Pennsylvania Department of Health
WALNUT CREEK HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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WALNUT CREEK HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  136 surveys for this facility. Please select a date to view the survey results.

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WALNUT CREEK HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to three complaints completed on March 21, 2024, it was determined that Walnut Creek Healthcare and Rehabilitation 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.






















 Plan of Correction:


483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:

Based on review of clinical records, facility policy, and facility documentation, and staff interview it was determined that the facility failed to maintain complete and accurate documentation as related to bathing and meal intake for 13 of 14 residents reviewed (Residents R1, R2, R4, R5, R6, R7, R12, R13, R14, R15, R16, R17, and R18).

Findings include:

Review of facility policy dated 1/5/24, entitled "Bed Bath, Shower / Tub" indicated that staff documentation was to include the date and time shower/tub, or bed bath was performed and if resident refused the reason why and what interventions were taken.

Review of facility policy dated 1/5/24, entitled "Assisting the Resident with In-Room Meals" indicated that staff documentation was to include how much of the meal the resident consumed and if the resident refused the reason why and what interventions were taken.


Review of Resident R1's clinical record revealed an admission date of 12/2/22, with diagnoses that included diabetes, high blood pressure, and breast cancer. The clinical record revealed that Resident R1was to have a shower on Sunday and Wednesday on day shift.

Resident R1's clinical record lacked documentation indicating if he/she received a shower or bath on five (2/21/24, 2/28/24, 3/3/24, 3/6/24, and 3/17/24) of eight scheduled showers in the past 30 days.

Resident R1's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on 14 (2/21/24, 2/23/24, 2/26/24, 2/27/24, 2/28/24, 3/1/24, 3/2/24, 3/3/24, 3/4/24, 3/6/24, 3/9/24, 3/11/24, 3/16/24, and 3/17/24) of 30 breakfast meals in the past 30 days.

Resident R1's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on 15 (2/21/24, 2/23/24, 2/26/24, 2/27/24, 2/28/24, 3/1/24, 3/2/24, 3/3/24, 3/4/24, 3/5/24, 3/6/24, 3/9/24, 3/11/24, 3/16/24, and 3/17/24) of 30 lunch meals in the past 30 days.

Resident R1's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on two (3/11/24, and 3/15/24) of 30 supper meals in the past 30 days.


Resident R2's clinical record revealed an admission date of 8/17/23, with diagnoses that included high blood pressure, anemia, and arthritis. The clinical record revealed that Resident R2 was to have a shower on Tuesday and Friday on evening shift.

Resident R2's clinical record lacked documentation indicating if he/she received a shower or bath on three (2/20/24, 2/29/24, and 3/14/24) of nine scheduled showers in the past 30 days.

Resident R2's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on 3 (2/20/24, 3/1/24, and 3/15/24) of 30 supper meals in the past 30 days.


Resident R4's clinical record revealed an admission date of 6/14/23, with diagnoses that included high blood pressure, anemia, and diabetes. The clinical record revealed that Resident R4 was to have a shower on Wednesday and Saturday on evening shift.

Resident R4's clinical record lacked documentation indicating if he/she received a shower or bath on one (3/16/24) of eight scheduled showers in the past 30 days.

Resident R4's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on five (2/23/24, 2/25/24, 2/29/24, 3/1/24, and 3/10/24) of 30 breakfast meals in the past 30 days.

Resident R4's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on five (2/23/24, 2/25/24, 2/29/24, 3/1/24, and 3/10/24) of 30 lunch meals in the past 30 days.

Resident R4's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on three (2/27/24, 3/16/24, and 3/17/24) of 30 supper meals in the past 30 days.


Resident R5's clinical record revealed an admission date of 6/26/15, with diagnoses that included high blood pressure, anemia, and dysphagia (difficulty in swallowing food and/or liquids).

Resident R5's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on one (2/25/24) of 30 breakfast meals in the past 30 days.

Resident R5's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on one (2/25/24) of 30 lunch meals in the past 30 days.

Resident R5's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on seven (2/23/24, 2/26/24, 2/27/24, 3/3/24, 3/9/24, 3/11/24, and 3/17/24) of 30 supper meals in the past 30 days.


Resident R6's clinical record revealed an admission date of 9/12/22, with diagnoses that included high blood pressure, anemia, and venous insufficiency (a condition that affects the blood flow to your legs resulting in swelling, pain, and changes in your skin). The clinical record revealed that Resident R6 was to have a shower on Sunday and Wednesday on day shift.

Resident R6's clinical record lacked documentation indicating if he/she received a shower or bath on one (2/25/24) of eight scheduled showers in the past 30 days.

Resident R6's clinical record lacked documentation indicating if he/she consumed their breakfast and what percent was consumed on one (2/25/24) of 30 breakfast meals in the past 30 days.

Resident R6's clinical record lacked documentation indicating if he/she consumed their lunch and what percent was consumed on one (2/25/24) of 30 lunch meals in the past 30 days.

Resident R6's clinical record lacked documentation indicating if he/she consumed their supper and what percent was consumed on ten (2/20/24, 2/23/24, 2/25/24, 2/26/24, 2/27/24, 3/7/24, 3/8/24, 3/13/24, 3/18/24, and 3/19/24) of 30 supper meals in the past 30 days.


Resident R7's clinical record revealed an admission date of 2/22/24, with diagnoses that included high blood pressure, anemia, and a stroke. The clinical record revealed that Resident R7 was to have a shower on Tuesday and Saturday on day shift.

Resident R7's clinical record lacked documentation indicating if he/she received a shower or bath on three (3/9/24, 3/12/24, and 3/19/24) of eight scheduled showers in the past 30 days.

Resident R7's clinical record lacked documentation indicating if he/she consumed their breakfast and what percent was consumed on eight (2/22/24, 2/26/24, 3/4/24, 3/6/24, 3/9/24, 3/12/24, 3/14/24, and 3/18/24) of 30 breakfast meals in the past 30 days.

Resident R7's clinical record lacked documentation indicating if he/she consumed their lunch and what percent was consumed on eight (2/26/24, 2/29/24, 3/4/24, 3/6/24, 3/9/24, 3/12/24, 3/14/24, and 3/18/24) of 30 lunch meals in the past 30 days.

Resident R7's clinical record lacked documentation indicating if he/she consumed their supper and what percent was consumed on one (2/22/24) of 30 supper meals in the past 30 days.


Resident R12's clinical record revealed an admission date of 2/15/22, with diagnoses that included high blood pressure, anemia, and peripheral vascular disease (when arteries become narrow affecting blood supply most commonly in the legs). The clinical record revealed that Resident R12 was to have a shower on Sunday and Wednesday on day shift.

Resident R12's clinical record lacked documentation indicating if he/she received a shower or bath on three (2/21/24, 2/28/24, and 3/3/24) of eight scheduled showers in the past 30 days.

Resident R12's clinical record lacked documentation indicating if he/she consumed their breakfast and what percent was consumed on 12 (2/21/24, 2/26/24, 2/27/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, 3/11/24, and 3/19/24) of 30 breakfast meals in the past 30 days.

Resident R12's clinical record lacked documentation indicating if he/she consumed their lunch and what percent was consumed on 14 (2/21/24, 2/23/24, 2/25/24, 2/26/24, 2/27/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, 3/11/24, and 3/19/24) of 30 lunch meals in the past 30 days.

Resident R12's clinical record lacked documentation indicating if he/she consumed their supper and what percent was consumed on two (3/4/24, and 3/12/24) of 30 meals in the past 30 days.


Resident R13's clinical record revealed an admission date of 7/28/22, with diagnoses that included diabetes, arthritis, and high blood pressure. The clinical record revealed that Resident R13 was to have a shower on Monday and Thursday on day shift.

Resident R13's clinical record lacked documentation indicating if he/she received a shower or bath on six (2/22/24, 2/26/24, 2/29/24, 3/4/23, 3/14/24, and 3/18/24) of eight scheduled showers in the past 30 days.

Resident R13's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on eight (2/26/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/14/24, 3/18/24, and 3/19/24) of 30 breakfast meals in the past 30 days.

Resident R13's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on ten (2/22/24, 2/25/24, 2/26/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/14/24, 3/18/24, and 3/19/24) of 30 lunch meals in the past 30 days.

Resident R13's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on two (3/4/24, and 3/12/24) of 30 supper meals in the past 30 days.


Resident R14's clinical record revealed an admission date of 5/27/23, with diagnoses that included high blood pressure, anemia, and dementia (a condition that affects the brains' ability to think, remember things, and function). The clinical record revealed that Resident R14 was to have a shower on Monday and Thursday on day shift.

Resident R14's clinical record lacked documentation indicating if he/she received a shower or bath on seven (2/22/24, 2/26/24, 2/29/24, 3/4/24, 3/11/24, 3/14/24, and 3/18/24) of eight scheduled showers in the past 30 days.

Resident R14's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on eight (2/26/24, 2/28/24, 3/4/24, 3/5/24, 3/6/24, 3/14/24, 3/18/24, and 3/19/24) of 30 breakfast meals in the past 30 days.

Resident R14's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on 11 (2/22/24, 2/25/24, 2/26/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/6/24, 3/14/24, 3/18/24, and 3/19/24) of 30 lunch meals in the past 30 days.

Resident R14's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on two (3/4/24, and 3/12/24) of 30 supper meals in the past 30 days.


Resident R15's clinical record revealed an admission date of 12/26/23, with diagnoses that included diabetes, dementia, and high blood pressure. The clinical record revealed that Resident R15 was to have a shower on Tuesday and Saturday on day shift.

Resident R15's clinical record lacked documentation indicating if he/she received a shower or bath on four (2/27/24, 3/5/24, 3/9/24, and 3/12/24) of nine scheduled showers in the past 30 days.

Resident R15's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on 14 (2/21/24, 2/26/24, 2/27/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/23, 3/9/24, 3/10/24, 3/11/24, 3/12/24, and 3/17/24) of 30 breakfast meals in the past 30 days.

Resident R15's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on 15 (2/21/24, 2/23/24, 2/26/24, 2/27/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, and 3/17/24) of 30 lunch meals in the past 30 days.

Resident R15's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on two (3/4/24, and 3/11/24) of 30 supper meals in the past 30 days.


Resident R16's clinical record revealed an admission date of 7/1/22, with diagnoses that included dementia, high blood pressure, and anxiety. The clinical record revealed that Resident R16 was to have a shower on Tuesday and Friday on evening shift.

Resident R16's clinical record lacked documentation indicating if he/she received a shower or bath on one (3/12/24) of nine scheduled showers in the past 30 days.

Resident R16's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on 12 (2/21/24, 2/26/24, 2/27/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/8/24, 3/9/24, 3/11/24, 3/18/24, and 3/19/24) of 30 breakfast meals in the past 30 days.

Resident R16's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on 15 (2/21/24, 2/23/24, 2/25/24, 2/26/24, 2/27/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/18/24, and 3/19/24) of 30 lunch meals in the past 30 days.

Resident R16's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on five (2/29/24, 3/4/24, 3/11/24, 3/12/24, and 3/16/24) of 30 supper meals in the last 30 days.


Resident R17's clinical record revealed an admission date of 3/2/21, with diagnoses that included high blood pressure, arthritis, and peripheral vascular disease.

Resident R17's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on 15 (2/26/24, 2/27/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, 3/16/24, 3/17/24, and 3/18/24) of 30 breakfast meals in the past 30 days.

Resident R17's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on 16 (2/23/24, 2/26/24, 2/27/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, 3/16/24, 3/17/24, and 3/18/24) of 30 lunch meals in the past 30 days.

Resident R17's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on four (2/20/24, 2/22/24, 3/4/24, and 3/11/24) of 30 supper meals in the last 30 days.


Resident R18's clinical record revealed an admission date of 7/4/23, with diagnoses that included high blood pressure, peripheral vascular disease, and epilepsy (neurological disorder that cause seizures). The clinical record revealed that Resident R18 was to have a shower on Monday and Friday on evening shift.

Resident R18's clinical record lacked documentation indicating if he/she received a shower or bath on one (3/4/24) of eight scheduled showers in the past 30 days.

Resident R18's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on 13 (2/21/24, 2/26/24, 2/27/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, 3/11/24, 3/18/24, and 3/19/24) of 30 breakfast meals in the past 30 days.

Resident R18's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on 16 (2/21/24, 2/23/24, 2/25/24, 2/26/24, 2/27/24, 2/29/24, 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/18/24, and 3/19/24) of 30 lunch meals in the past 30 days.

Resident R18's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on two (3/4/24, and 3/12/24) of 30 supper meals in the last 30 days.


During an interview on 3/21/24, at 9:00 a.m. the Nursing Home Administrator confirmed that Residents R1, R2, R4, R5, R6, R7, R12, R13, R14, R15, R16, R17, and R18 lacked documentation indicating if a shower or bath was given as directed and / or meal intake in the last thirty days.

28 Pa. Code 211.5(f)(ii)(ix) Medical records

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



 Plan of Correction - To be completed: 04/15/2024

Residents 1,2,4,6, 7, 12, 13,14,15, 16, and 18 did not have documentation of showers given and meal percentages were not recorded. The facility to conduct a body audit on all identified residents to ensure no new skin issues are identified. The residents' charts will be audited to ensure that each has a current shower schedule in task. Facility dietician to review Residents 1, 2, 4, 5, 6, 7, 12, 13, 14, 15, 16, 17, and 18 for weight loss and need for supplementation or recommendation.
Current residents were reviewed to ensure that they have a current shower schedule in Task and meal intake to ensure that documentation can be completed.
Director of Nursing or designee will educate Licensed Nurses and Certified Nursing Assistants regarding documentation of showers and meal intake. Reviewed policy for tub/shower residents and assisting residents with meals. Certificate nursing assistants will be educated on hire on documentation of meal intakes and shower completions daily on Point of Care. Licensed staff will monitor the documentation daily per shift to ensure that completion of Point of care documentation is completed prior to Nursing assistance leaving at the end of their shift. Management will review Point of care documentation daily in morning meetings to ensure documentation is completed and follow up on any missed documentation.
The Director of Nursing or designee will audit resident shower and meal documentation to ensure completeness of documentation. These audits will be conducted for five residents from each neighborhood five times a week for three weeks, then two times a week for two weeks, followed by audits once a month for three months. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.

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 review of nursing time schedules and staff interview, it was determined that the facility failed to provide a minimum of one nurse aide (NA) per 12 residents during the evening shift for one of 21 days reviewed (3/16/24); and one NA per 20 residents during the overnight shift for one of 21 days reviewed (2/24/24).


Findings include:

Review of facility staffing ratio information revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:

3/16/24 census of 99 residents 7.40 NAs worked and 8.25 were required

Review of facility staffing ratio information revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:

2/24/24 census of 105 residents 4.27 NAs worked and 5.25 were required

During an interview on 3/20/24, at 3:35 p.m. the Nursing Home Administrator confirmed the accuracy of the facility provided staffing information and confirmed the facility failed to meet the minimum NA ratio on the above days and shifts.



 Plan of Correction - To be completed: 04/15/2024

The facility will continue to take measures to adequately provide staff to ensure the needs of residents are met.
The facility will continue to take measures to adequately provide staff to meet the required nurse aide to resident ratios on the evening and overnight shifts. The facility evaluates that admissions are considered relative to scheduled staffing patterns daily to meet ratio requirements.
The Director of Nursing or designee will provide re-education on minimum staffing ratios to RN Supervisors, HR, and Scheduling who are responsible to maintain adequate staffing and staffing ratios. Director of Nursing or designee will re-educate HR, Scheduler and RN supervisors of protocols for calling in staff related to call offs.
The Director of Nursing or designee will audit the daily schedules to ensure that the minimum number of staff to resident ratios have been scheduled and will audit that protocols were followed a call off occurred. These audits will be conducted five times a week for four weeks, then once weekly for four weeks. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.

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