Pennsylvania Department of Health
THIRD AVENUE HEALTH & REHAB CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

THIRD AVENUE HEALTH & REHAB CENTER
Inspection Results For:

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THIRD AVENUE HEALTH & REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated complaint survey completed on April 16, 2024, it was determined that Third Avenue Health & Rehab 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:

483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program:

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.

§483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.

Observations:

Based on observations and interviews with resident sand staff, it was determined that the facility failed to maintain an effective pest control program.

Findings include:

Observations during an environmental tour of the facility on April 16, 2024, at approximately 11:30 AM, down the service entrance hallway in the presence of the Director of Nursing, revealed that the doors to the kitchen, dry storage room, and mechanical room were open. Further observation revealed that the door from the mechanical room leading to the outside of the building was also open to the outside, providing a means of entry for pests.

Observation of the dietary dry storage room revealed that there were mice droppings on the floor and on a pest glue trap located beneath a metal shelving unit on the right-hand side of the room.

The facility's pest control company invoice/report dated March 6, 2024, failed to include information related to services provided and/or results of any inspection.

Review of the facility's pest control company invoice/report dated April 3, 2024, indicated that "service to all rooms and restrooms, service to kitchen and dining room, check all rooms for mice, and rebait exterior bait stations" was completed. The report did not identify the outcome of the checks and bait stations related to presence of rodent/mice activity.

Interview with the Director of Nursing on April 16, 2024, at approximately 12 PM confirmed the presence of rodent activity in the facility, as evidenced by by mice droppings in the facility's dietary dry goods storage room, and that the reports from the pest control company were limited in information regarding pest activity and recommendations for the facility to employ to deter and eliminate the pest activity.

Refer F812

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

Plan of Correction - To be completed: 05/07/2024

1. Mouse dropping were cleaned from dry storage areas, the doors to the outside were closed along with the kitchen/dry storage doors. The pest control company completed a facility visit and report of their visit including results of the visits and treatments provided
2. To identify other residents that have the potential to be affected, the NHA/designee completed a facility house wide sweep to ensure there is no evidence of mice
3. To prevent this from reoccurring, the NHA/designee educated the maintenance director on the facility pest policy. The pest company will round the facility q 2weeks and a detailed report of findings and treatment in the facility will be issued
4. To monitor and maintain ongoing compliance, the NHA/designee will completed facility wide sweep weekly x 4 then monthly x 2 to ensure no evidence of mice are present
5. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

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

This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.

§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 staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

Observations during a tour of the dry storage room was conducted with the Director of Nursing on April 16, 2024, at approximately 11:30 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, was identified:

The door to the dry storage room was open.

A 5 lb. bag of chicken bread coating and a 25 lb. bag of flour were opened, and no date was noted when they were opened and put into use. The packages were not closed securely, simply loosely folded closed at the opening at the top of each bag, failing to fully protect the contents.

A ziplock plastic bag, containing an opened package of walnuts was observed in a brown box on a metal shelf. The brown box also contained another bag of opened walnuts and loose walnuts were observed in the bottom of the box.

The baseboard molding running along the bottom of the wall of dry storage room, beneath the metal shelving unit on the right-hand side of the room was missing, exposing dry wall and approximately a inch gap was observed between the wall and the floor. A glue trap and mouse droppings were observed along the same wall.

The dry storage room is located next to the kitchen.

Observation of the kitchen revealed a grey and orange personal backpack on the metal kitchen counter next to the toaster and below the kitchen knives mounted on the wall.

Observations of the kitchen and dry storage room were confirmed with the facility's Certified Dietary Manager on April 16, 2024, at approximately 11:45 AM.

Interview with the Director of Nursing on April 16, 2024, at approximately 12:30 PM, confirmed that the kitchen and all food storage areas should kept in a sanitary manner and all foods and beverages should be stored in a safe and sanitary manner.

Refer F925

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

28 Pa. Code 211.6 (f) Dietary Services

Plan of Correction - To be completed: 05/07/2024

1. The chicken bread coating, the walnuts, and flour were discarded. The molding was replaced, the mouse droppings were removed, the door was closed, and the personal back pack was removed.
2. To identify other areas of concern, the NHA/designee completed a kitchen audit to ensure no other identified storage and sanitation concerns were present
3. To prevent this from reoccurring, the NHA/designee educated the dietary department on the storage of dry food policy. Education also included ensuring all doors to the kitchen and dry storage are shut and personal belongings do not belong in kitchen area
4. To monitor and maintain ongoing compliance, the NHA/designee completed weekly x 4 then monthly x 2 pantry/dry storage rounds to ensure items are stored appropriately, the doors are closed, and no personal belongings are present in the kitchen
5. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

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.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on observation, clinical record review and staff interview, it was determined that the facility failed to maintain an environment free of potential accident hazards to the extent possible on one of three resident hallways (Rooms 9-16).

Findings include:

Observations made during an environmental tour of the facility on April 16, 2024, at approximately 11 AM revealed an unattended, and unlocked, treatment cart in the hallway of the resident unit.

Further observation of the treatment cart revealed that the second drawer was open, exposing the contents of prescription creams and/or ointments. The sixth drawer was also open and exposed treatment supplies used to perform treatments to residents.

Observation of the top of the cart revealed a laptop, and packages of unopened curettes (tool with a sharp blade to remove nonviable skin).

Observation further revealed residents were ambulating and self-propelling in wheelchairs in the hallway while the opened cart was left unattended.

Interview with the Director of Nursing revealed that the facility's wound care consultant was performing wound care in a resident's room during observation. The Director of Nursing confirmed that the cart was not to be left opened and unattended with its contents accessible to residents creating a potential accident hazard.

During an interview on April 16, 2024, at approximately 11 AM, the Director of Nursing confirmed the potential accident hazards in the resident hallway and the presence of independently mobile residents in that same hallway. on the unit.

28 Pa. Code 211.12 (d)(5) Nursing Services.

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

Plan of Correction - To be completed: 05/07/2024

1. Sharp items were removed and treatment cart was locked. The wound care provider was educated at time of occurrence.
2. To identify other areas of concern, the DON/designee completed rounds to hallways were free of potential accident hazards to resident safety
3. To prevent this from reoccurring, the DON/designee licensed nursing staff on ensuring medication and treatment cart are locked when not occupied and all potential hazards are out of reach of the residents. The wound care provider was educated on ensuring sharp items are not left unattended and treatment carts are locked when unoccupied
4. To monitor and maintain ongoing compliance, the DON/designee will complete an audit weekly x4 then monthly x 2 to ensure the facility is free from potential accident hazards that may affect resident safety
5. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

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