Pennsylvania Department of Health
BETHANY VILLAGE RETIREMENT CENTER
Patient Care Inspection Results

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BETHANY VILLAGE RETIREMENT CENTER
Inspection Results For:

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BETHANY VILLAGE RETIREMENT 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, and Civil Rights Compliance survey completed on January 11, 2024, it was determined that Bethany Village Retirement Center was not in compliance with the following 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.


 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 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.
§483.60(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 facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food, beverages, and nutritional supplements in accordance with professional standards for food service safety in the main kitchen, four of four nourishment areas, and two of three medication storage areas.

Findings include:

Review of facility policy, titled "Food Product Shelf-Life Guidelines", last revised January 28, 2022, revealed, "Manufacturer/supplier code dates, use by dates, use thru dates, or expires on dates should always be considered the first level of control ...products with a 'Sell By', Best By or (Before) or 'Use-By': Adhere to that date for quality reasons."

Further review of the aforementioned policy revealed that butter should be kept refrigerated or frozen.

Review of facility policy, titled "Labeling and Dating Guide," last revised June 17, 2017, revealed, all juices have a use by date of three days or by expiration date.

Observation of the walk-in refrigerator on January 8, 2024, at 9:53 AM, revealed: one bag of shredded red cabbage not dated; and four packs of margarine not dated.

Observation in walk-in freezer on January 8, 2024, at 9:56 AM, revealed: three bags of onion rings not dated; one bag of sausage links not dated; and one piping bag of whipped topping not dated.

Observation during initial tour of the Colonial Park pantry area refrigerator on January 8, 2024, at 10:12 AM, revealed: one container of apple juice, red colored beverage, orange juice, and cranberry juice all not labeled or dated; and one container of thickened cranberry juice labeled with a use by date of January 5, 2024.

Further observation of the Colonial Park pantry area on January 8, 2024, at 10:15 AM, revealed: one open pack of hot dog buns not dated; four packs of English muffins not dated; one shelf of individual boxed cereals all not labeled with use by dates; one bin of individual jelly packets labeled use by January 6, 2024; one bin of oatmeal packets labeled use by January 4, 2024; and one bin of individual butter packets not dated and left out at room temperature.

Observation during initial tour of the Oak Lane pantry area refrigerator on January 8, 2024, at 10:21 AM, revealed one bin of individual creamer packets not dated.

Further observation of the Oak Lane pantry area on January 8, 2024, at 10:23 AM, revealed: four packs of individual cookies labeled use by January 4, 2024.

Observation during initial tour of the Oak Terrace pantry area refrigerator on January 8, 2024, at 10:26 AM, revealed one container of apple juice, red colored beverage, orange juice, and cranberry juice all not labeled or dated.

Observation during initial tour of the Oak View pantry area on January 8, 2024, at 10:28 AM, revealed: one bin of individual butter packets not dated and left out at room temperature; one bin of individual jellies not dated; and one bin of individual crackers not dated.

Interview with the Employee 1 (Food Service Director) on January 8, 2024, at 10:32 AM, revealed it is his expectation that expired items are discarded, food and beverages are labeled and dated per facility policy, and food items are stored in accordance with professional standards.

Interview with the Nursing Home Administrator (NHA) on January 9, 2024, at 10:41 AM, revealed it is the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food items are stored in accordance with professional standards.

Observation of the Oak View/Oak Place medication room refrigerator on January 10, 2024, at 11:09 AM, revealed: 23 cartons of Ensure Plus protein supplement dated January 1, 2024.

Observation of the Oak Lane medication room refrigerator on January 10, 2024, at 11:16 AM, revealed: two cartons of Ensure Clear therapeutic nutrition supplement dated January 1, 2023; and one opened container of thickened lemon water with a best by date of July 12, 2023.

Email correspondence with the NHA on January 11, 2024, at 9:06 AM, revealed that he spoke with the manufacturer and the dates on the packaging are use by dates. He further revealed, "we have posted the attached [document] and updated the stockroom manager and nurses for awareness. Ensure has been difficult to get nationally and in short supply but we should not be holding on to it."

During a follow-up interview with the NHA on January 11, 2024, at 10:35 AM, he revealed the guidelines for stocking supplements have been posted and staff has been educated.

28 Pa. Code 211.6(f) Dietary services


 Plan of Correction - To be completed: 02/29/2024

The kitchen and pantry food items discovered to be unlabeled and out of date were immediately discarded.

The medication room items (Ensure) identified in the nurse medication rooms as being outdated were also immediately discarded at time of discovery by the Director of Nursing.

A daily walk through of the pantries, refrigerators and freezers is being conducted by the Food Services Director or designee to ensure that all food items are labeled and dated, with any outdated foods and unlabeled or undated foods discarded.

Education was provided to the Storeroom Clerk on January 11, 2024 by the Nursing Home Administrator and the Director of Nursing regarding the need to check dates on supplements and food items stored in the facility medication rooms. Moving forward these items will be checked routinely for date upon entering each area for weekly restocking activities, with any outdated items removed and disposed of.

A daily walk-through of the pantries, refrigerators and freezers for outdated or unlabeled or undated food items will be completed by the Food Service Director or designee. Items that are out-of-date will be discarded and unlabeled foods will be labeled and dated if storage date is known or if not will be discarded. Documentation of unlabeled or outdated items will be completed to determine if additional action is required.

All dining staff will be in-serviced on the proper labeling and dating of foods and storage requirements, with training completed by January 31, 2024.

The Director of Nursing, Nursing Home Administrator or designee will conduct a weekly audit of all supplements and foods stored in medication rooms. Any outdated item will be discarded, and re-education of staff will be provided as needed when any items are found to be out of compliance.

A weekly audit of outdated/unlabeled food items from the daily walk through of refrigeration and freezer units will be completed by the Food Service Director or designee. If findings indicate that there continue to be outdated or unlabeled food items, staff will be re-in-serviced on proper storage of leftovers and labeling and dating procedures. Audits will be completed monthly with action plan developed if any non-compliance with labeling and dating concerns continue to exist.

Food service safety requirements related to unlabeled or outdated items will be presented as a standing agenda item as part of the facility's 2024 Quality Assurance and Performance Improvement meetings, for review and approval.

483.20(g) REQUIREMENT Accuracy of Assessments: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.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the assessment accurately reflects the resident's status for one of 20 residents reviewed (Resident 28).

Findings include:

Review of Resident 28's clinical record revealed diagnoses that included pain and unsteadiness on feet.

Review of Resident 28's Quarterly Minimum Data Set (MDS-a tool used to assess all care areas specific to the resident), with an Assessment Reference Date of December 8, 2023, revealed under Section J 1900 the Resident had a fall with a major injury since admission/entry or reentry or prior MDS.

Review of Resident 28's clinical record revealed a fall dated September 13, 2023. According to the investigation, Resident 28 was found on the floor in her room and stated she "fell out of her chair but didn't remember how."

Review of Resident 28's progress notes revealed the following documentation, "At several points during the shift resident displayed no s/s [signs and symptoms] of any discomfort but as soon as she was asked about her fall she would change her demeanor and state that she was having pain. Approximately 1200 resident stated she was having chest pain again and also stated 'I probably broke a couple of my ribs'. Although no swelling/bruising noted MD ordered CXR [chest x-ray] to rule out injury."

Review of the Radiology Report dated September 13, 2023, revealed, in part, "There may be residuals of subacute minimally displaced fracture of the sternum." The sternum is a partially T-shaped, vertical bone that forms the anterior portion of the chest wall centrally.

An interview with Employee 3 (Resident Nurse Assessment Coordinator) on January 11, 2024, at 10:35 AM, revealed she had not completed the MDS assessment in question and explained Resident 28 had no major injury as documented on the MDS, but instead had a history of possible fracture as noted on the radiology report.

An additional interview with Employee 3 revealed the MDS was coded incorrectly and she would be completing a modification of the assessment.

An interview with the Director of Nursing on January 11, 2024, at 11:02 AM, revealed Resident 28 had no major injury or fracture from the fall on September 13, 2023, and confirmed the MDS had been coded incorrectly.

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


 Plan of Correction - To be completed: 02/29/2024

Resident 28's Quarterly Minimum Data Set (MDS) Section J completed on December 8, 2023, was modified immediately following the discovery of the incorrect coding.

The modification completed was related to resident 28's December 8, 2023, MDS Section J originally being coded as a fall with major injury and was corrected to code for fall with injury.

The Director of Nursing and RNAC discussed the concern. Re-education was completed by reviewing the RAI manual for coding of MDS Section J and falls.

To monitor compliance with correct coding of Section J of the MDS the RNAC and Director of Nursing will review/discuss all resident future falls with suspected major injury for the next 12 months prior to submission of the MDS. The RAI manual will be utilized as a guideline for determination if criteria for major fall is met.

The accuracy of assessments related to MDS Section J completion will be presented as a standing agenda item as part of the facility's 2024 Quality Assurance and Performance Improvement meetings, for review and approval.

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 facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain oxygen equipment in a sanitary manner for one of 20 residents reviewed (Resident 43).

Findings include:

Review of facility policy, titled "Oxygen Therapy", last revised December 4, 2023, revealed "When masks and cannulas are not in use, place in clean plastic bag attached to the concentrator and off the floor."

Review of Resident 43's clinical record revealed diagnoses that included Chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and hypertension (high blood pressure).

Review of Resident 43's physician orders revealed an order for "O2 (oxygen) at 2 L/m (liters/minute- unit of measure) by shift", with a start date of February 24, 2023.

Review of Resident 43's MAR (Medication Administration Record- documentation for medication/treatment administered or monitored) revealed he last received a nebulizer treatment on December 28, 2023, at 10:35 PM.

Observation in Resident 43's room on January 8, 2023, at 11:00 AM, revealed his oxygen tubing that was attached to his concentrator was wrapped around his enabler bar on his bed, it was dated January 7, 2024, and there was an oxygen mask laying out on his bedside table.

Observation in Resident 43's room on January 9, 2023, at 10:28 AM, revealed his oxygen tubing that was attached to his concentrator was wrapped around his enabler bar on his bed, it was dated January 7, 2024, and there was an oxygen mask laying out on his bedside table.

Interview with Employee 4 (Licensed Practical Nurse) on January 10, 2024, at 10:30 AM, revealed Resident 43 typically sits up in his chair during the day with an oxygen tank, and at night he goes back to bed and uses the oxygen in his room.

During an interview with the Director of Nursing on January 10, 2024, at 10:58 AM, she revealed that Resident 43 last received a nebulizer treatment through an oxygen mask on December 28, 2023, and she would expect Resident 43's oxygen tubing and mask in his room to be stored per facility policy, and changed before being placed back on the Resident.

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



 Plan of Correction - To be completed: 02/29/2024

Upon discovery that Resident 20's oxygen tubing and mask were not stored per Asbury Bethany Village policy and procedure the Director of Nursing immediately removed and disposed of the devices replacing with new.

At that time, the Director of Nursing provided re-education to the team that held responsibility for the storage of resident 20 oxygen tubing and mask regarding proper storage. Resident 20 did not experience harm due to the failure to follow facility oxygen therapy policy.

The Director of Nursing or designee will conduct an initial audit of all residents receiving oxygen therapy to ensure that oxygen tubing and masks are being stored properly per facility policy. Any deficiency will be immediately corrected by discarding of any oxygen tubing or mask not properly stored and replaced with new.

In addition to the audit to prevent future improper storage of oxygen tubing and masks, the Director of Nursing or designed will provide re-education to all nursing staff regarding the correct method for storage of these devices which will include a review of the facility policy "Oxygen Therapy". The audits and re-education will be completed by 1/29/2024.

To monitor compliance with adherence to the storage of resident oxygen tubing and masks on-going the Director of Nursing or Designee will conduct audits of all residents with the device's weekly times 3 weeks and then monthly.
The oxygen device audits will be presented as a standing agenda item as part of the facility's 2024 Quality Assurance and Performance Improvement meetings, for review and approval.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly: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.
§483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:

Based on facility policy review, observation, and staff interviews, it was determined that the facility failed to ensure that garbage and refuse was disposed of properly, and sanitary conditions were maintained in the garbage storage area for one of one dumpster observed.

Findings include:

Review of facility policy, titled "Sanitation & Infection Control Garbage and Refuse Disposal", dated January 2016, revealed "All garbage, refuse, glass, tin cans, cardboard, paper, etc. generated within the Food & Nutrition Services Department shall be disposed of in a sanitary manner ...Dumpster lids shall be closed at all times. Area around dumpsters shall be free of waste products including food, medical, paper trash and other waste to prevent harborage and feeding of pests. All parties utilizing the dumpsters for waste and/or recycling purposes are responsible for maintaining the area by ensuring that the dumpster lids are closed and the area around the dumpster is free of waste."

Observation of the receiving dock area dumpster on January 8, 2024, at 9:46 AM, revealed the dumpster lids were open and there was food, paper, and other refuse waste surrounding the front of the dumpster.

Interview with Employee 2 (Maintenance Director) on January 10, 2024, at 9:21 AM, revealed the receiving dock should be cleaned daily and it has been difficult between housekeeping, dietary, and maintenance to keep the area clean on a daily basis.

Interview with the Nursing Home Administrator on January 11, 2024, at 10:45 AM, revealed it is his expectation that the dumpster lids should be kept closed and areas around the dumpster should be clean and free of waste.

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


 Plan of Correction - To be completed: 02/29/2024

Upon discovery of the community's dumpster with open lids and surrounding refuse, the area was addressed and cleaned by facilities and housekeeping personnel.

Observation by the Administrator and Facilities Director concluded that cardboard boxes are not consistently being broken down by all users from various departments, leading to the dumpster becoming full sooner than is expected; preventing the lids from being closed, and occasionally causing the build-up of rubbish in the dumpster area.

The topic was addressed by the Administrator to the Storeroom Clerk, dining, and housekeeping staff members, the departments which provide the most refuse to this dumpster, during the week of the survey, and also at the January 11, 2024 Safety Committee Meeting.

Further education will be provided to staff members of the dining, housekeeping, laundry, and storeroom and will include the breaking down of boxes, proper disposal of trash, and the closing of lids on trash receptacles, to align with the facility policy, "Sanitation & Infection Control – Garbage and Refuse Disposal." The education will be completed by January 31, 2024.

Walking rounds will include audits by the Administrator, Facilities Director, or designee, Daily x 10, Weekly x 5, and Monthly x 4, to ensure adherence to the policy and proper conditions of the dumpster area, with instances of non-compliance corrected and addressed promptly to the appropriate staff members and department leaders.

The staff education, walking round audits, and results of the findings will be presented as a standing agenda item at the facility's monthly 2024 Quality Assurance and Performance Improvement meetings, for review and approval.

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

Based on document review and staff interview, it was determined that the facility failed to ensure a required minimum of one Licensed Practical Nurse (LPN) per 40 residents on night shifts for 21 of 21 nights reviewed (July 4-10, 3023, October 4-10, 2023, and January 4-10, 2024).

Findings Include:

Review of the facility provided staffing ratio information for July 4-10, 3023; October 4-10, 2023; and January 4-10, 2024, on night shift, revealed a resident census of 65-69 residents; thus, requiring a LPN staffing ratio of 1.63-1.73 on those shifts. The information also revealed an LPN ratio of 1-1.13, therefore, the facility did not meet the minimum LPN ratio required for the facility census of residents on those shifts.

Interview with the Nursing Home Administrator on January 11, 2024, at 10:15 AM, revealed that they will need to hire another nurse to cover the need.



 Plan of Correction - To be completed: 02/29/2024

Upon discovery and completing further analysis of its night shift staffing hours, it was determined by the facility to create and advertise two new LPN positions to address the shortfall and meet the required LPN ratio.

One new fulltime and one new part-time LPN night shift position were each defined and advertised through the facility recruiter.

The administrator will work urgently with the recruiter, reviewing progress at each weekly staffing meeting, to identify internal or external candidates who can fulfill the duties and be hired and onboarded to meet the ratio requirement.

Education about the staffing ratio was provided on January 17, 2024, and subsequent actions to meet the night shift LPN ratio requirement will also be addressed as a standing agenda item at each of the facility's monthly Quality Assurance and Performance meetings for review and approval.

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