Pennsylvania Department of Health
DEER MEADOWS REHABILITATION CENTER
Patient Care Inspection Results

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DEER MEADOWS REHABILITATION CENTER
Inspection Results For:

There are  167 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.
DEER MEADOWS REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey and State Licensure Survey, completed on November 22, 2024, it was determined that Deer Meadows Rehabilitation Center, was not in compliance with 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 related to the health portion of survey process.



 Plan of Correction:


483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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.
§483.25(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 observation, review of clinical records and facility policies and interviews with staff, it was determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice and physician orders, to promote healing of pressure ulcers and prevent development of pressure ulcers for four of six residents reviewed for pressure ulcer. (Resident 53, Resident R90, Resident R277 and Resident R14)

Findings Include:

Review of facility policy "Wound Management Guidelines" revised April 1, 2022, revealed residents will receive the appropriate treatment for their skin issues as identified in the type of skin/wound presentation and the indicated treatment and interventions for the identified issues.

Further review of facility policy "Wound Management Guidelines" revealed the nurse will identify the impairment and stage, if indicated/applicable, based on the skin assessment. The nurse should notify the physician of findings and identify the appropriate treatment and interventions after discussing with the physician. The physician order should be documented in the electronic health record or on physician form and transcribed to the treatment administration record (TAR).

Review of Resident R53's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated November 11, 2024, revealed the resident was cognitively impaired and at risk for developing pressure ulcers/injuries. Continued review of Resident R53's quarterly MDS revealed the resident had diagnoses of malnutrition (a health condition that develops when someone doesn ' t have enough nutrients to meet their body ' s needs), adult failure to thrive, and dementia (decline in cognitive function severe enough to interfere with daily life).

Review of Resident R53's care plan revised August 22, 2024, revealed the resident was at risk for pressure ulcer developed/impaired skin integrity related to immobility, and bowel and bladder incontinency (the loss of bowel and bladder control).

Review of Resident R53's "weekly skin checks" assessment dated November 16, 2024, revealed the resident had a new open area to the right hip. The assessment indicated that the wound team was not notified. The nursing supervisor was notified a note was written.

Review of Resident R53's progress notes revealed a nurses note dated November 16, 2024, that revealed the resident had an unstageable pressure wound located on the right hip. Wound care was provided, a skin assessment was completed, and the nursing supervisor was made aware.

Review of Resident R53's entire clinical record revealed no documented evidence that the physician was made aware of the new skin impairment identified on November 16, 2024, for subsequent treatment orders.

Review of Resident R53's treatment administration record revealed no documented evidence wound treatment was completed or that the skin impairment was assessed on November 17, 2024.

Review of Resident R53's progress notes revealed the physician was not made aware of Resident R53's new skin impairment until November 18, 2024.

Review of Resident R53's clinical record revealed a wound treatment order was not obtained and transcribed onto the treatment administration record until November 18, 2024.


Review of physician order for Resident R90 dated June 4, 2024, revealed an order for heel boots to be worn at all times while in bed.

Review of care plan for Resident R90 dated December 06, 2023, revealed that the resident to wear bilateral heel boots.

Observation of Resident R90 on November 19, 2024, at 10:20 a.m. revealed that the resident was lying in the bed. Resident's heels were touching against the mattress without any offloading measures.

A follow up tour with Employee E15, Unit Manager, on November 19, 2024, at 11:00 a.m. confirmed that Resident R90 should have been wearing heel boots while in bed.

Review of physician order for Resident R277 dated November 11, 2024, revealed an order for heel boots to be worn at all times while in bed.

Review of care plan for Resident R277 dated August 29, 2024, revealed that the resident at risk for pressure ulcer development/impaired skin integrity.

Observation of Resident R277 on November 19, 2024, at 10:13 a.m. revealed that the resident was lying in the bed. Resident's heels were touching against the mattress without any offloading measures. It was observed that there was heel boots placed on the windowsill.

A follow up tour with Employee E15 on November 19, 2024, at 11:00 a.m. confirmed that Resident R277 should have been wearing heel boots while in bed.

Review of physician order for Resident R14 dated August 8, 2024, revealed an order for heel boots to be worn at all times while in bed.

Review of care plan for Resident R14 dated January 10, 2024, revealed that the resident at risk for pressure ulcer development/impaired skin integrity.

Observation of Resident R14 on November 19, 2024, at 10:48 a.m. revealed that the resident was lying in the bed. Resident's heels were touching against the mattress without any offloading measures. There was heel boots on the wheelchair.

A follow up tour with Employee E15 on November 19, 2024, at 11:00 a.m. confirmed that Resident R14 should have been wearing heel boots while in bed.

28 Pa. Code 211.10(c) Resident care policies

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







 Plan of Correction - To be completed: 01/13/2025

Resident R54 has physician order for the wound
Resident R54 is currently being seen weekly by wound team
Resident R90, R277, R4 heel booths were placed on residents
Director of nursing or designee completed initial audit of all residents with order for heel booths to ensure heel booths are being applied as ordered
Director of nursing or designee will complete daily audit Monday to Friday at clinical stand up of residents with new wound to ensure that they have an order for treatment
Staff educator or designee will complete education with nursing staff about F0686
Director of nursing or designee will complete weekly audit of resident with order for heel booths weekly x4 and monthly x3 months
Director of nursing will present audit reports at monthly QAPI until substantial compliance is achieved

483.10(e)(2) REQUIREMENT Respect, Dignity/Right to have Prsnl Property: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(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.
Observations:

Based on the review of clinical records, facility investigation, interviews with resident and staff, it was determined that the facility failed to treat residents with respect and dignity related to the right to retain and use personal possessions for one of 35 residents reviewed. (Resident R34)

Findings Include:

Interview with Resident R34 on November 20, 2024, at 12:15 p.m. stated when he was at the dialysis on November 19, 2024, facility staff searched his room, went through his personal possession, took his over-the-counter medications, and discarded some of the food items that was in the refrigerator in his room without his permission. Resident stated he never had staff search his room or remove his personal possession without permission and he has been a resident of the facility for over on year. Resident stated the search was due to state survey in the facility.

Continued interview with Resident R34 stated he called the administrator when he returned from the dialysis and the administrator told the resident that the staff removed medication from his room. Resident also stated he felt like his rights were violated when staff went through his possessions and did not tell him even after he returned from dialysis.


Interview with Unit Manager, Employee E15 on November 20, 2024, at 12:15 p.m. stated staff did remove medications and food from his room without his permission and did not notify him prior to searching his room. Employee E15 stated resident was at dialysis when the resident's room was searched. Employee E15 stated she visits his room occasionally and did not see anything in his room that warrants search of his room, like medication or other items. Employee E15 stated she did an assessment of the resident to self-administer the medication and it was determined that the resident could self-administer medication safely and some of the medications were returned to him.

Review of Resident R34's clinical record revealed no evidence that resident's personal possession created a safety risk to warrant a search of his personal belongings or removal of personal possession without his permission or notification.

Interview with the Nursing Home Administrator on November 22, 2024, at 10:47 a.m. confirmed that the resident called him, and the resident was upset over staff removing medication and food from his room without his permission. Nursing Home Administrator confirmed that staff should have obtain permission from resident prior to opening the refrigerator and removing medication.

28 Pa. Code 201.18(b)(2) Management.

28 Pa. Code 201.29(a) Resident rights.

28 Pa. Code 201.29(c) Resident rights




 Plan of Correction - To be completed: 01/13/2025

The provider submits the following plan of correction in good faith and to comply with Federal regulation. This plan is not admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the statement deficiencies.

Discussed concern with R34 regarding his right to dignity/Right to have personal property that staff will not search or remove his personal property without his permission
Administrator educated DON about F0557
Staff educator or designee will educate all staff about F0557 by 12/31/2024
Social service director or designee will interview 20% of residents weekly to find out if their right to keep personal property were infringed upon weekly x4, then monthly x3
Result of audit will be presented at Monthly QAPI until substantial compliance is achieved


483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(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, interviews with staff and review of facility policy, it was determined that the facility failed to maintain comfortable and safe temperature levels for one of eight units in the facility ( Bair Pavilion Second Floor).

Findings include:

Review of the facility policy titled, "Temperature Extremes" last reviewed in November 2021 states it is the policy of the facility to provide comfortable and safe temperature levels. The same policy states, "Temperature throughout this facility shall be maintained at between 71 degrees and 81 degrees F. Any temperature outside of this range required specific interventions to avoid potential negative impact on the residents' well-being."

On November 19, 2024, at 12:00 p.m. on Bair Pavilion Second Floor nursing station the surveyor recognized the unit was uncomfortably warm. Licensed Practical Nurse (LPN) Employee E11 said, "This is nothing, it gets even hotter."

Interview with the Director of Maintenance, Employee E12 on November 19, 2024, at 12:28 p.m. explained the residents' rooms are heated by their wall units but the hallways are heated by the boiler. The Director of Maintenance said they could manually turn off the air handlers (that circulates conditioned air ) to regulate the temperature, so it is not so warm on the floor. The Assistant Director of Maintenance, Employee E13 using a device to measure the temperature of the air, registered the second-floor nursing station at 86 degrees.

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




 Plan of Correction - To be completed: 01/13/2025

Maintenance director adjusted the boiler temperature on 11/9/2024 to keep the unit temperature between 71 degrees to 81 degrees
New thermostat installed in the duct work on Bair Pavillion 1st and 2nd floor to regulate the temperature and keep temperature between 71 degrees F to 81 degrees F on 12/5//2024
Director of maintenance/designee will complete audit of Bair Pavillion 1st and 2nd floor temperature weekly x4 and monthly x3 to ensure that unit's temperature is within 71 degrees and 81 degrees
Result of audit will be presented at monthly QAPI until substantial compliance is achieved

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 review of clinical record, observations, and staff interview it was determined that the facility failed to provide nail care for a dependent resident for one of 35 residents reviewed (Resident R18).

Findings Include:

Review of Resident R18's annual Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 25, 2024, revealed the resident was cognitively impaired, diagnosed with heart failure, high blood pressure, cerebrovascular accident (Stroke) and dementia. Further review indicated the resident had impairments on both sides of his upper body and was dependent on staff for personal hygiene.

Observation of Resident R18 with Licensed Practical Nurse Employee E11 on November 21, 2024, at 10:15 a.m. stated the resident clenches his hands and uses a palm guard because his hands are contracted. The LPN opened Resident R18's hands to reveal his bilateral palms were a deep red color. Further observation revealed the resident fingernails were significantly long and required trimming. The LPN indicated it was difficult to trim his nails short and confirmed the nails were too long and needed to be trimmed.

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




 Plan of Correction - To be completed: 01/13/2025

Resident R18 nail care completed and hands checked for impairment on 11/21/2024
Initial audit of residents who needs assistance with nail care completed on 11/22/2024
Staff educator or designee will educate all nursing staff about F0677 by 12/31/2024
Director of nursing or designee will complete weekly audit of 25% residents who needs assistance to complete activity of daily living x4 weeks, then monthly x3 months
Result of audit will be presented at the monthly QAPI meeting until substantial compliance is achieved

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to implement fall interventions for two of five residents reviewed for falls (Resident R4 and R110).

Findings Include:

Facility policy titled "Fall Prevention and Management" (revised January 2023), indicated that the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents.

Clinical record review revealed Resident R4 was admitted to the facility June 28, 2024 with a diagnosis that included but not limited to Acute Respiratory Failure with Hypercapnia (inability of lungs to exchange oxygen and high levels of carbon dioxide properly), Cognitive Communication Deficit (communication difficulty caused by a cognitive impairment), and anxiety disorder.

Review of Resident R4's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 27, 2024, revealed Resident R4 has severe cognitive impairment and has a history of falls.

Review of Resident R4's clinical record revealed a physician order dated April 4, 2023, for bilateral floor mats every shift.

Observations on November 22, 2024, at 10:40 a.m. revealed Resident R4 was in bed with no bilateral floor mats in place.

Interview on November 22, 2024, at 10:45 a.m. with LPN, Employee E14, confirmed Resident R4's did not have bilateral floor mats in place.

Review of Resident R110's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated November 6, 2024, revealed the resident was cognitively impaired and had a diagnosis of abnormalities of gait and mobility.

Review of Resident R110's care plan revised August 16, 2024, revealed the resident was at risk for falls related to decreased functional mobility and use of antipsychotic medication. Interventions dated March 23, 2023, revealed bilateral floor mats should be placed next to the bed.

Review of Resident R110's clinical record revealed a physician order dated January 6, 2024, for bilateral floor mats every shift.

Observations on November 20, 2024, at 10:52 a.m. revealed Resident R110 was in bed and a floor mat was only placed on the right side of the bed.

Interview on November 20, 2024, at 11:00 a.m. with Unit Manager, Employee E7, confirmed Resident R110's left side floor mat was not in place due to being sent to be cleaned.

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





 Plan of Correction - To be completed: 01/13/2025

R4 and R10 Floor mats were put in place
Initial audit of residents with order for floor mats completed to ensure that floor mat are in place as ordered
Staff educator or designee will complete education of nursing staff about F0689 by 12/31/24
Director of nursing or designee will complete weekly audits of residents with order for floor mat weekly x4 and monthly x3
Director of nursing will present audit report at monthly QAPI until substantial compliance is achieved

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on review of facility policy, observations, review of clinical record, and resident interview, it was determined that the facility failed to monitor and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for one of seven residents reviewed for nutrition (Resident R162).

Findings Include:

Review of facility "Weight Policy" revised 04/03/2017, revealed residents should be weighed at least monthly, unless otherwise specified, and that any confirmed weight change should be reported to the physician and registered dietitian for their evaluation and recommendations.

Review of Resident R162's care plan revised October 7, 2024, revealed the resident was at risk for alteration in nutrition/hydration. Interventions dated October 7, 2024, included to obtain weights as ordered and monitor PO (by mouth) intake.

Review of Resident R162's clinical record revealed a physician note dated November 8, 2024, that the physician was requested by staff to assess Resident R162 for poor appetite. The physician recommended a multivitamin, an updated weight, and to consult the dietitian. The physician noted the last weight available for Resident R162 was 123 pounds from October 22, 2024.

Review of Resident R162's clinical record revealed the facility did not obtain a new weight until November 19, 2024.

Review of Resident R162's weight history revealed a documented weight of 111.5 pounds on November 19, 2024, which reflected a significant weight loss of 9.3%/11.5 pounds in one month.

Further review of Resident R162's clinical record revealed that the Registered Dietitian did not timely address the physician's consult related to Resident R162's poor appetite, until November 20, 2024.

Interview on November 22, 2024, at 11:45 a.m. with Registered Dietitian, Employee E17, confirmed the physician's consult from November 8, 2024, for Resident R162's poor appetite, was not addressed until November 20, 2024.

Continued interview with on November 22, 2024, at 11:45 a.m. with Registered Dietitian, Employee E17, revealed Resident R162 was reweighed in the morning of November 22, 2024, at 111 pounds which confirmed the weight loss from November 19, 2024.


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

28 Pa. Code 211.12 (d)(5) Nursing Services.




 Plan of Correction - To be completed: 01/13/2025

R162 is currently on weekly weight and last week completed on 12/10/2024
Dietician reviewed resident weight on 12/7/24 and 12/11/24
Dietician will complete initial audit of resident with 5% weight loss within 1 month and 10% within 6 months by 12/20/24 to ensure that weighty loss was addressed. If weight loss was not addressed, dietician will address weight loss at the time of the audit
Staff educator/designee will educate nursing staff about facility weight policy by 12/31/2024
Dietician will review resident weight changes at daily clinical stand-up Monday to Friday x 2 weeks for recommendation, and then 25% weekly audit for 2 weeks, and then 25% monthly x 3
Dietician will present audit report at monthly QAPI until substantial compliance is achieved

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 review of clinical records, review of facility policy, observations, and interview with staff, it was determined that the facility failed to administer oxygen as ordered by the physician for two of four residents receiving oxygen therapy. (Resident R4, Resident R149)

Findings include:

Review of facility policy "Oxygen" (revised September 2023), revealed oxygen therapy is to be administered by licensed nurses with a physician's order to provide a resident with sufficient oxygen to their blood and tissues".

Clinical record review revealed Resident R4 was admitted to the facility on November 22, 2019, with a diagnosese of Type 2 Diabetes (insufficient production of insulin, causing high blood sugar), Hypertension (high blood pressure), and Hyperthyroidism (thyroid gland makes too much thyroid hormone).

Review of Resident R4's physician orders, dated June 1, 2023, revealed that Resident R4 was order oxygen therapy at 2 liters via nasal cannula.

Observation on November 19, 2024 at 10:25 a.m. revealed Resident R4's oxygen was being administered at 3 liters via nasal cannula.

Interview with nurse aide, Employee 5, on November 19, 2024 at 10:30 a.m. confirmed Resident R4 was receiving oxygen therapy at 3 liters.

Clinical record review revealed Resident R149 was admitted to the facility on May 1, 2023 with a diagnosis of Chronic Obstructive Pulmonary Disease (condition that prevents airflow to the lungs, causing breathing problems), Coronary Artery Disease (blood supply to the heart muscle is partially or completely blocked), and Aphasia (damage to portions of the brain that are responsible for language).

Observation on November 19, 2024 at 10:50 a.m. revealed Resident R149 was receiving 2.5 liters of oxygen via nasal cannula.

Clinical record review revealed Resident R149 had no active order for oxygen therapy administration.

Interview with Unit Manager, Employee 6, on November 19, 2024 at 11:10 a.m. confirmed Resident R149 had no active order for oxygen therapy to be administered.


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

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




 Plan of Correction - To be completed: 01/13/2025

Resident R4 oxygen administration adjusted to 2L as ordered
Resident R 149 order for oxygen received from her physician and being administered as ordered
Initial audit of residents on oxygen completed to ensure that oxygen is being administered as ordered
Staff educator or designee will complete education of nursing staff by 12/31/2024
Director of nursing or designee will complete audit of residents on oxygen weekly x4 and then monthly x3 to ensure that oxygen is administered as ordered by physician
Report of audit will be presented at monthly QAPI until substantial compliance is achieved

483.25(m) REQUIREMENT Trauma Informed 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(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.
Observations:


Based on review of clinical records, interviews with staff and review of facility policy, it was determined that the facility failed to provide culturally competent, trauma informed care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident two of 35 sampled residents (Resident R34 and R106 ).

Findings include:

A review of the clinical record revealed that Resident R34 was admitted to the facility, with diagnoses of anxiety disorder, major depressive disorder, and post-traumatic stress disorder (PTSD). Review of Resident R34's hospital discharge instructions received on admission, dated June 23, 2023, indicated psychiatry was consulted for reporting black outs in context of PTSD. Prior to this hospital stay, the hospital records reported the resident was hospitalized previously for suicidal ideation, alcohol abuse, depression and PTSD from working as a firefighter at World Trade Center. The same hospital reports a month prior to admission the resident had particularly difficult flash backs after seeing gallon bins at Home Depot that were used at the WTC. Hospital reported the resident would benefit discussing pursing outpatient therapy as the resident's PTSD appears to be secondary experiences from when he was a firefighter, including 911.

Resident R34's current care plan, initiated September 13, 2024, revealed a care plan for PTSD. Further review of the care plan did not address resident's actual diagnoses/condition of PTSD, identifying the resident's past experiences and possible triggers that may cause re-traumatization.

Review of Resident R106 clinical record revealed the resident was admitted on February 1, 2020, diagnosed with adjustment disorder with mixed anxiety and depressed mood, and PTSD.

Resident R106's was care planned for ineffective coping related to post-traumatic stress disorder, dated May 24, 2023. Further review of the care plan did not address resident's actual diagnoses/condition of PTSD, identifying the resident's past experiences and possible triggers that may cause re-traumatization.

On November 22, 2024, at 10:17 a.m. the Second-floor unit manager, Register Nurse Employee E7 confirmed specific triggers were specified in the plan of care.

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




 Plan of Correction - To be completed: 01/13/2025

Resident R34 and R106 PTSD trigger added to care plan
Social service director will complete initial audit of residents that have care plan for PTSD for PTSD trigger by 12/20/24
Administrator complete education about identifying resident PTSD trigger and adding trigger to PTSD care plan
Director of social worker/designee will complete audit of resident with new diagnosis of PTSD care plan for trigger weekly x4 and monthly x3
Director of social service will present result of audit at monthly QAPI until substantial compliance is achieved

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 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 §483.71 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 the observations and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to the care of urinary catheters and respiratory care equipment for four of 35 residents reviewed.

Findings Include:

Observation of Resident R135 on November 19, 2024, at 10:32 a.m., revealed that the resident had a urinary catheter. Further observation revealed that the catheter bag was on the floor.

Observation of Resident R17 on November 19, 2024, at 10:25 a.m., revealed that resident's oxygen tubing which was connected to oxygen concentrator was lying on the floor without any bag.

Observation of Resident R61 on November 19, 2024, at 10:28 a.m., revealed that resident's urinary catheter bag and the tubing was on the floor mats, it was observed that the Nurse Aide who was providing care to the resident was stepping on the floor mat while the catheter tubing and bag was on it. Further observation revealed that there was nebulizer machine and tubing on windowsill. The nebulizer mask and tubing were not bagged, and it was directly placed on the windowsill.

Observation of Resident R90 on November 19, 2024, at 10:20 a.m., revealed that resident had tracheostomy to assist with breathing. The tracheostomy blue corrugated tubing with fluid collection bag was placed in a trash container while the resident was actively using the tracheostomy.

A follow up tour with Employee E15, Unit Manager on November 19, 2024, at 11:00 a.m. confirmed the above observations.

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

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



 Plan of Correction - To be completed: 01/13/2025

R61 and R 135 catheter bags replaced
Catheter bags for R61and R135 secured to bed frame

Resident R17 oxygen tubing replaced and oxygen canula bag attached to concentrator for storage of oxygen tubing
R61 Nebulizer tubing removed from window seal discarded and replaced with a new one stored in a bag at bedside
R90 corrugated tubing with fluid collection bag replaced and trash container removed
Initial audit of residents with foley catheter was completed to ensure placement that catheter bags are not touching the floor, oxygen tubing, tracheostomy tubing and nebulizer storage was completed
Initial audit of residents on oxygen tubing, nebulizer tubing and tracheostomy tubing completed to ensure that tubing is not on the floor or in trash container or stored on window seal and proper storing of tubing's
Staff educator or designee will complete infection control education about catheter bag placement, Oxygen tubing, nebulizer tubing storage and tracheostomy corrugated tubing to all nursing staff by 12/31/2024
Infection control nurse/designee will complete weekly audit of catheter placement, oxygen tubing/nebulizer tubing storage and Tracheostomy corrugated tube placement. Audit will be completed weekly x4 weeks, then monthly x 3 months
Results of audit will be presented at the Monthly QAPI meeting until substantial compliance is achieved.


483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program: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.
§483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.
Observations:

Based upon observations, interviews, and review of facility documentation, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for two of eight units in the facility (Bair Pavilion first and second floor).

Findings include:

On November 19, 2024, at 11:33 a.m. surveyor observed a live roach in Blair Pavilion second floor nursing station. Licensed Practical Nurse (LPN) Employee E11 said, "It happens a lot." The LPN indicated when staff observed pests, they document their findings in the maintenance book.

Review of the maintenance book, the LPN stated the last time the area was treated for pest was on October 22, 2024. Further review of the maintenance book revealed documented sightings of roaches and mice on the unit since last treated. On November 21, 2024 at 1:00 p.m. surveyor observed additional pest sightings with Unit Manager, Registered Nurse, Employee E7.

Observations on November 19, 2024, at 12:42 p.m. revealed multiple fruit flies hovering in Resident R72's room, Room 108A, over the bedside table.

28 Pa Code 201.18(b)(3) Management




 Plan of Correction - To be completed: 01/13/2025

Pest Exterminator made a visit on 11/20/24 to treat Bair 1 and 2
Pest Exterminator completed weekly visit to all units for sighting of pest and completed treatment as needed
Staff educator/designee will educate all staff about using the pet log to document pest activity on the unit that will require treatment by pest exterminator
Maintenance will audit exterminator log and exterminator report for treatment weekly x4 and then monthly x3
Report of audit will be presented at the monthly QAPI until substantial compliance is achieved.


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