Pennsylvania Department of Health
SHENANDOAH SENIOR LIVING COMMUNITY
Patient Care Inspection Results

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SHENANDOAH SENIOR LIVING COMMUNITY
Inspection Results For:

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SHENANDOAH SENIOR LIVING COMMUNITY - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on February 16, 2024, it was determined Shenandoah Senior Living Community 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:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:

Based on review of the facility's abuse prohibition policy and procedures, clinical records, and select investigative reports and staff interview it was determined that the facility neglected to provide care and services necessary to avoid physical harm, a fractured hip and a fractured ankle, and maintain physical health of two residents out of eight residents sampled (Residents CR1 and 2).


Findings include:


A review of the facility's policy entitled "Abuse Policy" states the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

A review of the clinical record revealed that Resident CR1 was admitted to the facility on December 6, 2023, with diagnoses which included malignant neoplasm of the lung, muscle weakness, difficulty walking, and need for assistance with personal care.

A Significant Change Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated December 31, 2023, indicated that the resident was cognitively intact.

A review of the resident's plan of care initially dated December 8, 2023, that the resident had limited physical mobility related to weakness and debility related to end stage disease process with planned interventions that the resident was to be transferred with the assistance of two staff members with her rolling walker.

A nursing progress note dated January 9, 2024, at 7:30 AM indicated Resident CR1 was complaining of left leg pain. The entry noted that the resident stated she was taken to the bathroom that morning, and now has leg pain. The resident's left was externally rotated.

A nursing progress note dated January 9, 2024, at 1:45 PM revealed that the facility had concerns with compliance with the resident's plan of care, noting that the resident requested the bedpan for toileting, but was instead transferred with the assistance of only one staff member to the toilet. The resident reported increased pain after toileting. The resident notified her daughter, and the resident's daughter came to the facility. The concern was then reported to staff and upon assessment found that the resident's left leg had a noted deformity. The resident's left hip and leg were shortened and externally rotated. The resident had pain and swelling and was sent out to the hospital on that date.

A review of a hospital Xray report dated January 9, 2024, revealed the resident had a displaced angulated fracture (two ends of the broken bone are at an angle to each other) of the left hip.

A review of the facility's investigation report dated January 9, 2024, revealed Resident CR1 reported to Employee 1 LPN (license practical nurse) that Employee 2, a nurse aide (NA), on night shift took her to the bathroom when Resident CR1 requested to use the bedpan to relieve herself. Employee 2 got the resident up into the wheelchair and took her to the bathroom to use the toilet instead of providing the bedpan as the resident requested. Employee 2 transferred the resident by herself to the wheelchair when the resident's plan of care indicated that the resident is to be transferred with the assistance of two staff. Employee 2 then transferred the resident by herself onto the toilet. The employee was unable to transfer the resident back to the wheelchair from the toilet, so Employee 2 used a sit to stand lift, without the assistance of another staff member, to transfer the resident back into the wheelchair. Resident CR1 reported to Employee 1 that she heard "snapping" while Employee 2 was transferring her to the toilet. The facility concluded that Employee 2 neglected to follow Resident CR1's plan of care to ensure the proper staff assistance was provided to safely transfer the resident. Employee 2 was terminated from employment at the facility.

A review of Resident CR1's statement regarding the event dated January 9, 2024, revealed that the resident stated Employee 2, NA, transferred her to the wheelchair to take her to the bathroom by herself. The resident stated that she was yelling out in pain during the transfer. The resident stated that Employee 2 told her to "stop yelling" so people don't think she is hurting the resident. The resident stated that Employee 2 took her to the bathroom and had her pivot and sit on the toilet. The resident stated while she was having her do that, she was yelling out in pain again. Resident CR1 stated Employee 2 transferred her off the toilet using a lift and that is when she "heard two snaps." The resident stated Employed 2 then transferred her to the wheelchair as the resident continued to yell out in pain. The resident then stated Employee 2 brought the wheelchair to the side of the bed and the resident stated, "oh no not again." The resident stated at that time Employee 2 left the room to get Employee 3, another nurse aide. The resident stated the Employee 2 and Employee 3 then placed the resident back in bed. The resident further indicated that Employee 4, LPN, came into the room after Employee 2 and Employee 3 left and administered her the scheduled pain medication. The resident then stated she called her daughter around 7:20 AM that morning to inform her of what happened during the night shift on January 9, 2024.


A review of a statement from Employee 2 dated January 9, 2024, revealed that the employee reported that Resident CR1 rang the call bell and indicated that she needed to be toileted. The employee stated that she transferred the resident by herself to the wheelchair. When asked about the resident's transfer status, the employee stated she did not know the resident was an assist of two. The employee stated when the resident sat down on the toilet it sounded like a crunch. When the employee was asked if she notified the LPN, or the RN (registered nurse) supervisor, Employee 2 stated "no." Employee 2 indicated that she had a difficult time getting the resident up from the toilet and stated that she told Employee 4 she was going to have to use the lift to get her up. Employee 2 stated that she used the sit to stand lift by herself to get the resident up and on the side of her bed. Employee 2 then stated Employee 3 came into the room to help lift the resident's legs into bed. Employee 2 was asked if the resident complained of pain during these transfers, the employee stated "yes, but I thought it was normal for her."

A review of a statement from Employee 3 dated January 9, 2024, revealed that Employee 2 came to Employee 3 for help with Resident CR1. Employee 3 indicated that when she entered the room Resident CR1 was already sitting on the side of the bed. Employee 3 revealed that Employee 2 stated to her, "I keep trying to lay her down and she keeps screaming that her legs hurt." Employee 3 stated she helped assist her legs into bed. Further Employee 3 indicated she was not aware that Employee 2 had transferred the resident to and from the bathroom.

A review of a statement from Employee 4 dated January 9, 2024, revealed that a little after 6:00 AM he administered Resident CR1's scheduled pain medications. The employee stated at that time she did not appear at ease and assumed pain was the culprit. The employee indicated that Employee 2 had cared for the resident that night (tour of duty). Employee 4's statement did not indicate awareness that Employee 2 had transferred to the toilet and needed a sit to stand lift to be transferred off the toilet and back to bed.

An interview with the Director of Nursing on February 16, 2024, at approximately 11:15 AM revealed that prior to the incident Employee 2 was educated on abuse, neglect and following a resident's plan of care in August 2023, and she knew where to find the information regarding the resident's transfer status.

A review of the clinical record revealed that Resident 2 was admitted to the facility on June 8, 2020, with diagnoses which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), muscle weakness, difficulty walking, and need for assistance with personal care.

An Annual MDS dated November 28, 2023, indicated the resident was moderately cognitively impaired.

A review of the resident's plan of care, initially dated June 8, 2020, revealed that the resident had limited physical mobility related to osteoarthritis with planned interventions initially dated August 3, 2023, for the resident to be transferred with the assistance of two staff members with a walker.

A nursing progress note dated January 12, 2024, at 7:38 PM revealed staff was assisting Resident 2 to the toilet when the resident's right knee buckled causing the resident to lose balance. Staff assisted the resident to a chair. The resident complained of pain to the right ankle. The physician was made aware, and x-rays were ordered.

A review of a facility investigation report dated January 12, 2024, revealed that at 4:15 PM Employee 5, a nurse aide, took Resident 2 to the bathroom. Employee 5 was transferring the resident, without the assistance of another staff member, to the toilet when the resident's knee gave out causing the resident to fall to her knees and her ankle to turn outward. Employee 5 called out for assistance from other staff and the resident was placed back into the wheelchair. The resident was required an assist of two staff members for all transfers. Upon assessment the resident's right ankle was swollen, painful, and bruised. X-rays were ordered. The facility's investigation concluded that Employee 5 neglected to follow the resident's plan of care and transferred the resident alone when the resident required assistance of two staff. The facility notified the employee's nurse staffing agency, and she was placed on the do not return list.

A review of an x-ray report dated January 12, 2024, revealed the resident had a mildly displaced acute oblique fracture (break in the bone at an angle that does not line up) of the right ankle.

The resident was transferred out to the hospital On January 12, 2024, for further treatment.

A review of a statement from Employee 5 dated January 12, 2024, revealed that the employee stated she was trying to toilet the resident. As the employee was assisting her turn, the resident screamed out, "oh my god my legs hurt." The employee indicated that she then assisted the resident to the floor and yelled for help.

An interview with the Director of Nursing on February 16, 2024, at approximately 11:15 AM revealed Employee 5 was just educated on January 12, 2024, prior to her shift on the importance of reviewing resident's Kardex and transfer status prior to performing any care involving resident transfers. This education was completed in response to the prior incident with Resident CR1 on January 9, 2024. Employee 5 was educated on the abuse policy, resident rights policy, following resident transfer orders and plan of care due Employee 2's he neglect of Resident CR1. The Director of Nursing confirmed Employee 5 still failed to implement the resident's plan of care and use the correct amount of transfer assistance for Resident 2, and the facility's education failed to prevent another incident of neglect from happening.

An interview with the Nursing Home Administrator and Director of Nursing on February 16, 2024, at approximately 1:45 PM confirmed that the facility failed to ensure that Resident CR1 and Resident 2 were provided the services necessary to avoid physical harm and Employee 2 and Employee 5 neglected to provide care planned for the resident, sufficient staff assistance with transfers, resulting in serious injuries.




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


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


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




 Plan of Correction - To be completed: 03/12/2024

1.Resident CR1 is no longer in the facility. Resident 2's care plan/Kardex accurately reflects current transfer status of resident. Social services to follow accordingly for any psychosocial needs.

2.Facility wide audit to be completed of resident transfer status and accurate documentation in care plan/Kardex. Any changes will be modified accordingly in Care plan/Kardex. Safety rounding form implemented and will be completed by RN supervisors every shift.

3.All nursing staff, including agency staff will be educated on reviewing resident's Kardex and transfer status prior to any care that involves transfer of a resident. All nursing staff, including agency staff will also be educated on Abuse/Neglect policies and procedures.

4.DON/Designee will complete transfer assist audit weekly for 4 weeks, then monthly for three months. Results will be reviewed at the QAPI meeting.

5.Corrective Action Date: March 12th, 2024

§ 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 observation and staff interview, it was determined that the facility failed to report confirmed cases of COVID-19 within 24 hours to the State Licensing Agency, Department of Health, Division of Nursing Care Facilities as required.

Findings include:

Review of the Division of Regulatory Oversight and Nursing Care Facilities Message Board revealed a posted message dated June 7, 2023, and again on September 17, 2023, regarding reporting requirements which noted as follows: In response to the PA Department of Health's release, on June 6, 2023, of PAHAN (Pennsylvania Health Alert Network)-2023 - 700-06-06-ADV Updated Reporting Requirements for COVID-19 Following the End of the COVID-19 Public Health Emergency and PENNSYLVANIA DEPARTMENT OF HEALTH 2023 - PAHAN - 701-06-06-ADV COVID-19 Outbreak Identification and Reporting for Healthcare Settings, the Division of Nursing Care Facilities is providing this reminder to long term care skilled nursing facilities that outbreaks of COVID-19 among residents and staff should continue to be reported to the Division of Nursing Care Facilities via the Event Reporting System.

An outbreak is defined as one or more residents with a probable or confirmed case of COVID-19 acquired in the facility.

A staff outbreak is defined as one or more health care personnel with a probable or confirmed case of COVID-19 who was working in the facility while infectious.

The facility census was 98 residents at the time of the survey ending February 16, 2024.

Review of the facility's COVID-19 line list revealed that the facility had an outbreak of COVID-19 starting on January 12, 2024, with a facility employee.

Further review of the facility's COVID-19 line list revealed the facility had an additional 9 employees tested positive for COVID-19 and 20 residents tested positive for COVID-19.

Interview with the Nursing Home Administrator on February 16, 2024, at approximately 1:45 PM confirmed that the facility failed to report confirmed cases of COVID-19 as required to the State Licensing Agency, Department of Health, Division of Nursing Care Facilities.



 Plan of Correction - To be completed: 03/12/2024

1.Documented COVID 19 cases from January 12th outbreak reported to DOH accordingly and accepted.

2.Any new COVID 19 infections for staff or residents reported within 24 hrs. to DOH under title reportable health diseases.

3.Daily review of all new COVID cases reviewed at AM meeting to ensure all confirmed cases are being reported in timely manner. RN supervisors to report any other COVID cases to DON/ADON in off hours.

4.NHA/Designee will audit weekly x 4 and then monthly for three months to ensure reporting compliance of COVID 19 within 24 hrs. of confirmed case.

5.Corrective Action Date: March 12, 2024


§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(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 a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 2 shifts out of 63 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:12 on the evening shift and 1:20 on the night shift based on the facility's census.

January 25, 2024 - 8 nurse aides on the evening shift, versus the required 8.25 for a census of 99.
February 10, 2024 - 4.80 nurse aides on the night shift, versus the required 4.85 for a census of 97.

An interview with the Nursing Home Administrator on February 16, 2024, at approximately 1:45 PM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates.




 Plan of Correction - To be completed: 03/12/2024

1. Facility cannot retroactively correct past Nursing ratios.

2. The facility continues recruitment for open Nursing positions, through online systems, fliers, and offsite recruiters. Sign-on bonuses continue to be offered to prospective employees for open positions.

3. Facility implemented system of daily staffing meetings Monday through Friday to ensure efforts are met to meet necessary NA ratios. Nursing Scheduler educated with this process.

4. NHA/Designee will audit ratios weekly for 4 weeks, then monthly for three months to ensure NA ratios are met. Audits will be submitted to QAPI for Review.

5. Corrective Action Date: March 12, 2024


§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for 14 shifts out of 63 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1 per 25 residents during the day, 1 per 30 residents during the evening, and 1 per 40 residents overnight based on the facility's census.

January 27, 2024 - 2.13 LPNs on the night shift, versus the required 2.43 for a census of 97.
January 28, 2024 - 1.07 LPNs on the night shift, versus the required 2.40 for a census of 96.
January 30, 2024 - 2.13 LPNs on the night shift, versus the required 2.43 for a census of 97.
February 1, 2024 - 3.20 LPNs on the evening shift, versus the required 3.33 for a census of 100.
February 1, 2024 - 2.13 LPNs on the night shift, versus the required 2.5 for a census of 100.
February 2, 2024 - 1.6 LPNs on the night shift, versus the required 2.45 for a census of 98.
February 3, 2024 - 2.13 LPNs on the night shift, versus the required 2.38 for a census of 95.
February 7, 2024 - 2.13 LPNs on the night shift, versus the required 2.43 for a census of 97.
February 8, 2024 - 2.13 LPNs on the night shift, versus the required 2.43 for a census of 97.
February 10, 2024 - 2.93 LPNs on the day shift, versus the required 3.88 for a census of 97.
February 11, 2024 - 3.20 LPNs on the day shift, versus the required 3.88 for a census of 97.
February 11, 2024 - 2.13 LPNs on the night shift, versus the required 2.45 for a census of 98.
February 12, 2024 - 2.13 LPNs on the night shift, versus the required 2.45 for a census of 98.
February 13, 2024 - 2.13 LPNs on the night shift, versus the required 2.45 for a census of 98.

An interview with the Nursing Home Administrator on February 16, 2024, approximately 1:45 PM, confirmed the facility had not met the required LPN to resident ratios on the above dates.




 Plan of Correction - To be completed: 03/12/2024

1.Facility cannot retroactively correct past Nursing ratios.

2.The facility continues recruitment for open Nursing positions, through online systems, fliers, and offsite recruiters. Sign-on bonuses continue to be offered to prospective employees for open positions.

3.Facility implemented system of daily staffing meetings Monday through Friday to ensure efforts were met to meet necessary LPN ratios. Nursing Scheduler educated with this process.

4.NHA/Designee will audit ratios weekly for 4 weeks, then monthly for three months to ensure LPN ratios are met. Audits will be submitted to QAPI for Review

5.Corrective Action Date: March 12, 2024


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