Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT LITITZ
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

KADIMA REHABILITATION & NURSING AT LITITZ
Inspection Results For:

There are 134 surveys for this facility. Please select a date to view the survey results.

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KADIMA REHABILITATION & NURSING AT LITITZ - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on June 7, 2024, at Kadima Rehabilitation and Nursing at Lititz, it was determined the facility was not in compliance under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

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 review of facility policy, observations, and interview with staff, it was determined that the facility failed to maintain appropriate sanitation during dishwashing.

Findings include:

Review of facility policy "Low Temperature Dish Machine Temperatures & Sanitizer Testing", undated, revealed that the sanitizer levels are to be checked at each meal cycle using a chlorine test strip. This test is to be recorded during the rinse/sanitize cycle of the first test run of the dish machine. The chlorine strength value is to be recorded on the dish machine temperature and sanitizer monitoring log. If the test strip indicates a value greater than or lesser than 50 ppm (parts per million), notify the Dining Services Manager and/or Administrator immediately for appropriate corrective action.

Observation on June 7, 2024, at 9:37 a.m. in presence of Employee E4 revealed the sanitizer strip revealed a value of 10 ppm. Observation at the log for June 2024 revealed water temperatures were recorded but there was no documentation of sanitizer strength.

Interview with Employee E4 at that time revealed that sanitizer is "checked daily or sometimes every other day and is usually 200 ppm".

Interview with the Nursing Home Administrator (NHA) on June 7, 2024, at 1:15 p.m. revealed that the log had been updated and the space to record the sanitizer had been omitted. The NHA also confirmed that the sanitizer should not have been 10 ppm and the service company had been contacted.

28 Pa. code 211.6(f) Dietary services

Plan of Correction - To be completed: 08/06/2024

1. Facility can not retroactively correct.

2. The log has been updated and the space to record the sanitizer is no longer omitted. The service company adjusted the sanitizer strength on 6/10/2024.

3. Administrator or designee will educate dietary staff on using the correct form and communicating immediately when the sanitizer test strip indicates a value greater than or less than 50ppm.

4. An audit of the dishmachine temperature and sanitizer monitoring log will be conducted weekly for four weeks and monthly for two months.

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 upon review of the clinical record and facility documentation, it was determined the facility failed to follow physician orders for one of twelve residents reviewed (Resident 28).

Findings include:

Review of Resident 28's physician orders revealed an order dated February 29, 2024, for "Dermal sleeves [worn to protect skin] to bilateral lower extremities for protection. Remove to assess skin. May remove for care/showers then reapply."

Review of Resident 28's active plan of care revealed "tubigrips [sleeves worn to protect skin] to bilateral legs at all times."

Review of documentation dated March 1, 2024, revealed "Resident acquired a skin tear to right lower leg measuring 9 cm [centimeters] x 4 cm with adipose tissue exposed. Sanguineous drainage was noted. Resident c/o [complained of] pain upon dressing change but denied pain after. The resident did not have tubigrips during transfers. Resident has an order for dermal sleeves to BLE [bilateral lower extremities] to be worn for protection."

Review of [community wound specialist] wound evaluation dated March 6, 2024, revealed "9.4 cm x 3.9 cm x 0.1 cm right lower lateral leg skin tear".

Interview with the Director of Nursing and Nursing Home Administrator on June 7, 2024, at 11:00 a.m. confirmed Resident 28 was not wearing tubigrips as ordered by the physician on the lower extremities during the transfer.

28 Pa. Code 211.12(d)(1)(3) Nursing Services
Previously cited 8/31/2023

Plan of Correction - To be completed: 08/06/2024

1. Facility is unable to retroactively correct.

2. Residents have the potential to be affected by this deficient practice and an audit of physician ordered resident compression garments will be performed to ensure compliance.

3. Director of Nursing or designee will educate nursing staff on following physician's orders and plan of care.

4. An audit will be conducted weekly for four weeks and monthly for two months. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that necessary services were provided for one of one residents with a pressure ulcer (Resident 20).

Findings include:

Review of Resident 20's clinical record revealed that the resident was admitted on May 8, 2024, with diagnoses of but not limited to stage 4 pressure ulcer (full thickness skin loss exposing underlying muscle, tendon, cartilage, or bone) of the sacral region (portion of spine between the lower back and tailbone and an unstageable pressure ulcer (pressure ulcer not stageable due to coverage of wound bed due to slough [non-viable yellow, tan, gray, green or brown tissue] and/or eschar [dead or devitalized tissue that is hard or soft in texture]) of the right heel.

Review of Resident 20's wound consult of May 15, 2024, revealed new recommendations for an x-ray of the right heel to rule out osteomyelitis (bone infection) and a wound culture of the right heel. A follow up wound consult of May 22, 2024, again recommended a wound culture of the right heel.

Review of physician's order dated May 22, 2024, indicated to obtain a wound culture of the right heel. Review of the clinical record revealed no evidence that the wound culture was obtained. An additional physician's order of May 29, 2024, instructed staff to swab the right heel for a wound culture. Further review of the clinical record revealed no evidence that the wound culture was obtained.

Interview with the Nursing Home Administrator on June 7, 2024, at 2:00 p.m. confirmed that the wound culture was not obtained as ordered.

28 Pa. Code 211.5(f) Clinical records
Previously cited 8/31/23

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

Plan of Correction - To be completed: 08/06/2024

1. Facility can not retroactively correct. A wound culture was obtained for resident #20 and results received on 6/14/2024.

2. Records of residents currently residing in the facility who have the potential to be affected by this practice have been reviewed to ensure that physician's orders are followed, that wound care is completed as ordered and that laboratory results are followed through in a timely manner.

3. DON or designee will educate licensed staff on following physician's orders and plan of care with regards to wound care and laboratory results.

4. An audit will be conducted weekly for four weeks and monthly for two months to ensure that orders are followed through in a timely manner. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

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 upon observation, clinical record review, and interviews with staff, it was determined the facility failed to ensure enhanced barrier precautions were in place for residents requiring enhanced barrier precautions for one of one residents reviewed (Residents 20).

Findings include:

Observations of Resident 20's room on all days of the survey failed to reveal evidence of enhanced barrier precautions.

Review of Resident 20's admission MDS (Minimum Data Set - periodic assessment of resident needs) dated May 15, 2024, revealed the resident had an in-dwelling catheter (flexible tube inserted into the bladder for removing fluid), ileostomy (opening in the abdominal wall for the end of the small intestine to pass out digested food into a pouch), a stage 4 pressure ulcer (full thickness skin loss exposing underlying muscle, tendon, cartilage, or bone) of the sacral region (portion of spine between the lower back and tailbone and an unstageable pressure ulcer (pressure ulcer not stageable due to coverage of wound bed due to slough [non-viable yellow, tan, gray, green or brown tissue] and/or eschar [dead or devitalized tissue that is hard or soft in texture]) of the right heel.

Interview with licensed staff Employee E3 on June 6, 2024, at 1:15 p.m. revealed that he/she was not aware of enhanced barrier precautions.

Interview with the Nursing Home Administrator on June 7, 2024, at 11:33 a.m. confirmed that enhanced barrier precautions were not in place for Resident 20.

28 Pa. Code 211.5(f) Clinical records
Previously cited 8/31/23

28 Pa. Code: 211.12(d)(1)(5) Nursing services
Previously cited 8/31/23

Plan of Correction - To be completed: 08/06/2024

1. Facility can not retroactively correct. Enhanced Barrier Precautions (EBPs) are in place for Resident #20.

2. Resident records residing in the facility who have the potential to be affected by this practice have been reviewed to ensure that Enhanced Barrier Precautions are in place.

3. DON or designee will educate all staff on the implementation of EBPs throughout the facility.

4. Audits will be conducted monthly for six months and the results will be submitted to the QAPI committee for ongoing monitoring.

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