Pennsylvania Department of Health
CONCORDIA AT VILLA ST. JOSEPH
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CONCORDIA AT VILLA ST. JOSEPH
Inspection Results For:

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CONCORDIA AT VILLA ST. JOSEPH - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance, and an Abbreviated Survey in response to one complaint, completed on March 14, 2024, it was determined that Concordia at Villa St Joseph 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:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

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 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based on review of facility policy, facility documentation, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents were free from verbal abuse for one of three residents (Resident R50).

Findings include:

Review of facility policy "Abuse, Neglect, and Exploitation" dated 1/5/24, indicated verbal abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability.

Review of the clinical record indicated Resident R50 was admitted to the facility on 5/31/20.

Review of Resident R50's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/13/23, indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and Multiple Sclerosis (a disease that affects the central nervous system).

Review of a Health Status Note dated 3/7/24, written by Registered Nurse (RN) Employee E4 stated, "This nurse reported signs/symptoms of fearfulness to the unit nurse manager and facility administrator for follow up."

A witness statement completed by the Nursing Home Administrator (NHA) indicated that Resident R50 was interviewed on 3/7/24, and stated Nurse Aide (NA) Employee E5 yelled at her while providing care on 3/6/24. Resident R50 denied physical harm but indicated that her feelings were hurt by the interaction. Resident R50 stated, "She came in and started changing me and just seemed mad at the world. She was telling me to turn over and I told her I couldn't. She said something using the f-word."

Review of NA Employee E5's witness statement dated 3/7/24, indicated a verbal statement was obtained by the NHA and Unit Manger RN Employee E6 via a telephone interview. NA Employee E5 indicated the incident occurred during last rounds at 5:30 a.m. on 3/6/24. NA Employee E5 stated, "It happened during last rounds at 5:30 a.m. on 3/6/24. Resident R50 pushed back at me when I was changing her and it hurt my back and I yelled at her. I said something like, "You gotta roll over you frickin' hurt my back." I was having a bad night and I didn't mean to take it out on her like that but when she pushed back on me and it hurt my back I yelled at her and I shouldn't have."

During an interview on 3/11/24, at 10:38 a.m. Resident R50 stated, "Things are lousy here, the staff are crappy." During this interview, Resident R50 stated that the NHA interviewed her about her interaction with NA Employee E5 and she has not seen NA Employee E5 since the interaction.

During an interview on 3/14/24, at 12:39 p.m. RN Employee E4 stated, "I went in to care for Resident R50 at 9:40 p.m. on 3/6 and that is when she informed me that NA Employee E5 yelled at her. I made sure that she felt safe and was not in immediate danger. After that I immediately notified Unit Manger RN Employee E6. Resident R50 didn't look like herself, I could tell something was wrong."

During an interview on 3/13/24, at 1:04 p.m. the Director of Nursing confirmed that the facility failed to make certain that residents were free from verbal abuse for one of three residents (Resident R50).

28 Pa Code: 201.18 (e)(1)(2) Management

28 Pa Code: 201.29 (a )(c)(d) Resident Rights

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

Plan of Correction - To be completed: 04/24/2024

Current residents have the potential to be affected.

The Director of Nursing confirmed that Employee E5 is not assigned to care for Resident R50.

It was confirmed that Employee E5 completed education on resident right to be free of Abuse and Neglect on 2/7/2024.

The Director of Nursing or designee will provide education to all staff to address resident right to be free of Abuse and Neglect.

An audit on current residents will be conducted to screen for potential abuse. Residents will be asked or appropriately assessed by DON or designee if they have experienced instances of abuse while residing in current facility.

If residents are identified in the audit as expressing concern for abuse, the Director of Nursing or designee will complete further investigation to determine staff person indicated by resident and necessary details regarding alleged abuse. Reporting will be conducted as required.

Audits of staff interactions and care for residents will be observed by DON or designee for 10 residents each week for 4 weeks or until substantial compliance is achieved.

Audit results will be reviewed with the Quality Assurance and Quality Improvement Committee for analysis and further recommendation.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§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 review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for two out of five sampled resident records (Residents R76 and R80).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated the following instructions for Section V Care Area Assessment (CAA) Summary, Questions V0200: "For each triggered Care Area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. The Care Planning Decision column must be completed within 7 days of completing the RAI (MDS and CAA(s)). Check column B if the triggered care area is addressed in the care plan."

Review of Resident R76's admission record indicated that he was admitted to the facility on 1/16/24.

Review of MDS dated 1/23/24, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), obstructive uropathy (a condition of excess urine accumulation in the kidney(s) that causes swelling of kidneys), and renal insufficiency (poor function of the kidney due to a reduction in blood-flow caused by renal artery disease).

Review of Resident R76's MDS dated 1/23/24, Section V Care Area Assessment (CAA) Summary, Question V0200 revealed the Urinary Incontinence and Indwelling Catheter care area was triggered, and the care decision was made to include it on Resident R76's care plan.

Review of active physician order dated 1/28/24, indicated Foley Catheter: (16 Fr [French = catheter size] and 10 ml [millimeter=balloon capacity]) (retention) every shift, and Foley catheter care every shift.

Review of the Resident R76's care plan dated 1/16/24, failed to include goals and interventions related to catheter care.

During an interview conducted on 3/14/24, at 10:02 a.m., Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E11 confirmed that the facility failed to implement a care plan addressing goals and interventions for Resident R76 being prescribed a catheter.

Further review of Resident R76's MDS dated 1/23/24, Section V Care Area Assessment (CAA) Summary, Question V0200 revealed the Cognitive Loss/Dementia care area was triggered, and the care decision was made to include it on Resident R76's care plan.

Review of the Resident R76's care plan dated 1/16/24, failed to include goals and interventions related to dementia.

Review of Resident R80's admission record indicated she was admitted to the facility 9/23/23.

Review of MDS dated 1/23/24, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and high blood pressure.

Further review of Resident R80's MDS dated 9/30/23, Section V Care Area Assessment (CAA) Summary, Question V0200 revealed the Cognitive Loss/Dementia care area was triggered, and the care decision was made to include it on Resident R76's care plan.

Review of the Resident R80's care plan initiated 9/22/23, revision dated 1/26/24, failed to include goals and interventions related to dementia.

During an interview conducted on 3/14/24, at 9:20 a.m., Registered Nurse Assessment Coordinator (RNAC) Employee E12 confirmed that the facility failed to implement a care plan addressing goals and interventions for Resident R76 and Resident R80's dementia care.

During an interview conducted on 3/14/24, at 1:00 p.m., the Director of Nursing (DON) confirmed that the facility failed to develop comprehensive care plans to meet resident care needs for two out of five sampled resident records (Residents R76 and R80).

Plan of Correction - To be completed: 04/24/2024

Current residents have the potential to be affected.

Resident R80 care plan was updated to include goals and interventions related to dementia.

Resident R76 care plan was updated to include goals and interventions related to dementia.

Resident R76 care plan was updated to include goals and interventions related to catheter care.

The Director of Nursing or designee will provide education to nursing staff responsible for care plan completion for appropriate inclusion of goals and interventions in regard to dementia and catheter care.

An audit on current residents will be conducted to determine if the care plan includes goals and interventions related to dementia and catheter care.

If residents are identified in the audit as not having appropriate care plan goals for dementia or catheter care, the Director of Nursing or designee will provide additional education to the responsible staff person.

Audits of care plans for patients with dementia or catheters will be completed for 10 residents each week for 4 weeks or until substantial compliance is achieved.

Audit results will be reviewed with the Quality Assurance and Quality Improvement Committee for analysis and further recommendation.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure appropriate treatment and services were provided for one of four residents (Resident R2) with an indwelling catheter (a tube inserted in the bladder to drain urine).

Findings include:

Review of facility policy "Catheter Care" dated 1/5/24, indicated residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.

Review of the clinical record indicated Resident R2 was admitted to the facility on 6/30/23.

Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/24, indicated diagnoses of urinary tract infection, retention of urine, and diabetes (too much sugar in the blood).

Review of a physician's order dated 2/12/24, indicated to change catheter and catheter bag as needed for leakage or blockage.

Review of a Health Status Note dated 2/19/24, Registered Nurse Employee E1 stated, "No output noted from foley catheter, flushed with approximately 200 milliliters (ml) sterile water with return of thick, cloudy, blood tinged urine with mucous noted."

During an interview on 3/13/24, at 1:28 p.m. RN Employee E1 stated, "Resident R2 stated she felt like she needed to pee, I straightened out her catheter tubing and a small amount of urine drained into the bag. An hour later I noticed that her foley had not drained any more urine into the bag. Resident R2 stated again that it still felt like she needed to pee so I flushed her catheter with 60 ml of sterile water and I got a few clots back. Resident R2 still stated that it felt like she had to pee, so I flushed her catheter wither another 60 ml of sterile water. I flushed it a few times with 60 ml of sterile water, I flushed it with 200 ml of sterile water in total."

During this interview, RN Employee E1 confirmed that she did not verify if Resident R2 had a physician order indicated to flush the catheter. RN Employee E1 stated that she notified the Certified Registered Nurse Practitioner (CRNP) that she had flushed Resident R2's catheter at a later time. RN Employee E1 stated that she was not sure if it was facility policy to flush a resident's catheter if the catheter was not draining urine and may be blocked.

During an interview on 3/14/24, at 8:57 a.m. RN Employee E2 stated, "If a catheter wasn't draining, I would check to see if there is a physician order to flush it. If there was no order, I would get an order to flush the catheter or I would change the catheter entirely."

During an interview on 3/14/24, at 11:57 a.m. the Director of Nursing confirmed that the facility failed to ensure appropriate treatment and services were provided for one of four residents (Resident R2) with an indwelling catheter.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights.

28 Pa. Code 211.10(c)(d) Resident Care Policies.

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

Plan of Correction - To be completed: 04/24/2024

Current residents have the potential to be affected.

The Director of Nursing or designee will provide education to nursing staff responsible for indwelling catheter care.

All physician orders for indwelling catheter care updated to include PRN flush if resident does not void for 8 hour shift as needed per direction of facility Medical Director.

An audit on current residents will be conducted to determine if all residents with indwelling catheters have proper physician orders for PRN flush if resident does not void for 8 hour shift.
If residents are identified in the audit as not having physician orders for PRN flush if resident does not void for 8 hour shift, the Director of Nursing or designee will provide additional education to the responsible staff person.

Audits will be completed on new residents with indwelling catheters each week for 4 weeks to determine presence of physician order for PRN flush if resident does not void for 8 hour shift.

Audits will be completed or for 4 weeks or until substantial compliance is achieved.

Audit results will be reviewed with the Quality Assurance and Quality Improvement Committee for analysis and further recommendation.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

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

Observations:

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for two of five residents reviewed (Resident R2 and R315).

Findings include:

Review of the facility policy "Oxygen Concentrator" dated 10/17/22, last reviewed on 1/5/24, indicated change oxygen tubing mask/cannula weekly and as needed if it becomes soiled or contaminated. If applicable, change the nebulizer tubing and delivery device every seventy-two hours or as recommended by the manufacture.

Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/24, indicated reentry to facility on 2/12/24, with the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), heart failure (heart doesn't pump blood as well as it should), chronic obstructive pulmonary disease (COPD - makes breathing hard).

Review of Resident R2's physician order dated 6/30/23, indicated Arformoterol Tartrate Inhalation Nebulization Solution 15 micrograms (mcg) /2milliliter (ml) (medication that helps with breathing), 2ml inhaled every morning and at bedtime.

Review of residents R2's physician order dated 9/29/23, indicate Budesonide 0.5 milligram (mg)/2ml, (medication that helps with breathing) inhale 2ml two times a day.

Review of residents R2's physician order dated 2/12/2024, indicate Ipratropium -Albuterol Solution 0.5-2.5 mg/3ml vial (medication that helps with breathing) inhale one vial four times a day.

Observation of Resident R2 on 3/11/24, at 10:58 a.m. indicated a nebulizer machine (machine that creates a mist to deliver medication into the lungs), sitting on top of an unlabeled bag on top of a dresser. The nebulizer failed to be labeled with a date.

Interview 03/11/24, 10:58 a.m. Registered Nurse (RN) Employee E9 confirmed the nebulizer was not in a bag and was not dated.

Review of the admission record indicated Resident R315 was admitted to the facility on 3/9/24, with the diagnosis of traumatic subarachnoid hemorrhage (bleeding in the brain), hypertension (high blood pressure), multiple fractures of ribs,

Review of Resident R315's orders dated 3/9/24, indicate oxygen at 3 liters per minute (lpm) every shift, night nurse to check every week on Saturday, if oxygen used, to make sure filter is cleaned and oxygen tubing and humidifier has been changed.

Observation of Resident R315 on 3/11/24, at 10:03 a.m. indicated use of oxygen via nasal cannula. The cannula failed to be labeled with a date.

Interview on 3/11/24, at 10:38 a.m. Registered Nurse (RN) Employee E8 confirmed Resident R315's nasal cannula failed to be labeled with a date.

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

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 04/24/2024

Current residents have the potential to be affected.

Resident R2 nebulizer tubing was replaced and dated.

Resident R315 nasal cannula was replaced and dated.

The Director of Nursing or designee will provide education to nursing staff responsible for sanitary conditions of respiratory equipment.

An audit on current residents will be conducted to determine if sanitary conditions of respiratory equipment are present.

If residents are identified in the audit as not having sanitary conditions of respiratory equipment, the Director of Nursing or designee will provide additional education to the responsible staff person.

Audits of sanitary conditions of respiratory equipment will be completed for 10 residents each week for 4 weeks or until substantial compliance is achieved.

Audit results will be reviewed with the Quality Assurance and Quality Improvement Committee for analysis and further recommendation.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§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 review of facility policy, observation, and staff interviews, it was determined that the facility failed to properly store medical supplies and biologicals in one of three medication carts and failed to properly secure medications and/or biologicals for two of six residents.

Findings include:

Review of the facility policy "Medication Storage" dated 10/17/22, last reviewed 1/5/24, indicates compliance guidelines including but not limited to:
- During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.
- External products: disinfectants and drugs for external use are stored separately from internal and injectable medications.

Findings include:

Review of Resident R329's medical record indicated an admission date of 3/1/24, with diagnosis of chronic obstructive pulmonary disease (COPD-difficulty breathing), diabetes (high blood sugar), hypertension (high blood pressure).

Review of Resident R329's physician orders 3/1/24, cleanse peri area and apply Z-guard (zinc-oxide paste to treat and prevent skin irritation) every shift.

Observation 3/11/24, 10:33 a.m. a tube of unlabeled Z- guard and peri-body cleanser noted sitting on overbed table. Resident R329 was in bed resting.

Interview 3/11/24, 10:33 a.m. Registered Nurse (RN) Employee E8 confirmed the Z-guard and per-body cleanser was on Resident R329's bedside table and removed it.

Review of Resident R90's clinical record indicated admission date of 2/15/24, with the diagnosis COPD, hypertension, and diabetes.

Review of Resident R90's physician order dated 3/11/24, indicated Trelegy Ellipta Inhalation Aerosol Powder (helps with breathing) Breath Activated 100-62.5-25 micrograms (mcg)/activated (act) one puff orally in the morning.

Observation on 3/11/24, 10:09 a.m. Trelegy Ellipta inhaler was sitting next to resident on window sill. Resident R90 stated "I use it myself once a day".

Interview 03/11/24, 10:37 a.m. with Registered Nurse Employee E8 confirmed the Trelegy Ellipta inhaler was in the room and removed it.

Observation 3/22/24, 12:43 p.m. Hall 2 Baden unit medication carts bottom drawer contained an unlabeled open tube of ciclopirox olamine cream (antifungal cream).

Interview 03/11/24, 12:44 p.m. Registered Nurse (RN) Employee E9 confirmed unlabeled open tube of ciclopirox olamine cream in the bottom drawer of the medication cart did not contain any type of identification on it and did not belong on the medication cart and removed it.

28 Pa. Code: 211.10(c) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Plan of Correction - To be completed: 04/24/2024

Current residents have the potential to be affected.

The Director of Nursing or designee will provide education to nursing staff responsible for storage and labeling of medications, medical supplies and biologicals.

An audit on current residents will be conducted to determine appropriate storage and labeling of medications, medical supplies and biologicals.
If medications, medical supplies or biologicals are identified as being improperly stored or labeled during the audit, the Director of Nursing or designee will provide additional education to the responsible staff person.

Audits of proper storage and labeling of medications, medical supplies and biologicals will be completed for 10 residents each week for 4 weeks or until substantial compliance is achieved.

Audit results will be reviewed with the Quality Assurance and Quality Improvement Committee for analysis and further recommendation.

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

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

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

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

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

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

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

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

Observations:

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly disinfect reusable equipment between residents for one of four nursing units observed (Baden Unit) and failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R85).

Findings include:

Review of facility policy "Glucometer Disinfection" indicated the facility will ensure blood glucometers (a device used to check blood sugar levels) will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. The glucometers will be a wipe pre-saturated with an EPA (Environmental Protection Agency) registered healthcare disinfectant that is effective against HIV (Human Immunodeficiency Virus), Hepatitis C and Hepatitis B virus.

Review of the EvenCare G3 Blood Glucose Monitoring System manual indicated the following approved products for cleaning and disinfecting the EvenCare G3 Meter:
- Dispatch Hospital Cleaner Disinfectant Towels with Bleach
- Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipes with Alcohol
- Clorox Healthcare Bleach Germicidal and Disinfectant Wipes
- Medline Micro-Kill Bleach Germicidal Bleach Wipes

Review of the facility policy "Clean Dressing Change" dated 10/17/22, last reviewed 1/5/24, indicated it is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross contamination. Policy explanation and compliance include but not limited to:
"Set up clean field on overbed table with needed supplies for wound cleansing and dressing application.
"Place only the supplies to be used per wound on the clean field at one time (include wound cleanser, gauze for cleansing, disposable measuring guide and pen/pencil, skin protectant products as indicated, dressings, tape.
"Loosen and remove the existing dressing.
"Remove gloves, pulling inside over the dressing. Discard into appropriate receptacle.
"Wash hands and put on clean gloves.
"Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e. clean outward from the center of the wound).
"Wash hands and put on clean gloves.
"Apply topical ointments or creams and dress the wound as ordered.
"Secure dressing. Mark with initials and date.

Review of the facility policy "Hand Hygiene" dated 10/17/22, last reviewed 1/5/24, indicated all staff will perform hand hygiene procedures to prevent the spread of infection to other personal, residents, and visitors. Hand hygiene table indicates but not limited to cleansing:
"After handling contaminated objects
"Before and after handling clean or soiled dressings, linens, etc.
"After handling items potentially contaminated with blood, body fluids, secretions, or excretions.

During an observation on the Baden Unit on 3/13/24, from 11:28 a.m. through 12:05 p.m. Registered Nurse RN Employee E3 was observed cleaning the glucometer machine (equipment used to monitor blood sugars) with an alcohol prep pad (gauze swab alcohol solution). Registered Nurse RN Employee E3 was observed obtaining a blood sample with a shared glucometer machine on Resident R321, wiping with an alcohol prep pad. Then with the same glucometer machine obtained a blood sample from Resident R320, wiping with an alcohol prep pad and then went to Resident R314 and obtained a blood sample. Then wiped glucometer machine with an alcohol prep pad.

During an interview on 3/13/24, at 2:10 p.m. RN Employee E3 confirmed that she did not clean the glucometer machine with the approved disinfectant per facility policy and manufacturer guidelines. RN Employee E3 stated, "I used the alcohol prep pad because that was how I was trained by the facility."

During an interview on 3/14/24, at 8:46 a.m. RN Employee E10 stated, "Glucometers are cleaned with Clorox wipes and left to dry for two the three minutes. The glucometers are cleaned prior to and after use and between residents."

During an interview on 3/14/24, at 8:48 a.m. RN Employee E2 stated, "We clean the glucometers with bleach, you clean for two minutes and then let it sit and dry for 5 minutes. They are cleaned between every resident use and after every use."

During an interview on 3/13/24, at 1:04 p.m. the Director of Nursing (DON) confirmed that the facility failed to properly disinfect reusable equipment between residents for one of four nursing units (Baden Unit).

Review of R85's Minimum Data Set (MDS-periodic assessment of care needs) dated 1/10/24, indicated admission date of 1/3/24, with the diagnosis of heart failure (heart doesn't work as it should), hypertension (high blood pressure), gastroesophageal reflux disease (GERD-stomach contents move back up the esophagus). Section M1040 coded D, open lesion(s) other than ulcers, rashes, cuts.

Review of Resident R85's physician order dated 1/17/24, Right Shin - cleanse with vashe wound cleaner, apply silver alginate (absorbent antimicrobial dressing) cut to fit, cover with border gauze. Change 3times weekly and PRN if soiled or dislodged.

Review of Resident R85's care plan dated 1/9/24, with revision on 2/29/24, indicates skin impairment related to wounds present on admission, chronic wound to right shin, interventions are in place.

Observation of Resident R85's dressing change on 3/13/24, at 11:00 a.m. Licensed Practical Nurse (LPN) Employee E7 failed to clean bedside table prior to placing clean barrier field and supplies: 4x4's times three packages, one package silver alginate, one package border gauze and scissors. LPN Employee E7 proceeded to remove a pen from her scrub top pocket and placed on clean barrier field. She opened her supplies writing the date/time/initial on the border gauze, applied the vashe wash to the 4x4's, picked up scissors cut and handled the silver alginate. She then removed her gloves, sanitized her hands, and applied new gloves. LPN Employee E7 removed soiled dressing and discarded into garbage can, dabbed the wound two times using the 4x4's with one 4x4, then with two 4x4's placed together. She then continued to apply the silver alginate and covered the wound with the border gauze.

During an interview on 3/13/23, at 11:16 a.m. LPN Employee E7 confirmed she failed to implement infection control practices to prevent cross contamination during a dressing change, failed to set up a clean barrier field and treat the wound without contaminating the wound bed for resident R85.

28 Pa. code: 201.14 (a) Responsibility of licensee.

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

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

28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Plan of Correction - To be completed: 04/24/2024

Current residents have the potential to be affected.

The Director of Nursing or designee will provide education to nursing staff responsible for disinfection of reusable equipment between residents.

The Director of Nursing or designee will provide education to nursing staff responsible for implementation of infection control practices to prevent cross contamination during a dressing change.

An initial audit of 10 current residents will be conducted to determine appropriate disinfection of reusable equipment between residents.

An initial audit of 5 current residents will be conducted to determine proper implementation of infection control practices to prevent cross contamination during a dressing change.

If disinfection of reusable equipment between residents is not completed properly or infection control practices to prevent cross contamination during a dressing change are not followed, the Director of Nursing or designee will provide additional education to the responsible staff person.

Audits of disinfection of reusable equipment between residents and implementation of infection control practices to prevent cross contamination during a dressing change will be completed for a total of 10 residents each week for 4 weeks or until substantial compliance is achieved.

Audit results will be reviewed with the Quality Assurance and Quality Improvement Committee for analysis and further recommendation.

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