Nursing Investigation Results -

Pennsylvania Department of Health
AVENTURA AT CREEKSIDE
Patient Care Inspection Results

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AVENTURA AT CREEKSIDE
Inspection Results For:

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AVENTURA AT CREEKSIDE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

A COVID-19 Focused Emergency Preparedness Survey was conducted by The Department of Health (DOH) on December 1, 2021. The facility was in compliance with 42 CFR 483.73 related to E-0024(b)(6).





 Plan of Correction:


Initial comments:


Based on a COVID-19 Focused Infection Control and Abbreviated Complaint survey, completed on December 1, 2021, it was determined that Aventura at Creekside Health and Rehabilitation Center, was not in compliance with the following requirements of 42 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:


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 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 review of the facility's COVID-19 infection control policy, observation and staff interviews, it was determined that the facility failed to consistently implement and maintain infection control practices, including PPE use, to prevent the potential spread of the COVID-19 infection in the facility

Findings include:

A review of facility policy entitled, Infection Control - Covid 19, with a policy review date of July 20, 2021, indicated signs will be posted educating visitors and family members about infection prevention.

According to information provided by the Pennsylvania Department of Health, PA-HAN-563 dated April 9, 2021, health care providers (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. Instructions for gown use include: Put on a clean isolation gown upon entry into the patient room or area. Change gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or area. Disposable gowns should be discarded after use unless following protocols for extended use or reuse.

Telephone interview with the facility's Nursing Home Administrator (NHA) during entrance conference on December 1, 2021, at approximately 9:05 AM revealed that the facility currently had an outbreak of COVID 19 among its residents and staff. He stated that the facility currently had three distinct zones - Green Zone (COVID free or recovered), Yellow Zone (Known or possible exposure to COVID) and Red Zone (COVID positive). He stated that an N95 mask and eye protection (goggles, eye/face shield, side protectors) were required on all units and if you enter a resident room, additional personal protective equipment (PPE) \ are required. In addition, the NHA stated that staff are to apply (DON) their PPE (gown, gloves) prior to entering the resident rooms and remove (DOFF) their PPE (gown, gloves) prior to exiting the resident rooms after performing resident care. The RED zone was primarily located at the end of the Peach Hall near rooms 138 - 139, but had to be expanded beyond this zone to due the number of positive cases and red rooms are located on other halls as well. The Yellow Zone was resident room 137, and Green Zone were all the remaining rooms.

Observation on December 1, 2021, at approximately 10:28 AM, revealed that Employee 2, (Podiatrist) standing outside the nursing station speaking with a resident within approximately 2-3 feet apart from the resident. The Podiatrist was wearing a surgical mask and prescription eyeglasses (without side protectors). He was then observed entering the nursing station, spoke with staff and exited the nursing station. The podiatrist was observed to enter resident room 124 at approximately 10:35 AM and was observed speaking with the resident.

An interview at approximately 10:37 AM, with Employee 2, (Podiatrist), confirmed that he was wearing only surgical mask and prescription eyeglasses without side protectors and not the required N95 mask and proper eye protection required at this time due to the COVID-19 outbreak in the facility. He stated that the facility had not made him aware of the required N95 mask and proper eye protection.

An observation at the end of the Peach Hall near rooms 138 - 139, on December 1, 2021, at approximately 10:38 AM and 12:05 PM, revealed a plastic zippered curtain suspended from the ceiling to floor without any signage, indicating that this was the COVID Red zone and the PPE and precautions required to enter.

A further observation on December 1, 2021 at approximately 10:42 AM, and 12:08 PM, revealed several resident rooms scattered throughout the facility with colored (Red, and Yellow) construction paper taped to the doors of the resident rooms. There were no instructions on these papers posted on the doors regarding the PPE and precautions that would be required to enter, and exit, these resident rooms. These rooms included resident room(s) 116, 115, and 111 with red construction paper and resident room 137 with a yellow construction paper taped to the resident door. Located within the plastic zippered curtain area, resident room 140, had yellow construction paper taped to the resident door.

A continued observation at approximately 10:55 AM revealed Employee 3, (Dietary staff) walking through the hallway, passing by several resident rooms, with their doors open, wearing an N95 respirator (mask), but without any eye protection, (goggles, eye/face shield, side protectors).

An interview at approximately 10:56 AM, with Employee 3, (Dietary staff), confirmed she was wearing an N95 respirator (mask), without any eye protection. This observation and interview was also confirmed by Employee 4, Registered Nurse - RN).

Observation revealed that the facility's employee sign-in entrance process requires that the staff member enter the building through the Peach employee lounge. The employee clocks in and then enters the Peach hallway and walks towards the Blue hallway and circles around the nurse's station for screening. Screening is the completed across from the nurse's station, near the mechanical room, where a wall mounted temperature monitor was located, which is utilized by the staff member as a part of the COVID - 19 screening process. The staff sign in (COVID screening) station is located in the middle of the building on the countertop of the nurse's station. This arrangement requires the employee to enter resident areas to complete the COVID-19 screening creating the potential to expose residents and staff.

Observation, at approximately 12:35 PM, on December 1, 2021, in the presence of the Corporate Nursing Home Administrator (NHA), and Employee 1 (Registered Nurse, Assistant Director of Nursing (ADON), confirmed that the blank Red, and Yellow construction paper on the resident doors, identify the rooms as Red Zone, Yellow Zone, but fail to include instructions regarding necessary PPE and precautions, required to enter. These staff members also confirmed that there was no signage at the plastic zippered curtain suspended from the ceiling to floor regarding the necessary PPE and precautions, required to enter.

Observation on December 1, 2021, at approximately 12:35 PM, in the presence of the Corporate NHA, and Employee 1 (RN, ADON), revealed Employee 5 (Physical Therapist), walking through the hallway, past resident rooms 105, 103, and 101, wearing an N95 respirator (mask), but without any eye protection, (goggles, eye/face shield, side protectors).

An interview at approximately 12:35 PM, in the presence of the Corporate NHA, and Employee 1 (RN, ADON), with Employee 5 (Physical Therapist), confirmed that she was wearing an N95 respirator (mask), but without any eye protection.

During a telephone interview with the NHA on December 1, 2021 at approximately 2:45 PM, he was made aware of the observations and acknowledged that the facility failed to maintain infection control practices and policies to prevent the potential spread of COVID-19.



28 Pa. Code 211.12 (a)(c)(d)(4)(5) Nursing Services.

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



 Plan of Correction - To be completed: 01/06/2022


0880 Infection Prevention

Preparation and/or execution of this Plan of Correction does not constitute admission or agreement of 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 because it is required by the provision of federal and state law.

1. Podiatrist was reeducated on facility policies, procedures, and protocols with respect to necessary PPE. Employee 3 and 5 were reeducated on proper PPE needed during outbreak. Proper signage and PPE instructions were added to Rooms 116,115,111 and 137 and current red zone location.
2. All other areas of the facility were audited to assure appropriate signage was in place, if needed. Touchless thermometer was added to the employee entrance to assure temperature is taken prior to entering facility. Signage remains in place reminding staff that if they have symptoms of COVID to not enter facility and notify the supervisor immediately.
3. All staff were re-educated on the appropriate use of PPE in red, yellow and green areas and signs and symptoms of COVID-19 with focus on if feeling ill to notify facility immediately.
4. A random audit will be conducted on staff during varied times of the day to ensure appropriate PPE is present. The audits will be conducted minimally weekly x4 and monthly x2 on at least 5 staff members.
5. Corrective action date 1/6/22

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 observation and staff interview it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean, safe, and orderly environment in one resident bathroom (Room 124).

Findings include:

An observation on December 1, 2021, at approximately 12:05 PM, of the resident bathroom, in resident room 124, revealed a large area of missing and broken floor tile with a dark (brown/black) area below the resident's sink. There was missing paint, paint chips, and a small hole in the wall beneath the sink. There was missing and broken/chipped plaster on the wall, a vertical water stain below the sink to the floor that was dark (brown/black) in color, along with bubbling of paint. In addition, the soft rubber like floor molding was detached and displaced from the wall, in a curve-like waved appearance below the resident's sink.

Further observation on December 1, 2021 at approximately 12:45 PM, of resident bathroom, in resident room 124, in the presence of the Corporate Nursing Home Administrator (NHA), and Employee 1 (Registered Nurse, Assistant Director of Nursing (ADON), confirmed that the residents' bathroom was not maintained in clean, safe and orderly manner as the facility's expectation.

During a telephone interview with the Nursing Home Administrator (NHA) on December 1, 2021 at approximately 2:45 PM, he confirmed that the resident's environment was to be maintained in a clean, safe, and orderly manner.


28 Pa. Code 207.2(a) Administrator's responsibility



 Plan of Correction - To be completed: 01/06/2022

0584 Safe Clean Homelike environment

Preparation and/or execution of this Plan of Correction does not constitute admission or agreement of 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 because it is required by the provision of federal and state law.
1. Resident room 124's bathroom was remodeled. All damaged drywall, plaster, cove molding, tile, and paint was removed and new materials were installed/applied.
2. Resident restrooms were audited for damage and will be placed on a priority repair schedule if necessary.
3. Education on restroom cleaning and maintenance schedules will be conducted with staff. Also, any restroom repairs added to the TELS will be priority. NHA/designee will review work orders and delegate appropriate directives.
4. An audit will be completed weekly x4 and monthly x2 to ensure restroom repair as well as cleanliness is maintained.
5. Corrective Action Date 1/6/22

211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. 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 2.7 hours of direct resident care for each resident.
Observations:

Based on review of facility nurse staffing data, it was determined that the facility failed to maintain a minimum of 2.7 hours of direct resident care for each resident.

Findings include:

A review of facility nurse staffing data, including deployment sheets for the week of November 24, 2021, through November 30, 2021, the facility's 24 hour daily nurse staffing nurse staffing was below 2.7 hrs per resident on the following day:

November 24, 2021 nursing hours of direct resident care for each resident was 2.65

Telephone interview with the Nursing Home Administrator (NHA) on December 3, 2021 at approximately 10:35 AM confirmed the nursing hours indicated above.



 Plan of Correction - To be completed: 01/06/2022

2020 Nursing Services
Preparation and/or execution of this Plan of Correction does not constitute admission or agreement of 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 because it is required by the provision of federal and state law.

1. The facility identified a new hire CNA who was rendering care on the floor, labeled as an orientee. This employee should have been listed as a trainee since the individual was providing actual care and not desk orientation.
2. Schedules were reviewed for past 14 days and modified if necessary to include all staff providing hands on care of our residents.
3. Education as given to all staff who develop/modify facility deployment sheets with respect to terminology and proper labeling of staff who are in orientation and who are rendering hands on care.
4. An audit will be conducted daily x7, weekly x4 and monthly x2 verifying that the PPE of nursing hours in the facility stays above the state minimum.
5. Corrective action date 1/6/22


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