Pennsylvania Department of Health
SENA KEAN NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SENA KEAN NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 117 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.


SENA KEAN NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey and an Abbreviated Complaint Survey completed on April 30, 2025, it was determined that Sena Kean Nursing and Rehabilitation 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:

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

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(e)(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 review of facility policies and documents, and clinical records, and resident and staff interviews, it was determined that the facility failed to provide written notification to the resident, family and/or the resident's representative, prior to a facility-initiated room change, including the reason for the change for one of 25 residents reviewed (Resident R53).

Findings include:

A facility policy entitled "Bed Hold Notification" dated 1/22/25, indicated that if the resident is covered by Medicaid and admitted to the hospital, the bed will be held automatically for 15 days by the Medicaid Provider regulations.

A facility policy entitled "Bed Holds and Returns" dated 1/22/25, indicated that residents who seek to return to the facility within the bed hold period defined in the state plan are allowed to return to their previous room, if available.

A facility policy entitled "Room Assignment/Change Policy" dated 1/22/25, indicated: when a room change is necessary, the resident and family will be consulted and reasons for the move will be explained by the Social Services Department/designee; each resident will be given reasonable, advance notice prior to transfer within the facility, notice will provided both verbally and in writing; Social Services will generate an in-house transfer notice to inform staff of the location and date of transfer within the facility, and that the transfer will also be documented on the resident's clinical record.

Resident R53's clinical record revealed an admission date of 2/10/19, with diagnoses that included morbid obesity, lymphedema (chronic condition causing swelling, usually in an arm or leg, due to a buildup of lymph fluid), and ongoing blood clots in the right leg. Review of a resident census document indicated he/she was enrolled in Medicaid and was coded as a "Paid Hospital Leave" dated 4/22/25, and coded as "Active" on 4/25/25, to a different room.

There was no evidence that the facility provided written notification with the reason for the change prior to the facility-initiated room change.

Review of the facility Daily Census report provided by the facility on 4/30/25, revealed that Resident R53's previous room was not occupied by another resident during his/her hospital stay between 4/22/25, and 4/25/25, or since his/her return to the facility on 4/25/25.

Review of a Bed Hold Policy notification provided to Resident R53 on 4/22/25, revealed that he/she was notified that his/her bed will be held for 15 days while he/she is admitted to the hospital.

During an interview on 4/28/25, at 2:02 p.m. Resident R53 confirmed that he/she was not permitted to return to his/her previous room upon return from the hospital, and that he/she wanted to return to their previous room and not stay in his/her current room.

During an interview on 4/29/25, at 1:24 p.m. the Nursing Home Administrator confirmed the facility failed to provide a written notice of facility-initiated room change to Resident R53.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 06/13/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.

The facility is unable to retroactively issue a written notice of room move to Resident R53.
An audit of 100% of room changes since the survey exit has been completed to ensure prior written notice was provided.

Re-education on the "Bed Holds and Returns" policy has been provided to the facility social worker by the Nursing Home Administrator (NHA) or designee.

NHA or designee will audit twenty-five percent (25%) of room moves weekly for four (4) weeks to ensure prior written notice is provided before executing any room moves.

Results of audits will be reviewed with the Quality Assurance Performance Improvement (QAPI) Committee

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

§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 review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in two of two unit refrigerators reviewed (West Unit and East Unit).

Findings include:

A facility policy entitled, "Pantries and Pantry Refrigerators and Freezers" dated 1/22/25, revealed, "The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation ...."

Observation on 4/30/25, at approximately 9:27 a.m. of the West Unit freezer revealed several ice packs that are used for treatments on resident's bodies stored next to popsicles, candy bars, and several other food items.

During an interview at the time of observation of the West Unit freezer with Social Services employee, he/she confirmed that ice packs that are used on resident's bodies should not be stored in the resident freezer with food.

Observation on 4/30/25, at approximately 9:31 a.m. of the East Unit freezer revealed several ice packs that are used for treatments on resident's bodies stored next to several food items.

During an interview at the time of observation of the East Unit freezer with Social Services employee, he/she confirmed that the ice packs that are used on resident's bodies should not be stored in the resident freezer with food.

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

Plan of Correction - To be completed: 06/13/2025

The ice packs were removed from the pantry freezer.

A facility wide audit of pantry freezers has been completed to ensure no ice packs used for treatments on residents' bodies are stored in the freezers by the Director of Nursing (DON) or designee.

Facility licensed staff to be re-educated on the facility policy entitled "Pantries and Pantry Refrigerators and Freezers" with emphasis on not storing ice packs in the freezers by the DON or designee.

DON or designee will audit fifty percent (50%) of pantry freezers weekly for four (4) weeks to ensure ice packs used for treatments on residents' bodies are not stored in the pantry freezers.

Results of audits will be reviewed with the Quality Assurance Performance Improvement (QAPI) Committee

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to provide oxygen according to physician's orders and failed to promote cleanliness and help prevent the spread of infection for two of 25 residents reviewed (Residents R21 and R59).

Findings include:

No facility policy was provided regarding management of oxygen therapy.

Resident R21's clinical record revealed an admission date of 9/27/22, with diagnoses that included respiratory failure with hypoxia (a condition where the lungs cannot provide enough oxygen throughout the body), chronic obstructive pulmonary disease (COPD - a group of lung disease that block airflow and make it difficult to breathe) , diabetes mellitus (a group of diseases that result in too much sugar in the blood), and morbid obesity with alveolar hypoventilation (a breathing disorder that could affect a person who is overweight).

Resident R21's clinical record revealed a physician's order dated 1/23/25, for O2 [oxygen]: therapy at 8 lpm (liters per minute) via nasal cannula [device that delivers extra oxygen through a tube and into your nose]. Pad tubing/humidify every shift for oxygen.

Observations on 4/27/25, at 2:15 p.m. revealed Resident R21 sitting in his/her wheelchair with oxygen being delivered via nasal cannula at 8 lpm. The concentrator filter on the right side of the concentrator was observed covered with a dusty gray substance.

During an interview with Resident R21 on 4/27/25, at 2:15 p.m. he/she indicated that the oxygen concentrator filter on the right side of the concentrator has never been cleaned and/or changed.

During an interview on 4/27/25, at 2:20 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that Resident R21's concentrator filter was dirty and covered with a dusty gray substance and did not appear to be cleaned weekly.

The Director of Nursing (DON) confirmed on 4/29/25, at 1:53 p.m. that Resident R21's oxygen concentrator's filters should be checked and cleaned weekly.

Resident R59's clinical record revealed an admission date of 6/21/22, with diagnoses that included irregular heartbeat, chronic obstructive pulmonary disease (COPD- a common lung disease causing restricted airflow and breathing problems), heart failure, and high blood pressure.

Further review of Resident R59's clinical record revealed a physician's order dated 3/06/23, for O2 therapy at 2 lpm as needed (PRN) via nasal cannula. There was a lack of evidence for a physician's order for maintaining/cleaning the oxygen equipment and lack of evidence that staff documented/recorded Resident R59's use of oxygen therapy on his/her medication administration record (MAR)/treatment administration record(TAR), and lack of evidence that staff performed respiratory assessments related to the use of supplemental oxygen.

Observation on 4/27/25, at 3:16 p.m. revealed Resident R59 sitting up in bed with supplemental O2 in place via nasal cannula, and the oxygen concentrator filter was covered with a thick layer of gray fluffy substance.

During an interview at that time, Resident R59 confirmed that he/she wears oxygen "24/7" (24 hours a day/seven days a week).

Continued observations on 4/28/25, and 4/29/25, between 8:00 a.m. and 3:00 p.m. revealed Resident R59 with his/her supplemental O2 in place.

During an interview on 4/27/25, at 4:28 p.m. the DON confirmed that the oxygen concentrator filter was covered in thick layer of gray fluffy substance.

During an interview on 4/28/25, at 10:28 a.m. the Assistant DON confirmed there was no order for cleaning the concentrator filter.

During an interview on 4/29/25, at 12:05 p.m. LPN Employee E2 confirmed that Resident R59 had his/her O2 on for the last three days and that he/she has it on all the time; there was no evidence of documentation in MAR/TAR that he/she has been receiving the O2; and no documentation that staff completed respiratory assessments related to O2 use.

During an interview on 4/29/25, at 12:23 p.m. the DON confirmed there was no evidence that staff monitored Resident R59's use of O2.

28 Pa. Code 211.10(c) Resident care policies

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

Plan of Correction - To be completed: 06/13/2025

Resident R21's oxygen concentrator filter has been changed.

Resident R59 has a physician order for maintaining/cleaning the oxygen concentrator.

An audit of current residents with oxygen to ensure changing/replacing of oxygen concentrator filters and of residents utilizing oxygen for physician orders for the maintaining/cleaning of the oxygen equipment by the DON or designee.

Facility licensed staff have been re-educated on cleaning and/or replacing oxygen concentrator filters as well as obtaining physician orders for the maintenance/cleaning of oxygen equipment by the Director of Nursing (DON) or designee.

DON or designee will audit twenty-five percent (25%) of oxygen concentrators weekly for four (4) weeks ensure the cleaning and/or replacing of filters. DON or designee will audit twenty-five percent (25%) of new oxygen orders for corresponding orders for maintaining/cleaning of oxygen equipment weekly for four (4) weeks.

Results of audits will be reviewed with the Quality Assurance Performance Improvement (QAPI) Committee

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on review facility policy and clinical records, observation, and staff interview, it was determined that the facility failed to provide appropriate suprapubic urinary catheter (tubing inserted directly into the bladder through a small incision in the lower abdomen and above the pubic bone to drain urine into a bag) care for one of three residents reviewed for catheters (Resident R51).

Findings include:

Review of facility policy entitled "Catheter Care, Urinary" dated 1/22/25, revealed "Be sure the catheter tubing and drainage bag are kept off the floor."

Review of Resident R51's clinical record revealed an admission date of 7/23/24, with diagnoses that included cerebral infarction (stroke), neuromuscular dysfunction of the bladder (a communication breakdown in the body that controls bladder function), and muscle weakness.

Review of Resident R51's clinical record revealed a physician's order dated 12/26/24, for a suprapubic catheter related to neuromuscular dysfunction of the bladder.

Observations on 4/29/25, at approximately 9:25 a.m. revealed that the bottom of Resident R51's urinary drainage bag was on the floor and there was not a privacy cover on the urinary drainage bag.

During an interview on 4/29/25, at approximately 9:27 a.m. the Assistant Director of Nursing confirmed that Resident R51's urinary catheter bag should not be on the floor and a privacy cover should in place.

28 Pa. Code 211.10(d) Resident care policies

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

Plan of Correction - To be completed: 06/13/2025

Resident R51's catheter was corrected during the survey to be off the floor and covered for privacy with a privacy bag.

An audit of 100% of catheter bags was completed to ensure privacy bags/covers were in place and that the bags were not on the floor.

Facility nursing staff will be re-educated on the "Catheter Care Urinary" policy with emphasis on keeping the drainage bag covered and off of the floor by the Director of Nursing (DON) or designee.

DON or designee will perform an audit of twenty-five percent (25%) of all catheter bags to ensure they are covered and not on the floor weekly for four (4) weeks.

Results of audits will be reviewed with the Quality Assurance Performance Improvement (QAPI) Committee

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:

§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Observations:

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure physician orders and resident's Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for one of 25 residents reviewed (Resident R97).

Findings include:

The facility policy entitled "Advance Directives" dated 1/22/25, revealed "The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive ...the interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan."

Resident R97's clinical record revealed an admission date of 4/23/24, with diagnoses that included dementia (thinking and social symptoms that interfere with daily living and functioning), hypertension (high blood pressure), and heart disease.

Resident R97's physician's orders dated 8/13/24, revealed an order for Do Not Resuscitate-Allow Natural Death (DNR).

Resident R97's clinical record revealed a POLST dated 4/9/24, for cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest).

During an interview on 4/29/25, at approximately 9:51 a.m. Registered Nurse Supervisor Employee E3, confirmed Resident R97's physician's orders and POLST were not consistent with each other.

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

28 Pa. Code 201.29(a) Resident rights

28 Pa. Code 211.5(f)(i)(iv) Medical records

28 Pa. Code 211.10(c) Resident care policies

Plan of Correction - To be completed: 06/13/2025

Resident R97 has since had a new POLST completed to match the physician's order and desire of resident's medical decision maker.

An audit of current resident POLSTs on file has been completed to ensure that the physicians' orders for CPR/DNR correctly matches the residents wishes according to the POLST.

Facility Registered Nurses have been re-educated on the facility "Advance Directives" policy with emphasis on ensuring orders match the resident's documented preferences and that the interdisciplinary team is informed of any changes by the Director of Nursing (DON) or designee.

DON or designee will perform an audit of twenty-five percent (25%) of changes in physician code status orders weekly for four (4) weeks as well as twenty-five percent (25%) of new admissions and readmissions for four (4) weeks to ensure the residents' POLST matches the admission/readmission orders.

Results of audits will be reviewed with the Quality Assurance Performance Improvement (QAPI) Committee

483.20(g) REQUIREMENT Accuracy of Assessments:

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

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

Observations:

Based on review of Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), clinical records and staff interviews, it was determined that the facility failed to ensure that the MDS assessment accurately reflected the status of one of 25 residents reviewed (Resident R57).

Findings include:

Review of MDS instructions for Section H "Bladder and Bowel" subsection H0400 "Bowel Continence" indicated that bowel continence is to be coded as "not rated" if during the seven day look-back period the resident had an ostomy (surgically created opening that allows bodily waste to exit the body through the abdominal wall instead of the anus), or did not have a bowel movement for the entire seven days.

Resident R57's clinical record revealed an admission date of 5/25/24, with diagnoses that included Parkinsonism (neurodegenerative diseases that cause motor symptoms such as shakes and tremors), dementia (loss of memory, language, problem-solving, and other thinking abilities), and high blood pressure.

Resident R57's clinical record revealed that he/she had a colostomy (an opening in the colon, allowing feces to be diverted through an opening on the abdomen) at time of admission.

Resident R57's Quarterly MDS with Assessment Reference Date (ARD) of 12/17/24, Subsection H0100 "Appliances" was coded as "Ostomy (including urostomy, ileostomy, and colostomy)" and Subsection H0400 "Bowel Continence" was coded as "Always Continent;" Quarterly MDS with ARD of 3/10/25 Subsection H0100 "Appliances" was coded as "Ostomy (including urostomy, ileostomy, and colostomy);" and Subsection H0400 "Bowel Continence" was coded as "Always Incontinent," although Resident R57 had a colostomy for the entire seven-day look-back period.

During an interview on 4/29/25, at 2:00 p.m. Registered Nurse Assessment Coordinator confirmed that the 12/17/24 and 3/10/25 MDS's were coded inaccurately and bowel continence should have been coded as "not rated" for Resident R57.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.5(f)(ix) Medical Records

Plan of Correction - To be completed: 06/13/2025

I hereby acknowledge the CMS 2567-A, issued to SENA KEAN NURSING AND REHABILITATION CENTER for the survey ending 04/30/2025, AND attest that all deficiencies listed on the form will be corrected in a timely manner.

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