Pennsylvania Department of Health
ASBURY HEALTH CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ASBURY HEALTH CENTER
Inspection Results For:

There are 192 surveys for this facility. Please select a date to view the survey results.

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ASBURY HEALTH CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, and Abbreviated Survey, in response to a complaint, completed on July 17, 2024, it was determined that Asbury Health Center 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.

Plan of Correction:

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

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on review of facility policies, facility infection control documentation, observations, and staff interviews, it was determined that the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility for 11 of 11 months. (September 2023 through July 2024).

Findings include:

A review of the facility's "IC Policy and Procedure"" reviewed 4/1/24, indicated the facility will identify, and reduce the risk of acquiring and transmitting infections among residents, employees, physicians, and other licensed independent practitioners, contract service workers, volunteers, students, and visitors.

Review of infection control information from September 2023 through July 2024, failed to reveal an infection prevention tracking infections inside the facility and failed to reflect an operational system to monitor and investigate causes of infection and manner of spread. There was no evidence of a system, which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner.

During an interview on 7/17/24, at 9:30 a.m. the Director of Nursing confirmed the facility failed to continue an infection control program for tracking infections inside the facility from September 2023 through July 2024.

28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

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

28 Pa Code 201.14(a) Responsibility of licensee.

28 pa code 201.18 (b)(1)(e)(1) Management.

28 Pa code 201.20(c) Staff development.

Plan of Correction - To be completed: 08/27/2024

The facility's Infection Preventionist reviewed the IC Policy and Procedure and was educated by a consulting Infection Preventionist on 7/18/24.

The facility's Infection Preventionist will ensure the comprehensive IC Policy and Procedure is implemented.

The Infection Preventionist will be educated by the DON/Designee on the necessary elements to implement and maintain a comprehensive infection control program.

DON or designee will audit the following 3 times per week for 2 weeks, weekly for 2 weeks, and monthly for 2 months: Symptom Line Listing, Outbreak Listing, Floor Plan Tracking, Reportable Infections, Isolation Precautions, Environmental Rounds, and Linen Handling/Storage.

Results will be forwarded to the quarterly QA committee for review.

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program:

§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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.

Observations:

Based on a review of the facility's antibiotic stewardship policy, infection control documentation and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program to include a system to monitor antibiotic use and conduct ongoing review of the treatment of infections (September 2023 through July 2024).

Findings include:

Review of the facility policy "Antibiotic Stewardship" reviewed 3/15/23 and 4/1/24, indicated antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose is to monitor the use of antibiotics.

The facility's infection control program had no documentation of antibiotic use for September 2023 through July 2024.

The facility's antibiotic use tracking system failed to provide feedback reports on specific antibiotic use in the absence of criteria being met for active infection, recommended length of time prescribed, appropriateness, and antibiotic resistance patterns.

The facility's antibiotic stewardship program failed to include necessary documentation and components or evidence that the program was in use within the facility at the time of the survey.

During an interview on 7/17/24, at 9:25 a.m., the Director of Nursing confirmed the facility was unable to locate the antibiotic stewardship information from September 2023 through July 2024.

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

28 Pa. Code 211.10(d) Resident care policies

28 Pa Code 201.14(a) Responsibility of licensee.

Plan of Correction - To be completed: 08/27/2024

The facility's Infection Preventionist reviewed the Antibiotic Stewardship policy and was educated by a consulting Infection Preventionist on 7/18/24.

The facility's Infection Preventionist will ensure the Antibiotic Stewardship program is implemented.

The Infection Preventionist will be educated by the ADON on the necessary elements to implement and maintain an acceptable Antibiotic Stewardship program.

DON or designee will audit the facility's antibiotic use tracking system for antibiotic use, criteria being met for active infection, recommended length of time prescribed, appropriateness, and antibiotic resistance patterns 3 times per week for 2 weeks, weekly for 2 weeks, and monthly for 2 months.

Results will be forwarded to the quarterly QA committee for review.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

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.

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:
Based on review of facility policy, clinical records, and resident and staff interviews, it was determined that the facility failed to make certain that showers were consistently provided for four of eight residents (Resident R7, R91, R110 and R111).

Findings include:

Review of the facility policy "Activities of Daily Living (ADLs)" dated 4/1/24, indicated that residents will be provided with care and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL) abilities are maintained. Activities of daily living include hygiene care and will be recorded in the medical record, and the residents response to the interventions will be monitored, evaluated and revised as appropriate.

During the Resident Council meeting held on 7/15/24, at 10:00 a.m., Resident R 91 stated that he had not had a shower because occupational therapy had stopped giving him them. Resident R91 stated that he got them daily, then "all of a sudden no one was helping him." He liked showers daily at home, he was there "for therapy."

Review of the clinical record record indicated that Resident R91 was admitted to the facility on 6/14/24, with diagnoses that included kidney failure, heart failure and placement of a pacemaker.

Review of Resident R91's kardex dated July 2024, identified as "tasks" in the electronic record indicated Resident R91 had not had a shower documented since 7/4/24, eleven days ago.

Review of the clinical record indicated Resident R7 was admitted on 4/10/23, with diagnoses which included traumatic brain injury without loss of consciousness, convulsions and abnormal posture.

Review of Resident R7's kardex dated July 2024, indicated he had a shower last on 7/4/24, eleven days ago.

Review of he clinical record indicated that Resident R110 was admitted 7/12/24, with diagnoses which included right shoulder and left foot fractures from a fall.

Review of Resident R110's kardex dated July 2024, indicated Resident R110 had not had any showers since admission or documented refusals of showers.

Review of he clinical record indicated that Resident R111 was admitted to the facility on 6/28/24, with diagnoses that included a fractured right lower extremity from a fall.

Review of Resident R111's kardex dated July 2024, did not include documentation of a shower being provided since 7/4/24, eleven days ago.

During an interview on 7/16/24, at 12:25 p.m., Registered Nurse Unit Manager Employee E22 stated that she attempted to "find" shower information on the residents identified and could not provide any additional information regarding why residents were not provided showers and confirmed that the facility failed to make certain that showers were consistently provided for four of eight residents (Resident R7, R91, R110 and R111).

28 Pa. Code: 211.11(d) Resident care plan.

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

Plan of Correction - To be completed: 08/27/2024

R7 and R111 were provided showers. R91 and R110 no longer resides in the facility.

Unit Managers or designee will confirm that all residents have scheduled shower days.

Nurses and CNAs will be educated by the ADON on the following: frequency of showers, where to document in the medical record, and action to take in the event of resident refusal.

Unit Manager or designee will audit 10 residents to confirm showers are being performed and documented 3 times per week for 2 weeks, weekly for 2 weeks, and monthly for 2 months.

Results will be forwarded to the quarterly QA committee for review.

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.

Plan of Correction - To be completed: 08/27/2024

R93 was assessed and suffered no ill effects from not obtaining or documenting the CBG on 7/3, 7/4, and 7/10/24. Of note, resident did not require insulin coverage any other days that week. R7 was assessed and suffered no ill effects from not obtaining or documenting the CBG on 6/13/24 at 2100 and 7/5/24 at 1700. R58 was assessed and suffered no ill effects from not alerting physician of abnormal blood glucose levels.

Orders were reviewed. Physical monitors were added to the sliding scale insulin orders which will prompt the nurse to check yes/no for notifying the provider.

Nurses will be educated by the ADON or designee on obtaining CBGs as ordered, documenting CBGs, administering required insulin coverage, and alerting physician of abnormal results.

Unit Managers or designee will audit CBGs and sliding scales for completion and appropriate follow up 3 times per week for 2 weeks, weekly for 2 weeks, and monthly for 2 months.

Results will be forwarded to the quarterly QA committee for review.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on observations and staff interview it was determined that the facility failed to maintain an environment free of potential accident hazards on the secured Dementia nursing unit (Willow).

Findings include:

Review of the facility policy " Accidents and Incidents- Investigating and Reporting: last reviewed 4/1/24, with a previous review date of 3/15/23, indicated that the facility is in compliance with current rules and regulations governing accidents and/or incidents.

Review of the facility policy "Safety and Supervision of Residents" last reviewed 4/1/24, with a previous review date of 3/15/24, indicated the facility strives to make he environment as free from accident hazards as possible. Resident safety and supervion and assistance to prevent accidents are facility- wide priorities.

During an observation on 7/15/24, from 9:05 a.m., through 9:30 a.m. the following was observed:

The residents rooms throughout the nursing unit had personal care items such as body creams, hair and body cleansers, mouth wash and soaps on their sinks in their rooms.

The resident lounge/dining room had a bottle of hand soap by the sink, the unlocked cabinet near the sink had a bottle of skin cream, another cabinet had Clorox wipes, under the sink was a soiled gown, a cup, and a brown substance spilled. A drawer had a bag of hand sanitizer.

During an interview on 7/15/24, at 9:30 a.m., Registered Nurse Employee E2 confirmed the facility failed to maintain an environment free of potential accident hazards on the secured Dementia nursing unit (Willow).

During a second observation with the Director of Nursing (DON) on 7/15/24, at 9:53 a.m., personal care items were also identified in the drawers of the residents sink areas and in the bathrooms.

During an interview on 7/15/24, at 9:53 a.m., the DON confirmed that the facility failed to maintain an environment free of potential accident hazards on the secured Dementia nursing unit (Willow).

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

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

28 Pa. Code 207.2(a) Administrator's responsibility.

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

Plan of Correction - To be completed: 08/27/2024

The hazardous items were removed from the secured dementia unit (Willow) in real time.

Unit Managers removed any hazardous items from the other three nursing units.

Nurses, CNAs, and housekeepers will be educated by the ADON or designee on the need to ensure hazardous items are not accessible to the residents.

Unit Managers or designee will audit the four nursing units for hazardous items 3 times per week for 2 weeks, weekly for 2 weeks, and monthly for one quarter.

Results will be forwarded to the quarterly QA committee for review.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

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.

The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.

Observations:
Based on review of facility policy and clinical record, and staff interview, it was determined that the facility failed to make certain significant medications are administered as ordered by the physician for one of three residents (Resident R155).

Findings include:

Review of the facility policy " Administration Procedures for all Medications", last reviewed on 4/1/24, with a previous review date of 3/15/23, indicated that medications are administrated in a safe manner.

Review of the facility policy "Medication and Treatment Orders" medications shall be given upon written order from the person duly licensed and authorized to prescribe such medications. All medications orders will be consistent with principles of safe and effective order writing.

Review of the clinical record indicated that Resident R155 was admitted to the facility on 7/9/24, with diagnoses that included Atrial Fibrillation (A fib- abnormal heart rhythm), history of venous thrombosis (blood clots) and embolism (blockage of an artery) of her right lower leg requiring surgery and history of having a heart stent due to a heart attack.

A review of a physician order dated 7/9/24, indicated Rivaroxaban (Xarelto) 20mg give one tablet in the evening for Afib.

A review of the Medication Administration Record (MAR) log dated 7/1/24 through 7/31/24, indicated the Rivaroxaban was not provided to Resident R155 for the dates 7/9/24, 7/10/24 and 7/11/24.

Review of a progress note dated 7/11/24, indicated that the physician was notified regarding the medication not being provided.

During an interview on 7/15/24, at 1:24 p.m., the Director of Nursing confirmed that the facility failed to make certain significant medications are administered as ordered by the physician.

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

28Pa. Code:211.9(e)(f)(g)(h) Pharmacy services.

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

Plan of Correction - To be completed: 08/27/2024

R155 no longer resides in the facility
.
Whole house audit was completed for any additional outstanding medications.

Nurses will be educated by the ADON or designee on the pharmacy escalation process to ensure medication arrives timely for new orders and alert the provider if unable to administer an ordered medication.

Unit Managers or designee will audit for missing medications 3 times per week for 2 weeks, weekly for 2 weeks, and monthly for 1 quarter.

Results will be forwarded to the quarterly QA committee for review.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:
Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to properly secure one of four medications carts reviewed (Hickory Nursing Units back hall medication cart).

Findings include:

Review of the facility policy " Security of Medication Cart", last reviewed 4/1/24, with previous review date of 3/15/24, indicated the medication cart shall be secured at all times when out of nurses view.

During an observation on 7/14/24, at 9:10 a.m., the Hickory back hall medication cart was observed unlocked and unattended near the nurses station.

During an interview on 7/14/24, at 9:16 a.m., Licensed Practical Nurse (LPN) Employee E3 confirmed that the medication cart was unattended and unlocked and that the facility failed to properly secure one of four medications carts reviewed ( Hickory Nursing Units back hall medication cart).

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

28 Pa. Code:211.12(d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 08/27/2024

The Hickory back hall medication cart was locked on 7/14/24. The nurses working on 7/14/24 were educated in real time by the DON.

All medications carts were observed by the DON on 7/14/24 to ensure they were locked.

All licensed nurses will be educated on the facility policy "Security of Medication Cart" by the DON or designee.

The DON/designee will audit all medication carts to ensure they are locked 3 times per week for 2 weeks, weekly for 2 weeks, and monthly for 2 months.

Results will be forwarded to the quarterly QA committee for review.

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