Pennsylvania Department of Health
NAAMANS CREEK COUNTRY MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

NAAMANS CREEK COUNTRY MANOR
Inspection Results For:

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NAAMANS CREEK COUNTRY MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on May 17, 2024 , at Naaman's Creek Country Manor, it was determined the facility was not in compliance under 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 as they relate to the Health portion of the survey process.

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 and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain dish machine water temperatures by manufacturer recommendations for food service safety in the main kitchen.

Findings include:

A review of the facility's policy titled "Machine Ware Washing" undated, revealed that dining services will properly clean and sanitize all service ware to destroy foodborne pathogens. The same policy revealed that the staff will monitor/document water temperatures routinely in the Mechanical ware washer water temperature log. Monitoring schedule: at least one time every meal (mid-morning - breakfast clean-up, mid-afternoon - lunch clean-up, and evening - supper clean-up). Standard temperature = Wash = > 150 F. Final Rinse = > 180 F.

A kitchen tour was conducted on May 14, 2024, at 9:34 a.m., with the presence of the Food Director Employee E4. An observation of the dish machine was conducted and revealed drinking cups and plates were being washed. An observation of the "Wash" temperature gauge revealed a temperature of 140F. The "Rinse" temperature gauge was observed not moving and was kept to "0" F.

A review of the dishwater temperature log revealed that the water temperature was last checked on the evening of May 13, 2024. The temperature log for the morning of May 14, 2024, was blank.

An interview was conducted with Employee E4 on May 14, 2024, at 9:45 a.m., who reported that the dish machine was recently serviced/checked by Ecolab and was functioning well until today.

The above was conveyed to the Nursing Home Administrator on May 14, 2024, at 9:50 a.m.

The facility failed to ensure dish machine water temperature in the main kitchen was maintained according to the manufacturer's recommendations for food service safety.

42 CFR 483.60(i)(2) Food Procurement, Store/Prepare/Serve-Sanitary

28 Pa. Code 201.14(a) Responsibility of licensee

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

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

Plan of Correction - To be completed: 07/08/2024

1.Ecolab contacted immediately to service the dish washer, Lunch was served on paper products

2.An audit of the last 30 days completed to ensure temperatures are being tracked per policy

3.Staff was re-educated on Dish ware washing policy

4.Dietary Director or Designee will complete random weekly audits X 4 weeks than monthly audits X 2 to verify that temperatures are being taken as per policy. Results of audits will be forwarded to monthly QAPI committee for review and recommendations X3 months.

483.10(e)(2) REQUIREMENT Respect, Dignity/Right to have Prsnl Property:

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(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.

Observations:

Based upon observation, it was determined the facility failed to ensure residents were treated with dignity and failed to ensure private health information was secure for one of 24 residents observed (Resident 56).

Findings include:

Observation of Resident 56's room on May 16, 2024, at 11:00 a.m. revealed the presence of two white boards. One board was located on the wall next to Resident 56's bed and the other board was located on the wall directly below Resident 56's television.

Further observation of these white boards revealed the following information "Dietary restrictions - Mildly thick/nectar thick liquids only. No ice, room temp liquids via teaspoon."

Further observation of Resident 56's room revealed a paper sign located above the head of Resident 56's bed. The sign indicated "no straws".

The above information was conveyed to the Nursing Home Administrator and Director of Nursing on May 17, 2024, at 10:00 a.m.

28 Pa. Code 201.18(b)(2) Management

Plan of Correction - To be completed: 07/08/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

1.Information removed from R56's room.

2.Audit completed to ensure no personal information posted in other residents rooms.

3.Staff re-educated on Resident dignity policy

4.SW or designee will complete random weekly audits X 4 weeks than monthly audits X 2 to verify that no personal information is posted in resident's rooms. Results of audits will be forwarded to monthly QAPI committee for review and recommendations X3 months.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on clinical records review and staff interview, it was determined that the facility failed to ensure skin impairment identified upon admission was comprehensively assessed for two of the six residents reviewed (Resident 57 and 235).

Findings include:

Review of the facility's policy titled "Pressure Injury Management Program Evaluating Risk, Prevention, Support Planning, Treatment, and Monitoring", last reviewed in October 2021, revealed that residents admitted with pressure ulcers receive the care and services necessary to promote healing. A review of the same policy revealed that an evaluation of the pressure ulcer should be documented. At a minimum, documentation must include the date observed and the following: location, size, exudate if present, pain, wound bed, and description of wound edges and surrounding tissue as appropriate.

Review of Resident 57's clinical records revealed Resident 57 was admitted to the facility on January 24, 2024, with a diagnosis of Pneumonia.

Review of Resident 57's admission skin assessment completed on January 26, 2024, revealed, the resident was admitted with a pressure ulcer (open wound caused by unrelieved pressure that results in damage to the underlying tissue) to the sacrum (tailbone). A review of the same assessment revealed no information regarding the wound's size, and description.

Review of Resident 57's clinical records revealed Resident 57 sacral wound was not comprehensively assessed until evaluated by the wound nurse practitioner (NP) on February 5, 2024, 10 days after a wound was identified on admission.

Review of Resident 235's clinical records revealed Resident 235 was admitted to the facility on May 9, 2024, with a diagnosis of Dementia and Urinary Tract Infection.

Review of Resident 235's admission skin assessment completed in May 2024, revealed the resident was admitted with a pressure ulcer to the right heel. Further review of the same assessment revealed no information regarding the wound's size and description.

Review of Resident 235's clinical records revealed Resident 235's right heel wound was not comprehensively assessed until evaluated by the wound Nurse Practitioner on May 13, 2024.

Interview was conducted with licensed nurse Employee E5 on May 17, 2024, at 9:30 a.m. Employee E5 reported that the admitting nurse is responsible for assessing the resident's skin for any impairment. Employee E5 added that although nurses don't initially document the stage of the wound, measurements, description of the wound, and the surrounding area should be assessed and documented.

An interview with the Director of Nursing conducted on May 17, 2024, confirmed Resident 57 and Resident 235's pressure ulcers should have been comprehensively assessed on admission.

The facility failed to ensure Resident 57 and Resident 235's pressure wounds identified upon admission were comprehensively assessed.

28 Pa Code 211.5 (f) Clinical records
Previously cited 7/20/23.

28 Pa code 211.10 (c) Resident care policies
Previously cited 7/20/23.

28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services
Previously cited 7/20/23.

Plan of Correction - To be completed: 07/08/2024

1.Resident 57 areas healed and resident 235 discharged.

2.Audit completed of the last 30 admissions to ensure comprehensive skin assessment was completed.

3.The nursing staff was re-educated on Pressure injury Management Program.

4.DON or designee will complete random weekly audits X 4 weeks than monthly audits X 2 to verify that comprehensive skin assessments are being completed upon admission and treatment orders are in place as appropriate. Results of audits will be forwarded to monthly QAPI committee for review and recommendations X 3 months.

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 clinical records review and staff interview, it was determined that the facility failed to monitor a fluid restriction order for one of the 18 residents reviewed (Resident 235).

Findings include:

Review of Resident 235's diagnosis list includes Congestive Heart Failure (CHF-weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), Kidney Failure, and Dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life).

Review of Resident 235's physician's order dated May 9, 2024, revealed an order for 2000 ml (milliliter) fluid restriction, and heart-healthy modification.

The clinical records review failed to reveal evidence that Resident 235's fluid intake was monitored to ensure the 2000 ml fluid restriction ordered by the physician was followed.

Interview was conducted with the Director of Nursing on May 17, 2024, at 11:00 a.m. The Director of Nursing confirmed that nursing does not have documented evidence that Resident 235 ' s 2000 ml fluid restriction order was monitored and followed.

The facility failed to ensure Resident 235's fluid intake was monitored to ensure the 2000 ml fluid restriction ordered by the physician was followed.

28 Pa. Code: 211.5(f) Clinical records

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

Plan of Correction - To be completed: 07/08/2024

1.Resident 235's orders corrected to monitor Fluid restriction

2.An audit was completed to ensure fluid restrictions are being captured.

3.The nursing staff was re-educated on fluid restriction policy

4.DON or Designee will complete random weekly audits X 4 weeks than monthly audits X 2 to verify that fluid restrictions are being monitored/followed. Results of audits will be forwarded to monthly QAPI committee for review and recommendations X3 months.

483.20(g) REQUIREMENT Accuracy of Assessments:

Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate assessments for one of three closed records reviewed (Resident 84).

Findings include:

Review of resident 84's nursing progress notes dated April 19, 2024, at 3:59 p.m., revealed resident was discharged to home at 11:00 a.m., ambulatory with a walker.

Review of the Discharge Return Not Anticipated Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated April 19, 2024, revealed that Resident 84 was discharged to the short-term general hospital.

Interview was conducted with licensed employee E3 on May 16, 2024, at 12:30 p.m., who confirmed that Resident 84's discharge assessment was coded in error.

The facility failed to ensure Resident 84's discharge assessment was completed accurately.

28 Pa. Code: 211.5(f) Clinical records

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

Plan of Correction - To be completed: 07/08/2024

1.Resident 84's MDS was corrected and re-submitted.

2.Audit completed of the last 30 days of discharge MDS to ensure accuracy of discharge status.

3.LPNAC/RNAC re-educated on accuracy of Assessments.

4. NHA will complete random weekly audits X 4 weeks than monthly audits X 2 to verify that discharge MDS were coded appropriately. The results of audits will be forwarded to monthly QAPI committee for review and recommendations X3 months.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based upon review of staffing records, it was determined the facility failed to meet the ratio requirement for Nurse Aides for the day and evening shift on multiple days reviewed.

Findings include:

The facility failed to meet the ratio requirement for Nurse Aides on the following dates and shifts:

December 31, 2023 - 7-3 (dayshift) and 3-11 (evening) shifts
January 1, 2024 - 7-3 shift
January 3, 2024 - 7-3 and 3-11 shifts
January 5, 2024 - 3-11 shift
January 6, 2024 - 3-11 and 11-7 shifts
March 10, 2024 - 3-11 shift
March 11, 2024 - 3-11 shift
March 16, 2024 - 3-11 shift
May 10, 2024 - 7-3 and 3-11 shifts
May 11, 2024 - 3-11 shift
May 12, 2024 - 7-3 shift
May 14, 2024 - 7-3 shift
May 16, 2024 - 7-3 shift

Interview conducted on May 28, 2024 at approximately 9:57 a.m. with the Nursing Home Administrator when the above information was conveyed.

Plan of Correction - To be completed: 07/08/2024

1. A review of the staffing schedules will be conducted to ensure compliance with the ratio of 1 nurse aide per 12 residents on 1st shift, 1 nurse aide per 12 residents on 2nd shift and 1 nurse aide per 20 residents on night shift

2. An in-service will be conducted with the Scheduler to ensure compliance with the ratio of 1 nurse aide per 12 residents on first shift, 1 nurse aide per 12 residents on 2nd shift and 1 nurse aide per 20 residents on night shift. Facility will continue to recruit for open positions. Agency staff will be utilized as needed.

3. An audit will be conducted weekly of the next 4 weeks of nursing schedules to ensure compliance with the ratio of 1 nurse aide per 12residents on first shift, 1 nurse aide per 12 residents on 2nd shift and 1 nurse aide per 20 residents on nightshift.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based upon review of staffing records, it was determined the facility failed to meet the ratio requirement for LPNs on multiple shifts (day shift of 7a.m.to 3 p.m and/or 3 p.m. to 11 p.m.) and on multiple days reviewed.

Findings include:

The facility failed to meet the ratio requirement for LPNs on the following dates and shifts:

January 1, 2024 - 7-3 (day) shift
January 3, 2024 - 3-11 (evening) shift
January 4, 2024 - 7-3 and 3-11 shift
January 5, 2024 - 7-3 shift
January 6, 2024 - 3-11 shift
March 10, 2024 - 3-11 shift
March 13, 2024 - 7-3 shift
March 14, 2024 - 3-11 shift
May 10, 2024 - 7-3 shift
May 13, 2024 - 7-3 and 3-11 shift
May 14, 2024 - 7-3 shift

Interview conducted on May 28, 2024 at approximately 9:57 a.m. with the Nursing Home Administrator when the above information was conveyed.

Plan of Correction - To be completed: 07/08/2024

1. A review of the staffing schedules will be conducted to ensure compliance with the ratio of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening and 1 LPN per 40 residents overnight.

2. An in service will be conducted with the Scheduler to ensure compliance with the ratio of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening and 1 LPN per 40 residents overnight. Facility will continue to recruit for open positions. Agency staff will be utilized as needed

3. An audit will be conducted weekly of the next 4 weeks of nursing schedules to ensure compliance with the ratio of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening and 1 LPN per 40 residents overnight.

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Observations:

Based upon review of staffing records, it was determined the facility failed to meet the ratio requirement for Registered Nurses on day (7 a.m.-3 p.m.) and eveing (3 p.m.-11 p.m.) shifts and multiple days reviewed.

Findings include:

The facility failed to meet the ratio requirement for Registered Nurses on the following dates and shifts:

January 2, 2024 - 7-3 and 3-11 shift
January 5, 2024, and March 12, 2024 - 7-3 shift
May 15, 2024, and May 16, 2024 - 7-3 and 3-11 shifts

Interview conducted on May 28, 2024 at approximately 9:57 a.m. with the Nursing Home Administrator when the above information was conveyed.

Plan of Correction - To be completed: 07/08/2024

1. A review of the staffing schedules for will be conducted to ensure compliance with the ratio of 1 Registered Nurse per 250 residents on 1st shift, 2nd shift, and on night shift

2. An in-service will be conducted with the Scheduler to ensure compliance with the ratio of 1 Registered Nurse aide per 250 residents on first shift, 2nd shift, and night shift. Facility will continue to recruit for open positions. Agency staff will be utilized as needed

3. An audit will be conducted weekly of the next 4 weeks of nursing schedules to ensure compliance with the ratio of 1 Registered Nurse per 250 residents on first shift, 2nd shift, and night shift. Facility will be in compliance with Department's revised guidance for staffing ratios that will allow use of mathematical calculations when

§ 211.12(i)(1) LICENSURE Nursing services.:

(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based upon review of staffing records, it was determined the facility failed to meet the State minimum requirement of 2.87 PPD for multiple days reviewed.

Findings include:

Review of staffing records revealed the facility failed to meet the State minimum requirement of 2.87 PPD for the following dates:

December 31, 2023 - 2.51 PPD
January 1, 2024 - 2.75 PPD
January 3, 2024 - 2.71 PPD
January 4, 2024 - 2.76 PPD
January 5, 2024 - 2.77 PPD
May 10, 2024 - 2.72 PPD
May 16, 2024 - 2.82 PPD

Interview conducted on May 28, 2024 at approximately 9:57 a.m. with the Nursing Home Administrator when the above information was conveyed.

Plan of Correction - To be completed: 07/08/2024

1. There were no immediate adverse effects

2. A review of the staffing schedules for 4 weeks will be conducted to ensure compliance with a minimum of 2.87 hours per patient day of direct nursing care

3. An in service will be conducted with the Scheduler to ensure compliance with a minimum of 2.87 hours per patient day of direct nursing care. Facility will continue to recruit for open positions. Agency staff will be utilized as needed

4. An audit will be conducted weekly for the next 4 weeks of nursing schedules to ensure compliance with a minimum of 2.87 hours per patient day of direct nursing care

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