Pennsylvania Department of Health
MONUMENTAL POST ACUTE CARE AT WOODSIDE PARK
Patient Care Inspection Results

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MONUMENTAL POST ACUTE CARE AT WOODSIDE PARK
Inspection Results For:

There are  175 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.
MONUMENTAL POST ACUTE CARE AT WOODSIDE PARK - 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, State
Licensure Survey and an Abbreviated Survey in response to two complaints, completed on April 5, 2024,
it was determined that Monumental Post Acute Care , 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 the survey process.




 Plan of Correction:


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


Based on observations of the physical environment, reviews of the pest control operators' service, reports and contract and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program.

Findings include:

A review of the pest control operator's contracted service agreement revealed that it was the responsibility of the maintenance department staff to repair structural concerns (gaps under doors, holes in walls, screens, around pipes, crevices around windows or doorways, faulty downspouts). The service agreement indicated that the repairs to the physical environment were essential to eradicate pest and rodent problems.

Observations of the physical enviornment of the facility revealed that the main kitchen, main dinning room, lobby, entrance to the facility, administrator's office, first floor nursing unit were located on the ground level of the building.

Observations of the food and nutrition services department on April 2, 2024 revealed that the double doors that were located adjacent to the main kitchen, leading directly outside were not sealed; allowing easy access to the interior for pests and rodents.

Observations of the food and nutrition services department on April 2, 2024 revealed a plumbing issue inside the janitor closet. The entire janitor closet was covered with water; as a result of the clogged floor mounted janitor sink drain. There was obvious on-going sewage back-up with water damage of the janitor closet door.

Observations of the food and nutrition department on April 2, 2024 revealed that ceiling tiles directly above the hot food preparation area were covered with a film of oil and grease. This was available food for pests to live and breed.

Observations of the food and nutrition department on April 2, 2024 revealed the dry food area with a piece of kitchen equipment used for deep fat frying foods. This commercial deep fat fryer was not completely cleaned for storage, as it contained cooking oils and food debris, which was food for common household pests.

Observations of the trash receptacles on April 2, 2024 located directly outside the food and nutrition department revealed the lid of the dumpster units were not covered. The units were surrounded by discarded trash and garbage (papers, food, plastic items). The unkept grounds and open dumpster units provided food and shelter for pests, rodents and birds.

Interview with the Director of Dietary Services, Employee E16, at 10:30 a.m., on April 2, 2024 confirmed the structural, plumbing, and lack of cleaning within the dietary services department to effectively remove common household pests from the interior of the building.

Further interview with the Director of Dietary Service, Employee E16 revealed that the pest control operator had asked the maintenance department to address holes around pipes of the air conditioning/heating units located inside the main dinning room. This dining room was built along side the central kitchen; where food preparation, storage and assembly for delivery to the nursing units takes place daily.

Review of the pest control operator's service reports for February and March, 2024 revealed the following:oOn February 8, 2024 the pest control service identified voids, holes or gaps inside resident rooms on the first and second floor nursing units. Rooms listed were 120 through 125 and Rooms 224 through 251. Treatment for mice, roaches and insects was necessary. On February 9, 2024 the pest control operator (PCO) reports indicated that mice activity was found in the main kitchen behind the hot food preparation area. On February 15, 2024 rooms 218, 224 and 251 were found to have mice activity. The rooms were identified with holes and gaps that structurally needed to be repaired.

On March 1, 2024 the PCO received verbal reports from the nursing staff indicating that there was a lot of mice activity on the second floor nursing unit. On March 5, 2024 mice activity and mice droppings were noted on the PCO's reports for rooms 239, 240, and 241. The notations were made inside the air conditioning and heating units inside the resident rooms; because holes were noted in and around the units attached to an outside wall. The PCO indicated that the kitchen and lobby were treated for roaches, insects and mice. On March 7, 2024 mice activity was noted in room 228 and 229. These rooms had multiple voids and holes according to the PCO. The kitchen and dining areas were treated for roaches, insects and mice. On March 12, 2024 the mice activity was noted in rooms 217, 220, 226, 238, 239, 240 and 242 on the second floor nursing unit. The PCO said that voids and holes need sealing in these rooms. The kitchen, dining area and lobby were treated for roaches insects and mice. On March 14, 2024 mice were observed along with voids, gaps and holes that were identified in resident rooms on the first floor nursing unit by the PCO. On March 19, 2024 mice and roaches were found in rooms 123, 206 and 210. A resident reported seeing the mice run in and out of the bathroom. Structural defects holes, gaps and voids were requested to be repaired to eradicate the pests and rodents inside the building. On March 28, 2024 the PCO indicated that roach activity was found on the first floor nursing unit. Structural voids, hole and gaps were identified in trash rooms and resident rooms on the first floor nursing unit. Mice activity was seen by the PCO in room 119. Mice activity and mice droppings were also seen in the administrator's office and other connecting offices on the first floor. On March 29, 2024 the PCO indicated that mice were seen in the main kitchen; because holes, voids and gaps have not been sealed properly. The PCO found that it was necessary to treat the kitchen, dishroom and lobby area for pests and rodents.

Interview with the administrator, Employee E1 at 2:00 p.m., on April 2, 2024 confirmed the pest and rodent presence throughout the facility. The administrator also confirmed the structural deficits and lack of housekeeping that was contributing to the common household pest problem for the facility.

Interview on April 2, 2024, at 11:05 a.m. with Resident R58 revealed the resident complained of mice.

Interview on April 2, 2024, at 11:26 a.m. with Resident R126 revealed the resident had a mice problem in the room.

Interview on April 2, 2024, at 11:30 a.m. with Resident R60 and Resident R8 revealed residents complained of mice in room. Observations revealed a container of grapes at the beside of Resident R60. The grapes were not stored in an air tight container.

Observation and interview on April 3, 2024, at 1:20 p.m. with Registered Nurse, Employee E9, confirmed Resident R60's grapes at bedside were not stored in an airtight container.

Observation on April 4, 2024, at 12:37 p.m. revealed Resident R15 had a piece of rotting fruit, which resembled a pear, on the windowsill. Registered Nurse, Employee E9, was made aware of observations.


28 PA. Code 201.18(b)(1)(3)(e)(1)(2.1) Management

28 PA. Code 201.21(c) Use of outside resources

28 PA. Code 201.14(a)(b) Responsibility of licensee












 Plan of Correction - To be completed: 05/27/2024

Pest control services were provided for resident's rooms for R58, R126, R60, R8

The double doors in the Kitchen have been resealed.

The janitor closet drain has been snaked (unclogged) and the room has been cleaned.

Ceiling tiles above hot food prep areas have been cleaned.

Deep Fryer has been thoroughly cleaned.
The lid to the dumpsters has been closed and the debris surrounding the area has been cleaned up.

Gaps in Air conditioning /heating units in the main dining room have been sealed.

Gaps and holes have been sealed in rooms 120- 125 and 224 through 251, 218, 228, 229, 217, 220, 226, 238, 239, 240, 242, 123, 206, 119 and the 1 east soiled utility room.

Gaps in Air conditioning /heating units in rooms 239, 240 and 241 have been sealed.

The Rotting piece of fruit on the windowsill of R15 has been removed.

The Maintenance Director or Designee has conducted an audit of all resident rooms to determine areas where holes/gaps need to be filled or repaired.

The Social Services Director or Designee will provide containers with lids for residents who wish to keep food/snacks in their rooms.

Pest Control Services will be provide to facility 3 X weekly.

The Maintenance director or Designee will conduct environmental rounds Weekly X 4 weeks and make repairs of any holes, missing baseboards etc., and will provide replacements as necessary.

Results will be reported in Monthly QAPI x 1 month

483.60(d)(3) REQUIREMENT Food in Form to Meet Individual Needs: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(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(3) Food prepared in a form designed to meet individual needs.
Observations:


Based on review of facility documentation, observation, and staff interview, it was determined that the facility failed to ensure that food was prepared appropriately for nine of nine residents on a pureed diet (Residents R52, R125, R4, R113, R445, R34, R55, R66, and R87).

Findings Include:

Review of undated facility documentation "Dysphagia Level 1/Pureed Diet" revealed the consistency of pureed foods should be smooth and thick enough to mound on the plate, and similar in consistency to that of pudding.

Review of facility documentation dated April 5, 2024, revealed the following nine residents were ordered a pureed diet: Residents R52, R125, R4, R113, R445, R34, R55, R66, and R87.

Observations on April 2, 2024, at 12:08 p.m. revealed Resident R52 was having lunch in the dining room. Observations of Resident R52's lunch revealed the pureed chicken and green, pureed vegetable had a watery appearance and was runny on the plate.

Observations on April 2, 2024, at 12:30 p.m. of the tray line steam table in the main kitchen with the Food Service Director, Employee E16, revealed when the pureed chicken and pureed vegetable were plated, the food items were runny on the plate and not thick enough to "mound on the plate".

Further interview on April 3, 2024, at 9:45 a.m. with the Food Service Director, Employee E16, confirmed the pureed items were runny and that the dietary staff was educated to make sure the pureed food items are prepared to the proper consistency.

28 Pa. Code 201.14 (a) Responsibility of licensee





 Plan of Correction - To be completed: 05/27/2024

Pureed foods are made in the thickness that is safe and palatable for R52, R125, R4, R113, R445, R34, R55, R66, R87

The Food service Director conducted in- servicing for dietary staff on preparation of pureed foods to proper consistence. (consistency safe for resident and that is too their individual liking)

The Food Service Director or designee will assess all puree trays to ensure safety and will speak with these residents to ensure individual palatability.

The Food Service Director or designee will monitor all puree trays daily x 7 days to ensure residents' wishes are followed safely.

Results will be reported in monthly QAPI 1 month

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program: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.
483.80(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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain an effective antibiotic stewardship program that included antibiotic use protocols and systems for monitoring antibiotic use, for four of four residents reviewed for antibiotics (Residents R45, R33, R124 and R15).

Findings include:

Review of facility policy, "Infection Control" undated, revealed, "The facility will maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection."

During Entrance Conference on April 2, 2024, at 10:51 a.m. information pertaining to the facility's Antibiotic Stewardship program was requested.

Review of progress notes for Resident R45 revealed a nurses note, dated March 27, 2024, at 10:41 p.m. which stated that the resident was readmitted to the facility after being hospitalized for a right foot infection. The note indicated that the resident was positive for MRSA (Methicillin-resistant Staphylococcus aureus, a bacteria causing infection that is tougher to treat than most strains of staphylococcus aureus because it's resistant to commonly used antibiotics) and the he was placed on contact isolation precautions.

Review of physician orders for Resident R45 revealed an order, dated March 27, 2024, for "Contact isolation for MRSA." Continued review revealed that the resident was prescribed amoxicillin-pot clavulanate (an antibiotic medication) to treat his right foot wound infection through May 8, 2024.

Clinical record review for Resident R33 revealed a nurses note, dated March 28, 2024, at 1:17 p.m. which indicated that the resident was evaluated during wound rounds and that the consulting wound physician recommended clindamycin (an antibiotic medication).

Review of Resident R33's Medication Administration Records (MARs) revealed that the resident was prescribed clindamycin for a right foot infection from March 28, 2024, through April 4, 2024.

Clinical record review for Resident R124 revealed a nurses note, dated March 28, 2024, at 11:00 a.m. which indicted that the resident was evaluated during wound rounds for bilateral leg wounds, and to continue the current treatment of gentamicin cream (topical antibiotic).

Review of Treatment Administration Records (TARs) for Resident R124 revealed that the resident was prescribed gentamicin cream to both legs for wound healing from March 8 to 14, 2024, and again on April 3 and 4, 2024.

Clinical record review for Resident R15 revealed a physician's note, dated March 30, 2024, at 5:53 p.m. which indicated that the resident's urine culture was positive for Morganella morganii, Providencia stewartia (bacteria) sensitive to IV (intravenous) antibiotics only. The physician noted that the resident would need an IV line placed.

Review of MARs for Resident R15 revealed that ceftazidime was initiated on April 1, 2024, via intravenous line for urinary tract infection.

During an interview on April 3, 2024, at 1:30 p.m. with Employee E6, Infection Preventionist, information pertaining to the facility's Antibiotic Stewardship program was again requested.

A follow-up interview with Employee E6, Infection Preventionist, was conducted on April 4, 2024, at 1:48 p.m. No infection data or antibiotic tracking was available for review for Residents R45, R33, R124 and R15. In addition, Employee E6, Infection Preventionist, was unable to provide any information related to the facility's Antibiotic Stewardship program.

Interview on April 5, 2024, at 10:47 a.m. the Director of Nursing presented a letter from the county health department, dated November 2022, regarding antibiotic stewardship, however, there was no information provided in the letter regarding any of the facility's actual antibiotic stewardship plans, policies or procedures. The Director of Nursing stated that he was still looking for the facility's Antibiotic Stewardship binder.

Follow-up interview on April 5, 2024, at 11:36 a.m. the Director of Nursing presented an infection control binder with data from 2019 and 2020. There was no recent data and there were no antibiotic stewardship plans, policies or procedures available for review in the binder.

Follow-up interview on April 5, 2024, at 12:17 p.m. the Director of Nursing presented another binder related to infection control. The binder contained staff trainings related to antibiotics, however, there was no recent data related to infections, antibiotic usage or any facility plans, policies or procedures related to Antibiotic Stewardship.

No information pertaining to the facility's Antibiotic Stewardship program, including antibiotic tracking, usage, prescribing protocols, policies or procedures were provided or made available for review at the time of the survey.

28 Pa Code 201.14(a) Responsibility of licensee

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




 Plan of Correction - To be completed: 06/04/2024

Antibiotic protocols and systems for ABT usage have been updated for (R 45, R33, R124, and R15)

Antibiotic protocols and systems for ABT usage have been updated for all residents receiving antibiotics.

Antibiotic Stewardship Policy and Program has been reviewed and is available in the facility.

Infection Preventionist or designee will conduct in serving on antibiotic Stewardship for Licensed Nurses and Medical Director.

Infection Preventionist or designee will audit Antibiotic Stewardship Practices monthly to ensure compliance.

Results will be reported in monthly QAPI Every monthly hereafter.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 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 on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to maintain an effective infection prevention and control program related to infection surveillance, antibiotic usage and isolation precautions for four of four residents reviewed for antibiotics (Residents R45, R33, R124 and R15).

Findings include:

Review of facility policy, "Infection Control" undated, revealed, "Surveillance data shall be routinely reviewed, and recommendations made for the prevention and control of additional cases."

Continued review revealed, "Investigates, controls and prevents infections in the facility; Decides what procedures, such as isolation, shall be applied to an individual resident; Maintains a record of incidents and corrective actions related to infections; Maintains a log of infections, of urinary catheters, residents with DRO [drug resistant organisms] and their room numbers and a log of residents on antibiotics."

Further review revealed, "When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility will isolate the resident only to the degree necessary."

Review of facility policy, "Standard Precautions" undated, revealed, "All resident blood, body fluids, excretions ad secretions other than sweat will be considered potentially infectious [and] Standard Precaution are indicated for all residents." Continue review revealed that PPE (Personal Protective Equipment), including gloves, masks and gowns, should be worn whenever there is planned or anticipated contact with blood and/or bodily fluids.

Review of facility policy, "Contact Precautions" undated, revealed, "Contact Precautions shall be used in addition to Standard Precautions for residents with specific infections that can be transmitted by direct and indirect contact." Continued review revealed, "Gloves should be worn when entering the room and while providing care for a resident."

Review of facility policy, "Droplet Precautions" undated, revealed, "Droplet Precautions shall be used in addition to Standard Precautions for residents with infections that can be transmitted by droplets." Continued review revealed, "A mask should be worn within approximately six feet of a resident at all times."

Observation on April 2, 2024, at 12:23 p.m. revealed a sign posted on Resident R45's door that stated, "Special Droplet/Contact Precautions." The sign further indicated that required PPE (Personal Protective Equipment) for entering the room included an N95 mask, protective eyewear, a gown and gloves. During an interview conducted at the time of the observation, Resident R45 stated that he felt very lonely with his door closed all day and wanted to know how much longer he needed to be in isolation.

Review of progress notes for Resident R45 revealed a nurses note, dated March 27, 2024, at 10:41 p.m. which stated that the resident was readmitted to the facility after being hospitalized for a right foot infection. The note indicated that the resident was positive for MRSA (Methicillin-resistant Staphylococcus aureus, a bacteria causing infection that is tougher to treat than most strains of staphylococcus aureus because it's resistant to commonly used antibiotics) and that he was placed on contact isolation precautions.

Review of physician orders for Resident R45 revealed an order, dated March 27, 2024, for "Contact isolation for MRSA." Continued review revealed that the resident was prescribed amoxicillin-pot clavulanate (an antibiotic medication) to treat his right foot wound infection through May 8, 2024.

Review of Resident R45's care plan, dated initiated March 28, 2024, revealed that the resident has MRSA in his right foot, with interventions including antibiotic therapy, contact precautions, use of PPE.

Continued observation on April 3, 2023, at 11:23 a.m. revealed that the sign for "Special Droplet/Contact Precautions" was still posted on Resident R 45's door.

Interview on April 3, 2024, at 1:30 p.m., Employee E6, Infection Preventionist, confirmed that Resident R45 only required Contact Precautions, not Special Droplet/Contact Precautions, and that the incorrect sign was on his door.

Continued observation on April 4, 2024, at 11:31 a.m. revealed a sign on Resident R45's door that stated, "Enhanced Barrier Precautions."

Interview on April 4, 2024, at 11:35 a.m. Employee E9, unit manager, revealed that the sign was changed on Resident R45's door to "Enhanced Barrier Precautions," however, Resident R45's physician's orders still reflected that he required Contact Precautions and that he was still receiving antibiotics therapy to treat the MRSA infection. Employee E9, unit manager, was unsure of the difference between Contact and Enhanced Barrier Precautions.

Clinical record review for Resident R33 revealed a nurses note, dated March 28, 2024, at 1:17 p.m. which indicated that the resident was evaluated during wound rounds and that the consulting wound physician recommended clindamycin (an antibiotic medication).

Review of Resident R33's Medication Administration Records (MARs) revealed that the resident was prescribed clindamycin for a right foot infection from March 28, 2024, through April 4, 2024.

Clinical record review for Resident R124 revealed a nurses note, dated March 28, 2024, at 11:00 a.m. which indicted that the resident was evaluated during wound rounds for bilateral leg wounds, and to continue the current treatment of gentamicin cream (topical antibiotic).

Review of Treatment Administration Records (TARs) for Resident R124 revealed that the resident was prescribed gentamicin cream to both legs for wound healing from March 8 to 14, 2024, and again on April 3 and 4, 2024.

Clinical record review for Resident R15 revealed a physician's note, dated March 30, 2024, at 5:53 p.m. which indicated that the resident's urine culture was positive for Morganella morganii, Providencia stewartia (bacteria) sensitive to IV (intravenous) antibiotics only. The physician noted that the resident would need an IV line placed.

Review of Medication Administration Records for Resident R15 revealed that ceftazidime was initiated on April 1, 2024, via intravenous line for urinary tract infection.

A follow-up interview with Employee E6, Infection Preventionist, was conducted on April 4, 2024, at 1:48 p.m. No infection surveillance data was available for review for the months of February, March and April 2024. No infection data or antibiotic tracking was available for review for Residents R45, R33, R124 and R15. No infection analysis was available for review to determine of any of the infections were facility acquired or reportable to PA-PSRS (Pennsylvania Patient Safety Reporting System). In addition, Employee E6, Infection Preventionist, was unable to provide a policy related to Enhanced Barrier Precautions or provide any information related to the facility's infection committee.

Interview on April 5, 2024, at 9:58 a.m. Employee E3, Assistant Administrator, revealed that the facility did not have a policy related to Enhanced Barrier Precautions.

Follow-up interview on April 5, 2024, at 11:32 a.m. infection committee information was reviewed with Employee E3, Assistant Administrator. The facility was only able to provide information from its last infection committee meeting that occurred in December 2023. Review of the December 2023 meeting minutes revealed that only infection data, such as the total number of infections, total number of antibiotics, vaccinations and testing for tuberculosis for the month of December 2023 were reviewed during that meeting. There were no laboratory or pharmacy personnel on the committee nor was there any data analysis from the laboratory or pharmacy. There was no information provided related to any infection control practices or processes, such as physical plant operations, medical equipment, PPE inventories and requirements, antibiotic stewardship and prescribing practices, education programs for staff or review of any pertinent health advisories. No other months of infection committee meetings were available for review at the time of the survey.

28 Pa Code 201.14(a) Responsibility of licensee

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




 Plan of Correction - To be completed: 06/04/2024

The special droplet precautions sign was removed from R45's door immediately during survey. Correct sign was added.

Infection surveillance, antibiotic usage and isolation precautions were updated for R 45, R33, R124, and R15)

infection control surveillance/ line listing and reporting logs have been updated for February, March, and April

Facility Infection Control Practices (such as: physical plant operations, medical equipment, PPE inventories and requirements, antibiotic stewardship, and prescribing practices as well as education for staff are all in place and reflected in policies available at the facility.

The Pharmacist Consultant is in attendance with the Infection control committee and antibiotic analysis is provided quality and kept on file with QAPI documents.

Laboratory data is up to data and will be kept on file in QAPI Binder
Infection control surveillance and Committee meeting meetings are up to date and will be kept on file in the facility.

Infection Preventionist or Designee will conduct in-servicing to licensed nurses on the facility's infection control Policy and procedures, Antibiotic Stewardship Policy, and Enhanced Barrier Precautions Policy.

Infection Preventionist or Designee will audit infection control surveillance, ABT Stewardship practices and PPSRS Reporting requirements monthly to ensure compliance.

Results will be reported on Monthly QAPI. x 3 months

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:


Based on staff interviews, observations, and record reviewed, it was determined that the facility failed to ensure proper accommodation of needs for one of seven residents reviewed regarding appropriate wheelchair size. (Resident R47)

Finding include:

Review or Resident 47's clinical record revealed that this resident was admitted into the facility on December 4, 2023, with diagnoses including chronic kidney disease, unspecified dementia (irreversible, progressive degenerative disease of the brain), type 2 diabetes (failure of the body to produce insulin), pain in unspecified joints and muscle weakness.

Review of Resident R47' s current care plan revealed that Resident R47 was at risks for falls related to ambulatory disfunction, decrease cognition, decreased mobility, and unsteady gait. Resident R47 was assessed by physical therapy on December 5, 2023, then provide a wheelchair.

Review of physical therapy notes revealed that Resident R 47 was re-assessed on February 20, 2024, and it was determined that the resident's wheelchair was too small and required a larger wheelchair.

Review of Resident R47's care conference notes dated March 20, 2024, revealed a request made by the resident's nephew for a larger wheelchair. Resident R47 was then re-assessed and determined that a larger wheelchair was necessary.

Observation of Resident 47 on March 2, 2023 at 10:40 a.m. and March 3, 2023 at 11:43 a.m. revealed that the resident was in the hallway outside of his room. The resident was sat in a noticeably improper fitted wheelchair.

Interview with Resident 47 on March 3, 2023 during observation revealed that he was uncomfortable in the wheelchair and would like a larger fitting wheelchair.

Interview with physical therapist, Employee E 23 on March 3, 2023 at 11:45 a.m. at time of observation, confirmed that the wheelchair the resident was observed in was obviously too small. It was not until the surveyor brought up the observation to the physical therapist, Employee E23 went to locate a larger wheelchair for the resident.


28 Pa. Code 210.29(4) Resident rights







 Plan of Correction - To be completed: 05/27/2024

R47 was provided with a larger properly fitting wheelchair.

All residents have been assessed by PT and all have the correct size wheelchairs.

Staff development coord. or designee will provided in-service to unit managers regarding the importance of care planning residents who are non compliant with using the correct chair

Physical Therapy will assess all residents who require wheelchairs on admission, quarterly and for significant changes to ensure they are using the appropriate size wheelchair.

Results will be reported in QAPI Quarterly

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that advanced directives were accurately reflected in residents' records for one of 35 residents reviewed (Resident R45).

Findings include:

Review of Resident R45's Significant Change MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated February 4, 2024, revealed that the resident was admitted to the facility on January 27, 2023, and had diagnoses including cerebrovascular accident (damage to the brain from interruption of its blood supply), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), seizure disorder (abnormal electrical activity in the brain) and aphasia (loss of ability to understand or express speech, caused by brain damage). Continued review revealed that the resident had a BIMS (Brief Interview for Mental Status) scored of six which indicated that the resident was severely cognitively impaired.

Review of Resident R45's POLST form (Pennsylvania Orders for Life-Sustaining Treatment), dated March 2, 2023, revealed DNR (do not resuscitate - do not perform lifesaving interventions in the event the resident has no pulse and had stopped breathing).

Review of Resident R45's active physician orders, revealed an order, dated April 2, 2024, for Full Code (allows for all interventions needed to restore breathing or heart functioning, including chest compressions, a defibrillator and insertion of a breathing tube).

Review of progress notes from March 6, 2024, through April 4, 2024, for Resident R45 revealed no indication as to why the physician's orders did not match the resident's POLST.

Interview on April 4, 2024, at 11:35 a.m. Employee E9, unit manager, confirmed that Resident R45's physician orders did not match his POLST and was unable to explain the discrepancy.

28 Pa Code 211.12(d)(3) Nursing services

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




 Plan of Correction - To be completed: 05/27/2024

R45's Medical Record has been amended to reflect the current Advance Directive.

NHA will In-service social workers and unit managers on the importance of medical records accurately reflecting the advance directive

Unit manager or Designees will audit all resident medical records to ensure that they accurately reflect the Advance Directives

Unit Managers or Designees will audit resident medical records quarterly to ensure that they continue to accurately reflect the current Advance Directive

Results will be reported in monthly x one month

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 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observations and interviews with residents and staff, it was determined that the facility failed to maintain a safe, comfortable and homelike environment on one of three nursing units reviewed (Two West unit).

Findings include:

Observation, on April 2, 2024, at 11:39 a.m. revealed that the window in room 249 was open and that there was no screen in the window.

Observation, on April 2, 2024, at 11:57 a.m. revealed the front panel of the heating/air conditioning system in room 226 was falling off.

Continued observation, on April 2, 2024, at 12:05 p.m. revealed a large hole in the wall above the baseboard by the bathroom. Interview, at the time of the observation, Resident R19 stated that the hole bothered her and wished that it could be repaired.

Continued observation, on April 3, 2024, at 11:01 a.m. of the Two West unit revealed that following:
Room 249 there was a hole in the wall along the baseboard behind the A bed;
Room 247 the dresser by the B bed had a broken drawer, there were holes in the wall behind the C bed, and there were large holes in the window screen;
Room 246 had a large hole in the window screen;
Room 245 was missing baseboard panels.

A tour was conducted on April 3, 2024, at 1:17 p.m. with Employee E7, Maintenance Director, who confirmed the above findings.

28 Pa Code 201.14(a) Responsibility of licensee

28 Pa Code 205.19(a) Windows and windowsills



 Plan of Correction - To be completed: 05/27/2024

249-The window in room has a screen

226- The front panel of the air conditioning system has been reattached.

226- hole in the wall above the baseboard by the bathroom has been repaired

249- hold in wall along baseboard by bed A has been repaired.

247- the dresser by bed b has been replaced. The holes in the behind bed C have been repaired. The window screen has been replaced.

246- Window screen has been replaced.

245: baseboard panels repaired.
All resident rooms have been audited by Maintenance.

The Maintenance director or Designee will audit window screens in all rooms and replace as necessary.

The Maintenance director or Designee will conduct environmental rounds Weekly X 4 weeks and make repairs of any holes, missing baseboards etc., and will provide replacements as necessary.

The Maintenance director or Designee will continue to make environmental rounds at least weekly to ensure a Safe Clean Homelike environment.

Results will be reported in monthly QAPI X 1 month

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on review of clinical records, facility policies and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation of one incident during a resident incontinence care for one of 32 residents reviewed. (Resident R 442).

Findings include:

Review of Resident R442's clinical record revealed that the resident was admitted to the facility on March 18, 2024, resident's cognition is intact. Resident R442 was transferred to facility for continued medical management and physical therapy/ occupational therapy services. Resident was transferred from the hospital after repeated falls, no head trauma and bilateral leg weakness and feeling anxious about ambulating.

On April 2, 2024, at 1:05 p.m. a family interview was held with the Resident R442, resident's husband, and son. It was reported that on March 23 to 24, 2024 Resident R442 waiting a long time to receive incontinence care. Resident R442 reported that she was wet and soil for hours from Saturday, March 23 to Sunday, March 24, 2024. Family reported to the social worker and made a grievance.

Review of the full investigation report that was reported to Social Service on March 25, 2024, it was revealed the steps taken in investigation: "social service spoke with resident; staff were requested to give statement regarding concerns. DON (Director of Nursing) / staff educator made aware for provided education to staff and Admin made aware of concerns and outcomes of result."

The investigation only had one statement from Nurse Aide, Employee E30, worked on shift 11pm-7am, wrote a statement stating: "starting of my shift at 11pm doing my regular routine/ rounds checking on my residents. [Resident R442] was laying in her bed watching tv. I did my second round by 2 a.m. and [Resident R442] was asleep... and asked if she needs to be change, she responded no. I did my third round by 5 a.m. provided her with ice cold water and I changed her."

The investigation stated that the social worker spoke with resident but there was no Resident's R442 statement. Also, no statement from Nurse Aide morning shift 7am-3pm statement.

An interview was held with Social Worker, Employee E11, Director of Social Worker, Employee E12 and Assistant Nursing Home Administrator (ANHA) Employee E3 on April 4, 2024, at 10:28 a.m. after reviewing Resident R442's investigation report, it was confirmed by the ANHA, Employee E3 that investigation was incomplete.


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

28 Pa. Code 211.10(d) Resident care policies

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














 Plan of Correction - To be completed: 05/27/2024

R442's Grievance investigation has been fully investigated and is complete.

NHA or designee will In-service the Grievance officer and social worker on the important of a thorough investigation

All current grievance investigations in-house have been reviewed to ensure they are thoroughly investigated, and they are complete.

Grievance officer or designee will audit grievances weekly x 4 weeks to ensure a thorough investigation has been conducted.

Results will be reported on monthly QAPI x 1 month

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 observations, review of facility policy, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide nail care for two of eight residents reviewed related to activities of daily living (Residents R45 and R70).

Findings include:

Review of facility policy "Grooming - Hair and Nails" revised January 31, 2024, revealed it is the policy of the facility to provide grooming services that promote an appropriately attractive appearance, improve morale, and prevent infections. Staff should provide fingernail care by cleaning fingernail beds and keeping fingernails trimmed and smooth

Observation, on April 2, 2024, at 12:24 p.m. revealed that Resident R45's fingernails were long, overgrown, and had dirt underneath them. Interview, at the time of the observation, Resident R45 stated that he does not like long nails, that he needed his fingernails trimmed and cleaned, and that he was unable to do it himself due to his right-sided hand and arm weakness.

Review of Resident R45's Significant Change MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated February 4, 2024, revealed that the resident was admitted to the facility on January 27, 2023, and had diagnoses including cerebrovascular accident (damage to the brain from interruption of its blood supply), muscle weakness and aphasia (loss of ability to understand or express speech, caused by brain damage). Continued review revealed that the resident had upper extremity impairment on one side and that he required maximal assistance with personal hygiene.

Review of Resident R45's care plan, dated initiated January 27, 2023, revealed that the resident requires assistance with activities of daily living related to decreased mobility and weakness, with interventions including to ensure that morning and evening care are provided daily.

Interview on April 4, 2024, at 9:26 a.m. Employee E4, Rehabilitation Director, stated that Resident R45 was currently receiving therapy services related to his right-sided weakness and need for assistance with activities of daily living. Employee E4, Rehabilitation Director, stated that nail care is done by nursing staff and is not something that therapy staff would do.

Continued observation, on April 4, 2024, at 11:31 a.m. revealed that Resident R45's nails were still long and dirty. Resident R45 again stated that he needed to have his fingernails trimmed and cleaned and that he was unable to do it himself.

Interview on April 4, 2024, at 11:35 a.m. Employee E9, unit manager, confirmed that Resident R45's fingernails needed to be trimmed and cleaned.

Observations on April 2, 2024, at 11:19 a.m. revealed Resident R70 had bilateral hand contractures and significantly long fingernails on both hands that required trimming and cleaning.

Review of Resident R70's comprehensive care plan dated initiated October 6, 2017, revealed the resident requires assistance with activities of daily living releated to decreased cognitiy, decreased mobility, and weakness. Further review revealed intervention date initiated November 15, 2019, for nail care/file nails on shower days (Monday and Thursday).

Interview and observation on April 4, 2024, at 12:30 p.m. with Registered Nurse, Employee E9, confirmed Resident R70 had long fingernails that required trimming and cleaning.

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





 Plan of Correction - To be completed: 05/27/2024

R45's nails are clean and clipped.

R70's nails are clean and clipped.

Staff Development coordinator or designee will conduct in- serving to nursing staff on the importance of nail care.

All residents' fingernails were assessed, and all are clean and clipped.

Unit Managers or designees will conduct nailcare audits weekly x 4 weeks to ensure residents nails are clean and trimmed.

Nurse aides will conduct nail as needed moving forward.

Results will report in monthly QAPI x 1 month

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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.
483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of 483.95(g).
Observations:

Based on a review of facility documentation and interviews with staff, it was determined that the facility failed to complete performance reviews for two of two nurse aides reviewed as required (Employees E28 and E29).

Findings Include:

Review of undated facility documentation, "Active Employees Over 1 Year", revealed that Employee E28 was hired by the facility as a nurse aide on July 12, 2022. Continued review revealed that Employee E29 was hired by the facility as a nurse aide on August 3, 2009.

Annual performance reviews were requested for Employees E28 and E29.

Interview on April 4, 2024, at 3:00 p.m. with the Nursing Home Administrator, Employee E1, revealed annual performance reviews were not completed for Nurse Aides, Employee E28 and E29.

28 Pa. Code 201.19(2) Personnel policies and procedures





 Plan of Correction - To be completed: 05/27/2024

Annual 12 hrs. in serving were completed for E 28 and E 29

All employees have been audited to determine those in need of the required annual 12-hr in -servicing.

The Staff Development Coordinator or designee will conduct the required 12hr in servicing be for any employees currently in need.

Staff Development Coordinator or designee will conduct 12 hrs. In-service education for nurse aides on an annual basis as required.

Results will be reported in monthly QAPI x 1 month

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:


Based on facility policy and observation, it was determined that the facility failed to ensure one of two medication carts observed remained locked on a secured nursing unit. (Second floor0.

Findings include:

Review of facility policy titled Grand Rx policy and Procedure Manual last revised June 1, 2020 revealed
that to properly maintain security of all medications, employee are to keep medication carts always locked, unless in immediate attendance and not let medication cart sit in nursing station, hall, or lounge unlocked.

Observation on second floor secured nursing unit on April 2,2024 at 11:00 a.m. revealed an unlocked medication cart in the hall with no employee in sight. Observed was a resident sitting in a wheelchair next to the open cart.

Interview with Licensed nurse, Employee E24 at time of observation confirmed that the medication cart was unlocked, and that this employee was assigned to the medication cart and stepped away to assists to a resident in another room.

28 Pa.Code 211.9 (a)(1) Pharmacy Services

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






 Plan of Correction - To be completed: 05/27/2024

E24 has received individualized education regarding the importance of keeping the medication locked or in eyesight at all times.

Staff development Coordinator or designee will conduct in-service education for licensed nurses regarding the importance of keeping the medication locked or in eyesight at all times.

Staff development coordinator or designee will conduct Random med cart checks on all units weekly x 4 weeks to ensure compliance. X 1 month
Results will be reported in monthly QAPI.

201.19(2) LICENSURE Personnel policies and procedures.:State only Deficiency.
(2) Employee performance evaluations, including documentation of any monitoring, performance, or disciplinary action related to the employee.

Observations:

Based on review of personnel records and interviews with staff, it was determined that the facility failed to complete annual performance reviews for staff as required for three of three personnel files as required (Employees E25, E26 and E27).

Findings include:

Review of undated facility documentation, "Active Employees Over 1 Year", revealed that Employee E25 was hired by the facility as a Registered Nurse on May 10, 2022. Continued review revealed that Employee E26 was hired by the facility as a Registered Nurse on December 28, 2020. Further review revealed that Employee E27 was hired by the facility as a licensed practical nurse on April 1, 2002.

Annual performance reviews were requested for Employees E25, E26 and E27.

Interview on April 4, 2024, at 3:00 p.m. with the Nursing Home Administrator, Employee E1, revealed annual performance reviews were not completed for Registered Nurse, Employees E25, Registered Nurse, E26, and Licensed Nurse, E27.



 Plan of Correction - To be completed: 05/27/2024

E25, E26, and E27 have completed Annual Performance Evaluations

Staff Development Coordinator will conduct in serving to Unit mangers and Department heads on importance of Annual Performance Evaluations

The Human Resources Director or Designee will complete annual Performance
Evaluations for all employees annually during the months of May and/or June.

The Human Resources Director or Designee will audit all employee files annually to ensure annual performance evaluations are completed.

Results will be reported in monthly QAPI x 1 month


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