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

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YEADON REHABILITATION AND NURSING CENTER
Inspection Results For:

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YEADON REHABILITATION AND NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to a complaint, completed on Yeadon Rehabilitation and Nursing Center, it was determined that March 15, 2024 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 process.












 Plan of Correction:


483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ: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.
483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
Observations:

Based on observations and interviews with resident and staff, it was determined that the facility failed to ensure a safe sanitary and functional environment for 6 residents and 15 residents rooms of two floors (Resident R1, R2, R3, R10, R14, R15; First, A, B, C and Second floor nursing units).

Finding Include:

Interview with Resident R1 on March 15, 2024, at 10:41 a.m. observations were made a dirty left over breakfast and of a take out order of scrambled eggs, steak and pasta . Resident R1 reported that it has been on her bedside "dresser for two days and it's still here". Observations of Resident R1's restroom revealed a takeout container with dirty water being soaked on the top the toilet lid. Resident R1 reported that that container belonged to her roommate, Resident R2 who was interviewed at this time and reported that she does not desire to keep that container and is unsure why it's on the toilet. The restroom also had two basins on the floor.

Interview and observations were completed on March 15, 2024, at 11: 40 a.m. with license nurse Employee E4 at the nursing station that has a refrigerator where residents are allow to store left over food. The inspection revealed a package for Resident R3 which was dated February 29, 2024, which was unopened. Interview was held in the Resident R3 room 117 which revealed dirty window shades and privacy curtain with large brown spots, window ceil had crumps, all over the ceil, brown and dark liquid spills, ants crawling on the window ceil, two large dirty containers and one large animal cracker container that was empty on the window sill. Resident also confirmed that he had his toothbrush and tooth paste on the same unsanitary window sill which belonged to him. Resident R3 reported that he doesn't want any containers saved and all container to be removed and thrown away.

During a tour with Unit Manager, Employee E3, on March 15, 2024, at 11:48 a.m., confirmed the above findings and revealed a broken toilet paper holder in room 117. A large pile of dirty pile of clothing on the Resident's chair which was across the Resident's R3 bed which needed to be washed by the facility. Room 108 was cleaned by the housekeeping staff, Employee E10; however, unit manager confirmed that B bed had dirty napkins underneath the bed, crumbs, bag of clothing. Bed C had pumpkin seeds on the edges of the walls, dirty hair, and grey dirt on the wet floor. Resident R10 who was located in bed C also had black 4-5 large bags against the wall that were on the floor of resident's belonging.

On March 15, 2024, at 2:19 p.m. on the second-floor room 223 with Resident R15 and Resident R14's lunch trays were still at the bedside. Resident R15 reported that he/she was done with his lunch an hour ago and prefers for his tray to be removed much more sooner.

On March 15, 2024, at 2:32 p.m. unit manger on the second floor, Employee E11 confirmed that staff are just collecting lunch trays from the second floor including trays from room 223.

On March 15, 2024, at 2:40 p.m. a strong urine smell was confirmed by the Administrator and Director of Nursing, Employee E2 on the first floor after you enter the A unit.

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

28 Pa. Code 201.18 (b)(1) Management.




 Plan of Correction - To be completed: 04/17/2024

1-Take out food containers were removed from R1 and R2's room. The basin was removed from the bathroom floor. R3's shade and privacy curtain were removed/replaced/cleaned. R3's window sill was cleaned and pest control was contacted for service regarding ants. The toilet paper holder in room 118 was replaced. Room 108 was re-cleaned. R10's bagged belongings were removed to be stored appropriately. R14 and R15's lunch trays were removed.

2-Current resident's rooms were audited for cleanliness: trash/food/food trays removed, blinds/privacy curtains clean, floors clean and free of debris and free of clutter. A cleaning schedule was produced from the results of the audit.
3-Housekeeping staff will be re-educated on room cleaning procedures.
4- NHA or designee will conduct 5 random room audits per week x 2 months to ensure rooms are cleaned, orderly and free of debris per policy.
Results will be reviewed during facility's monthly QAPI meeting.

483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:

Based on review of facility policy, and interviews with residents and staff, it was determined that the facility failed to establish grievance policies and procedures that include the right to file a grievance for 2 of 13 residents reviewed.

Findings include:

Review of facility policy titled "Grievance Policy" revealed "each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal .

Interview with Resident R2 on March 15, 2024, at 10:41 a.m. revealed that call bell response being a problem, last weekend it took two hours to get a response. Resident R2 did notify administration and he reported that " I'll take care of it".

Interview with Resident R1 on March 15, 2024, at 10:43 a.m. revealed that call bell response being a problem and last weekend it took couple of hours for her call bell to be answered. The call bell response is the worse during the shift form 3PM-11PM, 11PM-7AM and weekends. Resident R1 also complained about food taste being horrible and that no menus are provided to make preference for meals. Resident R1 did inform the nurse supervisor and administration and was told by the administrator "I'll take care of it".

During a tour with Unit Manager, Employee E3, on March 15, 2024, at 11:48 a.m. Resident R13 filed a grievance with the Unit Manager, Employee E3 as the Resident's R13's call bell response was 1.5 hours. Employee E3 reported that she had a meeting with her staff to address the response time, but it was not documented as a grievance, nor was it communicated to the Resident R13 the resolution of the outcome of his grievances.

Three months from December 2023, January -March 2024 were reviewed and the above grievances were not documented nor reflected in the grievance log for those dates. Three grievances were pulled that had a call bell, dietary and care issues which the forms reveled that residents or resident representatives were not contacted to share the resolution of the grievance.

Interview with the Nursing Home Administrator on March 15, 2024, at 2:43 p.m. confirmed that the results of the grievances were not communicated to residents or resident representatives. The Nursing Home Administrator shared that they implemented call bell audit program of doing audits three times a week as on the last Resident Council meeting notes which occurred on February 29, 2024, residents expressed a concern with call bell of lack of response.


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



 Plan of Correction - To be completed: 04/17/2024

1- A grievance form was completed for R1 regarding call bells, taste of food and lack of menus to indicate preference. A grievance form was completed for R2 regarding call bells. A grievance form was completed for R13 regarding call bells.
2-Grievances from December 2023 thru March 2024 will be reviewed and completed per facility policy
3-Current staff were re-educated on facility's grievance policy and process
4-NHA or designee will audit grievances weekly to ensure proper notifications/resolutions have been made.

NHA or designee will complete 3 random call bell audits weekly x 2 months.

Results will be reviewed during facility's monthly QAPI meeting.

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