Pennsylvania Department of Health
HEALTH CARE CENTER AT WHITE HORSE VILLAGE, THE
Patient Care Inspection Results

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HEALTH CARE CENTER AT WHITE HORSE VILLAGE, THE
Inspection Results For:

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HEALTH CARE CENTER AT WHITE HORSE VILLAGE, THE - 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 February 23, 2024, it was determined that Health Care Center of White Horse was not in compliance with the following requirements of 42 CFR 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as it relates to the Health portion of the survey process.



 Plan of Correction:


483.25 REQUIREMENT Quality of Care: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.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based on clinical records review and staff interview, it was determined the facility failed to follow the physician's order regarding medication for one of the 12 residents reviewed (Resident 44)

Findings include:

Review of Resident 44's clinical record including diagnosis list includes Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period).

Review of Resident 44's clinical record including physician order dated June 20, 2023, revealed an order of Novolog (fast-acting insulin) Flex Pen U-100 Inulin administered seven units subcutaneously (Insertion of medication beneath the skin by injection) with meals. Hold if blood sugar is below 180 mg/dl.

Review of Resident 44's clinical record including January 2024, Medication Administration Record (MAR) revealed from January 1, 2024, until January 31, 2024, Novolog insulin was administered to the resident on the following days out of parameter: January 9, 2024, at 8:00 a.m., (BS-134 mg/dl); January 13, 2024, at 8:00 a.m., (BS-140 mg/dl); January 15, 2024, at 8:00 a.m., (BS-97 mg/dl); January 16, 2024, at 8:00 a.m., (BS- 124 mg/dl); January 18, 2024, at 8:00 a.m., (BS- 143 mg/dl); January 22, 2024, at 8:00 a.m., (BS- 108 mg/dl); January 22, 2024, at 12 noon, (BS- 165 mg/dl); January 23, 2024, at 8:00 a.m., (BS- 90 mg/dl); January 23, 2024, at 12 noon, (BS- 90 mg/dl); January 24, 2024, at 8:00 a.m., (108 mg/dl); January 25, 2024, at 8:00 a.m., (BS- 153 mg/dl); January 27, 2024, at 8:00 a.m., (BS- 102 mg/dl); January 28, 2024, at 8:00 a.m., (BS- 129 mg/dl); January 29, 2024, at 4:00 p.m., (BS- 125 mg/dl).

Review of February 2024 MAR revealed that from February 1, 2024, until February 22, 2024, Novolog insulin was administered to the resident on the following days out of parameter: February 1, 2024, at 8:00 a.m., (BS- 143 mg/dl); February 2, 2024, at 8:00 a.m., (BS- 171 mg/dl); February 3, 2024, at 8:00 a.m., (BS- 172 mg/dl); February 7, 2024, at 8:00 a.m., (BS- 124 mg/dl); February 7, 2024, at noon, (BS- 156 mg/dl); and February 19, 2024, at 4:00 p.m., (BS-139 mg/dl).

Review of Resident 44's clinical record revealed Resident 44 was administered Novolog Insulin outside of parameter 14 times in January 2024, and six times in February 2024.

The above information was conveyed to the Director of Nursing on February 23, 2024, at 11:00 a.m.

The facility failed to ensure Resident 44's insulin parameters order was followed.

28 Pa. Code 211.5(f) Clinical Records

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



 Plan of Correction - To be completed: 04/23/2024

On 02/23/2024 physician order for resident 44 Novolog insulin was reviewed by physician, and order was discontinued. A new order was given by physician to check blood sugar twice a day and follow sliding scale with insulin coverage.

House audit: All residents receiving insulin with parameters will be audited to ensure order was followed correctly.

Nurses will be educated on following insulin orders and utilizing sliding scale coverage.

Audit of insulin orders will be completed for accuracy weekly x 4 then monthly x 2.
483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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.
483.25(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:


Based on clinical records review and staff interview, it was determined that the facility failed to timely follow a wound treatment recommended by the physician for one of the four residents reviewed (Resident 38).

Findings include:

Review of Resident 38's clinical record revealed Resident 38 had Stage three (Thickness skin loss) to the sacrum (tail bone) with a wound treatment of Medihoney (A dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns), cover with foam dressing daily.

Review of Resident 38's clinical record revealed a wound consult dated December 22, 2023, revealed a new wound treatment recommendation to cleanse the sacrum with normal saline, and apply Santyl (A topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin) to the base of the wound then secure with a bordered foam daily and as needed.

Review of Resident 38's December 2023, Treatment Administration Record (TAR) revealed that the Medihoney treatment was discontinued on December 22, 2023. A review of the same TAR revealed that the Santyl treatment recommended by the wound NP (Nurse Practitioner) on December 22, 2023, was not implemented until December 27, 2023, five days after the wound treatment was recommended.

Interview with licensed nurse Employee E3 on February 23, 2024, at 10:00 a.m., revealed the Nurse Practitioner's wound treatment recommendation to discontinue previous treatment of Medihoney was followed on December 22, 2023, but the recommendation to start new treatment of Santyl to the resident sacrum was missed until the error was discovered on December 27, 2023, five days after the wound treatment order was initiated. Employee E3 reported that the staff applied skin barrier cream to the resident Stage 3 sacrum.

The facility failed to ensure wound care treatment for resident 38's stage three sacral wound was followed.

28 Pa. Code 211.5(f) Clinical Records

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




 Plan of Correction - To be completed: 04/23/2024

Resident 38 physician order and TAR audited to ensure treatment orders followed.

House audit: Current residents receiving pressure wound treatments have been audited to ensure physicians orders are being followed.

Reeducation of nurses on following Phyicians orders on wound treatments.

Audits of residents' pressure wound orders against treatment order record are accurate and being followed. Audit weekly x4 and monthly x2.
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 a review of clinical records and staff interviews, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for one of the 12 residents reviewed (Resident 52).

Findings include:

Review of Resident 52's Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated January 4, 2024, revealed resident was discharge to a critical access hospital.

Review of the nursing progress notes dated January 4, 2024, at 1:24 p.m., revealed Resident was discharged to Independent Living (IL). Resident medication instructions, and education provided with understanding. All belongings accounted for.

An interview was conducted with the RNAC (Registered Nurse Assessment Coordinator) Employee E4 on February 22, 2024, at 10:00 a.m., and confirmed that the resident's discharge to home/community and was not hospitalized. Employee E4 confirmed that Resident 52's MDS was coded incorrectly.

The facility failed to ensure Resident 52's discharge status was accurately assessed.

28 Pa. Code 211.5(f) Clinical Records

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



 Plan of Correction - To be completed: 04/23/2024

I hereby acknowledge the CMS 2567-A, issued to HEALTH CARE CENTER AT WHITE HORSE VILLAGE, THE for the survey ending 02/23/2024, AND attest that all deficiencies listed on the form will be corrected in a timely manner.
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 review of facility staffing data, it was determined that the facility failed to ensure a minimum of one licensed practical nurse per 25 residents on night shift for three weeks of facility staffing reviewed (Weeks of August 31, 2023, December 28, 2023, and February 16, 2024).

Findings include:

Review of the weeks of August 31, 2023, December 28, 2023, February 16, 2024, revealed the following dates the nightshift did not meet the requirement of one licensed practical nurse per 25 residents:

Review if the week of August 31, 2023, thru September 6, 2023, revealed that the facility failed to meet the requirement by -.30 for every nightshift.

Review of the week of December 28, 203 thru January 3, 2024, revealed that on December 28, 2023, and December 29, 2023, the facility failed to meet the requirement by -.25, on December 30, 2023, thru January 2, 2024, the facility failed to meet the requirement by -.33, and on January 3, 2024, the facility failed to meet the requirement by -.28 every night shift.

Review of the week of February 16, 2024, thru February 22, 2024, revealed that on February 16, 2024, the facility failed to meet the requirement by -.23, on February 17, 2024, thru February 19, 2024, the facility failed to meet the requirement by -.18, and on February 20,2024 thru February 22, 2024, the facility failed to meet the requirement by -.15.

The above information was communicated to administrator.


 Plan of Correction - To be completed: 04/23/2024

The facility staffing plan will ensure that a minimum of one licensed practical nurse for 40 residents will be available on the night shift. This LPN staffing ratio is consistent with the Pennsylvania Department of Health, Bureau of Long-Term Care, Division of Nursing Facilities Minimum Staffing Ratios and PPD Calculation Instructions - Minimum Ratios as of 7/01/23 grid.

The facility will adjust LPN staffing on the night shift to ensure compliance with the above staffing requirement.

The facility will implement the staffing calculator on an ongoing basis to monitor performance in this area.

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