Pennsylvania Department of Health
ORWIGSBURG NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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ORWIGSBURG NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 92 surveys for this facility. Please select a date to view the survey results.

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ORWIGSBURG NURSING AND REHABILITATION 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 a Civil Rights Compliance survey completed July 26, 2024, it was determined that Orwigsburg Nursing 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:

483.24(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 clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide services to maintain adequate grooming and personal hygiene for four of 20 sampled residents. (Residents 17, 31, 68 and 87)

Findings include:

Clinical record review revealed that Resident 17 had diagnoses that included diabetes and a history of respiratory disease. According to the Minimum Data Set (MDS) assessment, dated June 10, 2024, she could communicate her needs and required supervision with her activities of daily living (ADLs) such as personal hygiene. The resident was hospitalized from July 8 to 18, 2024, after a decline in condition. After returning from the hospital, she was more dependent on staff for all mobility and care, including her ADLs. On July 23, 2024, at 12:28 p.m., the resident was observed in bed with long and jagged finger and toe nails. At that time, the resident stated, "They haven't helped me trim my nails in a while." On July 25, 2024, at 12:49 p.m., the resident was again observed with untrimmed finger and toe nails.

Clinical record review revealed that Resident 31 had diagnoses that included diabetes and hypertension. According to the MDS assessment, dated May 30, 2024, he could communicate his needs and required substantial assistance from staff for all ADLs such as personal hygiene. On July 23, 2024, at 1:38 p.m., the resident was observed in his chair with long, yellow, and jagged fingernails. In an interview with the resident at that time, he stated that he preferred his nails short but needed help to cut them. On July 24, 2024, at 11:52 a.m., and on July 25, 2024, at 10:04 a.m., the resident was again observed with untrimmed fingernails.

Clinical record review revealed that Resident 68 had diagnoses that included macular degeneration and anxiety. According to the MDS assessment, dated June 12, 2024, he could communicate his needs and required substantial assistance from staff for ADLs such as personal hygiene. On July 23, 2024, at 10:34 a.m., the resident was observed in bed with long, yellow, jagged fingernails with dark debris caked underneath the nails. In an interview with the resident at that time, he referenced his hands and stated, "I can't get any help here with them." On July 24, 2024, at 11:25 a.m., and on July 25, 2024, at 9:37 a.m. and 12:41 p.m., the resident was again observed with untrimmed fingernails. On July 25, 2024, at 12:41 p.m., the resident stated, "these nails are really sharp and dangerous and I keep trying to get them to help me."

Clinical record review revealed that Resident 87 had diagnoses that included history of a stroke with residual weakness to one side of the body and osteoarthritis. According to the MDS assessment, dated April 6, 2024, he could communicate his needs and was dependent on staff for ADLs such as personal hygiene. On July 23, 2024, at 10:40 a.m., the resident was observed in bed with long and jagged fingernails. In an interview with the resident at that time he stated that he did not prefer his nails this long but could not cut them on his own. On July 24, 2024, at 12:08 p.m., and on July 25, 2024, at 10:14 a.m., the resident was again observed with untrimmed fingernails.

In a group interview on July 24, 2024, at 10:07 a.m., Residents 7, 23, 24, 34, 45, 98, and 99, stated that routine nail care was not done by staff as a part of ADL assistance.

In an interview on June 25, 2024, at 1:54 p.m., the Director of Nursing stated that staff was to perform nail care with the residents' showers.

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

Plan of Correction - To be completed: 09/05/2024

1. Residents 17,31,68 and 87 have had nail care performed to the residents liking.
2. Current residents have been reviewed to ensure that nail care has been performed.
3. Staff Development/ designee will inservice nursing staff on nail care schedules.
4. Staff Development/ designee will conduct random audits to ensure residents have had nail care. Audits will be completed weekly for 4 weeks. Audits will be reviewed at QAPI for further recommendations.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to assess bladder incontinence and provide services to restore as much bladder function as possible for two of 24 sampled residents. (Residents 57, 60)

Findings include:

Review of the facility policy entitled, "Urinary Continence and Incontinence - Assessment and Management," last reviewed January 16, 2024, revealed that facility staff was to complete a urinary incontinence assessment periodically and when there was a change in voiding. Staff would define each resident's level of continence and identify the type of incontinence.

Clinical record review revealed that Resident 57 was admitted to the facility on March 30, 2024, with diagnoses that included anxiety and hemiplegia. A "Bowel and Bladder Program Screener" was completed on April 3, 2024, and May 1, 2024, and indicated that the resident was a candidate for a scheduled toileting program. According to the Minimum Data Set (MDS) assessment, dated June, 24 2024, the resident needed assistance from staff for toileting. The assessment further indicated that the resident was incontinent of urine and was not on a toileting program. Further review of the "Bowel and Bladder Program Screeners" revealed that Resident 57's type of urinary incontinence was not identified and there was no indication that the resident was on a scheduled toileting program. There was no documented evidence that a scheduled toileting program had been implemented.

Clinical record review revealed that Resident 60 was admitted to the facility on December 23, 2023, with diagnoses that included diabetes mellitus. A "Bowel and Bladder Program Screener" was completed on December 27, 2023, March 27, 2024, and June 28, 2024, and indicated that the resident was a candidate for a scheduled toileting program. According to the MDS assessment, dated June 29, 2024, the resident needed assistance from staff for toileting, was frequently incontinent of urine, and was not on a toileting program. Further review of the "Bowel and Bladder Program Screeners" revealed that Resident 60's type of urinary incontinence was not identified and there was no indication that the resident was on a scheduled toileting program. There was no documented evidence that a scheduled toileting program had been implemented.

In an interview on July 26, 2024, at 10:00 a.m., the Director of Nursing confirmed that there was no documented evidence that the residents' urinary incontinence had been assessed in accordance with facility policy or that toileting programs were implemented for Residents 57 and 60.

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

Plan of Correction - To be completed: 09/05/2024

1. Resident 57 has been put on a toileting program and resident 60 has been placed on a toileting program.
2. Current residents will be reviewed to ensure a bowel and bladder program is initiated as appropriate.
3. Staff Development/ designee will re-inservice licensed staff to the bowel and bladder program.
4. Audits will be completed by the Unit Manager/ designee weekly for 4 weeks. Audits will be reviewed by QAPI for further recommendations.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:

§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to offer non-pharmacological interventions prior to the administration of as needed anti-anxiety medications for one of 24 sampled residents. (Resident 57)

Findings include:

Clinical record review revealed that Resident 57 had diagnoses that included schizophrenia and anxiety. On June 10 and 24, 2024, and July 8 and 22, 2024, the physician ordered an anti-anxiety medication, alprazolam, be given every eight hours as needed for 14 days. Review of the medication administration records for June and July 2024, revealed that staff had administered the as needed alprazolam 30 times. There was no documented evidence that staff attempted non-pharmacological interventions prior to the administration of the as needed anti-anxiety medication.

In an interview on July 26, 2024, at 10:05 a.m., the Director of Nursing confirmed that there was no documented evidence that staff attempted non-pharmacological interventions prior to the administration of the as needed anti-anxiety medication.

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

Plan of Correction - To be completed: 09/05/2024

1. Non-pharmacological interventions added to PRN alprazolam order for resident 57.
2. Current residents with PRN antianxiety medications reviewed and NPI added to orders.
3. Staff Development/designee to re-inservice licensed staff on NPI and documentation of NPI.
4. Audits will be completed by Unit Managers weekly x 4. Audits will be reviewed at QAPI for further recommendations

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

§483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;

Observations:

Based on clinical record review, review of facility documentation, observation, and resident interview, it was determined that the facility failed to ensure that a resident's preference at meal times had been accommodated for one of 24 sampled residents. (Resident 27)

Findings include:

Clinical record review revealed that Resident 27 had diagnoses that included diabetes mellitus and congestive heart failure. A Minimum Data Set assessment dated May 23, 2024, indicated that the resident was alert and able to make his needs known. Resident 27's ongoing care plan revealed he had the potential to be at nutritional risk and an intervention was to honor his food preferences. On July 23, 2024, at 10:55 a.m., Resident 27 stated that he frequently received items he disliked on his meal trays. On July 23, 2024, at 12:40 p.m., Resident 27's lunch tray was observed and he received rice as a side dish. Review of Resident 27's meal ticket at that time revealed that rice was listed as a food the resident disliked. In an interview at that time the resident stated that he did not want the rice and would not eat it.

Plan of Correction - To be completed: 09/05/2024

1. Resident 27 has had preferences updated.
2. Current residents afforded the opportunity to update meal preferences.
3. Food Service Director/ designee will inservice dietary staff on tray accuracy.
4. Food Service Director/ designee will complete audits of 5 trays weekly x 4 weeks. Audits will be reviewed at QAPI for further recommendations.

483.60(g) REQUIREMENT Assistive Devices - Eating Equipment/Utensils:

§483.60(g) Assistive devices
The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.

Observations:
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide adaptive equipment to assist with eating meals for one of 24 sampled residents. (Resident 1)

Findings include:

Clinical record review revealed that Resident 1 had diagnoses that included dysphagia and aphasia. On March 19, 2024, the physician ordered that staff provide the resident a two handled cup at all meals. Review of an occupational therapy note dated July 17, 2024, revealed that it was recommended for the resident to continue to use a two handled mug or regular mug/cup with a lid and straw to aid independence. On July 23, 2024, from 12:40 p.m. through 12:55 p.m., and on July 25, 2024, from 12:40 p.m. through 12:55 p.m., Resident 1 was observed in the dining room without a two handled cup or regular mug/cup with a lid and straw for her beverages.

In an interview on July 26, 2024, at 10:20 a.m., Registered Nurse 1 confirmed that the resident should have received her drink in a two handled cup at all meals.

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

Plan of Correction - To be completed: 09/05/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.

1. Resident 1 is receiving the proper cup at meals.
2. Resident receiving adaptive equipment will have it placed directly on the tray instead of the beverage cart.
3. Food Service Director/ designee will inservice staff on adaptive equipment placement.
4. Food Service Director/ designee will audit adaptive equipment weekly x4 weeks. Audits will be reviewed at QAPI for further recommendations.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on facility policy review, clinical record review, observations, and interviews, it was determined that the facility failed to follow policy related transmissions-based precautions and use of personal protective equipment for one of 24 sampled residents. (Resident 47)

Findings include:

Review of the facility policy entitled, "Isolation- Categories of Transmission-Based Precautions," last reviewed on January 16, 2024, revealed that transmission-based precautions (TBP) were additional measures to protect staff, visitors, and other residents from becoming infected when a resident was diagnosed with specific pathogens. A sign was hung on the room entrance door so that staff and visitors were aware of the need for precautions.

Clinical record review revealed that Resident 47 was admitted to the facility on May 13, 2024, with a diagnoses that included dementia, pneumonia, and methicillin-resistant staphylococcus aureus (a drug resistant infection) in the sputum. On May 13, 2024, a physician ordered that staff use TBP when providing care. On July 24, 2024, at 9:35 a.m., a sign was observed outside Resident 47's room that directed staff and visitors to follow TBP, including use of a gown and gloves, when in the room. On July 24, 2024, from 9:38 a.m. to 9:50 a.m., Nurse Aide (NA) 1 was observed without a gown in Resident 47's room and providing care, including incontinence care and assistance with bathing without a gown. On July 24, 2024, at 1:08 p.m., a visitor was observed in the room without a gown.

In an interview on July 25, 2024, at 10:37 a.m., the Infection Preventionist confirmed that Resident 47 was on TBP and that all staff and visitors in the resident's room should have followed the policy and worn appropriate protective equipment including gowns.

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

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

Plan of Correction - To be completed: 09/05/2024

1. Resident 47 is on transmission-based precautions.
2. Current residents have been evaluated to ensure they do not require transmission based precautions.
3. Staff Development/ designee will provide staff education on transmission based precautions.
4. Infection Control/ designee will do weekly audits x 4 weeks. Audits will be reviewed at QAPI for further recommendations.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for 17 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from July 5 through 25, 2024, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for ten residents on day shift (7:00 a.m. to 3:00 p.m.) on July 6, 12, 13, 14, and 20, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 11 residents on evening shift (3:00 p.m. to 11:00 p.m.) on July 6, 14, 15, 16, 18, 19, 20, and 25, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on July 6, 7, 8, 10, 13, 15, 16, 17, 18, 19, 20, 21, 22, 24, and 25, 2024.

Plan of Correction - To be completed: 09/05/2024

1) The findings of the nurse aide nursing staff care ratios cannot be retroactively corrected.
2. Facility will provide a minimum of one nurse aide per 10 residents during day shift and one nurse aide per 11 residents on evening shift and one aide per 15 residents overnight.
3. Scheduler will be educated on the requirements there must be a minimum of one aide per 10 residents during dayshift and a minimum of one aide per 11 residents on evening shift and one nurse aid per 15 residents overnight.
4. NHA/designee will conduct random audits to verify that nurse aide dayshift, evening shift and overnight shift ratios meet the requirements daily for 5 days, weekly for 4 weeks and then monthly for 2 months.
5. Audit results will be presented at the QAPI meeting for review and recommendations.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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 a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for one of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from July 5 through 25, 2024, revealed the facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift (11:00 p.m. to 7:00 a.m.) on July 17, 2024.

Plan of Correction - To be completed: 09/05/2024

Findings of LPN nursing staff care ratio cannot be retroactively corrected.
1) Facility will provide a minimum of one LPN per 25 residents during dayshift, a minimum of one LPN per 30 residents during evening shift and a minimum of one LPN per 40 residents during the overnight shift.
2) Scheduler will be educated on the requirements of one LPN per 25 residents during dayshift, a minimum of one LPN per 30 residents during evening shift and a minimum of one LPN per 40 residents during the overnight shift.
3) NHA/designee will conduct random audits to verify that LPN dayshift, evening shift and overnight shift ratios meet the requirements daily for 5 days, weekly for 4 weeks and then monthly for 2 months thereafter. Trends will be tracked and reported to QAPI committee.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Plan of Correction - To be completed: 09/05/2024

1. The findings of less than 3.2 hours for direct care of each resident cannot be retroactively corrected.
2. The facility will provide 3.2 hours of direct care for each resident daily.
3. The scheduler will be educated on the requirements of 3.2 direct care hours per day.
4. NHA/ designee will conduct daily audits for 5 days, then weekly for 4 weeks and then monthly for 2 months.
5. Audit results will be presented at the QAPI meeting for review and recommendations.

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