orders, dated 12/20/07, included an order for a Dilantin drug level to be done the following morning, 12/21/07. The laboratory testing records reflected that the test was not done until 1/9/08, 19 days after the order was to be implemented. Interview with Registered Nurse 4 on 1/9/08 at 12:21 p.m. revealed that she was not aware of why the Dilantin level was not done as ordered. A comprehensive resident assessment, dated 12/21/07, for Resident R14 revealed that the resident had a diagnosis of anemia (low blood count). Physician orders, dated 12/13/07, included an order for a thyroid function test, as well as testing of the resident's blood levels of B12 and folate, to be done the following morning. The laboratory testing records reflected that the tests were not done until 1/9/08, 25 days after the order was to be implemented. complete a laboratory requisition at that time. Also, the nursing shift supervisor on the night shift will review each laboratory listing for the next date and compare the laboratory requisitions to that listing to ensure laboratory tests have laboratory requisition completed. These laboratory requisitions are then passed to the laboratory technician. STAT laboratory orders will continue to be called into the contracted laboratory.. Licensed staff and unit clerks will be in-serviced on this policy and system revision by February 1, 2008 by the facility Staff Development Department. A quality assurance audit has been developed to monitor and ensure compliance and will be conducted by the Floor Charge Nurses or designee five times weekly for one month and then three times weekly. The Quality Assurance Committee reviews results, monitors data collection, and will make recommendations. Interview with Registered Nurse 5 on 1/7/08 at 5:00 p.m. revealed that she was not aware that the laboratory testing was not done as ordered. 42 CFR Quality of Care. Previously cited 10/15/07, 7/16/ Pa. Code (d)(1)(3) Nursing services. Previously cited 7/16/ Pa. Code (d)(5) Nursing services. If continuation sheet 4 of 8

5 S FOR MEDICARE & MEDICA SERVICES 2567-L NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D (X4) PROVER'S PLAN OF CORRECTION F 309 Continued From page 4 F 309 Previously cited 11/16/07, 10/15/07, 9/6/07, 8/17/07, 7/16/07. F (e)(2) RANGE OF MOTION F 318 SS=D Based on the comprehensive assessment of a resident, the facility must ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Completion Date: 02/06/2008 This REQUIREMENT is not met as evidenced by: Based on a review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident with limited range of motion had splints applied to prevent a further decrease in range of motion for one of 34 residents reviewed (Resident R15). Findings include: The facility policy for splinting devices, updated August 2007, indicated that splints were to be applied according to physician orders to increase range of motion or prevent a decline in range of motion. A comprehensive resident assessment, dated 8/9/07, for Resident R15 indicated that the resident had a diagnosis of arthritis, a history of stroke, was dependent for transfers and walking, and had limited range of motion and partial loss of voluntary movement of the foot on one side. A physical therapy note, dated 8/13/07, indicated that the resident had instability and right foot drop and was wearing a right Resident R15 was evaluated by a physical therapist and was picked up for treatment. The Ankle Foot Orthotic short leg brace was discontinued and the resident is a transfer from bed to chair with minimal to moderated hand held assist of two to the left side to minimize right inversion injury to ankle. The resident s plan of care was updated to reflect this change. Also, restorative ambulation was discontinued. Residents in the facility were reviewed to ensure orders for splinting devices were in place and concurrent with each resident s plan of care. A new therapy policy has been implemented which includes a procedure for the handling of misplaced devices. Nursing will now fill out a Nursing to Therapy Communication Form that includes all necessary information. Therapy will have a quickened response if a device cannot be located and will re-evaluate Approved: 01/23/2008 If continuation sheet 5 of 8

6 S FOR MEDICARE & MEDICA SERVICES 2567-L NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D (X4) PROVER'S PLAN OF CORRECTION F 318 Continued From page 5 F 318 ankle foot orthotic (external splint/brace applied for support and stabilization of the leg/foot) for positioning and stability and to decrease the resident's fall risk during transferring and walking. The care plan, updated 12/18/07, as well as physician orders, nursing intervention records, and physical therapy notes, dated 12/18/07, indicated that the resident was to wear the orthotic at all times when out of bed. The treatment records for 12/18-31/07 and 1/1-9/08 indicated that the resident did not wear the splint because it was missing. There was no documented evidence that further follow-up was done to locate the missing device or to obtain a replacement. Observations on 1/7/08 at 11:00 a.m. and 5:15 p.m., 1/8/08 at 9:30 a.m. and 11:52 a.m., and 1/9/08 at 1:00 p.m. revealed that the resident was out of bed and seated in a wheelchair and was not wearing the orthotic. the resident and provide specific direction to nursing. Therapy and nursing staff will be in-serviced on this new policy and system revision by February 1, A quality assurance audit has been developed to monitor and ensure compliance and will be conducted by the Quality Assurance Nurse in conjunction with the therapy department directors three times weekly for one month and then two times weekly. The Quality Assurance Committee reviews results, monitors data collection, and will make recommendations. Interview on 1/9/08 at 1:00 p.m. with Licensed Practical Nurse 1 revealed that the orthotic was missing for some time. Interview on 1/9/08 at 1:15 p.m. with Physical Therapy Aide 2 revealed that the resident was having problems with her right foot turning inward, which created problems with walking, and the orthotic was used to assist with these problems. 28 Pa. Code (d)(5) Nursing services. Previously cited 11/16/07, 10/15/07, 9/6/07, 8/17/07, 7/16/07. F (h) ACCENTS AND SUPERVISION F 323 SS=D The facility must ensure that the resident environment remains as free of accident hazards as is possible; and Completion Date: 02/06/2008 If continuation sheet 6 of 8

7 S FOR MEDICARE & MEDICA SERVICES 2567-L NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D (X4) PROVER'S PLAN OF CORRECTION F 323 Continued From page 6 F 323 each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observations, clinical record reviews, and employee interviews, it was determined that the facility failed to ensure that a personal alarm was in use and resident personal items were within reach to prevent accidents for one of 34 residents reviewed (Resident R14). Findings include: The comprehensive resident assessment, dated 12/21/07, for Resident R14 revealed that the resident had a previous fall with a fracture and was at risk for falling. The plan of care, dated 12/21/07, indicated that the resident was to have a tether alarm (personal alarm with a clip to attach to the resident's clothing) in place when in bed or in a wheelchair. The resident's personal items were to always be within his reach. Observations on 1/7/08 at 2:55 p.m. and 4:45 p.m. revealed that the resident was in bed without the personal alarm being in place. The over bed table with the water pitcher and cup on it was at the foot of the bed and out of his reach. Interview on 1/7/08 at 4:45 p.m. with Nurse Aides 8 and 9 revealed that the personal alarm was only used when the resident was in a wheelchair. They indicated that the resident was able to drink independently and had no explanation as to why the water pitcher and cup were out of his reach. Interview on 1/7/08 at 4:50 p.m. with Registered Nurse 5 revealed that the Resident R14 was changed to a sensor alarm due to the facilities investigation noting that the resident is noncompliant at times with transfers and is able to self remove tether. This change will help to ensure this residents safety so that if the resident attempts to transfer independently the staff will be alerted. Residents plans of care were reviewed to ensure alarms necessary were in place. The facility policy on Nursing Care Instructions has been revised to include a Basic ADL Needs form which addresses ADL requirements for each resident including what safety alarms are to be used and when. The Basic ADL Needs form will be revised promptly by unit clerks/licensed staff as changes occur. This Basic Needs ADL form will be posted inside each resident's closet door for staff to utilize throughout each shift. The facility policy on Resident Safety Checks has also been revised to include that an asterisk will be marked by each residents name on the Daily Census Record to ensure that the licensed nurse is monitoring for each resident who is care planned for an alarm and that the alarm is in place. The nurse aides will also continue to monitor resident alarms per the current facility policy. Which includes a Approved: 01/24/2008 If continuation sheet 7 of 8

8 S FOR MEDICARE & MEDICA SERVICES 2567-L NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D (X4) PROVER'S PLAN OF CORRECTION F 323 Continued From page 7 F 323 personal alarm was to be used when the resident was in bed. 42 CFR (h) Accidents and Supervision. Previously cited 10/15/07, 8/17/ Pa. Code (d)(5) Nursing services. Previously cited 11/16/07, 10/15/07, 9/6/07, 8/17/07, 7/16/07. visual and sound test of each alarm in place on the 7 am to 3pm shift and the 3pm to 11pm shift, and a visual check of each alarm in place on the 11pm to 7am shift. Nursing staff will be in-serviced by February 1, 2008 on these policies and systems revisions by the Staff Development Department. A quality assurance audit has been developed to monitor compliance and will be conducted by Nursing Management three times weekly for one month and then 2 times weekly. The Quality Assurance Committee reviews results, monitors data collection, and will make recommendations. If continuation sheet 8 of 8

12/17/2015 F 0000 F 0314 F 0314 SS=G PRINTED: 9/12/2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION SQC111

12/17/2015 F 0000 F 0314 F 0314 SS=G PRINTED: 9/12/2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION SQC111 1.00 DEPARTMENT O HEALTH AND HUMAN SERVICES (XI) PROVER/SUPPLIER/CLIA ENTIICATION NUMBER: (X3) SURVEY D: NAME O PROVER OR SUPPLIER: (X4) PROVER'S PLAN O CORRECTION (EACH 0000 INITIAL COMMENT 0.00 0000