Pennsylvania Department of Health
EMMANUEL CENTER FOR NURSING AND REHAB AT MARIA JOSEPH MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EMMANUEL CENTER FOR NURSING AND REHAB AT MARIA JOSEPH MANOR
Inspection Results For:

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EMMANUEL CENTER FOR NURSING AND REHAB AT MARIA JOSEPH MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Revisit Survey completed on February 22, 2024, it was determined that Emmanuel Center for Nursing and Rehab at Maria Joseph Manor failed to correct the deficiencies cited during the survey of January 11, 2024, and continued to be out of 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.

Plan of Correction:

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 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(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 a review of clinical records, observation, and resident and staff interviews, it was determined that the facility failed to provide care in a manner respectful of each resident's dignity for one resident (Resident 1), and failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' request for assistance as reported by two residents out of 11 sampled (Residents 12 and 11).

Findings include:

A review of Resident 1's clinical record revealed he was admitted to the facility on January 23, 2024, with diagnoses which have included malignant neoplasm of the prostate, chronic kidney disease, diabetes, COVID-19, bronchopneumonia, and clostridium difficile [C-diff] (a bacterium infection that causes an infection of the colon).

A review of a nurses progress note dated February 11, 2024, at 1:19 AM, revealed that the resident was positive for C - diff, and was placed on contact precautions, and began treatment, Vancomycin (antibiotic).

Observation on February 22, 2024, at approximately 11:20 AM, revealed that a metal apron on the wall outside the resident's room, 101, containing personal protective equipment (PPE) supplies. Continued observation revealed 2 paper signs taped on the door to the resident's room. The first sign noted "C-Difficile requires special care" with pink highlighted words, "handwashing only" and a line drawn to the information stating that the C-diff spores are not killed by alcohol - based hand sanitizer. The second sign read "Contact precautions."

A second observation on February 22, 2024, at approximately 12:40 PM, that the above noted two signs remained posted on the door to the resident's room.

Interview with alert and oriented Resident 1 on February 22, 2024, at approximately 1:50 PM, revealed that the resident was aware of his diagnosis of c-diff, treatments, and safety precautions, but verified that he would not like that information shared with others as noted on the signs on the door to his room.

Interview with the Nursing Home Administrator (NHA), on February 22, 2024, at approximately 2:10 PM, confirmed that signs identifying a individual medical condition, or resident care needs, should not have been placed on the resident's door, visible to others.

During an interview with Resident 11 on February 22, 2024, at 10:30 AM the resident stated that staff do not consistently answer call bells timely and provide care in a timely manner. Resident 11 stated that he prefers to get out of bed each day between 6:30 and 7:00 AM. Resident 11 stated that on Saturday February 17, 2024, agency nursing staff did not get him out of bed until 8:00 AM. Resident 11 reported that this morning, February 22, 2024, his wife (Resident 12) rang the call bell to request staff assistance to get out of bed. Resident 11 stated that the call bell rang greater than 30 minutes before staff answered her call bell and assisted Resident 12 out of bed.

Interview with the nursing home administrator on February 22, 2024, at approximately 2:30 PM verified that all residents at the facility should be treated with dignity and respect. The NHA confirmed that the facility staff were to answer call bells promptly and provide assistance in a timely manner to promote each resident's quality of life.

Refer F 880

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

Plan of Correction - To be completed: 03/14/2024

Resident # 1 sign was removed from door.
Residents 11 & 12 were interviewed, preferences added to plan of care.
Care staff are educated on residents' rights policy, in relation to PHI, and the call light policy.
Dietary, housekeeping and activities staff educated on the importance of answering call lights.
New PHI compliant signage created for use with isolation rooms.
The administrator or designee with interview 10% of resident's who have call light times exceeding 15 minutes to ensure care needs are met. 5x/week for 4 weeks then 3 times per week for 2 weeks, then 1 time weekly for 2 weeks.
Adverse trends will be addressed in QAPI.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

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(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on a review of clinical records, and resident and staff interview it was determined that the facility failed to ensure the presence of planned and prescribed preventative measures to prevent injury to one resident out of 11 sampled (Resident 42).

Findings include:

A review of Resident 42's clinical record revealed that the resident had diagnoses to include Parkinson's disease and peripheral vascular disease.

A current physician order, initially dated June 25, 2022, was noted for Derma-savers to the resident's bilateral lower extremities at all times for protection. May remove for care.

A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated December 19, 2023, revealed that the resident required substantial/maximal assistance for upper and lower body dressing and was dependent on staff for chair/bed-to-chair transfers.

Resident 42's care plan. last revised August 30, 2023, revealed that the resident had the potential for complications with impaired skin integrity including skin tears, bruising, and/or pressure related to peripheral vascular disease, immobility, and incontinence. Planned interventions included Derma-savers to bilateral lower extremities at all times, may remove for care (hygiene). The care plan also identified that the resident had the potential for deficits with activities of daily living with planned interventions included the use of a total mechanical lift with the assistance of two staff for transfers.

A nurses note dated February 20, 2024, indicated that the resident had several ecchymotic areas on the resident's right shin. The resident stated that it happened February 16, 2024, while being transferred in the mechanical lift, and her Derma-Savers were being washed after being soiled. Examination revealed four ecchymotic areas varying in size along with one scabbed skin tear on the resident's anterior (front) shin. The ecchymotic areas covered an area on the shin of 15 cm x 4.5 cm and were dark purple in color. The skin tear was 1.5 cm by 0.3 cm and scabbed. Registered Nurse supervisor made aware. CRNP made aware with no new orders. Resident representative made aware. Immediate intervention was to acquire a "spare pair" of Derma-savers to be kept in resident's drawer, so an immediate replacement is available if necessary.

Interview with Resident 42, a cognitively intact resident, on February 22, 2024, at 11:20 AM confirmed that her leg was injured during transfer when the Derma-savers were not in place and her leg rubbed/bumped the lift while being transferred.

During an interview on February 22, 2024, at approximately 1:30 PM, the director of nursing (DON) confirmed that an extra pair of Derma-savers should have been available for the resident to prevent injury. The DON confirmed the facility failed to ensure consistent application of the planned and prescribed preventative measure to protect the resident's skin during the transfer and prevent accidents and injuries.

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

Plan of Correction - To be completed: 03/14/2024

Resident #42 plan of care updated, and information added to Kardex.
Community audited for all resident using Derma-savers, Care plans reviewed, updated as needed. Information added to Kardex.
Care staff educated by nursing leadership team on interventions for following care plan interventions for residents who utilize derma sleeves to maintain skin integrity.
DON or designee with audit use of Derma-savers weekly x 4 weeks, then monthly until compliance is achieved.
Adverse trends will be addressed in QAPI.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§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)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on a review of clinical records, observation and resident and staff interviews, it was determined the facility failed to consistently implement and maintain infection control practices to prevent the potential spread of infection for one resident requiring contact precautions out of 11 residents sampled (Resident 1).

Findings include:

Interview with the facility's Nursing Home Administrator (NHA) during entrance conference on February 22, 2024, at approximately 9:25 AM revealed that the facility currently had a resident with clostridium difficile [c-diff] (a bacterium infection that causes an infection of the colon), and indicated that strict infection control practice is to be maintained to prevent the spread of the infection.

A review of Resident 1's clinical record revealed admission to the facility on January 23, 2024, with diagnoses which have included malignant neoplasm of the prostate, chronic kidney disease, diabetes, COVID-19, bronchopneumonia, and C-diff.

A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated January 28, 2024, indicated that the resident was cognitively intact with a BIMS (brief interview to assess cognitive status) score of 15 (13 - 15 represents cognitively intact).

Resident 1's care plan, revised on February 12, 2024, indicated the resident has infection, Bronchopneumonia, and C - Diff with a goal that the infection will resolve without complications by target date April 29, 2024. Planned interventions, initiated February 7, 2024, were to provide medications, treatments, and labs as ordered, monitor, observe, document complications, adverse side effects related to medication use, and review with MD for recommendations, vital signs as ordered, and precautions per protocol to prevent infection.

A review of a microbiology report (lab result) dated February 10, 2024, indicated that the resident's stool sample was positive for C-diff. Nursing noted on February 11, 2024, at 1:19 AM, that new orders were noted for contact precautions, and Vancomycin (antibiotic).

Observation on February 22, 2024, at approximately 11:20 AM, a metal apron on the wall outside the resident's room, 101, with personal protective equipment (PPE) supplies and signage on the resident's door, regarding contact precautions required for C-diff. An observation inside the resident's room a plastic gray bin just inside the room on the right side with a sign above stating "please do not overfill bins", used for disposal of the PPE, and the lid to this bin was wide open when observed and soiled PPE inside. A wheeled metal bin used for the resident's laundry was also observed inside the room, on the right side approximately 6 - 8 feet away from the plastic bin.

Observation on February 22, 2024, at approximately 12:40 PM, revealed that Resident 1 was lying in bed with his bedside table positioned over the bed with his meal tray on top. The lid to the gray plastic bin of soiled PPE was again observed to be open exposing used PPE. The lid to the metal laundry bin was closed, but a hospital gown was hanging out of the closed bin, and a plastic insulated meal plate lid had been placed on top of the metal laundry bin.

Interview with the NHA, on February 22, 2024, at approximately 2:10 PM, confirmed that the facility failed to consistently implement and maintain infection control practices to prevent the potential spread of infection.

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

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

Plan of Correction - To be completed: 03/14/2024

Resident 1s room was reviewed trash and linens immediately emptied, lids placed correctly. No other residents currently on isolation.
The DON or designee will educate all staff on infection/isolation guidelines to include the handling of soiled linens and ensuring all PPE is disposed of properly with trash not overflowing.
The DON or designee will complete physical audits on isolation rooms to check for trash control and soiled linen storage 5x/week for 4 weeks and then 1x/week for 4 weeks then monthly until 100% compliance or three months.
Adverse trends will be reported in QAPI.

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