Pennsylvania Department of Health
MIDTOWN OAKS HEALTH & REHAB CENTER
Patient Care Inspection Results

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MIDTOWN OAKS HEALTH & REHAB CENTER
Inspection Results For:

There are  145 surveys for this facility. Please select a date to view the survey results.

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MIDTOWN OAKS HEALTH & REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a complaint survey completed on March 20, 2024, it was determined that Midtown Oaks Health and Rehab 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:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:


Based on review of policies, investigative reports, and residents' clinical records, as well as staff and family interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan and transfer status for one of 10 residents reviewed (Resident 1).

Findings include:

The facility's current policy regarding abuse, neglect and exploitation indicated that neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 9, 2024, revealed that the resident was severely cognitively impaired, required assistance from staff for transfers, and had diagnoses that included dementia. The resident's fall care plan, revised on February 15, 2024, indicated that she was a physical assist of two for transfers. A physical therapy discharge summary for Resident 1, dated February 15, 2024, revealed that on discharge Resident 1 required a physical assist of two for transfers.

A nursing note for Resident 1, dated February 25, 2024, revealed that while being transferred from her wheelchair she pulled her legs up at the knees. Resident 1 had to be placed back in the wheelchair and her right calf caught on the bracket where the foot pedal attaches causing a skin tear. The wound was cleansed, and a sterile dressing was applied.

The facility's investigation determined that Nurse Aide 1 transferred Resident 1 by himself. A witness statement, dated February 25, 2025, indicated that Resident 1 was changed and cleaned in bed. While sitting up in bed she was transferred to her wheelchair. Her legs were tucked up and her calf was cut on the right leg. The nurse was notified and first aid was completed. Resident 1 was harder to transfer when she tucked up.

Education paperwork provided by the facility, dated February 22, 2024, revealed that concerns were reported to the Director of Nursing and Nursing Home Administrator regarding Nurse Aide 1. It was reported that Nurse Aide 1 transferred a resident in a manner that was against their care plan and was not in line with the therapy recommendation. This could be an issue of safety and could cause the resident to have a fall or injury.

A nursing note for Resident 1, dated March 10, 2024, revealed that the skin tear on the right calf reopened and would care was ordered.

Observations of Resident 1 on March 20, 2024, revealed that she was visiting with a family member. She was sitting in her wheelchair, and there was a dressing applied to her right lower leg.

Interview with the Director of Rehab on March 20, 2024, at 3:27 p.m. confirmed that Resident 1 was a moderate assist of two staff for transfers.

Interview with Nurse Aide 1 on March 20, 2024, at 4:45 p.m. confirmed that he transferred Resident 1 by himself because he was not aware that she was a two-person physical assist. The education he received regarding the unsafe transfer with Resident 1 was dated February 22, 2024; however, he confirmed that the form was dated inaccurately.

Interview with the Director of Nursing on March 20, 2024, at 2:55, 3:45, and 4:45 p.m. confirmed that Nurse Aide 1 transferred Resident 1 by himself and that the resident required a two-person physical assist. The Director of Nursing also confirmed that the education was inaccurately dated for February 22, 2024, instead of February 25, 2024.

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

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

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: 04/11/2024

The resident is now being transferred assist of 2 per the care plan. The right calf skin tear is resolve per wound nurse note dated 3/26/2024, orders discontinued, and care plan has been updated. Nurse aide 1 was disciplined and educated on the importance of following the residents care plan.

All resident care plans were reviewed to ensure the proper transfer status was care planned. A system change was implemented. A form was created which will include the residents transfer status that was placed on the inside of the resident's closet door for easy reference and privacy. The therapy team will update the forms as resident transfer status changes. Education was provided to staff on the importance of following the resident scare plan including transfer status. Staff was also educated on the system change.

Therapy will report transfer status changes in daily morning meeting. The NHA/designee will perform audits to ensure the transfer status changes are being changed on the form inside the resident's closet door and the care plans are being updated. This will be an ongoing process. The DON/designee will audit the resident transfer status five times a week for one week, then twice a week for two weeks, and then bi-weekly for two weeks. Audits will be ongoing randomly.

Outcomes of the audits will be presented to the quality assurance process improvement committee for review and recommendations.



201.14(d) LICENSURE Responsibility of licensee.:State only Deficiency.
[Reserved]
Observations:


Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the Department of Health of an incident that had the potential for serious harm to a resident for two of 10 residents reviewed (Residents 1, 3).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 9, 2024, revealed that the resident was severely cognitively impaired, could usually understand, was usually understood, required assistance from staff for transfers, and had diagnoses of dementia (memory loss).

A nursing note for Resident 1, dated February 25, 2024, revealed that the resident was being transferred from the wheelchair when the resident pulled her legs up at the knees. The resident had to be placed back in the wheelchair and her right calf caught on the bracket where the foot pedal attaches causing a skin tear. The wound was cleansed, and a sterile dressing was applied.

Interview with Nurse Aide 1 on March 20, 2024 at 4:45 p.m. revealed that he transferred Resident 1 from the bed to the wheelchair by himself and was not aware that she was a two-person physical assist.

There was no documented evidence to indicate that this incident was reported to the Department of Health.

Interview with the Nursing Home Administrator on March 20, 2024, at 5:20 p.m. confirmed that this incident was not reported to the Department of Health and should have been.

An admission MDS assessment for Resident 3, dated January 26, 2024, revealed that the resident was cognitively impaired, was ambulatory, had behaviors, and had a diagnosis of dementia with behavioral disturbances and wandering.

A nurse's note for Resident 3, dated March 16, 2024, at 4:08 p.m., revealed that the resident was in the common area with other residents and punched a female resident on the right buttock and hip. The resident was redirected away from the common area and towards his room. A nursing assessment of the female resident revealed no swelling or discoloration to the area.

A physician's order for Resident 3, dated March 16, 2024, included an intervention for aggressive/combative behaviors by moving the resident to a quiet room until the episode was resolved, removing potentially harmful objects from the immediate environment, and protecting other residents in the immediate area from harm.

There was no documented evidence to indicate that this resident-to-resident incident was reported to the Department of Health.

Interview with the Director of Nursing on March 20, 2024, at 1:32 p.m. confirmed that the Department of Health was not notified of this incident.

Chapter 51.3(f) Notification.



 Plan of Correction - To be completed: 04/11/2024

Event report was submitted for resident 1. Wound nurse's documentation indicated the skin tear is healed without issue. Education counseling done with nurse aide on the importance of following the residents care plan.

Event report for resident 3 was submitted. Neither resident involved in this incident had any ill effects and were unable to recall the incident due to cognition.

A whole house review of nurse's notes done to ensure all appropriate events have been submitted to the department of health via electronic event report. Nursing department education done on reportable events.

A whole house audit done on resident transfer status by therapy. A process change occurred which included creating a form that has been placed on the inside of the residents closet door to reflect the current transfer status for quick reference. The therapy team will be responsible to update the form as a transfer status changes.

Audits of the progress notes will be done daily in morning meeting to ensure all appropriate incidents are submitted to the department of health via electronic event report.

Audits will be done daily in morning meeting as therapy reports transfer status changes to ensure the care plan and form inside the closet doors are updates timely has changes occur. This will be an ongoing process.

Audit results will be reported to the quality assurance process improvement committee for review and recommendations.
211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(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 a review of nursing schedules, staffing information provided by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 12 residents on the day shift for one of 21 days and one NA per 20 residents on the night shift for seven of 21 nights.

Findings Include:

Review of facility census data indicated that on February 13, 2024, the facility census was 96, which required 4.8 (96 residents divided by 20) NA's during the night shift. Review of the nursing time schedules revealed 4.53 NA's provided care on the night shift on February 13, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 14, 2024, the facility census was 96, which required 4.8 NA's during the night shift. Review of the nursing time schedules revealed 4.5 NA's provided care on the night shift on February 14, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 17, 2024, the facility census was 97, which required 8.08 (97 residents divided by 12) NA's during the day shift. Review of the nursing time scheduled revealed that 8.03 NA's provided care on the day shift on February 17, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 4, 2024, the facility census was 101, which required 5.05 NA's during the night shift. Review of the nursing time schedules revealed that 5.0 NA's provided care on the night shift on March 5, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 8, 2024, the facility census was 103, which required 5.15 NA's during the night shift. Review of the nursing time schedules revealed that 4.97 NA's provided care on the night shift on March 8, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 13, 2024, the facility census was 98, which required 4.9 NA's during the night shift. Review of the nursing time schedules revealed that 4.88 NA's provided care on the night shift on March 13, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 15, 2024, the facility census was 101, which required 5.05 NA's during the night shift. Review of the nursing time schedules revealed that 4.94 NA's provided care on the night shift on March 15, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 16, 2024, the facility census was 102, which required 5.1 NA's during the night shift. Review of the nursing time schedules revealed that 5.0 NA's provided care on the night shift on March 16, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Interview with the Nursing Home Administrator on March 20, 2024, at 4:15 p.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the days listed above.



 Plan of Correction - To be completed: 04/11/2024

Although the facility cannot correct the staffing hours on the cited dates, efforts are continuously being made to maintain the staffing hours within regulatory guidelines.
The facility will continue with recruiting efforts, as well as, offering employment incentives in order to increase staff availability. If staffing concerns warrant, consideration will be given to placing a hold on admissions.

The Administrator/Designee has been auditing the direct care staffing ratios and will continue to audit weekly times 4 weeks, then monthly times 2 months. The audit outcomes will be presented to the Quality Assurance Committee for review and recommendations.
211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:


Based on review of nursing schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift for three of 21 days (24-hour periods) reviewed.

Findings Include:

Review of facility census data indicated that on March 6, 2024, the facility census was 100, which required 4.0 LPN's during the day shift. Review of the nursing time schedules revealed that 3.88 LPN's worked the day shift of March 6, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 9, 2024, the facility census was 103, which required 4.12 LPN's during the day shift. Review of the nursing time schedules revealed that 4.0 LPN's worked the day shift of March 9, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 11, 2024, the facility census was 99, which required 3.96 LPN's during the day shift. Review of the nursing time schedules revealed that 3.94 LPN's worked the day shift of March 11, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Interview with the Nursing Home Administrator on March 20, 2024, at 4:15 p.m. confirmed that the facility did not meet the required licensed practical nurse-to-resident staffing ratios for the days listed above.





 Plan of Correction - To be completed: 04/11/2024

Although the facility cannot correct the staffing hours on the cited dates, efforts are continuously being made to maintain the staffing hours within regulatory guidelines.
The facility will continue with recruiting efforts, as well as, offering employment incentives in order to increase staff availability. If staffing concerns warrant, consideration will be given to placing a hold on admissions.

The Administrator/Designee has been auditing the direct care staffing ratios and will continue to audit weekly times 4 weeks, then monthly times 2 months. The audit outcomes will be presented to the Quality Assurance Committee for review and recommendations.

When there are staffing challenges, administrative staff can/will assist with mealtime, answering call bells, etc. When there is a call off, the scheduler makes contact with all staff via phone/text to find coverage. We encourage staff to take turns in staying beyond their regularly scheduled shift to cover a call offs. DON and ADON can work the floor when needed.

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