Pennsylvania Department of Health
PLEASANT ACRES REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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PLEASANT ACRES REHABILITATION AND NURSING CENTER
Inspection Results For:

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PLEASANT ACRES REHABILITATION AND NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Findings of an abbreviated complaint survey completed on February 7, 2024, at Pleasant Acres Rehabilitation and Nursing Center identified that the facility 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:


483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observation and resident and staff interview, it was determined that the facility failed to maintain a safe, clean, home-like interior on three of five nursing units observed (100, 200, and 300 units).

Findings include:

Observations on February 7, 2024, revealed the following:

- 9:40 AM and at 1:48 PM in the 100 unit visiting lounge: an accumulation of dust and debris on the side frame and rungs of the double seat chair. Additionally, a wheelchair leg and bunched up blanket were present on top of the cabinet.
- 9:42 AM and at 1:48 PM in the 100 unit hallway bathroom: the curtain in the 100 unit hallway bathroom had multiple holes present in the top mesh portion of the curtain.
- 9:44 AM and 1:48 PM in the 100 unit main dining room: a pile of soiled linens including a hospital gown, blankets, towels, and sheet, as well as a clean incontinence brief were present on the countertop near the sink. The sink was noted to be discolored, and dried streaks of liquid were present on the wall behind the sink and on the cabinet below the sink. The grout to the left side of the sink was cracked and discolored. Multiple chairs in the dining area were noted to have dried drips on the sides as well as soiled rungs. At 11:49 AM, residents were observed eating lunch in the dining room.
- 10:00 AM and 1:55 PM: Resident 5's (a Resident on the 200 unit) overbed table had multiple rings and dried blobs/drops of liquid. Additionally, in Resident 5's bathroom, a brown substance was present in the shower chair commode bucket and on the shower chair seat.
- 10:23 AM in the 300 unit dining room: the floors were dirty with crumbs and spills and the tabletops were dirty. At 12:45 PM, the floors remained dirty with crumbs and spills, the tabletops remained dirty, and Residents 1, 2, 3, and 4 were observed to be eating in the dining room at that time.
- At 10:34 AM and at 2:00 PM in Resident 6's bathroom (on the 200 unit): an accumulation of hair in the shower drain, and multiple areas of a black substance were present on the rubber bathmat in the shower stall. An immediate interview with Resident 6 at 10:34 AM, revealed that she had a concern with the hair in the drain. She also confirmed that she uses the bath mat when she showers.

Following a tour and observation of the aforementioned concerns, starting at 1:48 PM, the Assistant Nursing Home Administrator, Director of Nursing, and Employee 3 (Environmental Services Regional Manager) acknowledged the concerns and confirmed that they would be addressed.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3) Management



 Plan of Correction - To be completed: 03/05/2024

This provided submits the following plan of correction in good faith and to comply with Federal regulations. 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. After, ANHA was toured by surveyor with environmental regional manager M1 visitor lounge was then cleaned, M1 visitor lounge had linens removed as well as wheelchair leg, M1 hallway bathroom was cleaned and curtain replaced, M1 main dining room had soiled linen and brief removed from countertop, M1 main dining room sink was cleaned as well as the wall behind it. M1 main dining room had grout replaced and cleaned. M1 main dining room chair were clean and free of drips and debris. M1 dining room sink cabinet was cleaned. R5 bedside table was cleaned and in bathroom the shower chair and commode bucket were cleaned. M3 dining room had floors cleaned off crumbs and spills and tabletops were cleaned. R6 hair was removed from the shower drain and black substance removed from the shower mat. To identify other residents that have the potential of being affected, the NHA/designee completed an audit on visitor lounges, unit dining rooms and resident bathrooms. Identified areas were cleaned at the time of the audit. NHA or designee educated the Housekeeping department and nursing department on importance of maintaining a clean and homelike environment for residents throughout the facility. Resident common areas, resident bedside tables and resident bathrooms will be audited 3x a week for 4 weeks then monthly x1 month to ensure resident common areas, resident bathrooms and resident bedside tables maintain a clean homelike environment. Audit results will be reviewed with QAPI Committee meeting monthly to determine the need for further audits.
483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for one of 13 residents reviewed (Resident 9).

Findings Include:

Review of Resident 9's clinical record revealed diagnoses that included dementia with agitation (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and major depressive disorder (mental disorder characterized by at least two weeks of low mood that is present across most situations).

Review of Resident 9's December 2023 and January 2024 MARs (Medication Administration Records - form used to document physician orders as well as when and how medications are administered to a resident) revealed that the following medications were not documented as being administered per physician orders on the noted dates: Lexapro (antidepressant) on December 16 and 22, 2023, and on January 6 and 24, 2024; Lisinopril (used to treat high blood pressure) on December 16 and 22, 2023, and on January 6 and 21, 2024; Memantine (used to treat moderate to severe dementia) on December 16 and 22, 2023, and on January 6 and 21, 2024; Depakote sprinkles (used to treat mental/mood conditions) on December 16 and 22, 2023, and on January 6, 21, and 28, 2024; and Trazadone (antidepressant) on January 28, 2024.

During an interview with the Assistant Nursing Home Administrator on February 7, 2024, at 2:30 PM, she revealed that she did not have any additional information regarding the missing medication administration documentation.

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


 Plan of Correction - To be completed: 03/05/2024

This provided submits the following plan of correction in good faith and to comply with Federal regulations. 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.
Resident 9 physician notified of medication omissions from past 30 days. No ill effects noted from medication omissions.
To identify other residents that have the potential to be affected, the DON/designee completed on audit on all of the resident's EMARS for the past 30 days. Residents with blanks in their EMAR had physician notification.
To prevent this from reoccurring, the DON/designee completed education to licensed nurses on the Medication Administration Policy which includes completing all medication passes, notification to physician of any refused or missed medications, and ensuring the med pass in the EMAR is in green before leaving their shift.
To monitor and maintain ongoing compliance, the DON/designee will audit 20 resident MARS weekly x 6 to ensure medication is administered as prescribed. Results of the audits will be reviewed at the QAPI meeting.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25(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 clinical record review, policy review, observations, and staff interviews, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for one of six residents reviewed for respiratory care (Resident 5).

Findings include:

Review of facility policy, titled "Hand Held Nebulizer/ Small Volume Nebulizer", revised March 2020, revealed "Drain any excess medication form nebulizer at end of treatment, rinse if needed. Store nebulizer equipment in a storage bag."
Review of Resident 5's clinical record revealed diagnoses that included Parkinson's Disease (long-term movement disorder where the brain cells that control movement start to die and cause changes in how one moves, feels, and acts) and heart disease (refers to problems affecting the heart).

Review of Resident 5's orders revealed an order for Albuterol Sulfate Inhalation Nebulization Solution (relaxes muscles in airways of the lungs for easier breathing) via nebulizer (turns liquid medicine into a fine mist that can be inhaled through a face mask or mouthpiece) four times a day for shortness of breath, cough/wheeze, effective January 31, 2024.

Observation on February 7, 2024, at 10:00 AM and again at approximately 1:55 PM, revealed Resident 5's nebulizer mask uncovered and laying directly on her nightstand.

During the observation at 1:55 PM, the Director of Nursing acknowledged it should have been bagged and confirmed that a replacement mask and tubing would be obtained for Resident 5.

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


 Plan of Correction - To be completed: 03/05/2024

This provided submits the following plan of correction in good faith and to comply with Federal regulations. 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. R5 tubing and mask was removed and replaced by nursing. To identify other residents that have the potential for being affected, the DON/designee completed an audit on residents who have current nebulizer orders to ensure mask is stored in plastic bag when not in use. DON/ designee will educate nursing staff that nebulizer tubing and mask must be stored in storage bag when not in use. Audits will be completed 2x a week for 4 weeks then x1 month to ensure residents with nebulizer equipment have it store appropriately when not in use. Audit results will be reviewed with QAPI Committee meeting monthly to determine the need for further audits.
§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on document review and staff interview, it was determined that the facility failed to ensure a required minimum of one Nurse Aide (NA) per 12 residents on both day and evening shifts for 13 of 21 days reviewed (January 13-16, 19-21, 23, February 2-6, 2024).

Findings include:

Review of facility provided staffing ratio/resident census information for January 10-16, 19-25, 2024, and February 1-7, 2024, revealed the following NA ratios, which did not meet the minimum NA ratio required for the facility census of residents on those shifts:

January 13th day shift - 352 residents and 26.92 NA ratio;
January 13th evening shift - 352 residents and 27.32 NA ratio;
January 14th day shift - 352 residents and 25.49 NA ratio;
January 14th evening shift - 352 residents and 25.92 NA ratio;
January 15th day shift - 351 residents and 28.25 NA ratio;
January 16th day shift - 351 residents and 28.85 NA ratio;
January 16th evening shift - 351 residents and 25.87 NA ratio;
January 19th evening shift - 354 residents and 25.70 NA ratio;
January 20th day shift - 352 residents and 22.62 NA ratio;
January 21st day shift - 352 residents and 21 NA ratio;
January 23rd evening shift - 354 residents and 26.81 NA ratio;
February 2nd day shift - 356 residents and 29.62 NA ratio;
February 2nd evening shift - 356 residents and 25.03 NA ratio;
February 3rd day shift - 354 residents and 24.18 NA ratio;
February 3rd evening shift - 354 residents and 29.29 NA ratio;
February 4th day shift - 353 residents and 22.74 NA ratio;
February 4th evening shift - 353 residents and 24.98 NA ratio;
February 5th day shift - 356 residents and 29.05 NA ratio;
February 5th evening shift - 356 residents and 24.95 NA ratio;
February 6th evening shift - 354 residents and 28.47 NA ratio.

During an interview with the Nursing Home Administrator on February 7, 2024 at 11:02 AM, he acknowledged that the facility had difficulty meeting required ratios for the past couple of weeks due to call offs and weather.


 Plan of Correction - To be completed: 03/05/2024

This provided submits the following plan of correction in good faith and to comply with Federal regulations. 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.
1. CNA staffing ratios were not met on the dayshift on January 13th, 14th, 15th, 16th, 20th, 21st, 2024 . CNA staffing ratios were not met on the dayshift on February 2nd, 3rd, 4th, and 5th, 2024. CNA staffing ratios were not met on the evening on January 16th, 19th, and 23rd, 2024. CNA staffing ratios were not met on the evening on February 2nd, 3rd, 4th, 5th, and 6th, 2024.
2. No residents were adversely affected by the shortage as non-nursing staff was available to answer call bells, deliver water, deliver food trays and other tasks that were in their scope of practice.
3. To prevent this from reoccurring, the NHA/designee completed education with the schedulers to schedule the staffing for 2.87 to maintain required PPD and to monitor staff ratios each shift per facility census. Nursing supervisors will be educated to make phone calls to replace call offs and no shows to maintain PPD and staff ratios. The NHA and DON will be notified to assist with obtaining replacement staff to ensure ratios are being met.
4. To monitor and maintain ongoing compliance, staffing meeting are held twice a day during the week and the scheduler checks in with administration and/or nursing leadership on any staffing updates through the weekend. The NHA/designee will audit 5 future schedules weekly x 4 weeks to ensure staffing PPD is 2.87 or above and staffing ratios are being met at the start of each day. The schedule will again be reviewed after the scheduled day to ensure ratios were met. Results of the audits will be reviewed in QAPI.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on document review and staff interview, it was determined that the facility failed to ensure a required minimum of one Licensed Practical Nurse (LPN) per 25 residents on day shift and one LPN per 40 residents on the overnight shift for five of 21 days reviewed (January 15, 20, and 21, 2024, and February 3 and 5, 2024).

Findings include:

Review of facility provided staffing ratio/resident census information for January 10-16, 19-25, 2024, and February 1-7, 2024, revealed the following LPN ratios, which did not meet the minimum LPN ratio required for the facility census of residents on those shifts:
January 15th night shift - 351 residents and 7.89 LPNs;
January 20th day shift - 352 residents and 10.84 LPNs;
January 21st day shift - 352 residents and 13.04 LPNs;
February 3rd day shift - 354 residents and 13.59 LPNs;
February 5th night shift - 356 residents and 8.52 LPNs.

During an interview with the Nursing Home Administrator on February 7, 2024 and 11:02 AM, he acknowledged that the facility had difficulties meeting required ratios in the prior couple of weeks due to call offs and weather.



 Plan of Correction - To be completed: 03/05/2024

This provided submits the following plan of correction in good faith and to comply with Federal regulations. 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.
1. LPN staffing ratios were not met on the nightshift on January 15th, 2024 and on dayshift on January 20th and 21st, 2024. LPN staffing ratios were also not meant on nightshift on February 5th, 2024 and on dayshift on February 3rd, 2024.
2. No residents were adversely affected by the shortage as non-nursing staff was available to answer call bells, deliver water, deliver food trays and other tasks that were in their scope of practice.
3. To prevent this from reoccurring, the NHA/designee completed education with the schedulers to schedule the staffing for 2.87 to maintain required PPD and to monitor staff ratios each shift per facility census. Nursing supervisors will be educated to make phone calls to replace call offs and no shows to maintain PPD and staff ratios. The NHA and DON will be notified to assist with obtaining replacement staff to ensure ratios are being met.
4. To monitor and maintain ongoing compliance, staffing meeting are held twice a day during the week and the scheduler checks in with administration and/or nursing leadership on any staffing updates through the weekend. The NHA/designee will audit 5 future schedules weekly x 4 weeks to ensure staffing PPD is 2.87 or above and staffing ratios are being met at the start of each day. The schedule will again be reviewed after the scheduled day to ensure ratios were met. Results of the audits will be reviewed in QAPI.

§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on review of staffing data furnished by the facility and staff interview, it was determined that the facility failed to ensure the total number of nursing care hours provided in each 24 hour period be a required minimum of 2.87 hours of direct care for each resident for two of 21 days reviewed (January 20, 2024, and February 4, 2024).

Findings include:

Review of staffing data provided by the facility dated January 10-16, 19-252, 2024, and February 1-7, 2024, revealed that the facility provided only 2.81 hours of direct care for each resident on January 20, 2024, and 2.86 hours of direct care for each resident on February 4, 2024.

During an interview with the Nursing Home Administrator on February 7, 2024, at 11:02 AM, he acknowledged that the facility had difficulties meeting required staffing ratios in the prior couple of weeks due to call offs and weather.



 Plan of Correction - To be completed: 03/05/2024

This provided submits the following plan of correction in good faith and to comply with Federal regulations. 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.
1. Staffing PPD for January 20th, 2024 and on February 4th, 2024 was under the minimum staffing PPD of 2.87.
2. No residents were adversely affected by the shortage as non-nursing staff was available to answer call bells, deliver water, deliver food trays and other tasks that were in their scope of practice.
3. To prevent this from reoccurring, the NHA/designee completed education with the schedulers to schedule the staffing for 2.87 to maintain required PPD and to monitor staff ratios each shift per facility census. Nursing supervisors will be educated to make phone calls to replace call offs and no shows to maintain PPD and staff ratios. The NHA and DON will be notified to assist with obtaining replacement staff to ensure ratios are being met.
4. To monitor and maintain ongoing compliance, staffing meeting are held twice a day during the week and the scheduler checks in with administration and/or nursing leadership on any staffing updates through the weekend. The NHA/designee will audit 5 future schedules weekly x 4 weeks to ensure staffing PPD is 2.87 or above and staffing ratios are being met at the start of each day. The schedule will again be reviewed after the scheduled day to ensure ratios were met. Results of the audits will be reviewed in QAPI.


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