Pennsylvania Department of Health
LINWOOD NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LINWOOD NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 107 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.


LINWOOD NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated complaint survey completed on July 23, 2024, it was determined Linwood Nursing 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:

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

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(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 observation and staff interview, it was determined the facility failed to maintain an environment free of potential accident hazards on one of two floors (second floor).

Findings include:

Observation on July 23, 2024 from 9:00 AM through 2:30 PM the following:

On the second floor unit residents were observed ambulating in the hallways and and self-propelling in wheelchairs. At this time two air purifier units were plugged into wall outlets on each side of the hallway near resident Room 7 and 13. The units were not secured, and moveable and obstructed continued access to the handrails on that side of the corridor and also not secured in any manner to prevent tipping. The cords and plugs created a potential tripping hazard.

A plastic container with three drawers was observed in the hallway near Room 4, which contained rubber gloves, protective gowns and masks, obstructing access to the handrail

An air purifier unit was observed plugged into the wall outlet in the 200 hallway near Room 203, 300 hallway near 301 and 400 hallway near Room 403 and 406. The units were not secured, and moveable and obstructed continued access to the handrails on that side of the corridor and also not secured in any manner to prevent tipping. The cords and plugs created a potential tripping hazard.

Plastic containers with drawers were also located in the 300 hallway near resident Room 306 and in the 400 hallway near Room 400, obstructing access to the handrails.

Interview the nursing home administrator (NHA) on July 23, 2024 at approximately 3:00 PM revealed the facility the air purifiers were placed in the corridors prior to her employment and agreed that the items positioned in the hallway impeded access to the handrails and created obstacles to residents' mobility in the hallways.

28 Pa. Code 201.18 (e)(2.1) Management

Plan of Correction - To be completed: 08/12/2024

689 Accident/Incidents

Air purifiers and plastic containers removed 07/23/2024.

Initial House audit completed to identify any other environmental hazards 07/29/2024

Education provided to all facility on maintaining an environment free of potential accident hazards.

Maintenance Director/Designee will conduct weekly environmental audits x4 then monthly x2 then as needed.

Findings reported at monthly QA.

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 review of the facility's infection control tracking log and staff interview, it was determined the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility.

Findings include:

A review of the facility's policy entitled Infection Control Policies and Practices (not dated), conducted during the survey ending July 23, 2024, revealed that the facility's infection control policies are intended to facilitate maintaining a safe sanitary comfortable environment and help prevent and manage transmission of disease and infections.

A review of the facility's infection control data provided during the survey of July 23, 2024, revealed that the facility's infection control program failed to reflect an operational system to monitor and investigate causes of infection and manner of spread. There was no evidence of a functional system, which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner.

A review of facility monthly infection control logs for June 2024 and July 2024, revealed the monthly line listing failed to consistently include the type of infection, pathogen, start date of antibiotic and length, precaution type and resolution date.

The facility failed to demonstrate a functioning system for surveillance for routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections (i.e., HAI and community-acquired), infection risks, communicable disease outbreaks, and to maintain or improve resident health status. The facility was unable to demonstrate how it tracks infections and addresses any areas needing corrective action.

Resident 1 was diagnosed with Salmonella, a bacterial infection foodborne illness on July 17, 2024, revealed by a urinalysis from July 13, 2024. However, this infection was not included in the data and no plans for any intervention with staff and residents to deter similar infections.

There was no indication that the limited data that was compiled was then evaluated to determine what could be done to prevent the spread or recurrence of infections within the facility.

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

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

Plan of Correction - To be completed: 08/12/2024

880 Infection Control

Facility Infection Control program re-evaluated for any outstanding infection control needs, including but not limited to monitoring and investigating causes and manner of spread.

R1 assessed 08/01 with UA issued resolved.

07/24/2024 Facility wide audit ongoing for any outstanding or new infection control needs.

Policy reviewed by QA team and dated as reviewed. Monthly Infection Control log line listing verified to include type of infection, pathogen, start date of antibiotic and length, precaution type and resolution date.

Infection control nursing, nurse management and general nursing staff re-educated on the facilities p/p for infection control.

Facility wide audit education provided to staff on policy "entitled Infection Control policy and procedure.

Infection Control Nurse/Designee will complete weekly audits x4 then monthly x2 and report findings at QA meeting.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:

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(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.

Observations:

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to protect the personal privacy rights of one of six residents sampled (Resident 1).

Findings include:

During an observation of Resident 1's room on July 23, 2024 at approximately 10:15 AM a hand written sign was observed taped to the back of the resident's bed which read "R Limb alert (RUE) NO IV, lab draws, BPs or tight clothing."

Interview with Resident 1 and her daughter on July 23, 2024, at 10:20 AM revealed that they did not know why that sign was posted behind the resident's bed. They stated they did not put the sign there, the facility did. When asked Resident 1 stated there was no reason that they could not use her right arm. She stated no one ever mentioned to her that her right arm should not be used. Resident 1 then asked if the sign could be removed from the wall behind her bed.

A review of the resident's clinical record indicated her right arm should not be used for blood draws, but did not identify the clinical reason or diagnosis.

Interview with the Nursing Home Administrator (NHA) on July 23, 2024 at 3:00 PM revealed that the NHA was unable to provide information regarding the reason for this sign posted behind the resident's bed, that failed to assure the resident's personal privacy.

28 Pa. Code 201.29 (a) Resident rights

Plan of Correction - To be completed: 08/12/2024

F583 Privacy/confidentiality

R1 Sign removed immediately.

House audit completed 7/31/24.

Re-education provided to nursing staff on p/p related Resident's Personal Privacy.

NHA/Designee will conduct facility environmental audits weekly x4 then monthly x2.

Findings and outcomes will be reported at monthly QA.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on observation, clinical record review and resident and staff interview, it was determined that the facility failed to ensure that a resident's comprehensive care plan included the care the resident required to attain the resident's highest practical physical well-being for one resident out of six reviewed (Resident 1).

Findings including:

Clinical record review revealed that Resident 1 was admitted to the facility on May 29, 2024, with diagnoses to include a displaced fracture of the right lower leg (broken ankle) with history of falls.

An interview and observation of Resident 1 at 10:00AM on July 23, 2024, revealed that the resident had a blue hard cast on her right leg, that extended from the base of her toes to just below her knee.

A review of the resident's current plan of care initially, dated May 30, 2024, revealed that the presence of the cast or the need for assessment of her exposed toes to ensure that adequate color, circulation, sensation and mobility was present without swelling, was not included on the resident's care plan.

Plan of Correction - To be completed: 08/12/2024

F0656 Develop/Implement Comprehensive Care Plan

1.R1 assessment completed 8/6/24 and care plan updated.

2.The facility will take the following steps to resolve the problem so that it does not reoccur:
Facility completed a 7 day look back period for care plans and updates done to current resident needs-completed 8/7/24
Any new Admission care plans will reflect current resident level of care needs related to diagnosis and/or orders.

3.Education was provided to ID team on policies entitled, "Comprehensive Care Plans" and "Change in Condition".

4.Auditing of new admission will be completed during morning IDT to address resident level of care needs related to current diagnosis and/or orders. Auditing will be done during morning clinical meeting as well as weekly for then monthly for two months and prn thereafter.

5.Date certain 8/12/24

483.25 REQUIREMENT Quality of Care:

§ 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 records and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of practice for one resident (Resident 1) out of six residents reviewed by failing to assure prompt and necessary treatment for treatment for a resident's complaints of physical discomfort, painful urination, which delayed diagnosis and treatment of a salmonella infection.

Findings included:

According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.292a. CRNP (Certified Registered Nurse Practitioner) Practice (b)(1)(2) indicates (b) When acting in collaboration with a physician as set forth in a collaborative agreement and within the CRNP's specialty, a CRNP may:
(1) Perform comprehensive assessments of patients and establish medical diagnoses.
(2) Order, perform and supervise diagnostic tests for patients and, to the extent the interpretation of diagnostic tests is within the scope of the CRNP's specialty and consistent with the collaborative agreement, may interpret diagnostic tests.

A review of clinical record revealed Resident 1 was admitted to the facility on May 29, 2024, with diagnoses, of the fracture of right ankle, muscle weakness and high blood pressure.

A review of an admission MDS (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated June 4, 2024, revealed that Resident 1 was moderately cognitively impaired with a BIMS score of 11 (Brief Interview for Mental Status tool used to screen cognitive condition of residents) and required staff assistance with activities of daily living and had a history of falls. The resident had a cast to her right lower leg due to fractured ankle.

During an interview with this resident conducted on July 23, 2024, at 10:00 AM the resident stated that a few weeks ago she starting having burning, pressure and discomfort when she urinated. She stated the CRNP (certified registered nurse practitioner) examined her and the CRNP informed the resident that she would "test her urine." The resident stated that this urine test was not completed until several days after the CRNP visit with the resident, until the resident voiced a complaint to Employee 1, LPN, licensed practical nurse (LPN), who contacted the physician, obtained an order and a urine sample to test the resident's urine. During the interview, the resident stated that she very upset that the urine test was delayed, and treatment was not started for many days because she continued to have discomfort when urinating.

A review of the resident's clinical record revealed a note written by the CRNP dated July 8, 2024, which indicated that she spent 30 minutes with the resident assessing the resident and answering questions. The entry noted that the resident complained of dysuria (pain or burning sensation while passing urine) and the CRNP noted "check UA C/S" (Urinalysis culture and sensitivity urine test and urine culture is a method to grow and identify bacteria that may be in the urine. The sensitivity test helps select the best medicine to treat the infection). However, a review of physician orders revealed that the CRNP did not order a UA/C&S on this date.

Documentation in the resident's clinical record dated July 13, 2024 written by Employee 1, LPN, at 3:55 PM indicated that a U/A C&S was obtained related to the resident's complaints of burning and pain with urination. This nurse's note was written late, the sample was obtained in the morning as indicated by the results. The courier service was contacted to pick up the sample.

Interview with the resident on July 23, 2024, at 11 AM confirmed that it was Employee 1 who finally contacted the doctor obtain an order and get her urine sample.

A review of the results of the resident's urine test, dated as reported July 17, 2024, at 1:52 PM revealed Salmonella (infection caused by salmonella bacteria that generally affects the intestinal tract, and occasionally the bloodstream and other organs due to eating or drinking contaminated food or water by contact with infected people or animals, or through contact with contaminated environmental sources) and Proteus Mirabilis (bacteria found in digestive tract).

An antibiotic was ordered on July 18, 2024, Ampicillin 500 mg one capsule three times a day. The resident had a medication allergy and this antibiotic had to be changed to Ciprofloxacin 250 mg one tablet every 12 hours. The resident received her first dose of antibiotic treatment on July 18, 2024, at 5:13 PM, 10 days after the resident's complaint was made to the CRNP of the resident's pain during urination.

Interview with Resident 1 on July 23, 2024 at 11:00 AM confirmed she waited days for treatment for her painful urination. She stated that Employee 1 finally listened to her and obtained an order for a urinalysis which identified the infection requiring treatment. The resident stated that she was very upset that she was admitted to the facility for therapy for a broken ankle and she ended up with a foodbourne infection illness.

The facility failed to timely address the resident's physical complaints. The resident made the CRNP aware of her complaints of dysuria on July 8, 2024, and recommended a UA C&S be completed, which was not obtained until five days later due to the resident's continued complaints. Treatment did not begin until July 18, 2024, ten days after the resident reported her complaints.

During an interview on July 23, 2024, at approximately 3:00PM the NHA confirmed the resident was not timely treated for her infection.

28. Pa. Code 211.2 (d)(3)(5) Medical director.

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

Plan of Correction - To be completed: 08/12/2024

F684 Quality of Care

1.R1 assessment completed 8/6/24 and care plan updated to meet current needs.

2.To protect the residents in similar situations the facility will take the following steps to prevent reoccurrence:
An audit was completed 8/7/24 with a 7 day look back on current resident needs related to change in condition and follow-up orders
Nursing staff and nurse practitioner re-educated on policy entitled, "Change in Condition". The nurse practitioner re-educated on facility protocol for order entry.
Facility will monitor its performance by auditing IDT morning meeting and order entries.
In addition, the facilities infection control nurse or designee will monitor for infection control risks, which include but not limited to infectious trends.

3.Licensed nursing staff and nurse practitioner re-educated on policy entitled, "Change in Condition". The nurse practitioner re-educated on facility protocol for order entry.

4.DON or designee will be complete during morning IDT. Auditing will be done during morning clinical meeting as well as weekly for 1 month, then weekly for four weeks then monthly for two months and prn thereafter.

5.Date certain 8/12/24

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities:

§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.

Observations:

Based on a review clinical records and facility documentation and interviews with residents and staff it was determined that the facility failed to demonstrate that its quality assurance program fully investigated and analyzed causes of adverse events, a resident's diagnosed salmonella infection, to evaluate the adequacy of the facility's response to the foodborne illness and implement any applicable performance improvement activities.

Findings included:

Findings include:

A review of the clinical record revealed that Resident 1 was admitted to the facility on May 29, 2024, with a diagnosis of a fractured ankle. An interview with Resident 1 on July 23, 2024, at 10:00 AM revealed she had concerns with food served at the facility. She stated the food the food served was extremely salty. She stated that she received food items that she disliked, including soft cooked eggs, egg whites, baloney sandwiches and a variety of other foods prepared by the facility that were not to her liking. She stated she also received "greasy" silverware at meals. As a result, she stated that she decided she no longer wanted to eat the facility's food and requested her daughter to bring her food and meals to her at the facility.

Resident 1 continued to explain during interview on July 23, 2024, at 11 AM that she began to have stomach discomfort and burning on urination and was seen by the CRNP (certified registered nurse practitioner) on July 8, 2024, who recommended a urinalysis with culture and sensitivity.

Review of the clinical record revealed after a delay in obtaining the urinalysis, a result of Salmonella was reported to the facility on July 17, 2024, and antibiotic treatment initiated for the resident July 18, 2024.

A review of facility documentation dated July 19, 2024, revealed that Employee 2 a Registered Nurse (RN) relayed to a representative from the local district Community Health Department that this resident's daily meals are provided by her family.

Continued interview with the resident on July 23, 2024, at 11 AM revealed that the resident stated that the facility informed she and her that the resident contracted the foodborne illness from the meals her daughter brought in to the facility. However, the resident stated that her daughter does not bring in all her meals and food and that she does consume some of the facility's food and beverages.

Additionally, the facility did not evaluate staff practice in the dietary department and assure current awareness of food safety practices and that facility staff were following proper procedures to prevent foodborne illness such as proper handwashing, ensuring food is cooked to proper temperatures, fruits and vegetables washed or peeled properly, and ensuring milk and dairy products are pasteurized.

The facility also did not evaluate the storage practices for the food the resident's daughter brings to the facility, including storage duration and appropriate temperatures.

The facility did not provide any training or education regarding the prevention of foodborne illness for facility staff as a result of the salmonella infection.

Interview with the Nursing Home Administrator on July 23, 2024 at 3:00 PM confirmed the facility did not initiate quality improvement activities in response to the resident's positive diagnosis of Salmonella and took no action internally, despite lack of evidence as to the conclusive source of the infection. The NHA stated that the facility did not consider the possibility that the facility was the potential source of the resident's infection.

28 Pa. Code 201.18 (e )(2)(3) Management

Plan of Correction - To be completed: 08/12/2024

687 Management QA

1.R1 issue resolved. Follow-up UA completed on 8/1/24.

2.To protect the residents in similar situations the facility will take the following steps to prevent reoccurrence:
Kitchen sanitation audit completed 8/6/24.
General observation of room audits completed 7/31/24 and addressed any food storage items identified.
Family of R1 provided information on proper food preparation and food storage.
Families and residents provided with information on proper food preparation and storage.

3.QAPI education for management staff completed
Food storage and prep education provided to residents, families and facility staff
Food borne illnesses education provided to facility staff.

4.Kitchen sanitation audit completed 8/6/24
General observation audit completed 7/31/24
Ongoing sanitation auditing and general observation audits will be completed by NHA or designee weekly for 4 weeks, then monthly for 2 months.
QAPI process will be monitored quarterly by consultants/designee for facility performance in identifying and analyzing concerns, investigation, effective interventions and that solutions are sustained and/or resolved.

5.Date certain 8/12/24.

§ 211.1(a) LICENSURE Reportable diseases.:

(a) When a resident develops a reportable disease, the administrator shall report the information to the appropriate health agencies and appropriate Division of Nursing Care Facilities field office. Reportable diseases, infections and conditions are listed in § 27.21a (relating to reporting of cases by health care practitioners and health care facilities).

Observations:

Based on review of clinical records, resident and staff interview, it was determined the facility failed to report a confirmed case of Salmonella to the State Licensing Agency, Department of Health, Division of Nursing Care Facilities.

Findings include:

According to the Pennsylvania Code Chapter 28 Reportable Disease, when a resident develops a reportable disease, the administrator shall report the information to the appropriate health agencies and appropriate Division of Nursing Care Facilities field office.

A review of Resident 1's clinical record revealed a laboratory result dated July 17, 2024 indicating a positive diagnosis for Salmonella (an infection caused by salmonella bacteria that generally affects the intestinal tract, and occasionally the bloodstream and other organs due to eating or drinking contaminated food or water by contact with infected people or animals, or through contact with contaminated environmental sources) of her urine.

Review of information submitted by the facility to the State Licensing Agency revealed that the facility failed to report Resident 1's diagnosis of Salmonella to the Division of Nursing Care Facilities, Scranton Field Office.

The facility failed to report this confirmed case of Salmonella to the State Licensing Agency, Department of Health, Division of Nursing Care Facilities, Scranton Field Office which was confirmed during interview with the Nursing Home Administrator on July 23, 2024, approximately 3:00 PM.

Plan of Correction - To be completed: 08/12/2024

4550 Reportable Diseases
Salmonella report completed
Facility completed a 7 day look back for any outstanding reportable diseases.

Infection control nursing, nursing administration and general nursing staff re-educated on the facility policy for infection control and reportables.

Weekly audit x4 then monthly x 2 to monitor for reportable diseases and reporting.

Findings reported at monthly QA

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 08/12/2024

P5520
The Administrator, Director of Nursing, and Scheduler will be educated on the state requirement for nursing hours including the Certified Nurse Assistants to resident ratios by the Clinical Consultant/designee.

Staffing meetings will be held 5 days a week to review the Certified Nurse assistant ratio from the previous day and the projected Certified Nurse Assistant ratio for the current day, as well as the upcoming week to ensure appropriate staffing levels by the Nursing Home Administrator/ designee.

If projected staffing ratios do not meet minimum then the facility will reach out to current staff and local staffing agencies to enlist to meet the minimum requirement. Facility will continue to recruit staff through all platforms.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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 nurse staffing and staff interview, it was determined the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for 2 shifts out of 42 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:25 on the day shift, based on the facility's census.

July 14, 2024 - 3.31 LPNs on the day shift, versus the required 3.56 for a census of 89.
July 16, 2024 - 3.00 LPNs on the day shift, versus the required 3.641 for a census of 91.

No additional excess higher-level staff were available to compensate this deficiency.

An interview with the Nursing Home Administrator via telephone on July 25, 2024, at approximately 10:00 AM, confirmed the facility had not met the required LPN to resident ratios on the above dates.

Plan of Correction - To be completed: 08/12/2024

P5530
The Administrator, Director of Nursing, and Scheduler will be educated on the state requirement for nursing hours including the Licensed practical nurses to resident ratios by the Clinical Consultant/designee.

Staffing meetings will be held 5 days a week to review the Licensed Practical nurse ratio from the previous day and the projected Licensed Practical nurse ration for the current day, as well as the upcoming week to ensure appropriate staffing levels by the Nursing Home Administrator/ designee.

If projected staffing ratios do not meet minimum then the facility will reach out to current staff and local staffing agencies to enlist to meet the minimum requirement. Facility will continue to recruit staff through all platforms.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, 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 3.2 hours of direct resident care for each resident.

Observations:
Based on a review of nursing staffing hours and staff interview, it was determined the facility failed to ensure the total nursing care hours provided in each 24-hour period was a minimum of 3.2 hours per patient day (PPD), effective July 1, 2024, on seven of 14 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following nursing care hours for each 24-hour period of concern:

July 8, 2024, PPD was 2.97
July 12, 2024, PPD was 2.97
July 13, 2024, PPD was 2.79
July 14, 2024, PPD was 2.54
July 19, 2024, PPD was 3.15
July 20, 2024, PPD was 2.80
July 21, 2024, PPD was 3.11

An interview with the Nursing Home Administrator via telephone on July 25, 2024, at approximately 10:00 AM, confirmed the facility failed to meet the required nursing staffing PPD as listed above.

Plan of Correction - To be completed: 08/12/2024

P5640

Staffing meetings will be held 5 days a week to review HPPD from the previous day and the projected HPPD for the current day, as well as the upcoming week to ensure appropriate staffing levels by the Nursing Home Administrator/ designee.

Census Management will be reviews daily to monitor for facility ability to meet min staffing hours.

If projected staffing levels are below the 3.2 minimum then the facility will reach out to current staff and local staffing agencies to enlist to meet the minimum requirement. Facility will continue to recruit staff through all platforms.

The Administrator, Director of Nursing, and Scheduler will be educated on the state requirement for nursing hours including the nurse to resident ratios by the Clinical Consultant/designee.

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