Pennsylvania Department of Health
COMPLETE CARE AT LEHIGH LLC
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

COMPLETE CARE AT LEHIGH LLC
Inspection Results For:

There are 81 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.


COMPLETE CARE AT LEHIGH LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and a Civil Rights Compliance survey completed on July 12, 2024, it was determined that Complete Care at Lehigh 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:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

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.

§483.60(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 observation and interview, it was determined that the facility failed to maintain sanitary conditions in the kitchen.

Findings include:

Observation in the kitchen on July 9, 2024, at 10:48 a.m., revealed the following:

The dish machine failed to achieve the appropriate concentration of sanitizer solution (50-100 parts per million) for three full cycles. There was a black substance on the walls that surrounded the dish machine. There was a back flow of water from a drain on the dish room floor. There was debris on a windowsill in the food preparation area.

In an interview, dietary employee 1 stated that she did not check the concentration of the sanitizer solution during operation that morning.

In an interview on July 10, 2024, at 11:45 a.m., the Director of Dietary confirmed that staff were to check the concentration of the sanitizer solution of the dish machine while it was operating and accurately record the value on the paper log.

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

Plan of Correction - To be completed: 09/10/2024

The dish machine was serviced by Ecolab and the hose was reattached to the sanitizer. The dish room was deep cleaned to remove all black substance after the obstruction was removed in the floor drainpipe. The windowsill was cleaned at the time is brought to the FSD' attention.
The dietary staff have been educated on the proper Sanitation process while operating the dish machine and the cleaning of the dish room and windowsills.
FSD or designee will perform a daily audit of the dish machine sanitation and cleanliness of the dish room and windowsills.
Results of the audit will be brought to the Quality Assurance Performance Improvement Committee for review and or recommendations.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

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

Observations:

Based on observation, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained in two of two shower rooms. (first-floor central bath and second-floor central bath)

Findings include:

Observations in the first-floor central bath on July 10, 2024, at 1:15 p.m., and July 11, 2024, at 12:20 p.m., revealed the following:

There was a shower chair that had a black substance at the base. A second shower chair had smudges of a brown substance on the seat and a black substance at the base. A bariatric shower chair had hair on the seat and at the bottom of the front base. The wheels on two of the lifts (equipment used to assist residents to a standing position) were dirty.

Observations in the second-floor central bath on July 9, 2024, at 1:30 p.m., and July 11, 2024, at 12:00 p.m., revealed the following:

The seat of a shower chair was cracked. In the left shower stall, the shower head was leaking. The wheels on three of the lifts were dirty. There was a shower chair that had a black substance under the seat.

28 Pa. Code 201.18 (e)(2.1) Management.

Plan of Correction - To be completed: 09/10/2024

Shower chairs observed with black/brown substance and hair were cleaned at the time this was brought to DON's attention.
The wheels of the lifts were cleaned at the time this was brought to the staff's attention. The shower head and handle set were replaced.
Staff educated by staff development coordinator on process of cleaning shower chairs. The Maintenance staff was educated on the cleaning process of the lift wheels.
DON or designee will audit weekly shower chairs for cleanliness. NHA or designee will audit the lift wheels and shower heads weekly for cleanliness and proper function.
Results of the audit will be brought to the Quality Assurance Performance Improvement Committee for review and or recommendations.

483.20(g) REQUIREMENT Accuracy of Assessments:

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for one of 24 sampled residents. (Resident 26)

Findings include:

Clinical record review revealed that on March 11, 2024, a physician ordered for Resident 26 to be provided with hospice services. Review of the MDS assessment dated June 22, 2024, revealed that staff did not indicate that the resident had hospice services in place during the review period. The MDS inaccurately reflected that the resident was not receiving hospice services.

In an interview on July 12, 2024, at 9:45 a.m., the Director of Nursing confirmed that the MDS assessment did not identify that Resident 26 received hospice services.

Plan of Correction - To be completed: 09/10/2024

MDS coordinator completed a modified MDS (6/22/24) for R26 to reflect that she received hospice services at that time.
All residents who are on hospice services have had their MDS audited for accuracy. Modifications will be completed if required.
MDS nurse who completed the 6/22/24 MDS was educated on not capturing hospice service. A weekly hospice list will be given to MDS nurse by social service department to ensure hospice services are captured in the MDS.
Random weekly audits will be completed by MDS coordinator to ensure residents on hospice services are captured in the MDS.
Results of the audit will be brought to the Quality Assurance Performance Improvement Committee for review and or recommendations.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for one of 24 sampled residents. (Resident 109)

Findings Include:

Clinical record review revealed that Resident 109 had diagnoses that included congestive heart failure. A physician's order dated May 30, 2024, directed staff to obtain a daily weight and to notify the provider for a weight gain of greater than or equal to two pounds (lbs.) in one day. There was no evidence that staff obtained the resident's weight or that the resident refused to be weighed on June 3, 7, 8, 29, 2024, or July 8, 2024.

Further review of the clinical record revealed that on June 24, 2024, the resident weighed 130.1 lbs. and on June 25, 2024, the resident weighed 133.8 lbs., which reflected a 3.7 lb. gain in 24 hours. There was no evidence that staff notified the physician of the weight change of greater than two pounds in one day.

In an interview on July 12, 2024, at 9:30 a.m., the Director of Nursing confirmed that there was no evidence that staff offered to weigh the resident on those dates or that the physician was notified of the weight change.

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

Plan of Correction - To be completed: 09/10/2024

DON during survey reviewed R109 daily weight order with the medical provider. Based on his status and refusals of daily weights the weights were discontinued.

All residents who have daily weight orders will be audited to ensure weights were obtained and the physician was notified if required.

All nurses will be educated on ensuring daily weights were obtained and physician was notified for weight variation ordered.

DON or designee will complete audit 2 x week to ensure daily weights completed and physicians notified as ordered.

Results will be brought to the Quality Assurance Performance Improvement Committee for review and or recommendations.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions to prevent further decline and/or improve range of motion for two of 24 sampled residents. (Residents 35, 54)

Findings include:

Clinical record review revealed that Resident 35 had diagnoses that included muscle weakness. Review of an occupational therapy discharge assessment dated June 25, 2024, revealed that staff recommended a daily restorative nursing program (RNP) for active range of motion to both arms. There was no evidence that the program was implemented.

In an interview on July 12, 2024, at 9:48 a.m., the Director of Rehabilitation Services confirmed that the RNP for active range of motion for Resident 35 was not implemented.

Clinical record review revealed that Resident 54 had diagnoses that included dementia, hemiplegia (weakness or paralysis of one side of the body), and a right hand contracture. Review of the MDS assessment dated May 11, 2024, revealed that the resident had cognitive impairment and was dependent on staff for personal hygiene and dressing. On March 27, 2023, the physician ordered for staff to apply a carrot splint to Resident 54's right hand at all times. Review of the care plan revealed that the resident had a risk of limitation in movement and the intervention was for staff to apply the splint on her right hand at all times except when care was being provided. Observations on July 9, 2024, at 9:40 a.m., July 10, 2024, at 10:16 a.m. and 2:35 p.m., and July 11, 2024, at 10:15 a.m. and 11:30 a.m., revealed that the resident was in her chair and the right hand carrot splint was not in place.

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

Plan of Correction - To be completed: 09/10/2024

R35 RNP for upper extremity ROM was implemented. R54 carrot splint was obtained and applied.

All residents will be audited to ensure splint and braces are in place.
Therapy will audit all residents discharged from OT to ensure recommendations for RNP upper extremity ROM are implemented.

Occupational therapist who did not develop RNP was educated by rehab director. Occupational Therapy will be educated by rehab director on implementing RNP's if appropriate when discharged from Occupational services.
Nurse and CNA's who did not have resident splint in place were educated. All nursing staff will be educated to apply splints as ordered.
DON or designee will complete 2x week audit to ensure resident's splints are on as ordered.
Rehab director or designee will complete weekly audits of occupational therapy discharges to ensure if recommended RNP for Bilateral Upper extremity ROM are put in place.

Results of the audit will be brought to the Quality Assurance Performance Improvement Committee for review and or recommendations.

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