Pennsylvania Department of Health
 LAFAYETTE MANOR, INC.
Patient Care Inspection Results

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LAFAYETTE MANOR, INC.
Inspection Results For:

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LAFAYETTE MANOR, INC. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to five complaints completed on May 24, 2024 it was determined that LaFayette Manor, Inc. 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 REQUIREMENT Free from Misappropriation/Exploitation: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.
§483.12
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.
Observations:
Based on a review of facility policy, clinical records, and incident investigation documents, it was determined that the facility failed to ensure that residents are free from misappropriation of property for 12 of 15 residents (Resident R1, R2, R3, R4, R, R6, R7, R8, R9, R10, R11, R12). This was identified as past non-compliance.

Findings include:

Review of the facility "Abuse Prevention Policy and Procedure" dated 8/17/23, indicated that the facility will assure that the resident is free from misappropriation of property, which the policy defined as, "the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident's belongings or money without the resident's consent.

Review of facility investigation of medications signed out by LPN Employee E1 form 5/10/24, at 1:45 p.m. through 5/11/24, at 7:15 a.m. revealed the following:

-Resident R1 had three pills of oxycodone/apap (commonly referred to as Percocet, an opioid pain medication used to treat moderate to moderately severe pain) 7.5/3.5 mg signed out, but not administered.
-Resident R2 had two pills of tramadol (commonly referred to as Ultram, an opioid pain medication used to treat moderate to severe pain) 50 mg signed out, but not administered.
-Resident R3 had one pills of tramadol 50 mg signed out, but not administered and three pills of hydrocodone/APAP (commonly referred to as Vicodin, an opioid pain medication used to treat moderate to severe pain) 5/325 singed out, but not administered.
-Resident R4 had three pills of oxycodone IR (an immediate release opioid pain medication used to treat moderate to severe pain) 5 mg signed out, but not administered.
-Resident R5 had one pill of tramadol 50 mg signed out, but not administered.
-Resident R6 had one pill of oxycodone IR 5 mg signed out, but not administered.
-Resident R7 had one pill of tramadol 50 mg signed out, but not administered.
-Resident R8 had one pill of tramadol 50 mg signed out, but not administered.
-Resident R9 had one pill of oxycodone IR 5 mg signed out, but not administered.
-Resident R10 had two pills of tramadol 50 mg signed out, but not administered.
-Resident R11 had one pill of tramadol 50 mg signed out, but not administered.
-Resident R12 had one pills of hydrocodone/APAP 5/325 singed out, but not administered.

Review of the facility investigation summary indicated "On 5/11/24, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified of controlled medication discrepancies involving one resident. DON and nursing supervisors conducted an audit of controlled substance documentation and identified 21 discrepancies involving 12 residents from 5/1024, through 5/11/24, with one LPN (licensed practical nurse) identified as not completing documentation on EMAR (electronic medication administration record)but signed off on controlled substance count sheet. Five alert and oriented residents were interviewed by nursing supervisor, four residents reported that they did not receive pain medications. One resident was unsure if received pain medications. DON contacted LPN in question on 5/11/24, LPN was not able to come to facility on this date. State police notified and conducted an investigation. Residents were interviewed by police."

The conclusion of the investigation revealed, "LPN suspended until investigation completed. Terminated from position. State board of licensure was notified, scheduled to come to facility for investigation.

On 5/11/24, the facility initiated a plan of correction that included:
-Suspension and subsequent termination of LPN Employee E1.
-State board of licensure notified.
-Abuse, neglect, misappropriation, exploitation education completed for all staff members.
-Human Resources director completed audit of new hire abuse training.
-Facility audit of controlled substance documentation.

Review of an employee statement written by Registered Nurse (RN) Employee E2 dated 5/11/24, indicated, "On 5/11/24, I was assigned as RN supervisor. [RN Employee E3] brought to my attention that the nurse working the previous shift [LPN Employee E1], signed out a narcotic from the control drug record on the "1st floor blue cart" but did not sign it out as administered in the eMar. As [RN Employee E3] and I looked through her controlled drug record we discovered that multiple narcotics were signed out by [LPN Employee E1] 5/10 - 5/11 and not documented in the eMar. [LPN Employee E1] had worked the previous two shifts on the 1st floor (5/10/24, at 1:45 p.m. to 5/11/24, at 7:15 a.m.). LPN Employee E4 was working on the "1st floor green cart" and identified the same concern that [LPN Employee E1] signed out narcotics from the control drug record but not the eMar during the same time frame 5/10-5/11. Suspecting narcotic diversion, I notified the DON who advised that I notify the state police immediately and she would be at the facility to continue investigating. I called the state police. Trooper arrived to investigate and interviewed five alert and oriented residents in my presence, that all had narcotics signed out of the narcotic drug record but not the eMar. All residents were agreeable to speaking with the Trooper. Residents were [Resident R4, R12, R2, R3, and R13]. Trooper asked the residents if they requested or were given the specific medication, one resident [Resident R13] said "I don't know." DON arrived at the facility and continued the investigation."

Review of an employee statement written by RN Employee E3 dated 5/11/24, indicated, "I was passing medications at approximately 8:00 a.m. when I noticed that a narcotic for a resident was signed out in the narcotic book but was not signed that it was given in Point Click Care, (PCC, the electronic charting system). I continued my med pass and again notice that another narcotic on another residents was signed out in the narcotic book bot not in PCC. At that time I thought it best to check each of the resident's narcotics to look for the same discrepancy. That is when I noticed the same occurrence on multiple residents. I made my supervisor aware and we spoke with some of the residents whose medications were involved. At that time the police were notified along with the DON."

The conclusion of the investigation was documented, "LPN suspended until investigation completed. Terminated from position. State board of licensure was notified, scheduled to come to facility for investigation.

On 5/11/24, the facility initiated a plan of correction that included:
-Suspension and subsequent termination of LPN Employee E1.
-State board of licensure notified.
-Human Resources director completed audit of new hire abuse training.
-Facility comprehensive audit of controlled medication administration for all residents.
-Pain assessments completed for residents identified with medication discrepancies.
-Education of controlled substance policy and medication administration policy to licensed nursing staff.
-Abuse, neglect, misappropriation, exploitation education completed for all staff members.
-Ad hoc QAPI (Quality Assurance and Performance Improvement) meeting conducted to review findings and identify additional actions necessary.
-Controlled substance audits initiated, five times per week.

During interviews completed on 5/17/24, seven staff members confirmed that they were provided abuse, neglect and misappropriation education.

During interviews completed on 5/17/24, three licensed nursing staff confirmed they were provided controlled substance policy and medication administration policy education.

During an interview on 5/21/24, at 4:30 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that residents are free from misappropriation of property for 12 of 15 residents who are ordered controlled medications.

28 Pa. Code 211.5(f)(g) Clinical records.

28 Pa. Code 211.9(a)(1)(k) Pharmacy services.

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


 Plan of Correction - To be completed: 06/05/2024

Past noncompliance: no plan of correction required.
483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff: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.
§483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

§483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:
Based on review of facility policy, resident observations, resident interviews and confidential staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of six of twelve residents (Resident R6, R14, R15, R16, and R17).

Findings Include:

Review of the facility policy "Activities of Daily Living" dated 8/17/23, indicated "Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene."

During an interview and observation on 5/17/24, at 1:45 p.m. Resident R14 was noted to have long, jagged fingernails. When asked, Resident R14 confirmed that she would like her nails clipped.

During an interview on 5/17/24, at 2:50 p.m. Resident R15 stated that call lights may be long, and on evening shift her medications are often late, depending on the nurse.

During an interview on 5/17/24, at 3:06 p.m. Resident R2 stated that she only gets showers once per week, and that it is her preference to have two showers per week. Resident R2 also stated that call lights can "take a while."

During an interview and observation on 5/17/24, at 3:07 p.m. Resident R1 stated, when asked about call light response, "It depends." Resident R1 was noted to have unbrushed, greasy-appearing hair.

During an interview on 5/24/24, at approximately 10:30 a.m Resident R6 stated that she was left on the bedside commode for an hour. "I was waiting and waiting and they never came after me." When asked if she had been in pain after being left so long on the commode, Resident R6 stated, "Oh, yes. My butt hurt so bad. They said they had 43 people to take care of, they didn't have enough help."

Review of a grievance filed by Resident R16 on 2/22/24, stated that staff were not assisting him to get out of bed for therapy and that he waited over one hour for his pain medication.

Review of a grievance filed by Resident R17 on 3/11/24, stated that the nurse aide failed to provide incontinence care when requested. Resident R17 was documented to have stated that she "knows facility is understaffed due to two call off this date." Resident R17 was then documented to have stated that the nurse aide "does not need to take it out on her."

Review of Resident Council minutes dated 2/19/24 indicated concerns about call light response.

Review of Resident Council minutes dated 3/28/24 indicated concerns long waits for bathroom assistance, call lights responses of over one hour, and call lights being turned off without caring for the resident's needs.

Review of Resident Council minutes dated 4/25/24, indicated concerns call lights being turned off without caring for the resident's needs.

During an interview on 5/24/24, 10:00 a.m. the Nursing Home Administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of six of twelve residents.

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

28 Pa. Code 201.18(e)(6) Management.

28 Pa. Code: 201.20(a) Staff development.

28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.


 Plan of Correction - To be completed: 07/02/2024


1. R6 skin assessment completed. No open areas noted. Resident assessed for toilet use
R14 finger nails trimmed and filed
R 15 medication times reviewed to accommodate needs of resident
R2 shower preference reviewed with resident and shower schedule adjusted to meet resident preference
R1 had hair washed and brushed
R16 was discharged from facility
R17 interviewed by Director of Nursing / designee regarding needs being met

2. Director of Nursing / designee will complete audit of current residents for proper grooming, nail care, routine and pain medication administration and timely incontinence care/bathroom assistance
3. Director of Nursing / designee will educate nursing staff on providing activity of daily living care to residents, call bell response, routine and pain medication administration and timely incontinence care/bathroom assistance
4. Audits of call bell response, resident grooming, routine and pain medication administration timing and timely incontinence care/bathroom assistance will be completed by Director of Nursing / designee 3x week x 4 weeks and monthly x2 months
5. Results will be reviewed through Quality assurance committee

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, clinical record review, and resident and staff interview, it was determined that the facility failed to follow physician orders for medication administration for one of five residents reviewed (Resident R14).

Findings include:

Review of the facility's policy, "Administering Medications," dated 8/17/23, indicated that medications shall be administered in a safe and timely manner, and as prescribed.

Review of the clinical record indicated Resident R14 was admitted to the facility on 10/7/23.

Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/10/24, included the diagnoses of anemia (too little iron in the body causing fatigue), chronic kidney disease (gradual loss of kidney function), and cancer. Review of Section O: Special Treatments, Procedures, and Programs revealed the Resident R14 had received chemotherapy within the previous 14 days of the assessment.

Review of Resident R14's medication administration record (MAR) dated April 2024, revealed the following:

4/2/24, 2:00 p.m. Gabapentin (nerve pain): documented as "9" ("9" is code for Other/See Nurse Notes).
4/2/24, 2:00 p.m. Rytary (Parkinson's): documented as "9."

Review of the associated progress note dated 4/2/24, at 3:48 p.m. indicated, "Has not returned from chemo yet."

Review of a progress note dated 4/2/24, at 4:44 p.m. indicated, "Resident returned from chemo at this time."

Further review of Resident R14's physician orders, MAR, and progress notes failed to reveal if the physician had previously addressed when medications missed while the resident was out to chemotherapy should be provided, if the physician was contacted by the facility for the missed medication, and whether the resident received the missed medications.

4/9/24, 2:00 p.m. Gabapentin: documented as "3" ("3" is code for Drug Refused).
4/9/24, 2:00 p.m. Rytary: documented as "3."
4/10/24, 2:00 p.m. Gabapentin: documented as "3."
4/10/24, 2:00 p.m. Rytary: documented as "3."

Review of a progress note dated 4/9/24, at 3:57 p.m. indicated, "Resident returned to [facility]."

Review of a progress note dated 4/10/24, at 6:01 p.m. indicated, "Returned to [facility] via wheel/chair van."

Review of Resident R14's MAR dated May 2024, revealed the following:

5/7/24, 8:00 a.m. mediations (amantadine, calcium carbonate, Cholecalciferol, gabapentin, Lasix, Lexapro, and Rytary) documented as "9".

Review of the associated progress note dated 4/2/24, at 3:48 p.m. indicated, "NPO (meaning nothing by mouth)."

Review of a progress note dated 5/7/24, at 6:20 p.m. indicated, "received call from [Resident R14's] daughter, daughter stated that her mother was upset because she did not receive her medications this am upon return from her PET scan, resident was out of the building from 6:50 am until 9:40 am, this nurse did speak with resident, resident told this nurse that she did not get her morning meds, med list reviewed with [Resident R14] at this time, was noted that there were four am meds that she had not received this day-Lasix, Tums, vitamin D supplement and Lexapro, all other am meds are scheduled more than once daily and she has received the afternoon and evening doses of those medications, [Resident R14] was requesting that the medications that she did not receive this am be given at this time, CRNP (Certified registered nurse practitioner) made aware and new order received to give one time dose of the four meds mentioned above. will give this evening. [Resident R14] informed, also daughter informed."

During an interview on 5/17/24, at approximately 3:30 p.m. the Nursing Home Administrator confirmed that on 4/2/24, the facility failed to address if or when the medications missed while Resident R14 was at chemotherapy would be provided, confirmed that on 4/9/24, and 4/10/24, that facility staff documented that Resident R14 refused her medications while she was not in the facility to have done so, and on 5/7/24, the facility failed to address if Resident R14 could have her medications prior to her PET scan, which is often the case, and failed to address what medications could be provided upon return to the facility after the pet scan.

During an interview on 5/17/24, at approximately 3:35 p.m. the Nursing Home Administrator confirmed that the facility failed to follow physician orders for medication administration for one of five residents reviewed.

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


 Plan of Correction - To be completed: 07/02/2024

1.R 14 medications reviewed and times adjusted to accommodate appointments
2.Residents with routine appointments had medications reviewed and times adjusted as indicated
3.Director of Nursing/ designee educated Licensed staff on medication time adjusted to accommodate appointments
4.Director of Nursing / designee will Audit medication administration weekly for 4 weeks and monthly for 2 months
5.Results will be presented to Quality Assurance committee

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 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 a review of CDC (U.S. Centers for Disease Control and Prevention) documents, facility policy, clinical record review, observations and staff interviews, it was determined that the facility failed to maintain infection control procedures to prevent the possible transmission of communicable diseases for one of three residents (Resident R14).

Review of the CDC document, "Neutropenia and Risk for Infection" dated 2/26/24, defined neutropenia as the decrease in the number of white blood cells, the body's main defense against infection, and further stated that neutropenia is common after receiving chemotherapy and increases the risk for the development of infection.

The facility policy "Transmission Based Precautions" dated 8/17/23, indicated "facility strives to maintain a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by utilizing the least restrictive precautions or isolation for the resident under certain circumstances." "Transmission-Based Precautions, in addition to Standard Precautions, are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents."

Further review of the policy failed to include information related to neutropenic isolation precautions (precautionary steps to prevent an resident with a suppressed immune system from contracting infections from staff or visitors). Precautions can include a notice placed on the door to alert people entering the room, instructions to wash hands with soap and water and/or wearing gloves, wearing a mask, leaving reusable equipment in the room, and being given or not given specific foods.

Review of the clinical record indicated Resident R14 was admitted to the facility on 10/7/23.

Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/10/24, included the diagnoses of anemia (too little iron in the body causing fatigue), chronic kidney disease (gradual loss of kidney function), and cancer. Review of Section O: Special Treatments, Procedures, and Programs revealed the Resident R14 had received chemotherapy within the previous 14 days of the assessment.

Review of a physician's order dated 4/22/24, indicated "Neutropenic Precautions."

Review of Resident R14's plan of care initiated on 2/26/24, indicated Resident R14 has a diagnosis of breast cancer and was receiving chemotherapy. Further review of her care plan failed to include information related to neutropenic precautions.

Review of Resident R14's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff dated 5/17/24, failed to include information related to neutropenic precautions."

During an observation on 5/17/24, at 1:45 p.m. signage was posted on Resident R14 door indicating the need to wear gloves and a mask. A set of plastic drawers were located in the hallway next to Resident R14's door. Observation of the drawers revealed there were only clear face shields available, no gloves or masks.

During an interview on 5/17/24, at 1:46 p.m. LPN Employee E5 confirmed that she was aware that neutropenic precautions are to prevent transmission of infection to the resident, not from the residents, and further confirmed that a face shield would not be effective to prevent the transmission of infection and that gloves and masks were not available at Resident R14's doorway.

During an observation on 5/17/24, at 2:43 p.m. Nurse Aide Employee E6 was observed entering Resident R14's room without wearing gloves or a mask.

During an interview on 5/21/24, at the Nursing Home Administrator confirmed the facility failed to maintain infection control procedures to prevent the possible transmission of communicable diseases for one of three residents.

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

28 Pa. code: 211.12(d)(1)(5) Nursing services.


 Plan of Correction - To be completed: 07/02/2024

1. R 14 personal protective equipment was stocked and sign maintained for neutropenic precautions
2. Employee 6 was educated on wearing appropriate personal protective equipment when caring for residents in neutropenic precautions.
3. Comprehensive audit completed by director of Nursing / designee for proper personal protective equipment for residents in neutropenic precautions
4. Director of nursing / designee educated staff on proper personal protective equipment for residents in neutropenic precautions.
5. Director of Nursing / designee will complete audits for proper personal protective equipment use for residents in neutropenic precautions 3x week x 4 weeks and monthly x 2 months
6. Results will be reviewed through Quality assurance committee

51.3 (e) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(e) If a health care facility is
aware of information which shows that
the facility is not in compliance with
any of the Department's regulations
which are applicable to that health
care facility, and that the
noncompliance seriously compromises
quality assurance or patient safety,
it shall immediately notify the
Department in writing of its
noncompliance.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for the failure to comply and the
steps which the health care facility
shall take to bring it into compliance
with the regulation.
Observations:
Based on a review of Pennsylvania Department of Health (PADOH) guidance memo, the PADOH Event Reporting System (ERS), clinical records, and staff interview, it was determined that the facility failed to notify the PADOH of reportable incidents.

Findings include:

Review of PADOH "COVID-19 Infection Control and Outbreak Response Toolkit for Long-Term Care" dated July 2023, indicated that nursing care facilities must report information about staff and residents that test positive for COVID-19 daily.

Review of facility reported events/incidents entered between 12/10/23, through 2/10/24, included reports of 14 residents who tested positive for COVID-19.

Review of the facility provided line-list of COVID-19 positive residents from 12/10/23, through 2/10/24, revealed 42 residents tested positive for COVID-19.

During an interview on 5/20/24, at 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to notify the DOH of reportable incidents.


 Plan of Correction - To be completed: 07/02/2024

1.Covid positive Residents identified during survey were reported to The PADOH via electronic reporting system
2.Nursing Home Administrator educated Director of Nursing and Assistant Director of Nursing on reportable disease reporting
3.Department of health notifications will be printed upon submission and monitored through infection control practices
4.Covid outbreaks will be reviewed through Quality assurance monthly


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