Pennsylvania Department of Health
WOODHAVEN HEALTH & REHAB CENTER
Patient Care Inspection Results

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WOODHAVEN HEALTH & REHAB CENTER
Inspection Results For:

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WOODHAVEN HEALTH & REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated survey in response to three complaints completed on April 19, 2024, it was determined that Woodhaven Health and Rehabilitation 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:


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:
Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to document notification of changes in conditions for three of six residents (Resident R1, R2, and R3).

Findings include:

Review of the facility, "Resident Change of Condition Policy" last reviewed 1/1/24, indicated the family/responsible party will be notified when there has been a accident or incident involving the resident, a discovery of an injury, a reaction to medication or treatment, a significant change in the resident's physical/emotional/mental condition, a need to alter the resident's medical treatment including a change in provider orders, when there is a consistent refusal of treatment or medications, and a need to transfer the resident to the emergency room and/or admission to the hospital.

Review of the clinical record revealed that Resident R1 was originally admitted to the facility on 6/16/21, and readmitted on 8/1/23.

Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 4/3/24, included diagnoses chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and chronic kidney disease (gradual loss of kidney function). Review of Section C: Cognitive Patterns indicated that Resident R1 is cognitively intact.

Review of Resident R1's demographic information indicated her daughter to be her emergency contact, responsible party, and healthcare power of attorney.

Review of a facility provided incident report dated 1/27/24, stated, "CNA (nurse aide) went to answer call light as resident stated she lost her balance and put herself on the floor. RN (registered nurse) supervisor assessed resident. Right elbow with scrapes, right shoulder has pink area." Review of the portion of the report entitled "Notifications" revealed the question of "Resident Representative Notified" as "No."

Review of Resident R1's progress notes revealed a note dated 1/24/24, and no new notes until 1/29/24. No progress notes were present providing information on Resident R1 placing herself on the floor, the injuries sustained then, or notification to her daughter.

Review of family submitted information dated 4/5/24, indicated the daughter of Resident R1 stated she was not informed of her mother's changes in condition.

During an interview on 4/19/24, at 11:55 a.m. Resident R1 stated that she has had emergencies that her daughter had not been notified of.

Review of the clinical record revealed that Resident R2 was admitted to the facility on 4/27/21.

Review of the MDS dated 2/9/24, included diagnoses psuedobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder) and coronary artery disease (damage or disease in the heart's major blood vessels). Review of Section C: Cognitive Patterns indicated that Resident R2 had cognitive impairment.

Review of Resident R2's demographic information indicated his son to be his emergency contact and responsible party.

Review of a progress note dated 2/16/24, at 6:00 p.m. indicated Resident R1 "had an unwitnessed fall at 5:10 p.m." Nurse was called to residents room by (nurse aides). Resident was on the floor on the right side of bed. RNS (Registered Nurse Supervisor) called and assessed resident. He said he was dancing in bed when he fell out of bed. Resident stated his right arm was in pain, no bruising or laceration noted at this time on right arm. Both knees have abrasions from the fall. Bed bolsters on bed, fall mats in place, and bed was in lowest position during fall with call light within reach. Resident placed back into bed, bed bolsters replaced, bed in lowest position, fall mats in place, and call bell left within reach. Non skid footwear placed on resident. VS WNL (Vital signs within normal limits). Neuro checks initiated. RNS notified MD and family.

Review of a second progress note dated 2/16/24, at 6:37 p.m. indicated "Call to MD and notified of fall, he has no family to notify."

Review of a facility provided incident report dated 2/16/24, stated, "Unwitnessed fall." Review of the portion of the report entitled "Notifications" revealed the question of "Resident Representative Notified" as "No."

Review of the clinical record revealed that Resident R3 was originally admitted to the facility on 1/17/23, and readmitted on 4/10/24.

Review of the MDS dated 3/20/24, included diagnoses diffuse traumatic brain injury (a widespread disruption in the normal function of the brain) and coronary artery disease. Review of Section C: Cognitive Patterns indicated that Resident R3 had severe cognitive impairment.

Review of Resident R3's demographic information indicated his daughter to be his emergency contact and responsible party.

Review of a grievance report submitted on 2/12/24, from Resident R3's daughter indicated that she was not notified that Resident R3 tested positive for Covid-19 on 2/5/24. Further review of the grievance form confirmed that the nurse failed to notify Resident R3's daughter.

During an interview on 4/19/24, at approximately 1:15 p.m. the Nursing Home Administrator confirmed that the facility failed to document notification of changes in conditions for three of six residents.


28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(1)(3) Management.

28 Pa. Code 201.29(a)(c)(d)(j) Resident rights.

28 Pa. Code 211.10(c)(d) Resident care policies.

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



 Plan of Correction - To be completed: 05/15/2024

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
Residents R1, R2, and R3 will have their physician notified of the change of condition.
Director or Nursing or designee will review the past 7 days of progress notes for current residents to identify change in condition status and document in the clinical record of the physician being notified.
To prevent this from happening again the Director of Nursing or designee will re-educate the license nursing staff on requirements for notification of change of a resident and documenting in the clinical record.
To monitor and maintain on going compliance the Director of Nursing/designee will audit five resident records weekly for 4 weeks then monthly for two month's.
Results will be taken to the QAPI for review and revision as needed.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:
Based on a review of facility policy, resident record, observation, resident interview and staff interview, it was determined the facility failed to provide necessary services to maintain adequate grooming and personal hygiene for ten of 18 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10).

Findings include:

Based on review of facility policy titled "Resident Bath/Showering/Scheduling Policy" dated 1/1/24, indicated residents will be bathed or showered according to their preferences in order to maintain health hygiene and skin condition.

During in observation on 4/19/24, at 11:40 a.m. Resident R4 was noted to be seated in a wheelchair in the hallway, with unkempt hair and long facial hair.

During an interview and observation on 4/19/24, at 11:43 a.m. Resident R5 confirmed that she had filed a grievance on 3/28/24, related to not receiving showers. Resident R5 stated she has missed multiple showers, and would like at least one per week adding, "I don't want to look like a hag, just because I'm in a place like this."

During an observation on 4/19/24, at 11:48 a.m. Resident R8 was observed with greasy appearing, unbrushed hair.

During an interview and observation on 4/19/24, at 11:55 a.m. Resident R1 requested assistance from the surveyor to put her socks on, stating she had been waiting two hours for help.

Review of a grievance report filed on 4/2/24, by Resident R2's son revealed a request for Resident R2 to have twice weekly showers, a haircut, and to be shaved. The resolution of the grievance indicated that Resident R2 received a shower on 4/2/24, and a haircut on 4/8/24, and that Resident R2's showers will be monitored for two weeks to ensure compliance from staff.

Review of Resident R2's electronic shower record from 3/1/24, through 4/19/24, revealed only bed baths, no showers.

During an observation on 4/19/24, at 12:05 p.m. Resident R2 was noted to be unshaven, with what appeared to be multiple days growth of facial hair.

During an observation on 4/19/24, at 12:10 p.m. Resident R6 was sleeping in a wheelchair in the hallway, wearing only a gown. Resident R6 was noted to have long fingernails and toenails.

Review of Resident R6's plan of care initiated 4/12/24, failed to include information related to a possible desire to remain in a gown.

During an interview and observation on 4/19/24, at 12:15 p.m. Resident R7 was observed with long, matted hair and a full beard. When asked, Resident R7 stated that he desired to keep the long hair and beard, but would like to have it brushed. Resident R7 was noted to have long fingernails on his left hand. Resident R7 stated that he is able to "pull at the other ones" and displayed using his left hand to tear off pieces of nail on his right hand, and stated that he is not able to use his right hand to pull at the nails on his left (due to injury to right arm), "I keep asking them to cut them."

During an interview on 4/19/24, at 12:21 p.m. Resident R9 stated she had been waiting two hours to have her leaking colostomy bag changed. At this time, Resident R9 pulled her blanket to the side to display the leaking colostomy bag.

During an observation on 4/19/24, at 12:27 p.m. Resident R10 was observed to be wearing pants and a shirt with food spillage on both.

During an interview on 4/19/24, 12:31 p.m. Resident R3 was observed with long nails on his left hand, which appeared contracted.

During an interview on 4/19/24, at approximately 1:15 p.m. the Nursing Home Administrator confirmed that the facility failed to provide necessary services to maintain good grooming and personal hygiene for ten of 18 residents.

28 Pa. Code: 211.10(a)(c)(d) Resident care policies.

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

28 Pa. Code: 201.29(j) Resident rights


 Plan of Correction - To be completed: 05/15/2024

R4 will be offered salon services and assistance with shaving. R5's shower schedule will be reviewed and she will be offered a shower. R8 will be offered a shower. R2's shower schedule was reviewed and resident will be shaved according to his preference. R6 will be assisted with nail care, offered podiatry services, and care plan will be updated to include preference for wearing a gown. R7 will be given assistance with brushing hair and given assistance with shaving and nail care. Resident R9 was given assistance with her colostomy pouch. R10 was changed into new clothing. R3 will be given assistance with nail care.
A full house audit on all residents was conducted to identify resident shower and hygiene needs for all residents. To prevent this from happening again Director of nursing or designee will educate the nursing staff on requirements for ADL care and shower schedules. To monitor and maintain ongoing compliance the director of nursing/designee will conduct an audit of ten residents for shower and personal hygiene needs weekly times 4 weeks then monthly for two months. results will be taken to QAPI for review and revision as needed.


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