Pennsylvania Department of Health
VALLEY MANOR REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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VALLEY MANOR REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are  179 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.
VALLEY MANOR REHABILITATION AND HEALTHCARE CENTER - 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 survey and an Abbreviated survey in response to one complaint completed February 14, 2024, it was determined that Valley Manor Rehabilitation and Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.


















 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,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.
§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on a review of facility policy, observation, and staff interview, it was determined that the facility failed to store and serve food under sanitary conditions in the kitchen and on two of three nursing units. (Central and South units)

Findings include:

A review of the facility policy entitled, "Food Policy," last reviewed September 28, 2023, revealed that the facility maintained personal food in accordance with safe food guidelines. Food was to be stored in the refrigerator or freezer in airtight containers, and labeled with the resident's name, room number, and the date it was placed in the refrigerator. Items were to be discarded after 72 hours.

Observation of the kitchen on February 11, 2024, at 9:07 a.m., revealed the following:

There were particles of debris scattered on the floor of the walk-in freezer. In the walk-in refrigerator, there were two boxes of thawing, raw bacon stored on a shelf over cooked, ready to eat eggs. There was a container of pureed fruit dated February 4, 2024. In an interview, Dietary Employee 1 (DE 1) stated that the pureed fruit should have been discarded. The wall tiles on the outside of the walk-in refrigerator were chipped and brown. The built-in wall fan that was over a food preparation table had an accumulation of dust in the grate cover and fan blades. There was a portion of a winged insect that was adhered to the outside of the grate. The can opener had a black substance along the edges of the mount that was attached to the food preparation table. There was a large cream-colored liquid residue under the sink attached to the dish machine unit. There was a cream-colored substance on the pipe under the sink. DE 1 stated that the sink was used for the garbage disposal. The garbage disposal was activated, and a large amount of the cream-colored liquid expelled from the sides of the pipe. There were two fruit flies observed in the dish machine area.

Behind the ice machine, the floor was wet and there was a portion of the wall that was covered in plastic and was adhered to the wall and floor with tape. The tape on the floor was wrinkled and wet. There was an open aerosol can on the floor behind the dish machine.

Observation of the kitchen on February 12, 2024, at 12:38 p.m., revealed DE 2 was wearing gloves and cutting a raw cucumber. DE 2 left the food preparation area and proceeded to the oven and opened the doors. DE 2 then returned to the food preparation table and continued cutting the raw cucumber. DE 2 did not change her gloves or perform hand hygiene after changing tasks. The glove on DE 2's right hand was ripped, and her pinky finger was exposed. In an interview, DE 2 stated that the raw cucumber was being prepared for a raw salad. There were various stained ceiling tiles outside of the walk-in refrigerator. The tiles on the wall across from the walk-in refrigerator were chipped and broken.

Observation of the pantry refrigerator on the South nursing unit on February 11, 2024, at 1:00 p.m., revealed two jars of liquid that were not labeled. There was a container of chocolate milk with a use by date of February 8, 2024. There was a container of egg nog with a use by date of January 15, 2024. There was a take-out container of food that was not dated. There was a yogurt drink and a container of sour cream, and neither were labeled with a resident name.

Observation of the pantry refrigerator on the Central nursing unit on February 12, 2024, at 12:38 p.m., revealed the freezer compartment had built-up ice and an orange colored spill. In the refrigerator compartment, there was yogurt that had expired January 29, 2024, three sticks of cheese with no date, and a pudding that had expired February 11, 2024. Inside the microwave, there was brown dry spillage and food debris spattered on the walls and ceiling.


28 Pa. Code 201.18 (b)(3)(e)(2.1) Management.







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

1. The kitchen was cleaned and free of debris. The thawing bacon was moved to a different storage area below other ready to eat foods. Outdated food was discarded and the hole in the wall behind the freezer was properly repaired. The wall fan over the food prep area was cleaned and the grate was replaced. The food prep table with the can opener was cleaned and the can opener was properly reattached. The pipe under the garbage disposal was repaired and the area was cleaned. The pest control company was called for service to address the fruit flies. The aerosol can was removed from the area behind the dish machine. The employee who did not change gloves in between cutting raw vegetables and checking on meat was educated about changing gloves in between each change of station. The kitchenette refrigerators on the South and Central Nursing units were both cleaned out with outdated food discarded. The microwave on Central Unit was cleaned.
2. To identify other like areas, the facility kitchenettes were inspected for safe food procurement and that the food is stored, distributed, and served in accordance with professional standards for food safety service.
3. To prevent recurrence, the facility staff will be educated on the regulation and facility policy for food safety and procurement. During the next resident council meeting the residents will be educated as well.
4. To monitor the corrective action, ensure that the deficient practice does not recur, the Admin/ DON or designee will complete random weekly audits on procedures for safe food preparation and procurement in the kitchen and on the nursing units. Audits will be completed 1X/week X 4 weeks; 1X/ bi-weekly X 1 month; 1X/month X 1 month to ensure good carryover. Results will be reviewed at the monthly QAPI meeting.
5. Date of compliance: March 5, 2024


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, it was determined that the facility failed to provide a safe, clean, and comfortable environment on three of three nursing units. (Central, North, and South)

Findings include:

Observations on February 12, 2024, from 10:00 a.m. to 11:00 a.m., revealed dirty floors in rooms 306, 307, and 402, cracked/broken floor tiles in room 402, trash on the floor in room 302, and a stained privacy curtain in room 308.

On February 11, 2024, at 9:30 a.m., and February 12, 2024, at 9:40 a.m., brown stains were observed on the wall adjacent to the sink in room 610.

On February 11, 2024, from 11:01 a.m. to 2:18 p.m., the following was observed:

Window curtains were in poor condition, disrepair, and/or falling from the rods in rooms 103, 104, 105, 106, 108, 109, 117, 205, 211, 213, and 215.

There were cracked floor tiles, a bent threshold plate, an unattached television cable, a leaking faucet, and a continuously running toilet in room 104.

The bedside cabinet for 205A had a broken drawer.

Multiple cigarette butts were on the ground adjacent to the residents' smoking area.

Observations on February 11, 2024, from 9:49 a.m. to 12:17 p.m., and on February 12, 2024, from 1:03 p.m. to 1:50 p.m., revealed the following:

Small winged insects were observed in rooms 510, 508, 515, and 609, and in the corridor.

Floors were dirty with debris in rooms 502 and 515, and there was a brown stain under the bedside table in 500A (present both days).

The surface of the wall was peeling behind the bed in 503A.

In room 504, the baseboard molding was loose and a corner of the wall was broken.

CFR: 483.10(i) Safe, Clean, Comfortable, and Homelike Environment
Previously cited 3/17/23.

28 Pa. Code 201.18(b)(1)(e)(2.1) Management.








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

1. The maintenance repairs including cracked floor tiles, unattached TV cable, leaking faucet, continuously running toilet, broken cabinet drawer, wall repair, baseboard molding that is loose, and cracked in the corner are scheduled to be completed. The pest control company has been contacted to exterminate the drain flies on the south unit.

Housekeeping is cleaning the floors noted to be dirty with debris and a brown stain under the bedside table. Any trash noted has been removed from the floor, the stained privacy curtain has been removed and washed. The curtains in poor condition or in disrepair are being replaced.
2. To identify other like areas of environmental concern, room audits will be completed, and any new findings will be corrected and added as a prioritized phased plan.

3. To prevent recurrence, housekeeping and maintenance staff will be educated on the regulation to provide and maintain a safe, clean, comfortable, and homelike environment.

4. To monitor the corrective action and ensure that the deficient practice does not recur, the Admin or designee will complete weekly audits on the facility environment and maintaining cleanliness and keeping in good repair. Audits will be completed 1X/week X 4 weeks; 1X/ bi-weekly X 1 month; 1X/month X 1 month. Results will be reviewed at the monthly QAPI meeting.

5. Date of compliance: March 5, 2024


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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.
§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).
Observations:

Based on facility policy review, clinical record review and interview, it was determined that the facility failed to notify the resident's physician and responsible party of changes in condition for two of 33 sampled residents. (Resident 4, 145)

Findings include

A review of the facility policy entitled, "Notification of Resident/Patient Change in Condition," last reviewed September 28, 2023, revealed that staff were to notify the physician and family or representative if there was a change in condition. The time of notification and the person to whom they spoke was to be documented in the nurse's note.

Clinical record review revealed that Resident 4 had diagnoses that included diabetes. The resident had a care plan intervention that directed staff to notify the physician if the resident's finger stick blood glucose level went below 70. Review of the Medication Administration Record revealed that the resident's blood glucose level was below 70 on December 10, 19 and 28, 2023. There was no documentation to support that the physician was notified of the low blood glucose levels.

In an interview on February 14, 2023, at 9:37 a.m., the Director of Nursing confirmed there was no evidence that Resident 4's physician was notified of the low blood glucose levels.

Clinical record review revealed that Resident 145 had diagnoses that included, aphasia (inability to understand and form speech), end stage renal disease that required hemodialysis, and seizure. In an interview on February 11, 2024, at 2:15 p.m., the resident's representative stated that they were not notified when Resident 145 was transferred to the hospital in January 2024. Review of the nurse's notes revealed that on January 4, 2024, the resident was transferred and admitted to the hospital for a change in condition. There was no evidence that Resident 145's representative was notified of the transfer to the hospital. Additionally, a review of the resident's weights revealed that on February 3, 2024, the resident weighed 125 pounds (lbs.). On February 5, 2024, the resident weighed 140.4 lbs., which indicated a significant weight gain of 15.4 lbs. (12.5%). Further review of the record revealed that Resident 145 continued to gain weight and weighed 143.3 lbs. on February 12, 2024, which indicated an ongoing significant gain of 18.3 lbs. (14.6%) since February 3, 2024. There was no evidence that the physician was notified of the significant weight gain.

In an on February 14, 2024, at 11:15 a.m., the Assistant Director of Nursing confirmed there was no evidence that Resident 145's representative was notified of the change in condition and transfer to the hospital and in an interview of February 14, 2024 at 11:53 a.m., the Director of Nursing confirmed that the physician was not notified of the resident's significant weight gain.

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








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

1. The physician for resident 4 was notified of the past low glucose levels for Dec 10, 19, 28, 2023.
The physician for resident 145 was notified of the weight gain of 18.3 lbs since Feb 3. The responsible party (mother) was contacted to inform her of the recent hospital stay.

2. To identify other like residents, current facility residents with insulin dependent diabetes will be audited to ensure the physician was notified of any blood sugar ranges outside of the set parameters. Additionally, current facility residents on HD will be reviewed to ensure there has been no significant weight gain and if there were, the physician was notified.

2a. To identify other like residents, a 2-week lookback will be completed on residents who were discharged to the hospital to ensure the resident's responsible party was notified of the transfer to the hospital.

3. To prevent recurrence the facility nursing staff will be educated on regulation and the facilities "Transfer Out/Bed Hold Policy" and notification of changes in condition.

4. To monitor the corrective action and ensure that the deficient practice does not recur, the DON/Admin/ designee will complete weekly audits on physician notifications for residents with low/high blood glucose levels and residents with significant weight changes, 1X/week X 4 weeks; 1X/ bi-weekly X 1 month; 1X/month X 1 month to ensure good carryover. Results will be reviewed at the monthly QAPI meeting.

5. Date of compliance: March 5, 2024

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
§483.45(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 a review of facility policy, observation, and staff interview, it was determined that the facility failed to properly store medications in three of four medication carts. (Central Hall 200, South Hall 500, South Hall 500/600)

Findings include:

Review of the facility policy entitled, "Preparation and General Guidelines," last reviewed September 28, 2023, revealed that all drugs were to be stored and administered in compliance with state and federal regulations. Once any medication or biological package was opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff wer to record the date opened on the primary medication container when the medication had a shortened expiration date once opened. Medications were to be administered from containers labeled with an expiration date, when applicable.

Observation on February 12, 2024, from 1:30 p.m. to 2:00 p.m, of the Central Hall 200, South Hall 500 and South Hall 500/600 medication carts revealed the following medications that were open with no opened date or expiration dates:

Eight Lantus insulin pens
Two insulin lispro pens
Two insulin aspart pens
One Basaglar insulin pen
Two Novolog insulin pen
One Humalong insulin pen
One Levemir insulin pen

According to the manufacturer's instructions the medications should be discarded 28 days after opening.

In an interview, on February 14, 2024, at 11:20 a.m., the Director of Nursing stated that the staff was to label all medications with open and expiration dates and all expired medication was to be removed from the medication cart.

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









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

1. The medication carts on central hall 200, south hall 500 and south hall 500/600 units were inspected. Any undated insulin pens were removed and disposed of. New pens were opened and dated according to regulation.

2. To identify other like residents, the remaining medication carts in the facility were inspected. Any undated insulin pens were removed and disposed of, new pens were opened and dated according to regulation.

3. To prevent recurrence, licensed nursing staff will be educated on preparation and general guidelines for medication storage and administration.

4. To monitor the corrective action ensure that the deficient practice does not recur, the DON/Admin/ designee will complete random weekly audits on procedures for management of insulin pens. Audits will be completed 1X/week X 4 weeks; 1X/ bi-weekly X 1 month; 1X/month X 1 month to ensure good carryover. Results will be reviewed at the monthly QAPI meeting.

5. Date of Compliance: March 5, 2024.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide services to maintain adequate grooming and personal hygiene for residents unable to carry out activities of daily living for one of 33 sampled residents. (Resident 58)

Findings include:

Clinical record review revealed that Resident 58 had diagnoses that included hypertension (high blood pressure) and chronic obstructive pulmonary disease. The Minimum Data Set assessment dated January 22, 2024, revealed that the resident was cognitively intact and required extensive staff assistance for personal hygiene. The care plan identified that Resident 58 had difficulty caring for himself due to physical limitations and interventions included that staff assist with daily hygiene and grooming. Observation on February 11, 2024, at 9:30 a.m., and February 12, 2024, at 9:09 a.m., revealed that Resident 58's fingernails on both hands were long and jagged and his face appeared unshaven. In an interview at that time, Resident 58 could not recall the last time staff provided or offered nail care or to have his face shaved and that he would not have refused.

In an interview on February 12, 2024, at 2:30 p.m., the Director of Nursing stated that nail care and facial shaving were to be done on resident shower days as needed.

CFR 483.24(a)(2) ADL Care provided for Dependent Residents.
Previously cited 3/17/23

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





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

1. Resident 58 had his fingernails/toenails trimmed and was shaven immediately.

2. To identify other like residents, an audit of current active residents will be completed to review ADL completion including nail trimming and shaving.

3. To prevent recurrence, facility nursing staff will be educated on the regulation which explains that a resident who is unable to carry out ADLs receives the necessary services to maintain good nutrition grooming and personal and oral hygiene.

4. To monitor the corrective action and ensure that the deficient practice does not recur, the DON/Admin/ designee will complete weekly audits on ADL completion including nail trimming and shaving. 1X/week X 4 weeks; 1X/ bi-weekly X 1 month; 1X/month X 1 month to ensure good carryover. Results will be reviewed at the monthly QAPI meeting.


5. Date of compliance: March 5, 2024


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 facility policy review, clinical record review, resident interview, and staff interview, it was determined that the facility failed to ensure physician's orders and care plan interventions were implemented for three of 33 sampled residents. (Resident 27, 70, 153)

Findings include:

Review of the policy entitled, "Medication Administration General Guidelines," last reviewed September 28, 2023, revealed that medications were to be administered in accordance with written orders of the attending physician.

Clinical record review revealed that Resident 27 had diagnoses that included cerebral palsy, paraplegia, and pain. On January 22, and February 8, 2024, the physician ordered staff to administer 10 milligrams of a narcotic pain medication (oxycodone), as needed for severe pain of seven or above (on a scale of zero to 10.) Review of January and February, 2024, Medication Administration Records (MAR) revealed the resident received the medication for pain assessed at less than seven on six occasions.

In an interview on February 14, 2024, at 9:39 a.m., the Director of Nursing confirmed the medication was given outside parameters.

Clinical record review revealed that Resident 70 had diagnoses that included dementia, hypertension, peripheral vascular disease, and congestive heart failure (CHF). On February 11, 2024, at 11:29 a.m., Resident 70 was observed on her bed and both of her lower legs appeared swollen and red. Resident 70 stated that staff were aware of her swollen legs. On February 6, 2024, a nurse noted that the resident presented with pitting edema to bilateral lower extremities. Care plan interventions to address the resident's edema included that staff were to apply TEDS (compression stockings) to both legs in the morning and remove in the evening. Resident 70 was observed on multiple occasions on February 11, 2024, between 11:49 a.m. and 2:48 p.m., and the compression stockings were not in place. Resident 70 was observed on February 12, 2024, at 12:05 p.m., and the stockings were not in place. The resident stated that staff had not offered to apply compression stockings to her legs and she had not refused. Resident 70 was subsequently observed at 12:59 p.m., and 1:22 p.m., and the stockings were not in place. There was no evidence that staff had attempted to apply the compression stockings in the morning or that the resident had refused.

In an interview on February 14, 2024, at 9:13 a.m., the assistant Director of Nursing (ADON) confirmed there was no evidence that staff were applying the compression stockings or that the resident had refused to wear them.

Clinical record review revealed that Resident 153 had diagnoses that included hypertension (high blood pressure). A physician's order dated December 14, 2023, directed staff to administer a medication (metoprolol tartrate) two times a day for hypertension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 100 millimeters of mercury (mm/Hg) or if the heart rate (the number of times a heart beats in one minute) was less than 60. Review of Resident 153's February 2024, MAR revealed that staff administered the medication 11 times with no documentation to support that the blood pressure and heart rate were assessed prior to medication administration per physician's order.

In an interview on February 14, 2024, at 9:20 a.m., the ADON confirmed there was no documented evidence that the blood pressure and heart rate were taken prior to the medication administration per physician's order.

CFR 483.25 Quality of Care
previously cited 3/17/23

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





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

1. Residents R27, R 70, R150 had no ill effects.

2. To identify other like residents, current facility residents will be audited to ensure that physician orders and care planned interventions are implemented.

3. To prevent recurrence, facility nursing staff will be educated on regulation regarding "Medication Administration General Guidelines" including physician orders and care planned interventions.

4. To monitor the corrective action and ensure that the deficient practice does not recur, the DON/Admin/ designee will complete random weekly audits on implementation of physician's orders and care plans 1X/week X 4 weeks; 1X/ bi-weekly X 1 month; 1X/month X 1 month to ensure good carryover. Results will be reviewed at the monthly QAPI meeting.

5. Date of Compliance: March 5, 2024.


483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:
Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that staff provided services consistent with professional standards of practice for two of two dialysis residents. (Residents 121, 145)

Findings include:

Review of facility policy entitled, "Dialysis Management," last reviewed September 28, 2023, revealed that the facility would initiate a communication log prior to a resident being transferred to the dialysis center. The form would serve as the general communication method between the two entities. The communication tool would be used each time the resident was sent to dialysis. The nurse assigned to the resident would assure the communication form was completed and sent with the resident to dialysis. The facility nurse would complete sections one and three of the form.

Clinical record review revealed that Resident 121 had diagnoses that included chronic kidney disease stage 5 that required hemodialysis. The resident had an arteriovenous fistula ( AVF-an artificial tube used to connect an artery to a vein for hemodialysis) in the left upper arm and a physician's order dated January 12, 2024, directing that staff was not to take blood pressure measurements in the resident's left arm. Review of Resident 121's blood pressure summary revealed that from January 12, 2024, through February 11, 2024, nursing staff had taken the resident's blood pressure in the left arm 15 of 42 times.

In an interview on February 14, 2024, at 9:15 a.m., the Assistant Director of Nursing (ADON) confirmed that nursing staff were to have taken the blood pressure in Resident 121's right arm due to the left arm AVF.

Clinical record review revealed that Resident 145 had diagnoses that included anoxic brain injury, end stage renal disease that required hemodialysis, heart failure, respiratory failure, aphonia (inability to produce voice), aphasia (inability to understand or form speech), seizure, and history of thrombosis and embolism. Review of the resident's dialysis communication forms revealed no evidence that section one of the communication form, which included medications administered prior to dialysis, status of the access site, and any relevant changes, was completed on February 5 and 7, 2024. Further review of the forms revealed that section three, which included vital signs, status of the access site, and mental status, was incomplete on February 2, 2024. There was no evidence that the resident's nurse adequately completed the dialysis communication form on those dates.

In an interview on February 14, 2024, at 9:13 a.m., the ADON confirmed the dialysis communication forms were incomplete.

CFR 483.25(1)Dialysis
Previously cited 3/17/23

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





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

1. Resident R 121 and 145 had no ill effects.

2. And 3. To prevent recurrence, the DON, Admin, and Contracted Dialysis company will complete staff education on recommendations and protocols regarding dialysis residents.


4. To monitor the corrective action and ensure that the deficient practice does not recur, the DON/Admin/ designee will complete random weekly audits on completion of the communication forms and compliance with orders as stated with dialysis residents. The audits will be completed 1X/week X 4 weeks; 1X/ bi-weekly X 1 month; 1X/month X 1 month to ensure good carryover. Results will be reviewed at the monthly QAPI meeting.

5. Date of Compliance is March 5, 2024.


483.35(g)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§483.35(g) Nurse Staffing Information.
§483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

§483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.

§483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

§483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.
Observations:

Based on observation and interview, it was determined that the facility failed to post accurate and current nurse staffing information.

Findings include:

During a tour of the facility conducted on February 11, 2024, at 8:28 a.m., the staffing information that was posted in the lobby was dated for February 9, 2024. On February 12, 2024, at 1:50 p.m., the staffing information that was posted in the lobby was for February 11, 2024.

In an interview on February 14, 2024, at 9:15 a.m., the Nursing Home Administrator confirmed that incorrect staffing data was posted.

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







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

1. The posted nurse staffing information was updated immediately.


2. and 3. To prevent recurrence, the DON, Admin, or designee will complete staff education to the Staff educator and Nursing supervisor on posting the nurse staffing information for each shift.

4. To monitor the corrective action and ensure that the deficient practice does not recur, the DON/Admin/ designee will complete random weekly audits on posting the nurse staffing information. Audits will be completed 1X/week X 4 weeks; 1X/ bi-weekly X 1 month; 1X/month X 1 month to ensure good carryover. Results will be reviewed at the monthly QAPI meeting.

5. Date of Compliance is March 5, 2024


483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:

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

Findings include:

Observation of the dumpster area during the environmental tour of the kitchen on February 11, 2024, at 9:07 a.m., revealed the following:

There was an accumulation of items that included cigarette butts, blue disposable gloves, napkins, plastic wrappers, and plastic utensils on the ground surrounding the dumpsters. The door to the dumpster was open, and there was trash inside of that dumpster. Additionally, the dumpster's sliding doors were observed open on both sides at 12:21 p.m.

Observation on February 12, 2024, at 8:41 a.m., revealed various items that included Styrofoam cups and pieces, paper and plastic products, and condiment packets along the side of the building.

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












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

1. The area around the dumpster area was cleaned, debris was removed and placed in the dumpster and the dumpster doors were closed.

2. The facility has only one dumpster area on the grounds.

3. To prevent recurrence, facility staff will be educated on the regulation and the requirements for properly disposing garbage and refuse.

4. To monitor the corrective action to ensure that the deficient practice does not recur, the Admin/ designee will complete random weekly audits on properly disposing of garbage and refuse. Audits will be completed 1X/week X 4 weeks; 1X/ bi-weekly X 1 month; 1X/month X 1 month. Results will be reviewed at the monthly QAPI meeting.

5. Date of Compliance: March 5, 2024

§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for one of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from January 1 through 7, 2024, January 14 through 20, 2024, and February 6 through 12, 2024, revealed the following:

The facility failed to meet the minimum NA to resident ratios of one NA for 20 residents on night shift (11:00 p.m. to 7:00 a.m.) on February 8, 2024.

In an interview on February 8, 2024, the Nursing Home Administrator confirmed the facility did not meet the minimum nurse aid to resident ratio for the above mentioned date.




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

1. Facility did have appropriates levels of staff scheduled to work on 2/8/2024.

2. The nursing staff to resident ratio audit will be completed for a 2-week lookback period to ensure there were no other dates of non-compliance.

3. NHA or designee will educate the DON/ADON/Staffing Scheduler/ and Nursing Supervisors on state ratio regulation. NHA will review staffing daily to ensure the nursing staff to resident ratios are met.

4. To monitor the corrective action and ensure the deficient practice does not recur, the DON will audit staff to resident ratios weekly X 4; bi-weekly X 2 and monthly X 1. The results will be reviewed at the QAPI meeting.

5. Date of compliance: March 5, 2024


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