Pennsylvania Department of Health
SENA KEAN NURSING AND REHABILITATION 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

SENA KEAN NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 106 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 completed on May 31, 2024, it was determined that Sena Kean Nursing and Rehabilatation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

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

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.

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

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

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

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

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

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

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

Observations:

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions during observation of care of a gastric tube for one of 25 residents reviewed (Resident R2).

Findings include:

Review of the facility policy entitled "Administering Medications" with a policy review date of 1/17/24, revealed that staff follows established infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.

Review of the facility policy entitled "Enhanced Barrier Precautions" implemented in April 2024, revealed Standard Precautions continue to apply to the care of all residents, regardless of suspected of confirmed infection or colonization status. Enhanced Barrier Precautions (EBP) employs targeted gown and glove use during high-contact resident care activities in which there is opportunity for transfer of Multi-Drug Resistant Organisms (MDRO) to staff hands and clothing. EBP are indicated for residents with any of the following wherever they reside in the facility: Infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply; or wounds and/or indwelling medical devices, regardless of MDRO infection of colonization status. Indwelling medical devices include, but not limited to central lines or PICC lines, urinary catheters, feeding tubes, tracheostomies and ventilators, and dialysis catheters. Appropriate notification/signage is placed at the room entrance indicating the type of precaution and instructions for Personal Protective Equipment (PPE) use. PPE will be available to staff for donning (put on) prior to entering the resident's room. Doffing (take off) to occur before leaving the residents room

Observation of a tube feeding administration for Resident R2 on 5/29/24, at 1:44 p.m. revealed that Licensed Practical Nurse (LPN) Employee E3 washed hands, donned gloves, entered Resident R2's room, and positioned Resident R2 for administration of the enteral tube feeding. LPN Employee E2 proceeded to check placement of Resident R2's enteral feeding tube and administer the enteral feeding. LPN Employee E2 then repositioned the resident in bed for comfort, doffed gloves and washed hands.

During an interview with LPN Employee E2 on 5/29/24, at approximately 1:55 p.m. it was confirmed that gloves and a gown should have been worn during administration with an enteral feeding tube due to EBP.

Observation of Resident R2's room revealed that there was no signage alerting persons of EBP for infection control and no PPE available outside of the room for use.

During an interview on 5/29/24, at approximately 1:58 p.m. the Infection Preventionist confirmed that EBP were not in place and employees should be wearing gloves and gowns when working with enteral feeding tubes.

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: 07/09/2024

Resident R2 has been assessed with no negative outcomes from the incident.

During the survey, signage alerting persons of residents meeting criteria for EBP were hung as well as making PPE available outside of each room for residents meeting criteria for EBP.

All current care staff have been educated on EBP, why and when EBP are indicated, the appropriate PPE required for EBP, as well as the procedures for donning and doffing PPE.

Director of Nursing, or designee, will audit residents meeting criteria for EBP for appropriate signage as well as available PPE. In addition, the audits will include observation of care for those with EBP to ensure proper PPE is utilized for 5 days, weekly for 3 weeks, and monthly for 2 months.

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

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

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

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a resident and/or his/her representative with a summary of the baseline care plan for three of five residents reviewed for baseline care plans (Resident R31, R103 and R105).

Findings include:

Review of facility policy entitled, "Care Plans Baseline" dated 1/17/24, revealed "The resident and/or representative are provided a written summary of the baseline care plan that includes, but is not limited to the following ...Goals and objectives, summary of medications, dietary instructions, and treatments."

Review of Resident R31's clinical record revealed an admission date of 1/10/24, with diagnoses that included chronic obstructive pulmonary disease (condition when your lungs do not have adequate air flow), hypertension (high blood pressure), and heart failure (a condition where the heart cannot supply the body with enough blood).

Review of Resident R31's clinical record revealed an assessment dated 1/10/24, "Baseline care plan" which revealed a question "Were the baseline care plans shared with the resident and/or resident representative?" The question revealed the answer no.

Further review of Resident R31's clinical record lacked evidence that a summary of the care plan that included goals and objectives, a summary of medications, dietary instructions and treatments was provided to Resident R31 and/or his/her representative.

Review of Resident R103's clinical record revealed an admission date of 2/5/24, with diagnoses that included hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones), hypertension, and hyperlipidemia (high cholesterol).

Review of Resident R103's clinical record revealed an assessment dated 2/5/24, "Baseline care plan" which revealed a question "Were the baseline care plans shared with the resident and/or resident representative?" The question revealed the answer no.

Further review of Resident R103's clinical record lacked evidence that a summary of the care plan that included goals and objectives, a summary of medications, dietary instructions and treatments was provided to Resident R103 and/or his/her representative.

Review of Resident R105's clinical record revealed an admission date of 4/23/24, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), hypertension, and dysphagia (difficulty swallowing).

Review of Resident R105's clinical record revealed an assessment dated 2/5/24, "Baseline care plan" which revealed a question "Were the baseline care plans shared with the resident and/or resident representative?" The question revealed no answer.

Further review of Resident R105's clinical record lacked evidence that a summary of the care plan that included goals and objectives, a summary of medications, dietary instructions and treatments was provided to Resident R105 and/or his/her representative.

During an interview on 5/30/24, at 1:57 p.m. the Regional Nurse Consultant confirmed that there was no evidence that Residents R31, R103 and R105 and/or their representatives were provided a summary of the care plan that included goals and objectives, a summary of medications, dietary instructions, and treatments.

28 Pa. Code 201.14(a) Responsibility of Licensee

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

Plan of Correction - To be completed: 07/09/2024

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.

A summary of the baseline care plan has been provided to R31, R103, and R105 and their respective representatives. The baseline care plan includes goals and objectives, summary of medications, dietary instructions, and treatments.

Current residents admitted in the past 30 days have been reviewed to determine if they and their representatives were provided with a summary of the baseline care plan and that the baseline care plan includes goals and objectives, summary of medications, dietary instructions, and treatments. And provided a copy if not previously provided.

RN Supervisors have been re-educated on the baseline care plan with emphasis on providing a summary to the resident and/or representative as well as the required components of the baseline care plan.

Director of Nursing, or designee, will audit new admissions for 5 days, weekly for 3 weeks and monthly for 2 months that new admissions and/or representatives receive summaries of the baseline care plan and that the baseline care plan includes goals and objectives, summary of medications, dietary instructions, and treatments.

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

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Observations:

Based on review of facility policy and clinical record, observation, and staff interviews, it was determined that the facility failed to ensure medications were consumed for one of seven residents reviewed during medication administration review (Resident R55).

Findings include:

Review of facility policy entitled "Administering Medications" dated 1/17/24, revealed "Medications are administered in a safe and timely manner ..." Review of facility education/training entitled "Checklist for oral medication administration" revealed "Remain with the resident until each medication is swallowed. Never leave medication at the resident's bedside." And Review of facilities audit tool entitled "Medication Administration Observation Audit," revealed "Resident is observed until all meds are ingested."

Review of Resident R55's clinical record revealed an admission date of 6/13/19, with diagnoses that included chronic obstructive pulmonary disease (condition when your lungs do not have adequate air flow), chronic kidney disease (a disease that affects the kidney's ability to filter waste products and extra fluid from the body), and disorientation (an altered mental state where a person does not know their location, identity, or time).

Observation on 5/29/24 at 9:42 a.m. revealed a medication cup filled with multiple unknown medications sitting on the resident's bedside tray table. Resident R55 was sitting in his/her wheelchair in front of his/her bedside table. Resident R55 stated "staff doesn't wait for me to take my pills because it takes me a while." He/she also stated, "there is a pill on the floor." A small white unknown medication was observed laying on the floor in front of Resident R55's bedside tray table. Further observations revealed the Licensed Practical Nurse (LPN) was down the hallway assisting other residents.

During an interview on 5/29/24, at 9:49 a.m. Registered Nurse Employee E1 confirmed that there was a cup filled with unknown medications sitting on Resident R55's bedside table without staff present. He/she also confirmed that medications should never be left at bedside and the nurse administering medications should stay with the resident until the resident ingested the medications.

28 Pa. Code 211.9(a)(1)(c) Pharmacy Services

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

Plan of Correction - To be completed: 07/09/2024

Resident R55 has been assessed and did not experience any negative outcomes of the incident.

Medication audits performed at the time of survey did not reveal other incidents of medication left at the resident bedside.

Education was started at the time of survey for current licensed staff related to the policy entitled "Administering Medications" with emphasis on remaining with the resident until each medication is swallowed and never leaving medications at the resident's bedside.

Director of Nursing, or designee, will complete medication pass audits for 5 days, weekly for 3 weeks, and monthly for 2 months that medications are not left the bedside and that each medication is swallowed prior to leaving.

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

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

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

§483.45(h) Storage of Drugs and Biologicals

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

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

Observations:

Based on review of facility policy, observations, and staff interviews it was determined that the facility failed to appropriately discard outdated medications for one of three medication carts reviewed (West A Hall medication cart).

Findings include:

Review of facility policy entitled "Administering Medications" with a policy review date of 1/17/24, indicated "The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container."

Review of Novolog Insulin manufacturer's guidelines revealed "after initial use a vial may be kept at temperatures below 30 degrees Celsius (86 degrees Fahrenheit) for up to 28 days, but should not be exposed to excessive heat or sunlight."

Observation of drug storage on 5/30/24, at 10:58 a.m. of the West A Hall medication cart revealed a vial of Novolog Insulin with an open date of 4/10/24, which was beyond the expiration date of 28 days after opening.

During an interview at the time of the observation, Licensed Practical Nurse (LPN) Employee E2 confirmed that the Novolog Insulin vial should have been discarded and not remaining in the medication cart for resident use as it was beyond the 28 days after opening.

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

28 Pa. Code 211.9(a)(1) Pharmacy services

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

Plan of Correction - To be completed: 07/09/2024

The expired Novolog Insulin was wasted at the time of the survey.

All open Novolog Insulins were audited for expiration dates and wasted if appropriate.

Current licensed nurses have been educated on the policy entitled "Administering Medications" with emphasis on checking the expiration date of opened multi-dose containers prior to administering.

Director of Nursing, or designee, will audit medication carts for open/expired Novolog Insulin vials for 5 days, weekly for 3 weeks and monthly for 2 months.

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

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