Nursing Investigation Results -

Pennsylvania Department of Health
ST. MARY CENTER FOR REHABILITATION & HEALTHCARE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ST. MARY CENTER FOR REHABILITATION & HEALTHCARE
Inspection Results For:

There are  45 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.
ST. MARY CENTER FOR REHABILITATION & HEALTHCARE - 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 December 5, 2014, it was determined that St. Mary Center for Rehabilitation and Healthcare, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.





 Plan of Correction:


483.35(i) REQUIREMENT FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
The facility must -
(1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and
(2) Store, prepare, distribute and serve food under sanitary conditions





Observations:

Based on observation during the environmental tour of the food service department, observation of meal service, observations of a nourishment room (one of three nursing units) and policy review, it was determined that the facility to maintain sanitary conditions. In addition, the facility failed to ensure that food and beverages were dated and properly stored.

Findings include:

A review of facility's "Labeling and Dating Policy" dated November 3, 2014, revealed that upon delivery, food was to be labeled and dated. Food without proper labeling and dating was to be discarded. Daily monitoring was to be done by the Food Service Director or designee.

Observation during the environmental tour of the food service department on December 2, 2014, at 10:00 a.m., revealed food in the dry storage room that was not labeled with a use by date. Observation in the he walk-in refrigerator revealed three cartons of a nutritional supplement (milkshakes) with December 1, 2014, use by dates, a pitcher containing a milk product dated November 15, 2015, and two cartons of nutritional supplement labeled with resident's names and dated for distribution on November 15, 2014.

The exterior of the ingredient bins in the dry storage room were soiled. The interior of the dessert refrigerator and interior and exterior of tray line refrigerator were soiled. The door gasket of the tray line refrigerator was torn. There was dried food on the ceiling above the tray line area. In the pot and pan washing area the shelving was heavily soiled with dried on food. The ceiling vent in the pot/pan washing area was dirty. The ceiling vent was not properly functioning in the janitor's closet.

The water in the sanitizing bucket utilized to clean work surfaces was tested and did not meet the posted 150-200 parts per million sanitization requirement.

The floor area behind the ice machine was dirty. There was no air gap between the floor drain and drain pipe of the ice machine in the food service department and the nourishment room on the St. Catherine/St. Francis Nursing Unit to prevent the backflow of contaminated water into the machine.

Observation of meal distribution during the breakfast on December 3, 2014, at 8:20 a.m., on the St. Catherine Nursing Unit revealed an opened two sided food delivery cart. Nine trays were still in the cart to be served to the residents and staff had placed four soiled trays in the same cart.


 Plan of Correction - To be completed: 12/03/2014

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the Statement of deficiencies.
It is the practice of this facility to ensure that (F 0371) food is procured from sources approved and considered satisfactory by Federal, State or local authorities; and food is stored, prepared, distributed and served under sanitary conditions.

Undated food in dry storage room was immediately discarded.
The three cartons of nutritional supplement milk shakes with the date of December 1, 2014 were immediately discarded.
The pitcher of milk product dated November 15, 2015 was immediately discarded.
The two cartons of nutritional supplement labeled with residents and dated for distribution on November 15, 2014 were immediately discarded.
The ingredient bins in the dry storage room were washed both interior and exterior and sanitized.
The interior of the dessert refrigerator was scrubbed and sanitized.
The interior and exterior of the tray line refrigerator was scrubbed, sanitized and polished.
There was a maintenance work order placed for repair of the gasket on the tray line refrigerator.
The ceiling tiles above the tray line were scrubbed.
The pot/pan washing area shelving was removed, scrubbed and sanitized before being placed back into the kitchen.
The ceiling vent in the pot/pan washing area was cleaned.
There was a maintenance work order placed for repair of the fan in the janitorís closet.
The water in the sanitizing bucket was immediately discarded and replaced with a new sanitizing solution which meets the 150-200 parts per million of quaternary sanitizer.
The floor behind the ice maker was cleaned.
The drain behind the ice maker was repaired with a proper air gap.
There was a work order request made to the maintenance department to repair the drain pipe area of the St. Catherine/St. Francis unit ice machine with a proper air gap.
Interim FSD observed meal pass and instructed CNA staff on proper infection control practices.

The facility will immediately refrain from occurrences associated with this deficient practice and educate entire staff.
An audit was performed to ensure that all food storage bins and containers were cleaned and properly sanitized.

All opened exposed foods must be properly wrapped, labeled and dated per labeling and dating policy.
Daily opening and closing supervisor checklists updated.
Daily, weekly, monthly, Cleaning MATRIX updated.
Meals pass observation during Breakfast, Lunch and Dinner.
All dietary staff in serviced on dating and labeling. Attendance log available.
All dietary staff in serviced on food safety. Attendance log available.
All dietary staff in serviced on cleaning and sanitation. Attendance log available.
All dietary staff in serviced on leftover policy and procedure. Attendance log available.
All dietary staff in serviced on proper food storage. Attendance log available.
All dietary staff in serviced on safe temperature range for refrigerated and frozen foods. Attendance log available.
The Food Service Director or designee will conduct daily/weekly and ongoing food safety, environmental inspections, meal pass observation and sanitation audits and report findings to the Administrator or designee.
Food Service Director and Regional manager or designee will conduct weekly environmental inspections, meal pass observation and sanitation audits and report findings to the Quality assurance committee and Administrator or designee monthly.
The Administrator or designee will do random environmental inspections, food safety and sanitation audits and report findings to the Food Service Director.

COMPLETION DATE: December 3, 2014 and ongoing

483.15(a) REQUIREMENT DIGNITY AND RESPECT OF INDIVIDUALITY: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.
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.


Observations:

Based on observation, it was determined that the facility failed to provide a quality dining experience that promoted dignity during dining on one of four nursing units. (St. Theresa)

Findings include:

On December 2, 2014, Residents R4, R29 and R54 were served their lunch by staff in the St. Theresa dining room. The three residents were seated at the same table. Resident R4 was served her tray at 11:59 a.m. and Resident R29 was served her meal at 12:01 p.m. Resident R54's meal tray was placed in front of her at 12:04 a.m., without staff opening the lid on the entree or opening any of the liquids. Resident R54 sat for 20 minutes with her tray in front of her while Residents R4 and R29 ate their meals. It was not until 12:24 p.m., when a staff member finally started to feed Resident R54 her meal.

On December 3, 2014, Residents R9, R23 and R29 were served their breakfast by staff in the St. Theresa dining room. The three residents were seated at the same table. Resident R23 was served her tray at 8:01 a.m., and was fed by staff. Resident R9 was served her tray at 8:06 a.m., and ate independently. Resident R29 waited and watched Residents R9 and R23 eat their meals for sixteen minutes until staff provided her tray at 8:17 a.m., so she could begin to eat.

28 Pa Code 201.29(j) Resident rights.


 Plan of Correction - To be completed: 12/29/2014

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the Statement of deficiencies.
It is the practice of this facility to ensure that (F 0241) we promote care for residents in a manner and in an environment that maintains or enhances each residentís dignity and respect in full recognition his or her individuality.
The dining assistance needs of R4, R9, R23, R29 and R54 were evaluated.
A seating chart was created, including appropriate seating for R4, R9, R23, R29 and R54. Residents will be seated according to the posted seating chart. To ensure a dignified dining experience, residents will be served together by table in the dining areas. Charge nurses will assign nursing assistants for the dining area as well as for tray service based on the number of residents in either area.
Completed 12/26/14

All residents who dine in the St. Anthony/St. Theresa area were evaluated for assistance needed during meals. A seating chart was created, including appropriate seating for all applicable residents. Residents will be seated according to the posted seating chart. To ensure a dignified dining experience, residents will be served together by table in the dining areas. Charge nurses will assign nursing assistants for the dining area as well as for tray service based on the number of residents in either area.
Completed 12/26/14

To ensure dining dignity issues do not recur, all residents who dine the St. Anthony/St. Theresa area were evaluated for assistance needed during meals. A seating chart was created, including appropriate seating for all applicable residents. Residents will be seated according to the posted seating chart. To ensure a dignified dining experience, residents will be served together by table in the dining areas. Charge nurses will assign nursing assistants for the dining area as well as for tray service based on the number of residents in either area. All nursing staff at the facility will be educated on dignity during dining and providing meals so that residents at each table may dine together, in accord with the Meal Monitoring and Supervision Policy and Procedure. Changes or updates to the seating chart will be made by the RCC/RN Supervisor as needed.
Completion date: 12/29/2014

The facility will monitor performance and compliance with weekly dining audits in the St. Anthony/St. Theresa area for three months and the monthly audits thereafter. These audits will be reviewed at the monthly Quality Assurance meeting. Adjustments will be made as needed. The Director of Nursing/Designee will oversee this process.
Completion date: 12/29/2014 and ongoing

483.15(c)(6) REQUIREMENT LISTEN/ACT ON GROUP GRIEVANCE/RECOMMENDATION: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.
When a resident or family group exists, the facility must listen to the views and act upon the grievances and recommendations of residents and families concerning proposed policy and operational decisions affecting resident care and life in the facility.


Observations:

Based on a review of resident council meeting minutes, policy review, the group interview, and staff interview, it was determined that the facility failed to resolve resident council grievances.

Findings include:

Review of the facility's policy "Resident Council" dated July 31, 2014, revealed that resident council grievances and recommendations were to be brought to the attention of the Administrator who will forward the concern to the appropriated department head for attention and response. Responses regarding resolutions were to be documented, reviewed by the administrator, and kept with the resident council minutes.

Review of monthly resident council meeting minutes from July 2014, through November 2014, revealed concerns regarding staff response to call bells, evening snacks not being provided, dietary concerns and missing property. During the group meeting on December 3, 2014, at 10:00 a.m., residents stated that their concerns are not addressed by the facility administration and that they do not receive documentation of resolution. The residents stated that staff response to call bells and not receiving evening snack continued to be an ongoing problems that have not been addressed by the administration.

Observation on December 3, 2014, revealed that from 8:11 a.m., through 8:25 a.m., (14 minutes) Resident R88's call bell was activated and not answered.

In an interview on December 5, 2014, at 9:45 a.m., the Administrator stated that she had no documented evidence to support that concerns from the monthly resident council meetings from July 2014 through November 2014, had been addressed.

28 Pa. Code 201.18(b)(1) Management.
Previously cited 11/22/13, 12/27/13

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

28 Pa. Code 201.29(i) Resident rights.





 Plan of Correction - To be completed: 01/16/2015

It is the practice of this facility to ensure that (F 0244) we listen to the views of residents and act upon grievances and recommendations of residents and families concerning proposed policy and operational decisions affecting resident care and life in the facility.

The Community Council meeting will be altered to include a ďResident Problem Solving GroupĒ which will include several residents, including the Resident Council President, and Department Directors. The Resident Problem Solving Group and attending Department Directors will meet between Community Council meetings and use the time to address concerns raised at Community Council.
Education was provided to Residents and Department Directors at the December Community Council meeting on December 15, 2014.
If there are any issues raised at Community Council, a plan of action will be created together by Residents and Department Directors. The first Resident Problem Solving Group will occur on January 12, 2015. Minutes of both meetings will be taken by Social Services, posted on resident units, and kept by the NHA. Social Service will distribute the minutes to the Problem Solving Group members for the group to report issue resolutions at the monthly Community Council meeting.
The Director of Social Services will oversee the Community Council and Resident Problem Solving Group.
The minutes are reviewed quarterly at the Quality Assurance meeting. The Director of Social Services, the Director of Nursing/Designee and the NHA/Designee will oversee this process.
Completion date: 1/16/2015 and ongoing

483.15(b) REQUIREMENT SELF-DETERMINATION - RIGHT TO MAKE CHOICES: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.
The resident has the right to choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care; interact with members of the community both inside and outside the facility; and make choices about aspects of his or her life in the facility that are significant to the resident.


Observations:

Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to ensure that accommodations were made regarding bathing schedule preference for one of 24 sampled residents. (Resident R88)

Findings include:

Clinical record review revealed that Resident R88 had diagnoses that included osteoporosis, hypertension and depression. A review of the Minimum Data Set (MDS) assessments of August 28, 2014, and November 17, 2014, revealed that the resident was alert, oriented and that her daily preference regarding bathing was very important to her. A review of the facility shower schedule revealed that the resident was to receive a shower during the day shift on Monday and Thursday of each week.

During the group interview on December 3, 2014, at 10:00 a.m., and during an individual interview on December 4, 2014, at 11:30 a.m., Resident R88 stated that she had not been getting her showers, particularly during the past two weeks. The facility was unable to provide any documentation that accommodations were being made regarding the resident's bathing preference.

During an interview on December 5, 2014, at 12:20 p.m., the Director of Nursing confirmed that the resident had not received scheduled showers during November 2014, with one of the reasons identified as resident refusal due to the shower being offered too late.

28 Pa. Code 201.29(j) Resident rights.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 11/22/13






 Plan of Correction - To be completed: 01/16/2015

It is the practice of this facility to ensure that (F 0242) we promote care for residents in a manner and in an environment that maintains or enhances each residentís right to choose activities, schedules and health care consistent with his or her interests, assessments, and plans of care; interact with members of the community both inside and outside the facility; and make choices about aspects of his or her life in the facility that are significant to the resident.

R88 was interviewed for bathing preferences by the Director of Social Services. R88 reported no complaints regarding her shower schedule. If there is a change in R88ís preferences or any scheduling issues, the schedule will be adjusted accordingly and R88ís Kardex will be updated. The CNAs caring for R88 be educated on any changes to R88ís bathing preferences or schedule. The RCC/RN Supervisor will monitor.
Completed 12/15/14

During the December Community Council meeting on 12/15/14, bathing preferences were addressed as an agenda item. Any resident who expressed a concern will be interviewed by Social Services to re-evaluate bathing preferences and schedule. Interviews will be completed by 12/19/14.
Any adjustments needed in bathing schedules will be completed, Kardexís updated and staff educated on bathing changes will be completed by 1/16/15.

The facility will continue to inquire about bathing preferences at the time of admission. The Director of Admissions will oversee this process. Bathing preferences will be addressed at Community Council Meetings monthly and monitored by the Director of Social Services. Bathing preferences will also be discussed at each residentís Care Conference, with any needed changes being overseen by the Director of Social Services/Designee and the RCC/RN Supervisor.

To monitor performance, bathing preferences will be addressed at Community Council Meetings monthly. In addition, a monthly audit of residents (inclusive of last known bathing preference and correlating documentation of bathing provided by staff) will be completed monthly and presented at the Quality Assurance meeting by the Director of Nursing/Designee.
Completion date: 1/16/2015 and ongoing

483.20(k)(3)(ii) REQUIREMENT SERVICES BY QUALIFIED PERSONS/PER CARE PLAN:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care.


Observations:

Based on clinical record review and observation, it was determined that the facility failed to ensure that care plan interventions were implemented to ensure resident safety for two of 24 sampled residents. (Residents R35, R54)

Findings include:

Clinical record review revealed that Resident R35 had diagnoses that included stroke and dementia. A fall assessment dated October 3, 2014, noted that the resident was at high risk to fall. The current care plan identified that the resident was at risk to be seriously injured from a fall. The care plan directed staff to maintain the bed in the lowest position when not providing direct care to the resident to prevent serious injury from a fall from bed. The resident was in bed without staff in attendance on December 3, 2014, at varies times 6:57 a.m., through 11:40 a.m., with the bed in the high position.

Clinical record review revealed that Resident R54 had diagnoses that included stroke and dementia. The current care plan identified that the resident was at risk for injury related to lower leg weakness and right side weakness. The care plan directed staff to maintain the bed in the lowest position to prevent serious injury from a fall from bed. The resident was in bed without staff in attendance on December 2, 2014, at 10:14 a.m., with the bed in the high position.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 11/22/13


 Plan of Correction - To be completed: 01/16/2015

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the Statement of deficiencies. It is the practice of this facility to ensure that (F 0282) services provided or arranged by the facility must be provided by qualified persons in accordance with each residentís written plan of care.
The care plans of R35 and R54 were evaluated for accuracy. Staff providing care to R35 at the noted dates/times was educated on low bed positioning, in accord with the resident care plan. Staff providing care to R54 at the noted dates/times was educated on low bed positioning, in accord with the resident care plan. The Director Nursing will oversee this process.
Completed 12/17/14
All residents requiring low bed positioning will have their care plan evaluated for accuracy, and updates made if needed. All nursing staff will be educated on following care plans related to low bed positions.
Completion date: 1/16/2015
The facility will audit a 10% sample of residents requiring a low bed position for safety monthly and present the results at the Quality Assurance meeting. The Director of Nursing/Designee will be responsible for monitoring this process.
Completion date: 1/16/2015

483.25 REQUIREMENT PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING: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.
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.



Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were followed for one of 24 sampled residents. (Resident R90)

Findings include:

Clinical record review revealed that Resident R90 had diagnoses that included atrial fibrillation (irregular heart rhythm), congestive heart failure and dementia. On November 20, 2014, a physician ordered a basic metabolic panel (BMP- a test to examine fluid and electrolyte status and kidney function), a complete blood count (CBC), a basic naturiuretic peptide (BNP- detects congestive heart failure), and a digoxin level (a test to determine how much digoxin is in the blood). There was no documentation in the clinical record that the BNP and the digoxin level were completed as ordered. In an interview on December 5, 2014, at 12:00 p.m., the Director of Nursing confirmed that the two blood studies were not done.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 11/22/13


 Plan of Correction - To be completed: 01/16/2015

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the Statement of deficiencies.
It is the practice of this facility to ensure that (F 0309) 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 comprehensive assessment and plan of care.

The labs ordered for R90 were completed on 12/8/2014.
An audit of residentsí ordered labs will be completed to ensure compliance with lab orders for other residents.
Completion date: 12/17/2014
Audits of laboratory services will be presented monthly at the Quality Assurance meeting and monitored by the Director of Nursing.
Completion date: 1/16/2015 and ongoing

483.25(e)(1) REQUIREMENT NO REDUCTION IN ROM UNLESS UNAVOIDABLE: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.
Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without a limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable.


Observations:

Based on clinical record review, observation and staff interview, it was determined that the facility failed to provide an orthotic device to prevent a decrease range of motion for one of 24 sampled residents. (Resident R35)

Findings include:

Clinical record review revealed that Resident R35 had diagnoses that included stroke and dementia. The Minimum Data Set (MDS) assessment dated October 1, 2014, identified that the resident required staff assistance for dressing and personal hygiene and had no limitations in range of motion. On October 22, 2014, Occupational Therapy discharged the resident from services with a recommendation for nursing staff to apply a palm protector to the resident's right hand to prevent a decline in range of motion and contractures. A physician's order was obtained on October 13, 2014, prior to discharge of Occupational Therapy services, for nursing staff to apply the palm protector to the resident's hand for six hours on and then two hours off. On December 3, 2014, the resident was observed from 7:40 a.m., through 11:54 a.m., without the palm protector in place. The palm protector was observed on the resident's bedside cabinet. At 11:54 a.m., the nurse aide (NA1) stated that he was not aware that he was to apply a palm protector to the resident's right hand.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 11/22/13


 Plan of Correction - To be completed: 01/16/2015

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the Statement of deficiencies. It is the practice of this facility to ensure that (F 0317) a resident who enters the facility without a limited range of motion does not experience a reduction in range of motion unless the residentís clinical condition demonstrates that a reduction of range of motion is unavoidable.
R35 has palm protectors ordered; Kardex and care plan were checked for accuracy of physician orders related to contractures. Any necessary updates were made.
Completion date: 12/5/2014
NA1 was educated on placement of palm protectors as well as location to find current device placement information.
Completion date: 12/16/2014
All residents with palm protectors ordered had Kardex and care plans audited for accuracy; any necessary updates were made, if needed. All nursing staff will be educated on the use of palm protectors and use/location of Kardexs to find information on placement of these devices.
Completion date: 1/16/2015
All ordered palm protectors will be accurately included on the Kardex and care plan, as ordered by the RCC/RN Supervisor.
An audit of all palm protectors will be completed monthly and reported at the monthly Quality Assurance meeting. The Director of Nursing/designee will monitor this process.
Completion date: 1/16/2015

483.25(e)(2) REQUIREMENT INCREASE/PREVENT DECREASE IN RANGE OF MOTION: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.
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.



Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide splinting devices to prevent further decline in range of motion for one of four residents sampled with limitations in range of motion. (Resident R25)

Findings include:

Clinical record review revealed that Resident R25 had diagnoses that included dementia with behaviors and anxiety. The Minimum Data Set (MDS) assessment dated November 11, 2014, indicated that the resident was cognitively impaired and had limited upper extremity mobility. There was physician's order dated August 21, 2014, for splinting devices to be placed on both hands at 8:00 p.m., and removed at 8:00 a.m., and then palm protectors were to be placed on both hands from 8:00 a.m. to 8:00 p.m. During an observation on December 4, 2014, at 11:30 a.m until 12:45 p.m., the resident did not have palm protectors in place. In an interview on December 4, 2014, at 1:00 p.m. the RN unit manager stated staff had not applied the palm protectors as ordered.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 11/22/13


 Plan of Correction - To be completed: 01/16/2015

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the Statement of deficiencies.
It is the practice of this facility to ensure that (F 0318) 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.

R25 has palm protectors and splints in place as ordered. The kardex and care plan were reviewed and updated where needed. The CNA assigned on the noted date/time was educated. The RN Unit Manager was also educated.
Completion date: 12/17/2014
All residents with palm protectors and splints ordered will have kardexs and care plans audited and updated, if needed. All nursing staff will be educated on the use of palm protectors and splints as well as the appropriate location to find information on these devices on the kardex.
Completion date: 1/16/2015
All ordered splints and palm protectors will be included accurately on the kardex and care plan by the RCC/RN Supervisor.
Audits of palm protectors and splints will be completed monthly and reported at the monthly Quality Assurance meeting. This process will be monitored by the Director of Nursing/designee.
Completion date: 1/16/2015 and ongoing

483.35(f) REQUIREMENT FREQUENCY OF MEALS/SNACKS AT BEDTIME:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community.

There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except as provided below.

The facility must offer snacks at bedtime daily.

When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span, and a nourishing snack is served.



Observations:

Based on clinical record review and a group interview, the facility failed to ensure that six of eight residents were offered an evening snack on a daily basis. (Residents R9, R13, R28, R61, R63, R71)

Findings include:

Six of eight residents (Residents R9, R13, R28, R61, R63, R71) who attended the group interview on December 3, 2014, at 10:00 a.m., stated that staff failed to offer a bedtime snack to them on a daily basis. Clinical record review revealed that from November 13, 2014, through December 2, 2014, staff failed to document on a daily basis that these six residents were offered a nightly snack.


 Plan of Correction - To be completed: 01/19/2015

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the Statement of deficiencies.
It is the practice of this facility to ensure that (F 0368) each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community. There will be no more than 14 hours between a substantial evening meal and breakfast the following day except when the facility offers snacks at bedtime daily. When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial meal and breakfast the following day if a resident group agrees to this meal span, and a nourish snack is served.

Evening snacks were offered to R9, R13, R28, R61, R63, and R71.
Completion date: 12/3/2014 and ongoing
Community Council Meeting on 12/15/2014 included evening snacks as an agenda item for discussion with all residents in attendance. Evening snacks will remain a regular agenda item at Community Council meetings. The new Resident Problem Solving Group (to which several of the above residents will be invited to be members) will also include evening snacks as a regular agenda item. Any issues with evening snacks will be addressed at the Resident Problem Solving Committee and resolutions reported back to the Community Council.
Completion date: 1/19/2015 and ongoing
Dining Services will alert the RN Supervisor of the arrival of evening snacks. The RN Supervisor will sign for receipt of evening snacks and ensure residents are offered the snacks. Appropriate documentation of evening snacks will occur. The RN Supervisor will monitor this process. All nursing staff will be educated on the process for receiving, offering and documenting evening snacks.
Completion date: January 16, 2015
A monthly audit of alert and oriented residents will be completed to ensure residents are being offered evening snacks. The monthly audits will be reviewed at the monthly Quality Assurance meeting. The Director of Nursing and Administrator or designees will monitor this process.
Completion date: 1/19/2015

483.35(i)(3) REQUIREMENT DISPOSE GARBAGE & REFUSE PROPERLY:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
The facility must dispose of garbage and refuse properly.


Observations:

Based on observation, it was determined that the facility failed to properly contain and dispose of garbage.

Findings include:

Observation during the environmental tour of the dumpster area on December 2, 2014, at 10:00 a.m., revealed an opened bag of garbage next to the compactor with debris on the ground. The dumpster was 1/3 filled and the door was left opened . Debris on the ground included milk carton, juice cup, paper, water bottle, cardboard, and a wicker basket.


 Plan of Correction - To be completed: 12/03/2014

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the Statement of deficiencies.
It is the practice of this facility to ensure that (F 0372) garbage and refuge is disposed of properly.

The opened bag of garbage and debris next to the compactor area was removed. The compactor area was cleaned.
The facility will immediately refrain from occurrences associated with this deficient practice and educate entire staff.
An audit was performed to ensure that the compactor area was properly cleaned and maintained.
Compactor and garbage area added to opening, closing and sanitation walk through. The area will be cleaned between each shift.
All dietary staff was in serviced on proper disposal of garbage and refuse and maintaining a clean compactor area.
Dietary & Housekeeping will audit the compactor area and present finding at the monthly Quality Assurance meeting.
COMPLETION DATE: December 3, 2014 and ongoing

483.70(h) REQUIREMENT SAFE/FUNCTIONAL/SANITARY/COMFORTABLE ENVIRON:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.


Observations:

Based on observation during the environmental tour, it was determined that the facility failed to ensure that all lighting within the laundry was functional.

Findings include:

Observations during the environmental tour of the laundry on December 5, 2014, at 11:45 a.m., revealed 12 sets of non-functional ceiling lights.

28 Pa. Code 207.2(a) Administrator's responsibility.









 Plan of Correction - To be completed: 12/15/2014

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the Statement of deficiencies.
It is the practice of this facility to ensure that (F 0465) we provide a safe, functional, sanitary and comfortable environment for residents, staff and the public.


The 12 lights found to be non-functional in the laundry areas were immediately replaced.
Completion date: 12/5/2014
Lighting fixtures in other service areas were audited for functionality. Any repairs or replacements were done.
Completion date: 12/8/2014
All Department Directors were educated on monitoring respective areas for proper lighting function and prompt reporting of any needed repairs via the Maintenance Log at the Department Director meeting on 12/15/2014.
A random audit of lightly fixtures will occur monthly and any needed repairs or replacements will be completed immediately. Audit results will be presented at the monthly Quality Assurance meeting. The Director of Maintenance and the Administrator/Designee will monitor this process.

ß 211.9(j) LICENSURE Pharmacy services.:State only Deficiency.
(j) Disposition of discontinued and unused medications and medications of discharged or deceased residents shall be handled by facility policy which shall be developed in cooperation with the consultant pharmacist. The method of disposition and quantity of the drugs shall be documented on the respective resident's chart. The disposition procedures shall be done at least quarterly under Commonwealth and Federal statutes.
Observations:

Based on clincal record review, it was determined that the facility failed to ensure that the quantity of all medications was documented at the time of discharge for one of three sampled residents that were discharged. (Resident CR2)

Findings include:

Clinical record review revealed that Resident CR2 was discharged from the facility on October 21, 2014. A review of the October 2014, physician orders revealed that the resident had orders for the following: albuterol sulfate inhalation nebulization solution (inhalation respiratory treatment), Bacid (probiotic), clonidine HCL transdermal patch (anti-hypertensive medication), heparin sodium injection solution (anti-coagulant), and Prevacid (gastroesophageal reflux). There was no documentation to support that a count of the medications had been completed at the time of discharge.










 Plan of Correction - To be completed: 01/16/2015

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the Statement of deficiencies.

It is the practice of this facility to ensure that (1895) disposition and discontinued medications and medications of discharged or deceased residents shall be handled by the facility policy which shall be developed in cooperation with the consultant pharmacist. The method of disposition and quantity of the drugs shall be documented on the respective residentís chart. The disposition procedures shall be done at least quarterly under Commonwealth and Federal statutes.

Upon discharge, all medications will be counted, documented and leave the facility in the appropriate manner. All nurses will be educated on proper procedure for disposition of pharmaceuticals.
Pharmaceutical disposition will be audited monthly and reported at the monthly Quality Assurance meeting by the Director of Nursing/Designee.
Completion date: 1/16/2015 and ongoing



Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port