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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

UNIONTOWN HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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UNIONTOWN HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, and an Abbreviated Survey completed on August 7, 2024, it was determined that Uniontown Health and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

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

This is a less serious (but not lowest level) deficiency 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 observations and staff interview, it was determined that the facility failed to properly restrain hair to prevent the potential for cross contamination in the Kitchen.

Findings include:

Review of facility policy "Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices" last reviewed 9/13/23, indicated hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens.

During an observation on 8/4/24, at 9:37 a.m. Dietary Aide Employee E1, was observed in the kitchen without a hair restraint.

During an interview on 8/4/24, at 1:35 p.m. the Nursing Home Administrator confirmed the kitchen staff should wear hair restraints.

28 Pa. Code: 211.6(c)(d)(f) Dietary services.

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

1. E1 immediately put on a hairnet.
2. Other dietary employees checked and hairnets in place.
3. Dietary manager/designee will educate dietary staff to have a hairnet in place at all times when in the dietary department.
4. Dietary manager/designee will audit dietary staff to ensure hairnets are in place at all times when in the dietary department. Will audit 5 employees 3 x week x 2 months. Audit results will be reviewed in Quality Assurance Performance Improvement Committee x 2 months

483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition:

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.

§483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Observations:
Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement for one of 4 residents (Resident R76).

Findings include:

Review of facility policy "Wandering and Elopements" last reviewed September 13, 2023, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain resident's safety. A complete elopement risk assessment will be completed on admission, readmission, quarterly, and with significant change. If identified as an elopement risk, the facility will utilize a Wanderguard (a monitoring device worn on the wrist or ankle that alerts staff when the resident leaves a safe area).

Review of clinical record indicated Resident R76 was admitted to the facility on 5/12/23, with diagnoses that included vascular dementia (brain damage caused my multiple strokes, causes memory loss), diabetes (too much blood sugar in the blood), and high blood pressure.

A review of the MDS dated 5/23/24, indicated that the above diagnoses remain current.

Review of clinical record indicated that Resident R76 had an Elopement Evaluation completed on admission, quarterly, and annually, which the last two placed resident to be at risk for elopement. The most recent Elopement Evaluation was completed on 6/24/24, and interventions included, but are not limited to the following: Wanderguard, alarm bracelets checked every shift, weekly maintenance checks on system, and staff aware of the resident's wander risk.

Review of facility documents indicated that Resident R76 was found to be outside of the facility at approximately 6:15 a.m. by the Registered Nurse Employee E1, who had stepped in the hallway and was able to see outside on sidewalk outside of main entrance doors. A review of facility documents also revealed that staff members had just assisted Resident R76 with morning care and got her into her wheelchair, she then self-propelled around the facility.

During an interview with Nursing Home Administrator (NHA), on 8/7/24, at 10:44 a.m., it was revealed that there are seven exit doors consisting of five units, dining area and front entrance which are equipped with a Wanderguard alarm system to detect the Wanderguard bracelets. All doors are equipped with a keypad that must have a code entered into them to allow the door to open after an alarm is triggered.

During an interview with Employees E2 and E3 on 8/7/24, at 12:22 p.m. and 12:24 p.m., it was confirmed that Registered Nurse Employee E1 found Resident R76 outside. When Resident R76 was approached she stated that she " just wanted to go outside, then she just wanted to go home, and then wanting to go to Korea." Registered Nurse Employee E1 redirected the resident back into the facility where it was discovered that her Wanderguard was not working and a new one was placed on her left ankle. During the interviews with Employees E2 and E3 they both stated that the Wanderguard's are checked every shift for placement and to see if they are blinking, they are checked for activation every week by maintenance with a wand.

During an interview on 8/7/24, at 12:15 p.m. Nurse Aid (NA) Employee E4 stated the NAs do not apply or check the wanderguard for the residents.

During an interview on 8/7/24, at 12:22 p.m. Licensed Practical Nurse (LPN) Employee E5 stated when they check the wanderguard on residents they check to make sure the light is on. Maintenance has something that they use to check the alarms, but stated nursing only checks to make sure the wanderguard is in place and has a light on, indicating the unit is functional.

During an interview on 8/7/24, at 12:24 p.m. Registered Nurse (RN) Employee E6 stated the wanderguard's are checked each shift for placement and flashing light. Maintenance is responsible for doing weekly checks, but they were unsure what that process involved.

During an interview on 8/7/24, at 1:10 p.m. the NHA confirmed that the facility failed ensure the wanderguard system was working correctly for Resident R76.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(1)(3) Management.

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

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

1. Resident R76 had a new wanderguard/alarm bracelet replaced on her left ankle.
2. All residents with physician ordered wanderguard/alarm bracelets were checked to ensure they were in working condition.
3. Maintenance/designee will educate licensed nurses on every shift check for placement of wanderguard/alarm bracelet and tester use to ensure wanderguard/alarm bracelets are in working condition.
4. Maintenance/designee will audit residents with a physician ordered wanderguard/ alarm bracelet to ensure they are functioning properly and in place 3 x week x 2 months. Audit results will be reviewed in Quality Assurance Performance Improvement Committee x 2 months

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:
Based on review of nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one nurse aide (NA) per ten residents during the day shift, 11 residents during evening shift, and/or one nurse aid per 15 residents during the night shift for ten of 21 days (7/8/24, 7/9/24, 7/10/24. 7/11/24, 7/12/24, 7/22/24, 7/23/24, 7/25/24, 7/26/24, and 8/3/24).

Findings include:

Review of the facility census data, nursing time schedules, and deployment sheets revealed the following nurse aide staffing shortages:
On 7/8/24, Census 92. Night shift short one NA.
On 7/9/24, Census 93. Night shift short two NA.
On 7/10/24, Census 93. Night shift short two NA.
On 7/11/24, Census 91. Night shift short two NA.
On 7/12/24, Census 94. Night shift short one NA.
On 7/22/24, Census 92. Night shift short one NA.
On 7/23/24, Census 94. Night shift short one NA.
On 7/25/24, Census 94. Night shift short one NA.
On 7/26/24, Census 94. Night shift short one NA.
On 8/3/24, Census 91. Night shift short one NA.

During an interview on 8/6/24, at 2:15 p.m. the Director of Nursing confirmed that the facility failed to provide a minimum of one nurse aide per 12 residents during the day and evening shift, and/or one nurse aid per 20 residents during the night shift on ten of 21 days.

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

1. The Facility will continue to take measures to adequately provide staff to ensure the needs of residents are met.
2. The Facility will continue to take measures to adequately provide staff to meet the required certified nursing assistant to resident ratios on dayshift, evening shift, and night shift.
3. The Director of Nursing/designee will provide re-education on minimum staffing ratios to RN Supervisors, HR, and Scheduling who are responsible to monitor staffing and staffing ratios.
4. The Director of Nursing/designee will audit the daily schedules to monitor the minimum number of staff to resident ratios are being met. If ratios are not met the Director of Nursing/designee will make attempts to meet the number of staff to resident ratios. These audits will be conducted daily for 14 days and then weekly X 3 weeks. Audit results will be reviewed in Quality Assurance Performance Improvement Committee x 2 months.

§ 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 review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift, per 30 residents during the evening shift, and per 40 residents during the night shift on two of 21 days (7/7/23, and 8/1/24).

Findings include:

Review of the facility census data, nursing time schedules, and deployment sheets revealed the following LPN staffing shortages:

On 7/7/24, Census 93. Evening shift short one LPN.
On 8/1/24, Census 94. Day shift short one LPN.

During an interview on 8/6/24, at p:15 a.m. the Director of Nursing confirmed that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift, per 30 residents during the evening shift, and per 40 residents during the night shift two of 21 days.

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

1. The Facility will continue to take measures to adequately provide staff to ensure the needs of residents are met.
2. The Facility will continue to take measures to adequately provide staff to meet the required licensed practical nurse to resident ratios on dayshift, evening shift, and night shift.
3. The Director of Nursing/designee will provide re-education on minimum staffing ratios to RN Supervisors, HR, and Scheduling who are responsible to monitor staffing and staffing ratios.
4. The Director of Nursing/designee will audit the daily schedules to monitor the minimum number of staff to resident ratios are being met. If ratios are not met the Director of Nursing/designee will make attempts to meet the number of staff to resident ratios. These audits will be conducted daily for 14 days and then weekly X 3 weeks. Audit results will be reviewed in Quality Assurance Performance Improvement Committee x 2 months.

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