Pennsylvania Department of Health
ATHENS 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

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ATHENS NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  61 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.
ATHENS NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to two Complaints completed on February 7, 2024, it was determined that Athens 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 as they relate 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 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.
§ 483.25 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 record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered vital signs, medications, and interventions for two of three residents reviewed (Residents 1 and 2).

Findings include:

Clinical record review for Resident 1 revealed a current physician's order for staff to administer Cinnamon 500 milligrams (mg) one tablet by mouth (PO) daily for diabetes mellitus and Chromium 200 micrograms (mcg) PO daily for diabetes mellitus.

Review of Resident 1's January and February 2024 MAR (medication administration record, a form to document medication administration) revealed staff were administering his Cinnamon and Chromium medications daily with the Chromium being held 14 times and the Cinnamon being held 14 times in January. Neither medication was held in February. There was no documentation in Resident 1's nursing documentation that indicated justification as to why both medications were held.

Observation of a facility medication cart on February 7, 2024, at 1:25 PM with Employee 1, licensed practical nurse, confirmed that the facility had Chromium 1000 mcg (not 200 mcg as ordered and five times the ordered dose) and Cinnamon 1000 mg (not 500 mg as ordered and twice the ordered dose) available for administration for Resident 1. Employee 1 acknowledged that she administered both medications to Resident 1 and failed to identify the incorrect milligram and/or microgram dosage for each medication.

Observation of the same facility medication cart on February 7, 2024, at 2:32 PM with Employee 1 and the Nursing Home Administrator (NHA) revealed that there was an unopened bottle of Cinnamon 500 mg (Resident 1's correct physician ordered dosage) upside down in the bottom drawer of the cart where other overflow/overstock medications are stored. The NHA revealed that he had purchased the over-the-counter Cinnamon 500 mg bottle at a local business over this past weekend and provided it to nursing staff on February 5, 2024, upon return to work. Employee 1 revealed that she was unaware that the correct Cinnamon dosage was available to administer to Resident 1.

The facility failed to procure and administer the correct dosage of Resident 1's Cinnamon and Chromium medications and failed to identify an incorrect dosage prior to administering Resident 1 medications.

Clinical record review for Resident 2 revealed a current physician's order for staff to monitor their blood pressure BP (blood pressure) medications if her systolic blood pressure (pressure when the heart contracts) was less than 100 mmHg (millimeters of Mercury) and diastolic blood pressure (pressure when the heart rests) was less than 60 mmHg. Resident 2's physician ordered Lisinopril (for high blood pressure) 5 mg PO daily and Carvedilol (for high blood pressure) 12.5 mg PO twice daily.

Review of Resident 2's clinical documentation revealed that staff documented her blood pressure as less than physician ordered parameters, but administered her Carvedilol and/or Lisinopril on the following dates:

January 12, 2024, at 10:50 AM 94/50 mmHg

January 13, 2024, at 10:15 AM 95/55 mmHg

January 13, 2024, at 7:31 PM 94/58 mmHg

January 14, 2024, at 11:49 AM 96/59 mmHg

January 18, 2024, at 7:45 PM 86/49 mmHg

January 19, 2024, at 9:28 AM 89/59 mmHg

January 20, 2024, at 12:48 PM 87/54 mmHg

January 23, 2024, at 9:50 AM 84/59 mmHg

January 23, 2024, at 8:47 PM 88/54 mmHg

January 24, 2024, at 7:22 PM 98/60 mmHg

January 26, 2024, at 9:27 AM 80/58 mmHg

January 27, 2024, at 9:06 AM 80/58 mmHg

Further review of Resident 2's clinical documentation revealed that there was no documentation of her blood pressure on the following dates; however, staff administered her Lisinopril and/or Carvedilol :

January 22, 2024, 8:00 PM

January 25, 2024, 8:00 PM

January 26, 2024, 8:00 PM

February 3, 2024, 8:00 PM

February 4, 2024, 8:00 AM

The surveyor reviewed the above information during an interview on February 7, 2024, at 2:10 AM, with the Nursing Home Administrator.

28 Pa. Code 211.10(c) Resident care policies

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


 Plan of Correction - To be completed: 03/19/2024

1. Resident 1 correct dose of medication was obtained and in place. Cannot retroactively correct incorrect doses. Resident 2 cannot retroactively correct.
2. Current resident over the counter medications doses will be verified for correct dose to prescribed order. Current residents will be reviewed for blood pressure medication parameters and appropriate administration.
3. Re-education to licensed nurses on Administering Medication policy.
4. DON/designee will complete random audits verifying medication order to medication and blood pressure parameters accuracy weekly x4, monthly x2 and reported to QAPI.

§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents during the day shift on four of 21 day shifts reviewed; a minimum of one nurse aide per 12 residents on three of 21 evening shifts reviewed; and failed to ensure a minimum of one nurse aide per 20 residents on eight of 21 overnight shifts reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following nurse aides (NA) scheduled for the resident census:

Day shift:

January 17, 2024, 5.66 NAs for a census of 69, requires 5.75 NAs.
January 18, 2024, 5.14 NAs for a census of 69, requires 5.75 NAs.
January 19, 2024, 5 NAs for a census of 70, requires 5.83 NAs.
January 24, 2024, 5.38 NAs for a census of 70, requires 5.38 NAs.

Evening shift:

January 20, 2024, 5 NAs for a census of 70, requires 5.83 NAs.

February 2, 2024, 5 NAs for a census of 72, requires 6 NAs.
February 4, 2024, 5 NAs for a census of 71, requires 5.92 NAs.


Overnight shift:

January 19, 2024, 3 NAs for a census of 70, requires 3.5 NAs.
January 20, 2024, 3 NAs for a census of 70, requires 3.5 NAs.
January 23, 2024, 2.79 NAs for a census of 69, requires 3.45 NAs.
January 31, 2024, 3.5 NAs for a census of 71, requires 3.55 NAs.

February 2, 2024, 2.13 NAs for a census of 72, requires 3.6 NAs.
February 3, 2024, 3 NAs for a census of 72, requires 3.6 NAs.
February 4, 2024, 3.5 NAs for a census of 71, requires 3.55 NAs.
February 6, 2024, 3.56 NAs for a census of 72, requires 3.6 NAs.

Interview with the Nursing Home Administrator on February 7, 2024, at 2:07 PM confirmed the above findings.


 Plan of Correction - To be completed: 03/19/2024

1. The facility cannot retroactively correct the nurse aid ratios
2. The facility is focusing on retention of existing nurse aides and recruitment of new nurse aides through efforts of the Human Resources Manager and Nursing Administration.
3. The scheduler has been reeducated regarding new nurse aid ratio. Calculation of the daily nurse aide ratios will be completed and reviewed for accuracy by the scheduler/designee.
4. Daily ratios will be audited weekly x 4 weeks then monthly x2 months. The audits will be reviewed at QAPI.

§ 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 a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse per 25 residents during the day on 13 of 21 day shifts reviewed; a minimum of one licensed practical nurse per 30 residents on 13 of 21 evening shifts reviewed; and failed to ensure a minimum of one licensed practical nurse per 40 residents on one of 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following licensed practical nurse (LPN)scheduled for the following resident census:

Day shift:

January 20, 2024, 2 LPNs for a census of 70, requires 2.8 LPNs.
January 21, 2024, 2 LPNs for a census of 70, requires 2.8 LPNs.
January 25, 2024, 2 LPNs for a census of 70, requires 2.8 LPNs.
January 26, 2024, 2 LPNs for a census of 71, requires 2.84 LPNs.
January 27, 2024, 2 LPNs for a census of 70, requires 2.8 LPNs.
January 28, 2024, 2 LPNs for a census of 70, requires 2.8 LPNs.
January 29, 2024, 2 LPNs for a census of 70, requires 2.8 LPNs.
January 30, 2024, 2 LPNs for a census of 69, requires 2.76 LPNs.
January 31, 2024, 2 LPNs for a census of 71, requires 2.84 LPNs.

February 2, 2024, 2 LPNs for a census of 72, requires 2.88 LPNs.
February 3, 2024, 1.63 for a census of 72, requires 2.88 LPNs.
February 4, 2024, 2 LPNs for a census of 71, requires 2.84 LPNs.
February 5, 2024, 2 LPNs for a census of 72, requires 2.88 LPNs.

Evening shift:

January 19, 2024, 2 LPNs for a census of 70, requires 2.33 LPNs.
January 20, 2024, 2 LPNs for a census of 70, requires 2.33 LPNs.
January 21, 2024, 2 LPNs for a census of 70, requires 2.33 LPNs.
January 22, 2024, 2 LPNs for a census of 70, requires 2.33 LPNs.
January 25, 2024, 2 LPNs for a census of 70, requires 2.33 LPNs.
January 26, 2024, 2 LPNs for a census of 71, requires 2.37 LPNs.
January 27, 2024, 1.88 LPNs for a census of 70, requires 2.33 LPNs.
January 28, 2024, 2 LPNs for a census of 70, requires 2.33 LPNs.
January 20, 2024, 2 LPNs for a census of 70, requires 2.33 LPNs.

February 2, 2024, 2 LPNs for a census of 72, requires 2.4 LPNs.
February 3, 2024, 1.06 LPNs for a census of 72, requires 2.4 LPNs.
February 4, 2024, 2 LPNs for a census of 71, requires 2.37 LPNs.
February 5, 2024, 2 LPNs for a census of 72, requires 2.4 LPNs.

Overnight shift:

January 26, 2024, 1 LPN for a census of 70, requires 1.75 LPNs.

Interview with the Nursing Home Administrator on February 7, 2024, at 2:07 PM confirmed the above findings.


 Plan of Correction - To be completed: 03/19/2024

1. The facility cannot retroactively correct the LPN ratios
2. The facility is focusing on retention of existing LPN's and recruitment of new LPN's through efforts of the Human Resources Manager and Nursing Administration.
3. The scheduler has been reeducated regarding new LPN ratio. Calculation of the daily LPN ratios will be completed and reviewed for accuracy by the scheduler/designee.
4. Daily ratios will be audited weekly x 4 weeks then monthly x2 months. The audits will be reviewed at QAPI.

§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure the total of nursing care hours provided in each 24-hour period was a minimum of 2.87 hours per patient day (PPD), effective July 1, 2023, on six of the 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed that the facility failed to meet the minimum hours per patient day on the following dates:

January 19, 2024, with 2.74 hours per resident per day
January 20, 2024, with 2.63 hours per resident per day
January 26, 2024, with 2.70 hours per resident per day

February 2, 2024, with 2.47 hours per resident per day
February 3, 2024, with 2.63 hours per resident per day
February 4, 2024, with 2.76 hours per resident per day

The facility failed to meet the required nursing staffing PPD.

Interview with the Nursing Home Administrator on February 7, 2024, at 2:07 PM confirmed the above noted findings related to the nursing PPD.


 Plan of Correction - To be completed: 03/19/2024

1. The facility cannot retroactively correct total nursing service hours.
2. The facility is focusing on retention of existing LPN's, nurse aides as well as the recruitment of new LPN's and nurse aides through efforts of the Human Resources Manager and Nursing Administration.
3. The scheduler will be reeducated regarding total number of hours of general nursing provided in a 24 hour period being a minimum of 2.87 hours of direct resident care for each resident. Per patient day hours will be completed and reviewed for accuracy by the scheduler/designee.
4. Daily Per Patient Day Hours will be audited weekly x 4 weeks then monthly x2 months. The audits will be reviewed at QAPI.


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

Visit the PA Power Port