Pennsylvania Department of Health
YEADON REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

YEADON REHABILITATION AND NURSING CENTER
Inspection Results For:

There are 219 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


YEADON REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey completed on June 27, 2024 at Yeadon Rehabilitation and Nursing Center it was determined that facility 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 as they relate to the Health portion of the survey.

Plan of Correction:

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Plan of Correction - To be completed: 07/03/2024

R 130's tracheostomy appliance was reinserted on June 25, 2024. Resident was assessed by nurse practitioner and pulmonologist on June 25, 2024. Resident was stable with no physical distress noted.
Employee involved in the incident was suspended pending investigation on June 25, 2024.

Current residents with tracheostomy care needs were assessed on June 25, 2024, to ensure equipment was present and tracheostomy was in place and stable.

In-service was initiated on June 25, 2024, with licensed staff in the building and was completed with all other staff on July 3, 2024.

DON or designee will conduct 5 weekly observations of tracheostomy care being completed x 2 months. Results will be reviewed during facility's monthly QAPI meeting.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:

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(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.

Observations:

Based on observation, staff interview and review of facility policy, it was determined that the facility failed to ensure that personal privacy was maintained related to patient care and tracheostomy care for one of 35 residents observed. (Resident R130)

Findings include:

Review of facility policy on "Dignity" dated April 1, 2022, reveal that under section Policy: "each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Under section "Policy Interpretation and Implementation" #11. Staff shall promote, maintain, and protect residents' privacy, including bodily privacy, during assistance with personal care and during treatment procedures.

Observation of tracheostomy care conducted on June 25, 2024, at 12:36 p.m. with Licensed nurse, Employee E14 and Unit Manager, Employee E15 and in the presence of Resident R130's husband revealed that Resident R130's bed was located close to the door and her roommate's bed was located closest to the window.

Further observation revealed that Resident R130's privacy curtain on the side of her bed facing the door (Resident R130's right side) was open and the curtain on the side of her bed facing the window (Resident R130's left side) was half closed. Resident R130's roommate was in bed and awake at the time of the observation. Employee E15 and resident's husband were standing talking to each other inside the room close to the door. Employee E14 was standing on the side of the bed closest to the window (Resident R130's left side). She was facing the door and Surveyor was standing at the foot of the bed facing Resident R130.

Further observation revealed that, Licensed nurse, Employee E14 started preparing the tracheostomy supplies in Resident R130 overhead table located on the side of the bed closest to the window (Resident R130's left side) and started the tracheostomy care without closing the privacy curtain. Further, Resident R130's door was open, and Resident can be seen from the hallway through the open door.

Interview with Licensed nurse, Employee E14 conducted at the time of the observation revealed that she was extremely nervous, which made her make the mistakes. Further, Licensed nurse, Employee E14 revealed that this was not the first time she performed a trach care and that she was just nervous and does not like to be watched which caused her to make the mistakes.

28 Pa. Code 210.29(i) Residents right

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

Plan of Correction - To be completed: 08/12/2024

Nursing staff will be re-educated on facility policy entitled "Dignity" and ensuring personal privacy is maintained related to patient care and tracheostomy care.

The DON or representative will conduct random weekly observations of patient care and tracheostomy care to ensure personal privacy is being maintained x 2 months. Results will be reviewed during facility's monthly QAPI meeting.

483.20(f)(1)-(4) REQUIREMENT Encoding/Transmitting Resident Assessments:

§483.20(f) Automated data processing requirement-
§483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:
(i) Admission assessment.
(ii) Annual assessment updates.
(iii) Significant change in status assessments.
(iv) Quarterly review assessments.
(v) A subset of items upon a resident's transfer, reentry, discharge, and death.
(vi) Background (face-sheet) information, if there is no admission assessment.

§483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.

§483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:
(i)Admission assessment.
(ii) Annual assessment.
(iii) Significant change in status assessment.
(iv) Significant correction of prior full assessment.
(v) Significant correction of prior quarterly assessment.
(vi) Quarterly review.
(vii) A subset of items upon a resident's transfer, reentry, discharge, and death.
(viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment.

§483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.

Observations:

Based on closed clinical record review, review of facility policy and interviews with staff, it was determined that the facility failed to ensure that resident assessments were completed in a timely manner for one of three discharged records reviewed (Residents R77).

Findings include:

Review of the undated facility policy titled "MDS 3.0 Completion" revealed that, "According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI (Resident Assessment Instrument) specified by the State."

Clinical record review for Resident R77 revealed a nursing note written on April 2, 2024, indicating that the resident was discharged in stable condition ambulating independently with daughter, with all belongings, scripts, paperwork and medications.

Further review of the clinical record for Resident R77 revealed an April 2, 2024, MDS (Minimum Data Set, comprehensive assessment of resident) that indicated the discharge status as 04 - Short-Term General Hospital.

Interview on June 27, 2024, at 11:38 a.m., with Employee E16, Resident Assessment Coordinator, confirmed that the resident was discharged with her daughter and the MDS was coded in error.

28 Pa. Code 201.2(a) Requirements

28 Pa. Code 211.5(f) Clinical records

Plan of Correction - To be completed: 08/12/2024

R185s MDS was corrected and resubmitted

Residents discharged within the last 30 days will be audited to ensure the correct discharge destination was entered

MDS staff will be re-educated on facility's policy entitled, "MDS 3.0 Completion- section A."

Lead NAC or designee will complete random weekly audit x 4 weeks of completed MDS to ensure an accurate discharge destination was entered and then monthly x 3 months. Results will be reviewed during facility's monthly QAPI meeting.

483.20(e)(1)(2) REQUIREMENT Coordination of PASARR and Assessments:

§483.20(e) Coordination.
A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes:

§483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care.

§483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.

Observations:

Based on review of clinical records, interview with staff and review of facility policy, it was revealed that the facility failed to revise a resident's PASARR (Pre-Admission Screening and Resident Review) with mental health diagnosis for one of 35 resident's records reviewed (Resident R77).

Findings include:

Review of the facility policy titled, PASARR date on April 1, 2022, stated the facility will coordinate assessment with the pre-admission screening and resident (PASARR) program. Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II residents review upon a significant change in status assessment.

Review of the clinical record on June 25, 2024 for Resident R77 revealed diagnoses that included schizoaffective disorder (schizoaffective -a mental disorder condition mix schizophrenia symptoms by delusions, hallucinations and mood disorder); major depressive disorder (depression-a mood disorder that causes a persistent feeling of sadness and loss of interest); anxiety (anxiety-intense, excessive and persistent worry and fear about everyday situations) and psychotic (psychotic -a mental disorder form of thinking, hallucinations means seeing).

Review of Resident R77's PASARR Level I screen completed on August 15, 2019, failed to indicate the resident's mental health diagnosis. Section III- (Mental Health) indicated serious mental illness diagnoses that include Schizophrenia, Anxiety Disorder, Bipolar disorder Depressive Disorder may lead to chronic disability. Section III-A (related questions related to the resident's diagnoses) answered "No" that the resident does not have a mental health condition or suspect dental health condition that may lead to a chronic disability.

Review resident's new diagnoses schizoaffective disorder, depressive that was add on January 25, 2022, facility failed to update resident's R77 PASSARR with a newly mental disorder and do a significant change in status assessment.

Interview with Social Worker, Employee E4 on June 26, 2024, at 1:40 p.m. confirmed that resident's PASSARR was not update with the new diagnoses.

28 Pa. Code 211.5(f)(iv)(vi) Medical records

Plan of Correction - To be completed: 08/12/2024

R77's PASARR was revised.

Facility will audit current residents' mental health diagnosis to ensure a PASARR in place and accurate.

Social Services and MDS staff will be re-educated on facility's policy entitled, "PASARR," to ensure new diagnosis are reflected on the PASARR as appropriate and that a significant change in status assessment is completed per RAI manual.

Social services or designee will conduct random weekly audits of 3 residents with PASARR's to ensure new diagnosis, if any, are reflected accurately x 2 months.
Social services will conduct random weekly audits of residents that have had a newly added mental health diagnosis to ensure a significant change in status assessment was completed x 2 months.
Results will be reviewed during facility's monthly QAPI meeting.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on observation, record review and interview with staff, it was determined that the facility failed to
develop a resident's care plan related to oxygen therapy for one of 35 clinical records reviewed. (Resident R112).

Findings include:

Observation on June 24, 2024 at 11:00 a.m. revealed Resident R112 in bed receiving oxygen therapy via nasal cannula. Observation of the oxygen concentrator revealed that it was set at 2 liters per minute.

Review of Resident R112's current care plan revealed that there was no care developed for oxygen therapy.

Interview on June 25, 2024 at 2:20 p.m. with Licensed nurse, Employee E19 confirmed that Resident R112's care plan was not updated to include oxygen administration.

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

Plan of Correction - To be completed: 08/12/2024

R112's care plan was updated to reflect 02 use.

Current residents with 02 use will be audited to ensure care plan reflects the 02 therapy.

Licensed staff will be re-educated on facility's policy on care planning including ensuring 02 therapy is care planned.

DON or designee will conduct random weekly audits of 3 residents with 02 to ensure care plan accurately reflects 02 therapy x 2 months. Results will be reviewed during facility's monthly QAPI meeting.

483.25 REQUIREMENT Quality of Care:

§ 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 observation, record review and interviews with staff and resident, it was determined that the facility failed to ensure a physician order was obtained realated to oxygen therapy for one of 35 clinical records reviewed. (Resident R112).

Findings include:

Observation on June 24, 2024 at 11:00 a.m. revealed Resident R112 was in bed and receiving oxygen therapy via nasal cannula.

Review of Resident R112's clinical record did not reveal oxygen therapy was included with physician orders.

Interview on June 25, 2024 at 2:20 p.m. with Employee E19 confirmed that Resident R112 was receiving oxygen therapy without a physician order.

28 Pa Code 211.3(b) Oral and telephone orders

28 Pa Code 211.5(f)(i) Clinical records

Plan of Correction - To be completed: 08/12/2024

A physician's order was obtained for R112 to have 02 therapy

Current residents with 02 therapy will be audited to ensure a physician's order is present.

Licensed nurses will be re-educated on facility's policy entitled "Oxygen Administration" and ensuring a physician's order is present for 02 therapy.

DON or designee will conduct random weekly audits of 3 residents on 02 therapy to ensure a physician is present x 2 months. Results will be reviewed during facility's monthly QAPI meeting.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on observations, review of clinical records and interview with staff, it was determined that facility did not ensure to provide sufficient services to restore bladder function for one of 35 residents reviewed. (Resident R61)

Findings include:

Review of Residents R61's clinical record revealed a medical history of calculus of ureter (kidney stones), benign prostatic hyperplasia with lower urinary tract symptoms, neuromuscular dysfunction of bladder, presence of urogenital implants, urinary tract infections, colostomy status.

During observations of wound care treatment on June 25, 2024, at 10:45 a.m., Resident R61 had bloody urine in the suprapubic catheter. Interview conducted with Licensed nurse, Employee 12 was assigned to care for Resident R61 stated that "it's always been like that..."

Review of R61's nursing notes, dated June 6, 2024, at 3:17 p.m. and June 3, 2024 at 8:33 a.m. indicate that "some sm (small) blood strands noted in urine; unit mgr (manager) aware-will obtain C&S (culture and sensitivity). Already on abt. (antibiotic)."

Review of R61's care plan included interventions for neurogenic bladder status post suprapubic catheter, "monitor/record/report to MD (physician) for s/s (signs and symptoms) UTI (urinary track infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, foul smelling urine,.."

Review of consult request documentation completed by Unit Manager, Employee E18, states "... Is the nephrostomy tube permanent? If not what needs to be done to have it removed? If it is permanent how often does it need to be replaced? Also, is the hematuria normal with this condition?"

Further review of progress notes, dated June 17, 2024 at 4:10 p.m revealed "urology appointment canceled related to transportation issues."

Interview with Regional Nurse, Employee E17, on June 27, 2024 revealed that Unit Clerk, Employee E10, had miscommunication when scheduling for Resident R61's appointment and requested resident to be transported via wheelchair instead of a stretcher resulting in cancelled appointment to see urologist.

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

Plan of Correction - To be completed: 08/12/2024

R61 appointment was rescheduled with correct transportation.

Current residents in need of urology follow up will be audited to ensure timely follow up is scheduled/has occurred.

Medical records director will educate Unit clerks will be re-educated on ensuring correct transportation methods are scheduled based on resident's needs.

DON or designee will conduct random weekly audits of 3 residents with indwelling catheters to ensure urology appointments were scheduled or completed as needed x 2 months. Results will be reviewed during facility's monthly QAPI meeting.

483.25(h) REQUIREMENT Parenteral/IV Fluids:

§ 483.25(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.

Observations:

Based on clinical record review, review of professional literature, review of facility policies and interviews with staff, it was determined that the facility failed to assess a PICC line in accordance with professional practice standards for two of four residents with peripheral central cathether lines (Resident R179).

Findings include:

Review of the undated facility policy, "Documentation Guidelines for Infusion Therapy" revealed that Midline Catheters and PICCs (Peripherally Inserted Central Catheter Line) documentation at established intervals, including the external length of the catheter and the original length of the catheter inserted, and arm circumference to check for edema and rule out deep vein thrombosis.

According to the standards of nursing practice guidelines in the Journal of the American Nurse's Association, dated November 2013, complications of a PICC line (Peripherally Inserted Central Catheter Line, type of IV used for long term use) includes, but is not limited to catheter-tip migration (assessed by external length of the catheter-amount of catheter tubing that is visible outside of the vein moves from original insertion and may cause medical complications).

Clinical record review for Resident R179 revealed that the resident was admitted on June 11, 2024, with a right upper arm PICC Line to be used for IV antibiotic therapy. Further review of the clinical record revealed a June 13, 2024 order for central line/midline change dressing weekly on Thursday; measure external catheter length with each dressing change; measure arm circumference on admission and as needed. Continued review of the clinical progress notes revealed no documentation of external catheter length or arm circumference.

Interview with the Unit Manager on the Transitional Care Unit, Employee E8, on June 2, 2024, at 10:47 a.m. confirmed that the external catheter length and arm circumference should be measured weekly with the dressing change and that it should be documented in the progress notes, and that Resident R179's progress notes do not include this documentation.

Interview with LPN on unit, Employee E9, on June 2, 2024, at 11:25 a.m. confirmed that she did not document the measurements of the arm circumference or the external catheter length since Resident R179 was admitted.

The facility failed to assess a PICC line catheters as ordered by the physician and in accordance with professional practice standards.

28 Pa Code 211.5(f) Clinical records.

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

Plan of Correction - To be completed: 08/12/2024

R179 was discharged.

Current residents with PICC lines will be audited to ensure external catheter length and arm circumference are documented per policy.

DON or or designee will educate Licensed nursing staff on facility's policy entitled, "Documentation Guidelines for Infusion Therapy," including completion and documentation of external catheter length and arm circumference.

DON or designee will conduct random weekly audits of residents with PICC lines to ensure external catheter length and arm circumference are documented per policy x 2 months. Results will be reviewed during facility's monthly QAPI meeting.

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

§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 observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Findings include:

The Policy: "Food Storage", which was dated January 17, 2019, states, "All foods should be covered, labeled and dated" and "Frozen food must be maintained at a temperature to keep the food frozen solid."

An initial tour of the Food Service Department was conducted on June 24, 2024, at 9:45 a.m. with Employee E3, Food Service Director (FSD), which revealed the following:

Observation in the walk-in refrigerator revealed an open box of hot dogs with the inner plastic lining open to the air and no date when product was open.

Observation in the walk-in freezer revealed an internal thermometer reading 17 degrees above zero and there were several food items not frozen solid including donut holes, sausage links and tater tots.

Interview with the FSD on June 24, 2024, at 9:55 a.m. confirmed that these food items should be frozen solid, and that they had recently had a problem with the freezer and had to call a repairman.

A review of the Freezer Temperature Log for June 2024, revealed that on June 19, 2024, the A.M. freezer temperature was 30 degrees and the P.M. freezer temperature was 32 degrees, and the comments section read, "call fridge tech."

Observations in the hot production area of the kitchen near the steamer revealed debris on the floor in the corner and the baseboards were soiled and dirty.

Observations in the dish room revealed a film of dirt on the wall behind the dish counter and under the counter including debris on the floor in the corners and dirty baseboards.

Interview with FSD at 10:15 a.m. on June 24, 2024, confirmed the above findings.

Observations during a follow-up visit on June 26, 2024, at 10:10 a.m. revealed a white PVC pipe above the prep sink covered in a thick layer of dust.

Observation in the walk-in freezer revealed that the inside thermometer was reading 9 degrees above zero and the whipped cream was soft as was the donuts and French fries, and there was an open box of beef liver which was open to the air.

Observation in the kitchen near the toaster revealed a fan with a heavy accumulation of dust and dirt on the surface of the fan blades and grill.

Interview with FSD at 10:25 a.m. on June 24, 2024, confirmed the above findings.

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

28 PA Code: 201.18(e)(1) Management.

28 Pa. Code 201.18(b)(3) Management

Plan of Correction - To be completed: 08/12/2024

Hot dogs, donut holes, sausage links, tater tots, French fries and beef livers were discarded.
Debris on floor near the steamer was removed and baseboards were cleaned.
Dish room floors and walls were cleaned. Debris from the floor was removed and baseboards were cleaned.
PVC pipe above prep sink, fan near the toaster and grill were cleaned.

Dietary director or designee will re- educate employees on facility policy entitled, "Food Storage."

Admin or designee will conduct weekly audits of proper food labeling and storage including freezer temperatures x 2 months.
Admin or designee will conduct weekly audits of the kitchen to ensure floors, baseboards, pipes and fans are free of dust and debris x 2 months.
Results will be reviewed during facility's monthly QAPI meeting.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§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 observation, interview with staff and review of facility policy, it was determined that the facility failed to ensure proper infection control procedures during tracheostomy care for one of one resident observed with a tracheostomy. The facility failed to ensure the proper processing of lines and accessibility to hand washing station in the laundry. (Resident R130)

Findings include:

Review of Facility Policy on Infection Control Program Overview dated October 24, 2022, revealed that under section "Purpose": 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. Under section "Goals": The goal of the infection control program are to provide a safe, sanitary and comfortable environment, prevent the development and transmission of communicable diseases and infections, ensure compliance with state and federal regulations relating to infection control. Under sections "Scope of the infection control program": The infection control program is comprehensive and that it addresses detection, prevention and control of infections among residents, staff, volunteers, visitors and others. Major activities of the program are preventing, identifying, reporting, investigating and controlling infections and communicable diseases for residents, staff volunteers, visitors and others. Under section "Division of responsibilities for infection control activities": The governing body is responsible for the infection control program. Infection Preventionist is responsible to carry out the daily functions of the infection control program. Those functions are described in the Infection prevention is job description. The infection prevention is the required state and federal training.

Observation of tracheostomy care conducted on June 25, 2024, at 12:36 p.m. with Licensed nurse, Employee E14 and Unit Manager, Employee E15, revealed that Licensed nurse, Employee E14 and Unit Manager, Employee E15 had put on personal protective equipment (face shield, gown, and gloves) prior to entering Resident R130's room.

Further observation revealed that Resident R130 had just finished eating lunch. Further, an overhead table with half eaten food, a plastic cup labelled "McDonald's" and a small item wrapped in "McDonald's" wrapper on it was next to Resident R130's bed. Licensed nurse, Employee E14 proceeded to remove the plate with half eaten food, leaving the "Mc Donald's" drink and the item in "McDonald's" wrapper on the table. Employee E14 then proceeded to wipe the half part of the top of the overhead table with sanitizing wipes but did not wipe the the other half top of the overhead table where the "McDonald's" drink and the item wrapped in "McDonald's" wrapper was. Further, Employee E14 started to set-up the tracheostomy care supplies on top of Resident R130's overhead table, next to the "Mc Donald's" food items. After setting up the tracheostomy care supplies, Employee E14 then asked Resident R130 if she could remove the "Mc Donald's" items from the overhead table. With Resident R130's permission, she removed the "McDonald's" items but did not sanitize the area. Employee E14 then changes her gloves with a pair coming from the tracheostomy care kit and proceeded to remove the gauze from around Resident R130's stoma. Employee E14 then proceeded to untie the tracheostomy tie from the flange, discarded the trach tie and proceeded to remove the entire tracheostomy tube out. Employee E14 proceeded to remove the inner cannula from the trach tube and place the trach tube on a gauze on top of the overhead table and wiped off secretions from the inner cannula.

Interview with Licensed nurse, Employee E14 conducted at the time of the observation revealed that she was extremely nervous, which made her make the mistakes. Further Employee E14 revealed that this was not the first time she performed a trach care and that she was just nervous and does not like to be watched which caused her to make the mistakes.

Observation of the laundry department conducted on June 25, 2024, at 8:12 am with Facility Administrator Employee E1 and Director of Housekeeping, Employee E21 revealed that, upon entering the soiled area of the laundry room, a pile of soiled clothing was observed on the floor next to two large bins filled with resident clothing.

Further observation of the soiled area of the laundry room revealed a sink for washing employee's hands located in far end to the right corner of the soiled area of the laundry room. Further, a soap dispenser was affixed to the wall above the sink.

Further observation revealed that the sink was surrounded by large plastic containers of laundry detergents and other laundry chemicals which rendered the sink and the hand soap inaccessible to anyone. Further observation of the laundry room revealed that there was no hand sanitizer and sink available anywhere else in the laundry area.

Interview with Director of Housekeeping, Employee E21 revealed that the sink was not working. Further, Employee E21 confirmed that large containers of laundry chemicals like laundry detergents and fabric softener were stored around the sink making it inaccessible to the laundry personnel.

Refer to F695

28 Pa. Code 201.14(a)Responsibility of licensee

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

Plan of Correction - To be completed: 08/12/2024

E14 was suspended pending investigation.
The pile of soiled clothing next to bins of resident clothing was removed.
The area near the sink was cleared.

DON or designee will re-educate Current licensed staff on hand hygiene during tracheostomy care.
Housekeeping/laundry employees will be re-educated by Administrator or designee on ensuring the floor is free from soiled laundry and the sink and soap dispensers are always accessible.

DON or designee will conduct 5 weekly observations of hand hygiene during tracheostomy care x 2 months.
Administrator or designee will conduct random weekly observations of soiled area to ensure the floor is free from soiled laundry and the sink and soap dispensers are accessible x 2 months.
Results will be reviewed during facility's monthly QAPI meeting.

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