Pennsylvania Department of Health
LECOM AT VILLAGE SQUARE, LLC
Patient Care Inspection Results

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LECOM AT VILLAGE SQUARE, LLC
Inspection Results For:

There are  201 surveys for this facility. Please select a date to view the survey results.

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LECOM AT VILLAGE SQUARE, LLC - 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 and an Abbreviated Complaint Survey completed on December 7, 2023, it was determined that LECOM at Village Square, LLC, 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:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:


Based on a review of facility records, observations, and staff interviews, it was determined the facility failed to maintain safe storage of ice for residents for one of one ice machines located in the kitchen.

Findings include:

Review of the manufacturer guidelines for the Modular Crescent Cuber (ice machine), dated 10/10/17, stated "Be sure there is sufficient extra water supply line and drain line for the appliance to be pulled out for service. Separate piping to approved drain. Leave a 2-inch (5 cm) vertical air gap between the end of each pipe and the drain."

Observations in the kitchen on 12/04/23, at approximately 11:15 a.m. revealed the ice machine drainage pipe resting on the floor drain and lacked a two-inch vertical air gap between the end of the pipe and drain. The drain and surrounding floor were observed unclean and black in color.

Interview with the Dietary Manager on 12/04/23, at approximately 11:15 a.m. confirmed the ice machine's drainage pipe and floor drain lacked a two-inch air gap allowing the pipe to rest on the unclean drain creating unsafe storage for ice.

28 Pa. Code 201.14(a) Responsibility of licensee




 Plan of Correction - To be completed: 02/02/2024

Ice machine was clean/sanitized by Spaeder contracting on 12/15/23. Ice was shoveled out of bin. Inside of bin cleaned and all covers that could be removed. Scrubbed inside and outside of hoses. After all pieces cleaned and bin emptied, machine ran with cleaner in it and ran for 20 minutes then flushed out. New Filter was installed and pads to elevate the drain line to a required two-inch air gap. Once new filter was installed, machine ran and allowed it to drop batch of ice and then melted ice and got debris out of bin. Sanitized the bin and allowed it to drop another batch of ice to ensure proper operation.

The Nursing Home Administrator/Designee will educate the Dietary Manager regarding monitoring the ice machine for safe storage of ice, including the required 2 inch (5cm) air gap.

The Nursing Home Administrator will monitor the Dietary Manager to ensure the ice machine is being routinely checked regarding the safe distribution of ice that includes leaving a 2 inch (5 cm) air gap between end of pipe and drain; as well as keeping it secured, keeping tubing and surrounding area clean.

This audit will happen 3 times per week for 2 weeks, weekly for 2 weeks and monthly for 2 months.

Results of the audit will be discussed at Quality Assurance Meeting.
483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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.
§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain resident dignity during medication administration for one of 18 residents reviewed (Resident R49).

Findings include:

Review of facility policy entitled "Resident Rights" with a policy review date of 11/7/2023, revealed, the resident shall be treated with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and in care for the necessary personal and social needs.

Review of Resident R49's clinical record revealed an admission date of 10/18/2023, with diagnoses that included Type 2 diabetes (a condition that affects the way the body processes blood sugar), angina pectoris (chest pain), Neurocognitive disorder with behavioral disturbance (decreased mental function due to a medical disease other than psychiatric illness), depression, and anxiety.

Observation of Resident R49 on 12/5/23, at 9:20 a.m. during medication administration revealed that he/she was administered insulin subcutaneously (SQ-Injection between the skin and muscle tissue) in the abdomen which required Resident R49's abdomen to be exposed. During the observation, prior to administration of the insulin, Licensed Practical Nurse (LPN) Employee E1 did not preserve resident dignity by closing the door to the room to prevent observations from passers by in the common area corridor and did not pull the privacy curtain between resident and their roommate in the room.

During an interview with LPN Employee E1 on 12/5/23, at 9:22 a.m. it was confirmed that resident dignity was not maintained for Resident R49 during medication administration.

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





 Plan of Correction - To be completed: 02/02/2024

R49 and all other residents will be treated with respect and dignity when receiving insulin by ensuring the insulin is administered in a private space.

Director of Nursing/designee will educate staff on appropriate practices of medication administration.

Director of Nursing/designee will preform audit of random residents who receive insulin for five(5) days a week times two(2) weeks; weekly times two(2) weeks; monthly times two(2) months to ensure resident rights are preserved.

Nursing Home Administrator to monitor Director of Nursing for completion. Results of audit will be reviewed at quality assurance meeting.
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 clinical record review and staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed and implemented for two of 18 residents reviewed (Residents R172 and R173).

Findings include:

Review of a facility policy entitled, "24/48 Hour Care Conference" dated 11/07/23, indicated that a care conference was to be completed within 24-48 business hours to discuss short- and long-term goals, dietary concerns, physical limitations, interests and hobbies, medical diagnoses, physical therapy goals/concerns, billing, and care plan preferences.

Review of Resident R172's clinical record revealed an admission date of 11/28/23, with diagnoses that included Type 2 Diabetes (condition that affects how the body uses glucose [sugar]), osteomyelitis (infection of the bone), amputation of right toes, inflammatory spondylopathy of the neck (inflammatory arthritis affecting the spine), and unstable angina (chest discomfort or pain caused by an insufficient flow of blood and oxygen to the heart).

Review of Resident R172's clinical record revealed two developed care plans: Advanced Directives dated 12/05/23, (seven days after admission), and Nutrition dated 12/06/23, (eight days after admission), and no evidence that a baseline care plan had been developed or a 24-48-hour care conference had been provided to the resident and/or representative.

Review of Resident R173's clinical record revealed an admission date of 11/30/23, with diagnoses that included respiratory failure, heart disease, heart failure, irregular heartbeat, high blood pressure, and Type 2 Diabetes.

Review of Resident R173's clinical record revealed two developed care plans; Advanced Directives dated 12/05/23, (five days after admission), and Nutrition dated 12/06/23, (six days after admission), and no evidence that a baseline care plan had been developed or a 24-48-hour care conference had been provided to the resident and/or representative.

During an interview on 12/06/23, at 11:40 a.m. the Director of Nursing and the Executive Director confirmed the 24-48-hour care conference was intended to present the resident and/or representative with the baseline care plan, there was no evidence that the baseline care plan was developed, and that the 24-48-hour baseline care plan summary had not been or provided to Residents R172 and R173 and their representatives.

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

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





 Plan of Correction - To be completed: 02/02/2024

Resident R172 and R173 had a review of their baseline care plans by the Director of Nursing. Director of Nursing developed the baseline care plans for the above mentioned residents and provided resident/responsible party a copy of the baseline care plan. Moving forward, baseline care plans will be created for all new residents within 48 hours of admission by the charge nurse.

Director of Nursing/designee will educate nursing staff on the process of developing baseline care plans. Baseline care plans for new admissions within the past 3 months, who still reside within our facility, have been audited for completion. All charts reviewed contained baseline care plans.

Baseline care plans for all new residents, moving forward, will be audited in daily clinical meetings 5 days a week times 2 weeks, weekly times 2 weeks and monthly times two months to ensure completion.

Nursing Home Administrator to monitor Director of Nursing/designee for completion of audit and to ensure baseline care plans are being developed for all new admissions. Results of audit will be reviewed at quality assurance meeting.
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 review of clinical record and facility policy, observation, and staff interview, it was determined that the facility failed to follow a physician's order for the administration of insulin for one of 18 residents reviewed (Resident R49).

Findings include:

Review of a facility policy entitled "Medication Dispensed According to Prescribers Orders" with a policy review date of 11/7/2023, revealed "Verbal, written, and/or electronic orders are dispensed according to the prescriber's orders and are tailored to the resident's needs."

Review of Resident R49's clinical record revealed an admission date of 10/18/2023, with diagnoses that included Type 2 diabetes (a condition that affects the way the body processes blood sugar), angina pectoris (chest pain), Neurocognitive disorder with behavioral disturbance (decreased mental function due to a medical disease other than psychiatric illness),depression, and anxiety.

Review of Resident R49's physician's orders revealed that there was an order for NovoLog (type of insulin) injection solution to inject subcutaneously (between the skin and muscle tissue) before meals and at bedtime.

Review of the Medication Administration Record revealed that insulin was to be administered at 7:30 a.m.

Observation of Resident R49 on 12/5/23, at 9:20 a.m. revealed that he/she was administered insulin subcutaneously after finishing breakfast.

During an interview on 12/5/23, at 9:22 a.m. Licensed Practical Nurse Employee E1 confirmed that Resident R49's NovoLog insulin should have been administered prior to eating meals and was administered after Resident R49 finished breakfast at 9:20 a.m.

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




 Plan of Correction - To be completed: 02/02/2024

Review of medication administration will be conducted with nursing staff to prevent further incidences of delayed insulin administration and possible other similar situations. Resident R49 was monitored for any signs or symptoms of hyper/hypoglycemia and was educated on the signs/symptoms to watch for to alert nursing staff if needed. No other residents were affected during this incident.

A report will be run by Director of Nursing/designee outlining which residents receive insulin in order to audit those residents for appropriate medication administration timing. Nursing staff has also reviewed and had the opportunity to discuss/ask questions on printed education related to medication administration and signed off indicating their understanding to help prevent another occurrence.

Director of Nursing/designee will conduct an audit/implement spot checks of random residents who receive insulin to ensure nursing staff is administrating medication as ordered by physician for 5 days a week times 2 weeks, weekly times 2 weeks and monthly times 2 months.

Nursing Home Administrator to monitor Director of Nursing for completion. Results of audit/compliance will be reviewed at quality assurance meeting.
483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program: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.
§483.80(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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:


Based on a review of facility policy and clinical records, review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), and resident and staff interviews, it was determined the facility failed to implement part or all of the Antibiotic Stewardship Program for one of 18 residents reviewed (Resident R39).

Findings include:

Review of facility policy entitled "Antibiotic Stewardship" dated 11/07/23, revealed "Antimicrobial prescribing protocols: assessment tools and management algorithms derived for and evidenced based clinical guidelines that are intended to be used as a resource for diagnosis and treatment of infections. Antimicrobial stewardship interventions and efforts to improve antimicrobial use will be regularly and will be implemented by a clinical leader."

Review of Resident R39's clinical record revealed an admission date of 9/19/23, with diagnoses that included malignant neoplasm of prostate (a disease in which cancer cells form in the tissue of the prostate), secondary malignant neoplasm of bone (a disease in which cancer has started in another part of the body and has spread to the bone via the bloodstream or lymph nodes), obstructive reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), and urinary tract infection (UTI).

Review of Resident R39's Indwelling Catheter care plan dated 9/21/23, revealed interventions to monitor/record/report to MD (doctor) for s/sx (signs/symptoms) UTI: pain, burning, blood tinged cloudiness, no output, deepening of urine color, increased pulse increased urinary frequency, foul smelling urine, fever, chills altered mental status behavior, change in eating patterns.

Review of Resident R39's clinical record revealed nursing progress notes dated 11/30/23, "Urine specimen collected as per, clear yellow urine noted, no sedimentation, denies any burning." Further nursing progress notes dated 12/04/23, revealed "Informed in morning report that resident had UA C&S [culture and sensitivity lab test for infection] sent on 11/30/23 d/t [due to] family request. Resident has no urinary c/o [complaints] as of 12/4/23. Results sent to Dr. ...and VORB [verbal order read back] was given for Cipro [antibiotic] 500 mg [milligrams] PO [by mouth] BID [twice a day]. Daughter notified via phone call."

Review of the RAI manual instructions for Section C0500 "Brief Interview for Mental Status (BIMS)" revealed that a score of 13-15 identified a resident as cognitively intact, and a score of 8-12 identified a resident as moderately impaired, and a score of 0-7 as severly impaired.

During an interview on 12/06/23, at 10:15 a.m., Resident R39 (BIMS of 15) indicated he/she was unaware that an antibiotic was prescribed for a urinary tract infection. Resident R39 further indicated he/she was not assessed by nursing staff related to an infection.

During an interview on 12/07/23, at 10:40 a.m. the Director of Nursing confirmed Resident R39's antibiotic was ordered related to a family request for a UA C&S, and Resident R39's clinical record lacked evidence that the facility utilized an infection assessment tool/Antibiotic Stewardship protocol for assessment of an infection.

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: 02/02/2024

R39 and all other residents will be thoroughly assessed for signs/symptoms of infection and findings discussed with them and family if appropriate. All findings will be relayed to physician for recommendation of appropriate treatment.

Director of Nursing/infection control preventionist/designee will educate nursing staff on proper assessments, notification and criteria for suspected infections to ensure compliance with infection control. Antibiotic Stewardship protocol/program will be discussed as well. Clinical staff will sign off, indicating their understanding of education provided.

All residents requiring an antibiotic will be evaluated for appropriate assessments, notification and appropriateness of antibiotic. Director of Nursing/infection preventionist/designee will monitor for completion appropriate assessments, resident/responsible party notification of findings and appropriateness of antibiotic use for 5 days a week times 2 weeks, weekly times 2 weeks and monthly times 2 months.

Nursing Home Administrator to monitor Director of Nursing/infection preventionist/designee for completion. Results of audit will be reviewed at quality assurance meeting which will include the infection preventionist/their designee.

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