Pennsylvania Department of Health
RIDGEVIEW HEALTHCARE & REHAB CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

RIDGEVIEW HEALTHCARE & REHAB CENTER
Inspection Results For:

There are 161 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.


RIDGEVIEW HEALTHCARE & REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit and abbreviated complaint survey completed on April 24, 2024, it was determined that Ridgeview Healthcare and Rehab Center failed to correct the deficiencies cited during the surveys of January 26, 2024, and March 7, 2024, and continued to be out of 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:

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

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.

§483.60(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 observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

A tour of the facility's kitchen dish room was conducted on April 24, 2024, at approximately 10:00 AM, revealing the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified:

The air conditioner located in the window directly above the dish washing area was observed to be coated with heavy layer of accumulated debris and dirt. A heavy coating of lint and dirt was observed on the cover of the air conditioner filter. The shelf below the ac unit was coated with a heavy coating of dirt, lint and dead bugs.

Interview with the Nursing Home Administrator on April 24, 2024, at approximately 2:30 PM, confirmed that the facility's dietary department, including the dishwashing area, should be maintained in sanitary manner.

28 Pa. Code 211.6 (f) Dietary services.

28 Pa. Code 201.18(e)(2.1) Management

Plan of Correction - To be completed: 05/28/2024

1. Air conditioner and window sill has been cleaned.
2. The other air conditioners and windows in the dietary area have also been inspected and cleaned.
3. Dietary staff have been educated on the need to ensure a sanitary work area.
4. Administrator or designee will conduct sanitation audits weekly x4 and monthly x2.

483.10(e)(4)-(6) REQUIREMENT Choose/Be Notified of Room/Roommate Change:

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.

§483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

§483.10(e)(5) The right to share a room with his or her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement.

§483.10(e)(6) The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.

Observations:

Based on clinical record and facility policy review and staff interview, it was determined the facility failed to ensure that in preparation for room change each resident/resident representative received written notice, including the reason for the change before the resident's room was changed for four of 24 room changes completed by the facility from April 2, 2024, through April 24, 2024 (Residents B1, B2, B3 and B4).

Findings include:

Federal regulatory guidance under notes that moving to a new room or changing roommates is challenging for residents. A resident's preferences should be taken into account when considering such changes. When a resident is being moved at the request of facility staff, the resident, family, and/or resident representative must receive an explanation in writing of why the move is required. The resident should be provided the opportunity to see the new location, meet the new roommate, and ask questions about the move.

A review of an undated facility policy provided to the survey team during the survey of April 24, 2024, entitled "Transfer: Room to Room" revealed that the purpose of this procedure is to provide guidelines for transferring residents from one room to another when such transfer has bed approved in accordance with facility policies. Room to room transfer will be occur when it is necessary to meet the resident's medical and nursing care needs or when feasibly possible when requested by the resident.

The policy guidelines indicated the following:
1)The resident should be consulted about the room transfer. The resident's request will be given consideration in making the transfer. If this is a planned transfer, the resident and family will be consulted by Social Service
2)Inform the resident about the transfer:
a.Where the room is located
b.Who the resident's new roommate, if any, will be
c.Who will be providing the resident's care
d.That his or her family and visitors will be informed of the room change
e.Why the transfer is necessary. (Note: If this information is not known, ask the supervisor about this information.)
3)Reassure the resident that all his or her personal effects will be brought to his/her new room.
4)Ensure that the new room is ready for receiving the resident.
5)If possible, Social Service or Nursing will take the resident to see his or her new room before the actual move is made.
6)The Unit Manager or Charge Nurse will give report to the receiving Unit Manager or charge Nurse.

The facility policy did not include the provision of a written explanation of why the move is required to the resident and/or representative.

A review of Resident B1's clinical record revealed that the facility changed Resident B1's room, on April 8, 2024, to another room on the unit as per medical necessity according to progress note. There was no documented evidence that the facility provided written notice, with an explanation for the reason for the room change, to the resident and/or the resident's representative.

Resident B2 was transferred from her room to another room on the same floor on April 10, 2024, as per medical necessity according to the documentation. There was no documented evidence that the facility provided written notice, with an explanation for the reason for the room change, to the resident and/or the resident's representative.

Documentation in progress notes in Resident B3's clinical record dated April 10, 2024 indicated the resident was moved from one room to another room on the same unit for medical necessity. There was no documented evidence that the facility provided written notice of the reason for the room change to the resident and/or the resident's representative.

A progress note dated April 11, 2024, indicated that the facility called Resident B4's responsible party and explained that the facility wanted to change the resident's room but no reason for the change was noted. There was no documented evidence that the facility provided written notice, with an explanation for the reason for the room change, to the resident and/or the resident's responsible party.

A review of documentation provided by the facility revealed that the facility initiated resident room changes on 24 occassions between April 2, 2024, and April 24, 2024. During interview with the NHA on April 24, 2024 at approximately 3:00 PM the NHA confirmed that the facility did not provide any written explanation of the reasons for these moves to the residents and/or their representatives.

28 Pa Code 201.29 (a) Resident Rights

Plan of Correction - To be completed: 05/28/2024

1. Facility cannot correct the deficiency for the cited residents as it occurred in the past.
2. Facility has implemented a new Notice of room change form and updated it's room change policy to reflect the need for written notice to residents and their representatives.
3. Nursing, admissions, and Social Services staff will be educated on the need to provide written notice of room changes and new roommates t residents and their responsible parties.
4. Administrator or designee will audit all room changes to ensure written notice was provided weekly x4 then monthly x2.

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities:

§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.

Observations:

Based on a review of the facility's plan of correction from the survey ending January 26, 2024, the outcome of the activities of the facility's quality assurance committee, current staffing of the facility's food and nutrition services department, menus and menu extensions, observations and interviews it was determined that the facility's procedures failed to effectively identify ongoing deficient practices related to the facility's food and nutrition services department, and its lack of effective oversight, and implement effective plans to correct and prevent further quality deficiencies related to menus, snacks and food service sanitation.

Findings included

During the survey ending January 26, 2024, deficient facility practice was cited for the facility's failure to assure qualified full time staff responsible for the oversight of the food and nutrition services department. In response to that deficiency the facility developed a plan of correction, that included a quality assurance monitoring program, indicated that the facility will take the following steps:

In coordination with Nutraco, our consultant dietary company, there is a Registered Dietician performing oversight of our dietary department on a fulltime basis primarily in facility, with remote work as needed. The RD will provide consultant services to the food service manager and assist with daily kitchen operations to ensure compliance.
Education has been provided to dietary director and dietician on the necessary oversight functions for the dietary department.
Administrator or designee will conduct weekly audits x 4 weeks then monthly x 4 months of consultant dietician timecards to ensure fulltime status as well as oversight and sign off of facility menus with results reported to QAPI as needed.

However, at the time of this current survey, ending April 24, 2024, quality deficiencies in dietary services, and the operations of the food and nutrition services department were identified as follows:

Based on observations, review of the facility's planned written menus and menu extensions, and staff interviews, it was determined that the facility failed to follow planned written menus and failed to ensure that the facility's dietitian periodically reviewed the "always available" menu for appropriateness of the corresponding menu extensions for residents prescribed a therapeutic diet, including Resident A1.

Based on observations, review of the facility's planned written menus and menu extensions, and staff interviews, it was determined that the facility failed to follow planned written menus and failed to ensure that the facility's dietitian periodically reviewed the "always available" menu for appropriateness of the corresponding menu extensions for residents prescribed a therapeutic diet, including Resident A1.

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness.

The above quality deficiencies identified a lack of oversight of the food and nutrition services department and that the facility's plan of correction for the deficiency cited during the survey of January 26, 2024, was ineffective in correcting and/or sustaining corrections related to operations and oversight of the food and nutrition services department.

At the time of the survey ending April 24, 2024, the facility employed two part time registered dietitians (RD)

During the week of April 8, 2024 through April 19, 2024, the RDs worked the following onsite hours in the facility according to interview with the NHA on April 24, 2024:

April 8, 2024, 8 hours
April 10, 2024, 8 hours
April 11, 2024, 3.75 hours
April 12, 2-24, 8 hours
April 15, 2024, 8 hours
April 17, 2024, 8.75 hours
April 18, 2024, 8.75 hours
April 19, 2024, 8 hours
April 19, 2024, 4.25 hours

During an interview on April 24, 2024, at 1 PM with facility's dietary manager, who was recently hired on March 4, 2024, the dietary manager stated that presently, she had not yet successfully completed the certification requirements and was not yet qualified for the dietary manager position. The dietary manager confirmed that the facility used the services of two part time registered dietitians that performed primarily clinical nutrition duties. She stated that they were available to her for consultation "if she needed anything regarding running the kitchen." The dietary manager stated that she was responsible for the oversight of the kitchen.

Based on the outcome of the survey ending April 24, 2024, the facility failed to demonstrate that the Registered Dietitians provided sufficient oversight of the operations of the facility's dietary department, dietary staff and food service management.

Refer F803, F809 and F812

28 Pa. Code 201.18 (e)(2)(3)(4)(6) Management

Plan of Correction - To be completed: 05/28/2024

1. The facility cannot correct the cited deficiency as it occurred in the past.
2. The facility has created a dietary QAPI subcommittee consisting of administrator, don, registered dietician, dietary manager, and available dietary staff to better monitor dietary issues and quickly implement fixes.
3. All staff have been educated on the QAPI process.
4. Administrator or designee will conduct QAPI audits weekly x 4 and monthly x2 to ensure that all noted QAPI processes are being followed and implemented as recommended by the committee.

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime:

§483.60(f) Frequency of Meals
§483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

§483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

§483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.

Observations:

Based on review of the minutes from Residents' Council meetings, and resident and staff interviews, it was determined that the facility failed to routinely offer evening snacks to residents including Residents A2, A3, A4, and A5).

Findings include:

During an interview on April 24, 2024 at 12:30 P.M., Resident A2, who was alert and oriented, the resident stated that the facility does not consistently offer snacks at bedtime, and when they do provide a snack, "it's only a cookie" and there is no variety of snacks offered.

During an interview on April 24, 2024 at 12:35 P.M., Resident A3, who was alert and oriented, the resident stated that the facility does not consistently offer snacks at bedtime and there is no variety of snacks.

During an interview on April 24, 2024 at 12:40 P.M., Resident A4 stated that the facility does not offer snacks at bedtime and there is no variety of snacks available for residents.

During an interview on April 24, 2024 at 12:45 P.M., Resident A5, a cognitively impaired resident stated that the facility does not offer snacks at bedtime and there is no variety when they do offer one.

Interview with the Resident Council President, Resident A2, on April 24, 2024 at 12 PM Resident A2 stated that food quality and HS snacks are brought up at the monthly Residents' Council meetings. He stated that currently, there is no activity director in the facility and the previous director did not include the complaints voiced by residents during the meetings, which included that they are not offered evening snacks and that they would like to receive bedtime snacks in the meeting minutes, which was confirmed by a review of the minutes from the Resident Council meetings dated March 18, 2024 and April 23, 2024,

During an interview on April 24, 2024, at 2 p.m., the Nursing Home Administrator and Director of Nursing were unable to verify that residents are routinely offered and provided varied snacks at bedtime as preferred by each resident on nightly basis.

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

Plan of Correction - To be completed: 05/28/2024

1. The facility cannot correct the deficiency for the cited residents as it occurred in the past
2. The facility has reviewed the HS snack policy and implemented a snack cart with resident input to be filled for the evening shift.
3. Nursing and dietary staff will be educated on the need to ensure residents receive HS snacks
4. Administrator or designee will conduct resident interview weekly x 4 and monthly x2 to ensure snacks are being received.

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed:

§483.60(c) Menus and nutritional adequacy.
Menus must-

§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

§483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

§483.60(c)(5) Be updated periodically;

§483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

§483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.

Observations:
Based on observations, review of the facility's planned written menus and menu extensions, and staff interviews, it was determined that the facility failed to follow planned written menus and failed to ensure that the facility's dietitian periodically reviewed the "always available" menu for appropriateness of the corresponding menu extensions for residents prescribed a therapeutic diet, including Resident A1.

Findings included:

A review of the current facility census at the time of the survey on April 24, 2024, revealed 104 residents were currently residing in the facility.

Review of the facility's Week 4 lunch menu for Wednesday April 24, 2024, revealed that the planned menu included spaghetti and meat sauce (8 oz), mashed broccoli (4 oz.), pound cake (4 oz.) milk (4 oz) and coffee or tea (8 oz).

The Week 4 lunch meal, Renal diet extension for the lunch menu on April 24, 2024, revealed that meal to be served to those residents prescribed a renal therapeutic diet was spaghetti and meatballs with Alfredo sauce (8 oz), carrots (4 oz.), diet vanilla pudding (4 oz.), milk (4 oz) and coffee or tea (8 oz).

However, observation of the lunch tray line revealed no spaghetti with Alfredo sauce or meat balls, carrots or sugar free vanilla pudding as planned for the renal diet extension.

Observation of the lunch meal served on April 24, 2024, at 12:00 PM revealed that chicken, spaghetti with butter and broccoli, pound cake and apple juice was served to the residents prescribed a renal diet.

Observation of Resident A1 at the lunch meal on April 24, 2024, revealed that the resident was prescribed a renal diet. The resident was a large plate of pasta salad, containing chopped ham and cheese on top of the salad for the lunch meal (ham, and some cheeses, may have a high sodium content and sodium is often restricted in most renal diets).

A review of the facility's "always available" menu for residents revealed that pasta salad was listed as an "always available" entree for residents.

Interview with the facility's dietary manager, who was recently hired on March 4, 2024, conducted on April 24, 2024, at 1 PM confirmed stated that she was unaware of the menu substitution for the renal diet extensions. She stated that she assumed that the cook made the chicken substitution due to the "tomato sauce" on the spaghetti (tomatoes are high in potassium and potassium is frequently restricted on renal diets). She stated that she did not know if the pasta salad was an appropriate substitution for a renal diet. The dietary manager stated that the cook made the decision to prepare the chicken and spaghetti with butter, and preparing broccoli instead of the carrots because carrots were unavailable. She was not able to state why pound cake was served instead of the sugar free pudding as noted on the menu.

During an interview April 24, 2024 at 1:30 P.M., the Nursing Home Administrator was unable to state if the facility's Registered Dietitian (RD) approved the renal menu changes and substitutions for April 24, 2024, lunch meal.

The administrator further confirmed that the facility was unable to provide evidence that the facility's registered dietitian periodically reviewed the "always available" menu for therapeutic diets and verified that the facility had not followed the planned menus as written,

28 Pa. Code 211.6 (a) Dietary services.

28 Pa. Code 201.18 (e)(2)(3) Management

Plan of Correction - To be completed: 05/28/2024

Facility cannot correct the deficiency for the cited residents as it occurred in the past.
2. Facility dietician has reviewed all renal diet extensions, as well as the always available menu to ensure that items in line with all relevant therapeutic diets are available. Dietician has ensured that all necessary items have been ordered to ensure that all resident diets can be met at all times.
3. Dietary staff have been educated by administration on the necessity of following all resident diets as prescribed.
4. Administrator or designee will conduct tray audits weekly x4 then monthly x2 to ensure all therapeutic are being followed.

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 observation and staff interview it was determined the facility failed to maintain an environment free of potential accident hazards and obstacles to safe mobility and use of mobility assistance devices on two of the two nursing units.

Findings include:

Observations of the second floor resident hallway, on April 24, 2024, at 10:00 AM, 11:45AM, 12:30 PM and 2:15 PM revealed three-drawer plastic bins containing boxes of gloves, disposable protective gowns, plastic bags and other items. These bins were located on both sides of the hallway against the wall, obstructing unimpeded access to the handrails, in front of rooms 209, 211, 213, 215, 214, 216, 219, 221, and 222.

Observations of the third floor resident hallway on April 24, 2024, at 9:45 AM, 11:30 AM, 12:15 PM and 2:00 PM. revealed three drawer plastic bins positioned on both sides of the hallway in front of rooms 302, 303, 304, 307, 309, 310, 317, 318 and 320, obstructing access to the handrails.

Interview with Director of Nursing on April 24, 2024, at 2:30 PM revealed that the plastic bins are for those residents requiring Enhanced Barrier Precautions (EBP) for infection control precautions.

Guidance dated March 20, 2024, provided by the Centers for Medicare & Medicaid Services (CMS) indicated that CMS supports facilities in using creative (e.g., subtle) ways to alert staff when EBP use is necessary to help maintain a home-like environment.

Observations throughout the day of the survey ending April 24, 2024, revealed that the placement of these multiple containers of PPE (personal protective equipment) positioned on both sides of the resident hallways impeded access to the hallway handrails on both sides of the hallway which are to be used for resident ambulation or mobility assistance and did not create a homelike environment.

Interview with the DON on April 24, 2024, at approximately 1:30 PM confirmed the storage bins prevent unimpeded access to the corridor handrails, which created an impediment to resident mobility and a potential accident hazard.

28 Pa. Code 201.18 (e)(2.1) Management

28 Pa. Code 205.9 (c) Corridors

Plan of Correction - To be completed: 05/28/2024

1.Three drawer plastic bins in front of rooms 302, 303, 304, 307, 309, 310, 317, 318, and 320 have been removed from the hallway and placed on the doorway to the resident rooms.
2. The facility will audit residents requiring enhanced barrier precautions to ensure a homelike environment is maintained with unimpeded access to hallway handrails and subtle storage of enhanced barrier precaution supplies.
3. Management, nursing staff and housekeeping will be educated on the importance of a homelike environment, maintaining access to hallway handrails, and storage of enhanced barrier precautions supplies in a subtle manner.
4. Nursing Administration/designee will audit enhanced barrier precaution storage and corridor handrails to ensure they are accessible to residents and a homelike environment is maintained weekly X 4 and monthly x 2 and as deemed necessary by the QA committee.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observations, the facility failed to maintain a clean and homelike environment on two of two resident units (Second and Third Floor).

Findings include:

Observations during a tour of the second floor resident unit on April 24, 2024, at 10:00 AM, 11:45AM, 12:30 PM and 2:15 PM revealed a very strong pungent urine-like odor. The pervasive offensive urine-like odor lingered on the unit at the time of each observation throughout the day.

Observations during a tour of the third floor resident unit on April 24, 2024, at 9:45 AM, 11:30 AM, 12:15 PM and 2:00 PM. revealed a very strong pungent urine-like odor. The pervasive offensive urine-like odor lingered on the unit at the time of each observation throughout the day.

28 Pa. Code 201.18 (e)(2.1) Management

Plan of Correction - To be completed: 05/28/2024

1. Hallway and rooms near elevator have been thoroughly cleaned. No immediate source for the odor was discovered.
2. Facility will review housekeeping schedule to ensure proper cleaning of resident areas daily. Facility has also implemented air purifiers in the area.
3. Housekeeping staff will be reeducated on proper sanitation procedures.
4. Administrator or designee will conduct sanitation audits weekly x4 then monthly x2 to ensure a clean and safe environment for the residents.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:

§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.

Observations:

Based on review of select facility polity, the minutes from Resident Council Meetings and grievance logs and resident and staff interviews, it was determined that the facility failed to demonstrate timely action to resolve resident grievances raised at resident group meetings and keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution.

Findings include:

A review of the minutes from the Resident Council Meeting held during the month of March 2024, revealed that the number of residents in attendance at the meeting was not noted. During that meeting, the residents present voiced concerns about activities programming and that the Nursing Home Administrator should come to the resident floors and see residents. At the time of the survey ending April 24, 2024, there was no documented evidence that the facility had addressed the residents' concerns and responded to the residents with the facility's efforts to resolve their concerns.

A review of the minutes from the Resident Council Meeting held during the month of April 2024, revealed that the number of residents in attendance at the meeting was not noted. During that meeting, the residents voiced the same concerns as the prior month, about activities, untimely call bell response by staff and the residents' requests that the Nursing Home Administrator visit residents on the resident units. At the time of the survey ending April 24, 2024, there was no documented evidence that the facility had addressed the residents' concerns and responded to the residents with the facility's efforts to resolve their concerns.

Review of the facility's grievances logs, accounting for grievances lodged with the facility by residents or on the residents' behalf dated March 2024 to the time of the survey ending April 24, 2024, revealed that the facility did not include the complaints and concerns voiced at Resident Council meetings as grievances lodged with the facility.

Interview on April 24, 2024, at 2 PM with the Nursing Home Administrator confirmed there was no documented evidence that resident grievances raised at resident group meetings were timely addressed and the residents informed of the facility's efforts to resolve their complaints.

28 Pa. Code: 201.18 (e)(1)(4) Management.

28 Pa. Code: 201.29 (a) Resident Rights.

Plan of Correction - To be completed: 05/28/2024

1. Facility will review old business at next resident council meeting to ensure that all resident issues are being addressed.
2. Moving forward, all resident council minutes will be reviewed by IDT to ensure all resident concerns are written up as grievances and responded to appropriately.
3. Activities staff, social services director, and therapy director will be educated on the grievance process.
4. Administrator or designee will review all resident council minutes monthly, as well as all resident grievances weekly x4 then monthly x2 to ensure timely response to resident issues.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:

Based on observations and resident and staff interviews, it was determined that the facility failed provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance including one resident out of 19 sampled (Residents A2)

Findings included:

An interview conducted on April 24, 2024, at approximately 12:15 PM with Resident A1, who was alert and oriented, revealed that the resident stated that staff do not respond timely to resident call bells. The resident stated that the staff "are wonderful but there is not enough" staff to care for the residents in the facility in a timely manner. The resident stated residents wait 30 minutes or longer for staff to answer their call bells when they request assistance. He stated that he requires staff assistance with his activities of daily living and it is "sometimes very hard to wait a long time" for assistance from staff.

An interview with the Nursing Home Administrator and Director of Nursing on April 24, 2024, at approximately 2 PM, confirmed that the staff are expected to respond to residents' requests for assistance in a timely manner.

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

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

Plan of Correction - To be completed: 05/28/2024

1. RESIDENT 2A's call bell times have been monitored in the past and will continue to be to ensure they are being answered in a timely fashion.
2. FACILITY WILL AUDIT RESPONSE TO RESIDENT REQUESTS/CALL BELL RESPONSE. Facility will also utilize enhanced rounding to better monitor call bell response times.
3. EDUCATION PROVIDED TO ALL STAFF IN REGARDS TO TIMELY RESPONSE TO RESIDENT REQUESTS.
4. NURSING MGT/DESIGNEE WILL AUDIT RESPONSE TO RESIDENT NEEDS WEEKLY X 4, MONTHLY X 2.

§ 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 on review of nursing time schedules and staff interviews, it was determined that the facility failed to provide a minimum of one nurse aide per 12 residents during the evening shifts, and one nurse aide per 20 residents during the night shift on three of 7 days (April 18, 19, 2024, and April 21, 2024)

Findings include:

Review of facility census data indicated that on April 18, 2024 the facility census was 103, which required 5.15 nurse aides during the evening shift.

Review of the nursing time punch detail documentation revealed 5.10 nurse aides provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on April 19, 2024 the facility census was 103, which required 8.58 nurse aides during the evening shift.

Review of the nursing time punch detail documentation revealed 8.07 nurse aides provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on April 21, 2024 the facility census was 102, which required 5.10 nurse aides during the night shift.

Review of the nursing time punch detail documentation revealed 5.00 nurse aides provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

An interview April 24, 2024, at 2 PM, the Nursing Home Administrator confirmed that the facility did not meet state minimum staffing for nurse aides.

Plan of Correction - To be completed: 05/28/2024

Facility will schedule CNAs to meet the current, required staffing ratios.
The facility is currently utilizing agency to bolster facility staffing. The facility is also using multiple outside resources such as partnerships with local high school and trade schools to recruit more staff. The facility is also utilizing a number of employee appreciation efforts to retain current staff.
Nursing Admin team will be re-educated on current staffing ratios and protocol for replacing call offs.
Nursing Admin team will review schedules to ensure proper staffing has been scheduled. When call offs occur the DON will be notified and DON or designee will utilize staff call list as well as agency support to fill the opening created.
IDT designee will conduct an audit on scheduled staffing levels to ensure minimum staffing levels are maintained. Audit will be conducted weekly with results reported to the QAPI as necessary.

§ 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.

Plan of Correction - To be completed: 05/28/2024

Facility will schedule LPNs to meet the current, required staffing ratios.
The facility is currently utilizing agency to bolster facility staffing. The facility is also using multiple outside resources such as partnerships with local high school and trade schools to recruit more staff. The facility is also utilizing a number of employee appreciation efforts to retain current staff.
Nursing Admin team will be re-educated on current staffing ratios and protocol for replacing call offs.
Nursing Admin team will review schedules to ensure proper staffing has been scheduled. When call offs occur the DON will be notified and DON or designee will utilize staff call list as well as agency support to fill the opening created.
IDT designee will conduct an audit on scheduled staffing levels to ensure minimum staffing levels are maintained. Audit will be conducted weekly with results reported to the QAPI as necessary.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement