Pennsylvania Department of Health
ABBEYVILLE SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ABBEYVILLE SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

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

Initial comments:
Findings of an Abbreviated Complaint Survey completed on June 11, 2024, at Abbeyville Skilled Nursing and Rehabilitation, identified deficient practice, related to the reported complaint allegations, under the 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 as they relate to the Health portion of the survey process.

Plan of Correction:

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

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.

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:

Based review of the facility's policy, clinical records facility documentation review, and staff interview, it was determined that the facility failed to thoroughly and timely investigate an allegation of being mishandled with roughness by a resident who verbalized feeling of not being safe in the facility for one of two residents reviewed (Resident CL1).

Findings include:

Review of the facility's policy titled "Abuse Prohibition", review date October 24, 2022, revealed that immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, initiate an investigation within 24 hours of an alleged of abuse that focuses on whether abuse or neglect occurred and to what extent; clinical examination for signs of injuries if indicated; causative factor; and interventions to prevent further injury. The investigation will be thoroughly documented within the Risk Management Portal. Ensure that documentation of witnessed interviews is located.

Review of Resident CL1's clinical records revealed Resident CL1 was admitted to the facility on April 25, 2024, to receive therapy post-abdominal surgery.

Review of Resident CL1's Admission Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated April 27, 2024, revealed resident was cognitively intact. The same MDS revealed that the resident required substantial/maximal assistance with toileting.

Review of Resident CL1's nursing progress notes dated April 27, 2024, at 6:19 p.m., revealed that at 3:00 p.m., the "resident was in the hall in front of the nurses' station very upset unable to verbalize the issue except that she had to wait to go to the bathroom on day shift. The resident called her daughter who came in within 10 minutes. The resident informed the daughter that she does not feel safe in the facility and thus requested to leave. The physician was notified, and the resident was discharged against medical advice. The resident left the facility at 5:02 p.m., and the Director of Nursing (DON) was informed of the issue at 6:51 p.m."

Review of facility's documentation revealed on April 28, 2024, the Resident's daughter sent an email to the facility's compliance department and reported observed care concerns from a male nurse during the Resident's stay in the facility which included leaving the bathroom door open while being assisted with toileting and not providing appropriate assistance with transfers. The daughter wrote in the email that she reported it to the charge nurse and requested not to let the male nurse assist her mother. The charge nurse informed her that the male nurse had spoken to them and that the incident would be reported to the supervisor. An hour later, she received a call from her mother, crying for help, and reported that the male nurse came back and mishandled the resident with roughness.

Interview with the Nursing Home Administrator (NHA) was conducted on June 11, 2024. The NHA reported the email sent to the compliance department was not forwarded to her until May 2, 2024. The NHA reported that the alleged perpetrator was an agency staff and was no longer allowed in the facility. The facility was unable to provide documented evidence that the alleged report of being roughly mishandled was investigated by the facility.

The facility failed to ensure Resident CL1's allegation of being roughly mishandled was thoroughly and timely investigated by the facility.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(a) Management

28 Pa. Code 201.18(b)(3) Management

28 Pa. Code 211.12(c) Nursing services

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

Plan of Correction - To be completed: 07/30/2024

FTAG 610 - Investigate/Prevent/Correct Alleged Violation

Allegation was investigated for Resident CL1. No harm identified.

A Comprehensive review of Incident Reports in the last 30 days (5/28/2024 through 6/28/2024) to be completed to ensure that all Abuse allegations have been investigated and reported timely.

The facility will take further steps to ensure that the problem does not recur by educating all staff on the Abuse Prohibition Policy as well as FTAG 610 in regards to reporting and investigating allegations.

Compliance will be monitored by the Director of Nursing / Designee by reviewing progress notes and Incident reports daily to ensure any abuse allegations are investigated timely. Results will be forwarded to the QAA committee to determine the need for further follow up/monitoring.

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ:

§483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Observations:

Based on observations and staff interviews it was determined that the facility failed to ensure a safe and sanitary environment for one of the two units observed (Stevens)

Findings include:

Observation in Resident R1's room conducted on June 11, 2024, at 10:45 a.m., revealed a multiple black pellet-looking object approximately 20 plus on the bottom wall vent and approximately 50 on the floor below the resident ' s television.

Observation of room 44 bathroom conducted on June 12, 2024, at 10:50 a.m., revealed three tiles were broken exposing a hole in the bottom wall of the bathroom.

Interview with licensed nurse, Employee E3 was conducted with the above observations on June 11, 2024, at 11:00 a.m. Employee E3 confirmed that the multiple black pellets-looking objects in resident 1's room were mouse droppings.

Observation conducted on June 11, 2024, at 1:30 p.m., revealed the mouse droppings observed earlier were still present in the resident's room.

Interview conducted with the maintenance director on June 11, 2024, revealed that he/she was not notified of the broken tiles/holes in room 44-bathroom bottom wall.

The above information was conveyed to the Nursing Home Administrator on June 11, 2024, at 2:00 p.m.

The facility failed to ensure a safe and sanitary environment in the Stevens Unit.

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

Plan of Correction - To be completed: 07/12/2024

Room 44, identified during survey had Maintenance repaired bathroom wall and housekeeping cleaned the floor in room 44 on June 11th, 2024.
Housekeeping director will do an education with the department on moving furniture to reach corners of the room as part of their daily cleaning. Maintenance will continue to respond timely to TELS tickets.
Maintenance director will conduct a one time audit of all resident bathrooms to ensure all tiles are secured properly. Housekeeping Director will conduct a random audit of 10 resident rooms twice a week for four weeks.
Audits will be reported to NHA and to QAPI committee.
Will be completed by July 12th, 2024

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