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

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MAHONING VALLEY NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  78 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.
MAHONING VALLEY NURSING AND REHABILITATION CENTER - 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 March 22, 2024, it was determined that Mahoning Valley Nursing and Rehabilitation Center 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:


483.25(k) REQUIREMENT Pain Management: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.
483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on a review of clinical records and select facility policy and resident and staff interviews, it was determined that the facility failed to provide person-centered pain management consistent with professional standards of practice for two out of the 20 residents sampled (Residents 8 and 43).

Findings include:

A clinical record review revealed Resident 43 was admitted to the facility on November 9, 2023, with diagnoses that included cervical and intervertebral disc disorders (conditions characterized by the breakdown of one or more of the discs that separate the bones of the spine and neck, causing pain in the back, neck, or frequently in the legs and arms).

A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 16, 2024 revealed that Resident 43 is cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). The MDS Section J-Health Conditions indicated that the resident almost constantly experiences pain or was hurting.

Resident 43's care plan noted the resident's potential for pain related to his disc disorders, which was initiated on November 10, 2023. Interventions developed to assist the resident with his pain included monitoring, recording, and reporting complaints of pain or requests for pain treatment, evaluating the effectiveness of pain treatment, and offering and encouraging non-pharmacological pain relieving methods such as repositioning, back rubs, soothing or distraction activity, guided imagery, breathing exercises, offering pillows or blankets, bathing, or elevation.

A physician's order was initiated on November 9, 2023, for Resident 43 to receive oxycodone HCL oral tablet 5 mg (an opioid medication) with instructions to give 1 tablet every 6 hours as needed for moderate to severe pain.

The resident's medication administration record (MAR) for March 2024 revealed that Resident 43 received oxycodone 5 mg on 22 occassions from March 1, 2024, through March 21, 2024.

There was no evidence that staff attempted any non-pharmacological attempts to relieve Resident 43's pain prior to administering as-needed opioid medication.

There was no documented evidence that the facility had consistently assessed Resident 43's level of pain to ensure that the opioid medication was administered as per physician's orders, for moderate to severe pain.

A review of progress note documentation and Resident 43's MAR for March 2024 revealed that the resident received oxycodone 5 mg on 18 occassions without documentation of the resident's pain level prior to administration of the medication.

During an interview on March 19, 2024, at 10:10 AM, Resident 43 stated that he experiences consistent back pain. The resident explained that the facility provides a medicated ointment and pain medication that helps with the pain but further stated that the facility is not offering alternative non-pharmacological interventions to assist with his pain relief.

During an interview on March 22, 2024, at approximately 10:00 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were unable to provide evidence that the facility consistently attempted non-pharmacological interventions prior to pain medications prescribed on an as needed basis. The NHA and DON were not able to provide evidence that the facility was consistently assessing the resident's pain levels prior to medication administration to ensure medications were being administered consistent with physician's orders.

A review of the clinical record revealed that Resident 8 was admitted to the facility on November 15, 2023, with diagnoses to include pyogenic arthritis, and spondylosis (degenerative arthritis of the spine).

A review of Resident 8's physician order's initially dated January 11, 2024, revealed an order for oxycodone (a narcotic opioid pain medication) 5 mg tablet, give two tablets by mouth, every four hours, as needed, for severe pain.

A review of the resident's February 2024 Medication Administration Record (MAR) revealed that staff administered the pain medication 48 times during the month of February. Of the 48 doses given, all were administered without non-pharmacological interventions attempted prior to giving the pain medication.

A review of the resident's March 2024 Medication Administration Record (MAR) revealed that staff administered the pain medication 12 times during the month of March Of the 12 doses given, 11 were administered with no non-pharmacological interventions attempted prior to giving the pain medication.

Interview with the Director of Nursing on March 22, 2024, at approximately 1:30 PM confirmed that there was no evidence that non-pharmacological interventions were consistently attempted and proved ineffective prior to administration of as needed pain medication.


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

28 Pa. Code 211.5 (f) Medical records




 Plan of Correction - To be completed: 05/13/2024

The facility has assessed Residents 8 and 43, with appropriate interventions for pain management in place.
The facility is revising documentation systems to ensure the consistent documentation of residents' pain levels as well as provisions for non-pharmacological interventions offered for pain relief.
The facility will conduct an in-service for nursing staff with regard to residents' pain levels as well as non-pharmacological interventions for pain management and documentation of same on the residents' Medication Administration Records.
The facility's Quality Assurance Committee will audit resident records weekly for four weeks and monthly for three months to ensure compliance.
The facility's Quality Assurance Performance Improvement Committee will provide oversight and supervision.

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on the review of the facility's abuse prohibition policy, clinical records, select facility investigations, and staff interviews, it was determined that the facility failed to timely report resident physical abuse to the State Survey Agency for one of the 20 residents reviewed (Resident 5).

Findings include:

A review of the facility's Prevention of Abuse/Neglect/Involuntary Seclusion/Exploitation: The Facility Procedures Policy, last reviewed by the facility in October 2023, revealed that the facility's policy is for staff to report any allegations of abuse, neglect, misappropriation of property, exploitation, or involuntary seclusion to their supervisor immediately. The facility administrator or designee will be responsible for the follow-up investigation and reporting to the required agencies within the required time frames. The policy indicated that the investigation results will be reported to the State Survey Agency and all other required agencies within five days of the allegation.

Facility investigation documents dated February 29, 2024, indicated that a nurse aide observed Resident 4 use the back of her hand to hit Resident 5 in the mouth.

A Resident Incident Investigation form dated February 29, 2024, revealed that Employee 2, a Nurse Aide, observed Resident 4 in the hallway telling Resident 5 to "shut up" and was holding her \ left wrist. \ let go of Resident 5's wrist and slapped \ with the backside of her hand across \ mouth. The residents were separated, and the incident was reported to supervisory staff.

A progress note dated February 29, 2024, at 5:25 PM indicated that \ hit her roommate with the back of her hand. Resident 4 stated that "she wouldn't knock it off! I want her to shut up!"

A progress note dated February 29, 2024, at 5:25 PM indicated that Resident 5 was unable to describe details of the interaction but indicated to staff that "I'm okay." Resident 5 was assessed with no skin impairments, open areas, bruising, swelling, or dental issues.

During an interview on March 21, 2024, at approximately 1:00 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to report physical abuse of Resident 5 perpetrated by Resident 4 to State Survey Agency within the required time frames.


28 Pa Code 201.14 (c) Responsibility of licensee

28 Pa Code 201.18 (e)(1) Management



 Plan of Correction - To be completed: 05/13/2024

The facility reported the incident on 03/22/2024.
The facility will conduct in-service education for all nursing and supervisory staff on reporting requirements of alleged violations in accordance with federal and state requirements and initiation of preventative measures to prevent recurrence.
Audits will be done, daily, to ensure compliance and protection of any residents in potential similar situations. Charge nurses will be instructed to notify the facility's Administrator or Director of Nursing Services if an alleged altercation occurs, and an immediate investigation will be conducted with interventions implemented.
The facility's Quality Assurance Committee will be responsible to monitor compliance weekly via daily meetings, 24 hour nursing report reviews, and/or notification to Administrator or Director of Nursing.
The facility's Quality Assurance Performance Improvement Committee will be responsible for compliance, oversight, and supervision.
483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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.
483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:


Based on a review of clinical records and staff interviews, it was determined that the facility failed to develop and implement individualized plans to manage residents' dementia related behavioral symptoms to promote resident safety and the residents' highest practicable physical and mental well-being for one resident out of 20 sampled (Resident 4).

Findings include:

A clinical record review revealed that Resident 4 was admitted to the facility on October 1, 2020, with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks).

A review of an annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 2, 2024 revealed that Resident 4 has severe cognitive impairment with a BIMS score of 02 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00-07 indicates severe cognitive impairment).

Nursing progress notes dated January 10, 2024, at 11:25 AM that indicated that Resident 4 was having increased behaviors that morning, incessantly calling out different things at staff, yelling for help, and yelling for different people.

A progress note dated January 13, 2024, at 4:46 AM indicated that the resident was calling out and yelling, "Get me the hell out of here!"

On January 23, 2024, at 4:30 PM progress notes indicated that the resident was consistently yelling out help, entering other residents rooms, arguing with other residents, and stating, "I am going to throw myself to the floor."

Nursing noted January 24, 2024, at 12:38 PM that the resident was agitated during a shower. The note indicated that the resident was swinging a shower head and attempting to bite and kick staff.

On February 16, 2024, at 12:34 AM, nursing noted that the resident was calling out continually, "Help! Help! Who the hell am I? Does anybody know me?"

Nursing progress notes dated February 28, 2024, at 10:43 PM indicated that the resident was agitated and restless throughout the shift, wheeling herself into other residents' rooms, yelling, and pulling apart her oxygen tubing and on February 29, 2024, at 5:25 PM the resident hit her roommate with the back of her hand. Resident 4 stated that "she wouldn't knock it off! I want her to shut up!"

Nursing documentation dated 2, 2024, at 1:57 AM indicated that the resident was screaming and yelling throughout the shift; on March 7, 2024, at 10:30 PM it was noted that the resident was entering other residents rooms, yelling at other residents, and attempting to open locked doors like the maintenance closet; and on March 15, 2024, at 3:50 AM it was documented that the resident was continually calling out and disrupting other residents.

A review of Resident 4's care plan, conducted during the survey ending March 22, 2024, revealed that the resident's plan of care did not include the resident's behaviors, such hitting, biting, yelling out, screaming, and entering other residents' rooms.

The facility failed to demonstrate the provision of necessary care and services, including individualized interdisciplinary non-pharmacological approaches to care, purposeful and meaningful activities, that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. There was no evidence that the facility provided the resident with specialized services and supports, such specialized activities, nutrition, and environmental modifications, based on the individual's abilities and dementia related behaviors.

During an interview on March 21, 2024, at approximately 1:10 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to demonstrate the development or implementation of an individualized interdisciplinary person-centered care plan that addressed Resident 4's dementia care and behaviors.



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

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







 Plan of Correction - To be completed: 05/13/2024

The facility has reviewed resident 4's status and behaviors with appropriate monitoring and interventions for dementia related behaviors in place.
The facility will review resident records and individualized plans of care for residents with dementia related behaviors and appropriate interventions to protect residents with/from residents with dementia related behaviors. The facility Administrator/designee will conduct an educational in-service for all facility staff regarding dementia related behaviors and appropriate interventions in an effort to facilitate care of residents with dementia and protect other residents in similar situations as well as notification of and in consultation with residents' physicians and practitioners. This will be done in addition to the annual education requirement for all staff members regarding residents with dementia and dementia-related care.
The facility's Interdisciplinary Team will be responsible for the development and implementation of care plans for residents with dementia.
The facility's Quality Assurance Committee will be responsible to monitor compliance via chart audits and nursing reports weekly for four weeks and monthly for three months for continued compliance.
The facility's Quality Assurance Performance Improvement Committee will be responsible for oversight and supervision.
483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:


Based on clinical record review and staff interview it was determined that the facility failed to develop a comprehensive person-centered plan of care to meet the individualized needs of one resident out 20 sampled (Resident 19).

Findings include:

Review of Resident 19's clinical record revealed that the resident was admitted to the facility on January 26, 2024, with diagnoses to include heart failure (a condition in which the heart fails to sufficiently pump blood throughout the body) and the presence of an automatic implantable cardiac defibrillator (AICD- is a microcomputer that is implanted under the skin of the upper chest area. It monitors heart rate and delivers therapy in the form of small electrical pulses. An AICD is a permanent device inserted into the right ventricle and typically placed near the collarbone under the skin of the chest).

A review of a cardiology progress note dated January 26, 2024, revealed that the resident had a single AICD implanted for heart failure. The cardiologist indicated that the resident was seen due to a planned move to the skilled nursing facility. He further indicated that a note was sent to the facility to ensure that the move does not affect his AICD device.

A review of the resident's current comprehensive care plan, conducted during the survey ending March 22, 2024, indicated that the facility identified a problem area of Resident 19's diagnosis of coronary artery disease (damage or disease in the heart's major blood vessels) due to hypertension, atrial fibrillation, AICD, and ischemic cardiomyopathy. However, the resident's care plan did not include AICD checks or monitoring for signs and symptoms of AICD complications.

The resident's care plan did not include any emergency care of the AICD device and actions to be taken if the AICD was activated (i.e., consulting the physician, obtaining vital signs [clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions] and keeping the resident and staff safe from the electrical shock. The resident should notify staff if a shock is felt, and staff should be aware not to touch resident is being shocked since the shock can be felt).

Interview with Employee 1 (RN, MDS Coordinator) on March 20, 2024, at 2:16 PM confirmed that the facility failed to fully address the care and management of Resident 19's AICD on the resident's person-centered plan of care.


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





 Plan of Correction - To be completed: 05/13/2024

The facility has reviewed resident 19's clinical record and the stated device, spoke with the resident's cardiologist, and care planned the device on 03/20/2024.
The facility Administrator/designee will conduct in-service education for the nursing staff and the Registered Nurse Assessment Coordinator and will revise policies and procedures regarding cardiology related devices and monitoring systems, with updates, as indicated. The facility will also include monitor tracking documentation for a cardiology related device in residents' medical records.
The facility's Quality Assurance Committee will be responsible to monitor compliance weekly for four weeks and monthly for three months to ensure compliance.
The facility's Quality Assurance Performance Improvement Committee will be responsible for oversight and supervision.
483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:

Based on clinical record reviews and staff interview, it was determined that the facility failed to ensure that a written notice of facility-initiated transfer to the hospital was provided to the resident and resident's representative for four residents out of 20 residents sampled (Residents 47, 8, 18 and 39).

Findings include:

A review of Resident 47's clinical record revealed that the resident was transferred to the hospital on August 28, 2023, and returned to the facility on September 18, 2023.

A review of Resident 8's clinical record revealed that the resident was transferred to the hospital on December 14, 2023, and returned to the facility on December 20, 2023. The resident was transferred to the hospital on December 22, 2023, and returned to the facility on December 30, 2023 and transferred again on January 5, 2024, and returned to the facility on January 11, 2024.

A review of Resident 18's clinical record revealed that the resident was transferred to the hospital on September 9, 2023, and returned to the facility on September 12, 2023.

A review of Resident 39's clinical record revealed that the resident was transferred to the hospital on February 21, 2024, and readmitted to the facility on February 22, 2024.

Clinical record reviews of the above residents revealed no evidence written notices had been provided to these residents and their representatives regarding the transfer that included all required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred, contact and address information for the Office of the State Long-Term Care Ombudsman, and, if applicable, information for the agency responsible for the protection and advocacy of individuals with developmental disabilities.

Interview with the Nursing Home Administrator on March 21, 2024, at 11:10 AM confirmed that there was no evidence that a written notification of transfer which contained all required contents was provided to residents and the residents' representatives for these facility initiated transfers.


28 Pa. Code 201.29 (c.3)(2) Resident rights

28 Pa. Code 201.14 (a) Responsibility of Licensee




 Plan of Correction - To be completed: 05/13/2024

The facility has reviewed the clinical records of residents 47,8,18, and 39.
The facility is in the process of reviewing and revising documentation systems for resident transfer/discharge to ensure compliance with resident and resident's representatives Notice Requirements Before Transfer/Discharge and provision of said required documents.
The facility Administrator/designee will review the discharge process with facility Charge Nurses and Social Services to ensure the facility's solutions are sustained.
The facility's Quality Assurance Committee will audit facility records for residents who are transferred/discharged, for compliance, weekly for four weeks and monthly for three months.
The facility's Quality Assurance Performance Improvement Committee will be responsible for oversight and supervision.
211.1(a) LICENSURE Reportable diseases.:State only Deficiency.
(a) When a resident develops a reportable disease, the administrator shall report the information to the appropriate health agencies and appropriate Division of Nursing Care Facilities field office. Reportable diseases, infections and conditions are listed in 27.21a (relating to reporting of cases by health care practitioners and health care facilities).

Observations:

Based on a review of the facility's influenza line listing and staff interview, it was determined that the facility failed to timely report confirmed cases of influenza for seven of seven residents reviewed (Resident 73, 14, 16, 3, 77, 78, and 79) to the State Licensing Agency.

Findings include:

Review of an infection control line listing for influenza for December 2023 and January 2024, revealed the following residents tested positive for influenza:

Resident 73 tested positive on December 30, 2023
Resident 14 tested positive on December 31, 2023
Resident 16 tested positive on January 2, 2024
Resident 3 tested positive on January 3, 2024
Resident 77 tested positive on January 3, 2024
Resident 78 tested positive January 3, 2024
Resident 79 tested positive January 11, 2024

An interview with the director of nursing on March 22, 2024, at approximately 10:45 AM confirmed that the facility failed to timely notify the State Licensing Agency, PA Department of Health, Division of Nursing Care Facilities of the confirmed cases of influenza.



 Plan of Correction - To be completed: 05/13/2024

The facility reported the cases of influenza to the county department of health for residents 73, 14, 16, 3, 77, 78, and 79 at the time of diagnosis, and reported the cases to the Division of Nursing Care Facilities field office on 03/22/2024.
The facility will review and revise policies and procedures for reportable diseases, infections, and conditions listed in sub-section 27.21a and review same with all relevant personnel to maintain reporting compliance.
The facility's Quality Assurance Committee will monitor resident records and nursing 24-hour reports to maintain compliance.
The facility's Quality Assurance Performance Improvement Committee will be responsible for oversight and supervision.

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