Nursing Investigation Results -

Pennsylvania Department of Health
NORTH STRABANE REHABILITATION AND WELLNESS CENTER, LLC
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
NORTH STRABANE REHABILITATION AND WELLNESS CENTER, LLC
Inspection Results For:

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NORTH STRABANE REHABILITATION AND WELLNESS CENTER, LLC - 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 Abbreviated Survey, in response to a complaint, completed on September 19, 2019, it was determined that North Strabane Rehabilitation and Wellness Center, was not in compliance with the 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 a review of facility policies, observations and staff interviews, it was determined that failed to accurately monitor dishwasher temperatures and sanitizer testing levels, failed to store food in a sanitary manner and failed to serve food in a manner to prevent the potential for cross contamination during tray line service in the main kitchen.

Findings include:

Based on the facility policy " Food Storage" last reviewed on 7/30/19, indicated that all foods shall be stored six inches from floor. All foods stored in freezers and refrigerators shall be stored on shelves to facilitate cleaning.

Based on the facility policy "Personnel Standards" last reviewed on 7/30/19, indicated that dietary staff shall follow sanitary standards.

Based on the facility policy "Dish Machine Temperatures (low temperature machines) and Sanitizer Testing" last reviewed on 7/30/19, indicated that dish machine temperatures requirements are wash and rinse 120-140 degrees(120 degrees minimum) and sanitizer strength at 50 ppm.

During an observation on 9/16/19, at 7:15 a.m. the facility deep freezer had multiple boxes stored on a broken pallet on the floor leaving the boxes smashed and lying partially on the floor.

During an observation on 9/16/19, at 7:22 a.m. of the small freezer, a styrofoam drinking cup containing soda and ice cubes was lying inside of cooler.

During an observation on 9/16/19, at 7:38 a.m. of the floor between the coffee maker and freezer the drain cover was loose and uneven which caused water to pool and not flow down the drain.

During an observation of tray line service on 9/16/19, from 7:41 a.m. through 8:30 a.m. Dietary Cook Employee E3 and Dietary Aide Employee E4 started trayline without washing hands before serving.

During the observation the following occurred:

Dietary Employee E3 left trayline to get items from areas of the kitchen and upon return to trayline, changed gloves without handwashing.

Dietary Aide Employee E4 placed silverware, salt/pepper, drinks on trays, placed lids on trays and took carts to deliver to units and upon return to trayline, did not wash hands.

During an observation on 9/18/19, at 11:39 a.m. the dish machine log dated September 2019, was reviewed with the Certified Dietary Manager (CDM). The temperatures on the log were less than 120 degrees daily for each meal 12 out of 18 days.

During an interview on 9/18/19, at 12:15 p.m. the CDM confirmed all above observations and confirmed the facility failed to maintain the dishmachine temperatures and sanitizing testing, failed to store food to prevent contamination, and failed to serve food in a sanitary manner.

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


 Plan of Correction - To be completed: 10/24/2019

The dietary staff were immediately educated on handwashing. The boxes were immediately removed from the floor, the drinking cup was immediately disposed of. The floor between the freezer and coffee maker has been repaired. The dish machine log cannot be retroactively correct, the staff was immediately educated on what to do if the dish machine temperatures are less than 120 degrees.

The facility will store food in a sanitary manner to prevent cross contamination during tray line and will monitor dishwasher temperatures and sanitizer testing levels.

Dietary staff were re-educated by the dietary manager/designee that food will be maintained, stored, prepared and served in a sanitary manner. Handwashing and glove change re-education was completed for the dietary staff by the dietary manager/designee. The kitchen staff were re-educated on the dish machine temperature requirements and what to do if the temperature is below 120 degrees by dietary manager/designee.

The Dietary manager/designee will monitor the dish machine temperature log and do handwashing audits daily for 2 weeks, weekly for 2 weeks, and then monthly for 3 months. The Nursing Home administrator/designee will do a kitchen audit weekly for 4 weeks then monthly for 3 to ensure proper kitchen sanitation and storage is maintained.
Results of audits will be presented to the Quality Assurance Performance Improvement Committee Meeting to make further recommendations and ensure ongoing compliance.
483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:
Based on observation and staff interview, it was determined that the facility failed to maintain resident dignity for two of two residents (Resident R20 and R26).

Findings include:

During an observation on 9/16/19, at 8:39 a.m. Resident R20 had a sign above the bed indicating "No BP's (blood pressure) In Lt (left) Arm."

During an observation on 9/16/19, at 8:40 a.m. Resident R26 had a sign above the bed indicating "No Straws."

During an interview on 9/17/19, at 10:35 a.m. the Director of Nursing confirmed the signs above resident beds did not provide dignity for Residents R20 and R26.

28 Pa. code: 201.29(j) Resident rights.
28 Pa. Code: 211.10(a)(b)(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(4) Nursing services.




 Plan of Correction - To be completed: 10/24/2019

The signage was removed from R20 and R26 to maintain their dignity and privacy.

The Director of Nursing/designee will check current resident rooms to ensure there is not signage posted.

The DON/designee will re-educate the nursing staff on dignity and resident rights related to posting signs regarding care needs in visible areas.

The nursing home administrator/designee audit five resident rooms weekly for 4 weeks and monthly for 3 months to ensure resident dignity and resident rights are being maintained. Results of audits will be presented to the Quality Assurance Performance Improvement Committee Meeting to ensure ongoing compliance.
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 an observation and staff interview, it was determined that the facility failed to maintain a safe comfortable homelike environment in one of two shower rooms (300 hall shower room).

Findings include:

During an observation on 9/16/19, at 11:36 a.m. of the shower room in 300 hall the following was observed:

The wheelchair scale is placed at the entrance of the shower room which created a potential tripping hazard.

Shower stalls from left to right:
#1 had black substance and missing tiles on floor and up edges of wall
#2 had black substance on floor and edges of wall.
#3 broken faucet and black substance on floor
#4 tiles loose on walls and black substance on floor and wall edges.

During an interview on 9/16/19, at 11:39 a.m. Nurse Aide (NA) Employee E1 and NA Employee E2 confirmed that the facility failed to maintain a safe homelike environment in the shower room.

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


 Plan of Correction - To be completed: 10/24/2019

The wheelchair scale was immediately moved upon discovery. The shower rooms have been cleaned and identified areas were corrected. The faucet and tiles were replaced.

The facility will maintain a safe, clean, comfortable and homelike environment for residents.

The Nursing Home Administer/designee will re-educate facility staff on maintaining a safe, clean, comfortable and home like environment for residents.

The nursing home administrator/designee will audit resident care areas weekly for 4 weeks and monthly for 3 months to ensure the facility maintains a homelike and safe environment. Results of audits will be presented to the Quality Assurance Performance Improvement Committee Meeting to make further recommendations and ensure ongoing compliance.
483.25 REQUIREMENT Quality of Care: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 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 review of facility policy and clinical records and interview with staff, it was determined that the facility failed to adequately assess and monitor a resident with a change in condition for one of three residents (Resident R27) and failed to provide services for one of three residents receiving hospice (Resident R48).

Findings include:

A review of the facility policy "Protocol - when to call the doctor" dated 7/30/19, indicated the nurse will obtain information, note any changes, and continue to monitor a resident for a change in condition.

A review of the facility policy "Hospice Care" dated 7/30/19, indicated all hospice assessments, plans of care, progress notes and services provided will be maintained in the medical record and nursing staff will ensure there is a current physician order.

A review of the clinical record revealed Resident R27 was admitted to the facility on 11/5/14, with diagnoses that included heart failure, and morbid obesity. A review of the minimum data set (MDS - periodic assessment of care needs) dated 8/2/19, indicated the diagnoses remain the same and Resident R27 is alert and oriented.

During an observation and interview on 9/18/19, at 9:00 a.m. noted a large ecchymotic (bruise) to left dorsal (top) hand. Resident R27 stated I got a shot there several weeks ago and it was very painful at the time. Stated it has gotten better, but it is still painful.

A review of the progress note dated 9/4/19, indicated a bruise to left hand from bloodwork.

The clinical record did not include assessment, treatment, or monitoring of the residents left hand injury.

During an interview on 9/18/19, at 11:20 a.m. the Director of Nursing (DON) confirmed the above findings that the clinical record did not include a nursing assessment and monitoring for change in condition related to a bruised left hand for Resident R27.

A review of the clinical record revealed that Resident R48 was admitted to the facility on 1/10/18, with diagnoses that included dementia and high blood pressure. A review of the MDS assessment dated 8/17/19, indicated the diagnoses remain current and Resident R48 is on hospice.

A review of a physician order dated 6/18/19, indicated to consult hospice services for evaluation.

A review of Resident R48's care plan dated 8/21/19, indicated hospice services were being provided.

A review of a nurses note dated 8/21/19, indicated Resident R48 was receiving hospice services.

A review of Resident R48's clinical record did not include a physician order for hospice, evidence of the completed consult for hospice, hospice assessments, and hospice progress notes of services provided.

During an interview on 9/19/19, at 1:00 p.m. the DON confirmed the above findings and the facility failed to to adequately assess and monitor a resident with a change in condition for Resident R27 and failed to provide hospice services for Resident R48.

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



 Plan of Correction - To be completed: 10/24/2019

Resident R27's bruise faded and healed. Resident R27 suffered no adverse effects. Bruises are investigated for origin and prevention, and incident reports are completed. Weekly skin assessments are completed, as well as when an area is identified. Areas identified are reviewed on our 24 hour report. Resident R48's physician was notified and an order for hospice was obtained. Hospice progress notes and assessments were placed on resident R48's chart.

The Medial Records Director/designee will review current resident hospice charts to ensure current hospice orders, progress notes and assessments are in the medical record.

The DON/designee will re-educate the licensed nursing staff on the facility policy for protocol when to call physician and hospice care. The Director of Nursing/designee will re-educate hospice staff on needing hospice progress notes and assessments after each visit in the chart.

The Medical records coordinator/designee will audit the hospice charts weekly for four weeks then monthly x3 to ensure all hospice notes and orders are present in the resident's record. The DON/designee will review report 5x a week x 2 weeks, weekly x 2 weeks, then monthly x 3 months to ensure that changes in condition have had the appropriate assessment and follow up to physicians. Results of audits will be presented to the Quality Assurance Performance Improvement Committee Meeting to make further recommendations and ensure ongoing compliance.
483.65(a)(1)(2) REQUIREMENT Provide/Obtain Specialized Rehab Services: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.
483.65 Specialized rehabilitative services.
483.65(a) Provision of services.
If specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as set forth at 483.120(c), are required in the resident's comprehensive plan of care, the facility must-

483.65(a)(1) Provide the required services; or

483.65(a)(2) In accordance with 483.70(g), obtain the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in any federal or state health care programs pursuant to section 1128 and 1156 of the Act.
Observations:
Based on a review of facility policy and clinical records, and resident and staff interview, it was determined that the facility failed to provide specialized rehabilitative services for one of three residents (Resident R53).

Findings Include:

A review of the facility policy "Restorative Nursing Program" dated 7/30/19, indicated restorative nursing will be provided to residents as deemed appropriate.

A review of the clinical record revealed that resident R53 was admitted to the facility on 6/20/17, with diagnoses that included heart failure, diabetes, and morbid obesity. A review of the minimum data set (MDS-periodic assessment of care needs) dated 8/20/19, indicated the diagnoses remain current and Resident R53 is alert and oriented.

During an interview on 9/16/19, at 9:00 a.m., Resident R53 stated that restorative nursing rehabilitation is not given as ordered.

A review of a physician order dated 9/9/19, indicated RNP (restorative nursing program) AROM (active range of motion) to bilateral upper and lower extremities 10 repetitions and 3 sets on the edge of the bed daily.

A review of the "Nursing Rehabilitation Active Range of Motion" documentation indicated Resident R53 did not receive active rehabilitation on 9/10, 9/12, 9/13, 9/14, 9/15, 9/16, and 9/17/19.

During an interview on 9/18/19, at 1:15 p.m. the Director of Nursing confirmed the above findings and the facility failed to provide specialized rehabilitative services for one of three residents (Resident R53).

28 Pa Code: 201.18(e)(1) Management.
28 Pa. Code: 211.10(c)(d) Resident care policies.



 Plan of Correction - To be completed: 10/24/2019

The restorative care cannot be retroactively completed for R53. The resident has not suffered any negative outcomes from the exercises not being performed as ordered.

The facility will provide specialized rehabilitative services to residents, overseen by the DON. Reviews will be done through our restorative meetings.

The DON/designee re-educated the nursing staff on the restorative nursing program, and documentation of the care provided.

The DON/designee will audit restorative documentation 5 times per week for 2 weeks, weekly for 2 weeks and then monthly for 3 months to ensure that restorative plans are being completed and documented. Results of audits will be presented to the Quality Assurance Performance Improvement Committee Meeting to make further recommendations and ensure ongoing compliance.

201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:
Based on review of facility infection control surveillance and staff interview, it was determined that the facility failed to comply with the following requirements of MCARE Act 403(a)(1)(ix).

Findings include:

MCARE Act, Section 403(a)(1), 40 P.S. 1303.403(a)(1) - Infection Control Plan, states:
(a) Development and compliance - Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of patients and health care workers and shall include:
(1) A multidisciplinary committee including representatives from each of the following, if applicable to the specific health care facility:
(i) Medical staff that could include the chief medical officer or the nursing home medical director.
(ii) Administration representatives that could include the chief executive officer, the chief financial officer or the nursing home administrator.
(iii) Laboratory personnel.
(iv) Nursing staff that could include a director of nursing or a nursing supervisor.
(v) Pharmacy staff that could include the chief of pharmacy.
(vi) Physical plant personnel.
(vii) A patient safety officer.
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility or ambulatory surgical facility.

A review of the facility infection control surveillance (tracking of all infections within the facility in an effort to identify trends or to prevent further infections from developing) and the Quality Assurance Committee meeting minutes for calendar year 2019, did not include documentation that the facility had a patient safety officer as a part of the interdisciplinary Quality Control Committee for January through September 2019.

During an interview on 12/16/16, at 1:50 p.m. the Director of Nursing confirmed that the Quality Assurance Committee meetings did not include a patient safety officer for January through September 2019.



 Plan of Correction - To be completed: 10/24/2019

The facility cannot retroactively correct that the Patient Safety Officer was not present at the Quality Control Committee from January through September. There were no negative effects on the residents noted.

The Quality Control Committee sign in sheets have been updated to include the Patient Safety Officer.

The Patient Safety Officer will be re- educated by the Nursing Home Administer/designee on their role and attendance at the infection control meeting.

The Nursing Home Administrator/Designee will audit the Infection Control Committee meeting attendance monthly to ensure the Patient Safety Officer has attended the Infection Control meeting. Results of audits will be presented to the Quality Assurance Performance Improvement Committee Meeting to make further recommendations and ensure ongoing compliance.

209.8(a) LICENSURE Fire Drills.:State only Deficiency.
(a) Fire drills shall be held monthly. Fire drills shall be held at least four times per year per shift at unspecified hours of the day and night.
Observations:
Based on a review of facility fire drill reports and staff interviews, it was determined that the facility failed to conduct monthly fire drills at least four times a year per shift for one of twelve months (October 2018).

Findings include:

A review of the facility fire drill reports for the first quarter of 2018 did not include a fire drill on the evening shift of 10/31/2018.

During an interview on 9/18/19, at 2:30 p.m. the Nursing Home Administrator confirmed the above findings and that the facility failed to conduct monthly fire drills at least four times a year per shift.


 Plan of Correction - To be completed: 10/24/2019

The documents for the 10/31/18 evening shift cannot be located.

The facility will conduct monthly fire drills per the regulation.

The Nursing Home Administrator/designee will re-educated the maintenance staff on conducting monthly fire drills and of those monthly drills they will occur on "off shifts" quarterly at least 4 times per year and maintain documentation both of time/place/and those individuals involved.

The Nursing Home Administrator/designee will audit the fire drill logs monthly to ensure a fire drill has been completed and meets the off shift requirements. Results of audits will be presented to the Quality Assurance Performance Improvement Committee Meeting to make further recommendations and ensure ongoing compliance.

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