Pennsylvania Department of Health
SOUTHMONT OF PRESBYTERIAN SENIORCARE
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SOUTHMONT OF PRESBYTERIAN SENIORCARE
Inspection Results For:

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SOUTHMONT OF PRESBYTERIAN SENIORCARE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and an Abbreviated survey in response to a complaint completed on May 31, 2024, it was determined that Southmont of Presbyterian Seniorcare 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 more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected 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 review of facility policy, clinical records, facility provided documents, and staff interview, it was determined that the facility failed to implement effective safety measures by not providing hot liquids in a manner that promotes safety for one of four residents reviewed (Resident R78), which resulted in actual harm of a second degree burn (involving the epidermis and dermis layers of the skin that is red blistered swollen and painful). This was identified as harm for past non-compliance for one resident (Resident R78).

Findings include:

Review of the facility policy "Investigating Adverse Events" last reviewed, November 2023, indicated the facility will implement measures for residents at risk for accidents to prevent serious injury when possible.

A review of the clinical record revealed that Resident R78 was admitted to the facility on 4/23/21, with diagnoses that included Parkinson's disease, dementia, and chronic kidney disease.

A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 4/3/24, indicated that Resident R78 had moderately impaired cognitive ability and required extensive assist of one person for eating.

A review of a nurse progress note dated 5/11/24, indicated resident R78's right upper thigh was noted to have blistering. The family and physician was notified.

A review of an incident report dated 5/13/24, indicated Resident R78 had redness and blistering noted to right upper thigh, noted to be a possible burn.

A review of a facility witnesses statements dated 5/12/24 and 5/13/24, indicated the following:

Nursing Assistant (NA) Employee E1 indicated resident "grabbed the bowl of soup off the dinner table" and "it ended up on the floor and in [resident] lap."

NA Employee E2 indicated "heard silverware and plate hit the floor, [resident] had knocked [resident's] food over, didn't see it on her clothes, was on her blanket and floor".

A review of a physician order dated 5/12/24, indicated cleanse right thigh blister with saline solution, apply adaptic (non adhering wound dressing) to blister and cover with gauze and wrap with kling (dry dressing) wrap.

A review of a wound progress note dated 5/14/24, indicated Resident R78 had a fluid-filled blister on top of right thigh measuring 5.5 centimeters (cm) in length and 5 cm in width.

A review of a kitchen temperature log report dated 5/10/24, indicated the soup was served at 184 degrees Fahrenheit.

A review of resident's care plan date initiated 6/29/23, indicated Resident R1 is to be offered mugs with lids to prevent burns due to history of Parkinson's disease.

During a telephone interview on 5/30/24 at 2:08 p.m., NA Employee E1, revealed "the soup was placed in middle of table and was uncovered."

During an interview on 5/28/24 at 9:30 a.m., The Nursing Home Administrator (NHA) revealed Resident R1 is dependent on staff for eating. "On 5/10/24, Resident R78 was set up at table and hot soup was placed in the middle of table when resident grabbed for soup and pulled soup onto lap and floor." The NHA confirmed that the facility failed to implement effective safety measures by not providing hot beverages in a manner that promotes safety for Resident R78, which resulted in actual harm of a second-degree burn. This deficiency is cited as past non-compliance.

The facility provided documentation of in-service training that was provided to the dietary staff, including Registered Nurses, Licensed Practical Nurses, and Nurse Aides, at the facility on 5/20/24, which addressed following the facility policy and procedures for abuse neglect and serving hot beverages.

The facility reviewed like residents for non-compliance with hot beverages and meal service on 5/20/24, and audited all residents' meals for accuracy daily times five days, and to continue weekly times three weeks, and monthly time two months thereafter.

The facility has adjusted employee workflow's to allow for increased supervision of the dining area while meals are being served. Protective aprons have been ordered for residents in the dementia unit in case of spills of hot liquids.

A review of the QA (Quality Assurance) documentation indicated substantial compliance for serving hot beverages has been achieved 5/20/24 and is ongoing.

During interviews with staff on 5/30/24, from 2:00 p.m. through 1:35 p.m. revealed NHA, DON, NA Employee E1, and NA Employee E2 confirmed proper procedure for serving hot beverages.

During interviews with Nurse Aide staff on duty on 5/30/24 from 2:00 p.m. through 2:35 p.m. confirmed proper procedures for serving hot beverages.

During an interview on 5/28/24, at 9:30 a.m. with the NHA, and review of the facility's immediate actions, education, and review of the QA monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction and achieved compliance on 5/20/24, which ensured residents are provided hot liquids in a manner that promotes safety.

28 Pa Code: 201.14 (a) Responsibility of licensee.

28 Pa Code: 201.18 (e)(1) Management.

28 Pa Code: 211.10 (c)(d) Resident care policies.

28 Pa Code: 211.11 Resident care plan.

Plan of Correction - To be completed: 06/18/2024

Past noncompliance: no plan of correction required.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

§483.60(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 policy, observations and staff interviews, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition and failed to properly label and date food products in the walk in coolers creating the potential for unsafe conditions and the potential for cross contamination in the main kitchen and in two of three kitchenettes(4th and 5th floor kitchenettes).

Findings include:

A review of the facility "Dietary- Sanitation", dated 11/20/23, indicated that the food service area will be maintained in a clean and sanitary manner.

During an observation on 5/29/24, at 9:29 a.m. the following was observed in the Main Kitchen:
In cooler #1
2 staff lunch bags
a piece of an aloe plant
undated opened mayo, 2 water bottles, a chocolate syrup
a beverage dispenser with a red liquid undated.

Cooler #2 Fans had white splotches, supposed "mold" on both fans

Cooler #3
bag of chicken tenders and potatoes undated

During an interview on 5/29/24 at 9:45 a.m., Director of Dietary Employee E5 confirmed the facility failed to properly label and date food products and maintain kitchen equipment as required.

During an observation of the 5th floor kitchenette on 5/29/24, at 11:00 a.m., the following was observed:

Gnats flying
all cabinets handles sticky
lower freezer has ice build up, possible seal not functioning.
cabinets have food debris dried
bread and buns moldy
cabinet with one bottle of ketchup, two mustards, one relish and chocolate syrup undated when opened.

During an observation of the 4th floor kitchenette on 5/29/24, at 11:15 a.m., the following was observed:

Gnats flying
cabinets sticky
cabinets soiled with food debris, bowls not stored properly
lower freezer has ice build up

During an interview on 5/29/24, at 11:39 a.m., the Nursing Home Administrator confirmed that the facility failed to maintain the kitchenettes of the 4th and 5th floors in a sanitary manner allowing for the potential for cross contamination.

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

28 Pa. Code: 211.6(c)Dietary services.

28 Pa. Code: 201.14(a) Responsibility of licensee.

Plan of Correction - To be completed: 07/08/2024

Cooler 1: staff lunch bags, aloe plant, undated opened mayo, 2 water bottles, chocolate syrup and beverage dispenser with a red liquid undated were all removed.
Cooler 2: Fans were cleaned on 5/29.
Cooler 3: The undated bags of chicken tender and potatoes were discarded.
Both the 4th and 5th floor kitchenettes were deep cleaned. Any undated items were discarded.
Reeducation will be provided to dietary staff by dietary director or designee on proper dating and labeling and general cleanliness. Audits will be completed of the cleanliness of the 4th and 5th floor kitchenettes daily times 5, weekly times 4 and monthly times 3 by dietary director or designee. Audits will be completed of the cooler's daily times 5, weekly times 4 and monthly times 3 to ensure there are no undated items by dietary director or designee. Cooler fans will be audited quarterly to ensure they are clean by dietary director or designee. Results will be reviewed at QAPI to determine if further audits or education are necessary.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

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.

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:
Based on review of facility policy, facility documents, clinical records, and staff interview, it was determined that the facility failed to identify and investigate incidents of possible neglect and abuse for two of three residents (Residents R27 and R35).

Findings include:

Review of the facility policy "Abuse Investigation/reporting Procedure", last reviewed 11/20/23, indicated that if the facility suspects alleged violations of abuse, neglect, exploitation or mistreatment(including injuries of unknown origin), the facility immediately conducts an investigation including interviews, observations and notification of necessary persons. The facility protects he resident(s) involved.

Review of the clinical record indicated that Resident R27 was admitted to the facility on 7/25/22, with diagnoses which included heart failure, kidney failure, a stroke with right sided hemiplegia. A MDS ( Minimum Data Set- a periodic review of resident care needs) dated 5/3/24, indicated the diagnoses remained current.

Review of an incident report dated 5/12/24, indicated that while staff were transporting the resident from the bathroom, staff bumped Resident R27's elbow on the doorframe causing a 1 cm x 1 cm skin tear. The treatment indicated a tegaderm(a clear, adhesive plastic dressing) was applied.

Review of a progress note dated 5/29/24, indicated that the wound worsened to 2.7 c.m. x 1.7 c.m. requiring a Xeroform dressing( A non adherent dressing).

Review of the clinical record indicated that Resident R35 was admitted to the facility with diagnoses which included dementia, difficulty walking, restless leg syndrome, anxiety and diabetes. A MDS dated 5/14/24, indicated the diagnoses remained current.

Review of the physicians order summary indicated Resident R35 is a transfer with two assist.

Review of an incident report indicated that while Resident R35 was being transferred with assistance of one staff, she obtained a skin tear of her left forearm when it hit into a walker. The incident report indicated a skin flap needed to be placed before a treatment was applied. An additional page attached to the incident report identified as "skin tear/bruise check list" indicated the area as a bruise measuring 7.5 cm x 2.5 cm.

During an interview on 5/29/24, at 1:22 p.m. the Director of Nursing confirmed that the facility failed to identify, investigate and report potential neglect for two of three residents.

28. Pa Code 201.14(a) Responsibility of licensee.

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

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

Plan of Correction - To be completed: 07/08/2024

Incident with R27 was thoroughly investigated. The original order of tegaderm caused the skin tear to increase in size when it was removed as it has an adhesive. Therefore, the order was changed to Xeroform dressing which is a non-adherent dressing.
Incident with R35 was thoroughly investigated. A PB22 was completed and the allegation of neglect was unsubstantiated. E3 corrected the Skin Tear/bruise checklist for R35. The area was actually a skin tear measuring 2.5cmX 2.5cm. The skin tear was treated by our wound nurse and was healed on 5/29.
Reeducation will be completed with DON and neighborhood managers by NHA or designee on §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Audits will be completed monthly times 3 of any abuse allegations received by the facility to ensure the investigation is thorough and allegations are reported to DOH if appropriate by NHA or designee. Results will be brought to QAPI to determine if further auditing is necessary.

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 a review of clinical records and staff interviews, it was determined the facility failed to provide person-centered care consistent with professional standards of practice by failing to follow physician orders for proper transfer of one of three residents(Resident R35) causing an injury.

Findings included:

Review of the clinical record indicated that Resident R35 was admitted to the facility with diagnoses which included dementia, difficulty walking, restless leg syndrome, anxiety and diabetes. A MDS(Minimum Data Set- a periodic review of resident care needs) dated 5/14/24, indicated the diagnoses remained current.

Review of the physicians order summary indicated Resident R35 is a transfer with two assist.

Review of an incident report indicated that while Resident R35 was being transferred with assistance of one staff, she obtained a skin tear of her left forearm when it hit into a walker. The incident report indicated a skin flap needed to be placed before a treatment was applied. An additional page attached to the incident report identified as "skin tear/bruise check list" indicated the area as a bruise measuring 7.5 cm x 2.5 cm.
During an interview on

During an interview on 5/29/24, at 11:45 a.m., Nurse Aide Employee E3 stated that she followed the "Southmont 5th Floor Need to Know Care Sheet" while transferring Resident R35 as that is how the staff provide care. The nurse aide staff do not have computer access.

During an interview on 5/29/24, at 2:50 p.m., the Nursing Home Administrator(NHA) stated that the facility Nurse Aides(NA) do not have access to kardex at this time. Stated that when a physician order is changed on the "Care Sheet" is to be updated by the unit secretary. Resident R35's care sheet transfer status had not been changed as the night nurse who took the order off did not update the sheet.

During an interview on 5/29/24, at 1:22 p.m. the Director of Nursing confirmed that the facility failed to fully investigate and review the incident and the information was not accurate on some of the report and the facility did not provide the Nurse Aide with the correct transfer order and the facility failed to provide person-centered care consistent with professional standards of practice by failing to follow physician orders for proper transfer of one of three residents causing an injury.

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

Plan of Correction - To be completed: 07/08/2024

The Skin Tear/bruise checklist was corrected for R35. The area was actually a skin tear measuring 2.5cmX 2.5cm. The skin tear was treated by our wound nurse and was healed on 5/29.
R35 transfer order and Need to know care sheet now match. An initial audit was completed on the 4th and 5th floors to ensure the Need to know care sheets match the transfer orders. The nurses will be reeducated on the proper process for updating the Need to know care sheets. An audit will be completed daily times 5, weekly times 4 and monthly times 3 on the 4th and 5th floors to ensure the Need to know care sheets match the transfer orders.
Results will be reviewed at QAPI to determine if further audits or education are necessary.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

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.

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on review of facility policy, observations, and staff interview, it was determined that the facility to make certain that medical supplies were properly stored and/or disposed of on one of two nursing units (Third Floor Nursing Unit).

Findings include:

During an observation on 5/29/24, at 10:50 a.m., the third floor emergency cart identified the following expired items:
5- argyle suction tubing kits, dated 10/31/23
3- intravenous catheter start kits, dated 4/24
2- intravenous luer lock kits dated 8/23
1- nasal cannula oxygen tubing kit dated 5/23
2- 100 cc saline bottles for oxygen use dated 1/1/24

During an interview on 5/29/24, at 11:30 a.m., Registered Nurse Supervisor Employee E4 confirmed the facility failed to properly dispose of expired emergency cart biologicals.

28 Pa. Code: 201.14 (a) Responsibility of licensee.

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

28 Pa. Code: 211.9 (a)(1) Pharmacy services.

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

Plan of Correction - To be completed: 07/08/2024

All expired items have been removed from the 3rd floor emergency cart and replaced with up to date supplies.
The emergency carts on 4th floor, 5th floor and the therapy department have been checked and are currently in compliance.
The nurses will be reeducated on replacing supply items that are due to expire. The check list for the emergency cart has been revised to include the expiration date.
Audits of the emergency carts will be completed weekly for 4 weeks then monthly thereafter. Results will be reviewed at QAPI to determine if further audits or education are necessary.

§ 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 review of nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per forty residents during the night shift for 3 of 21 days (5/11, 5/12, and 5/14/24).

Findings include:

Review of the facility census data, nursing time schedules, and deployment sheets from 5/5/24 through 5/25/24, revealed the following nurse LPN staffing shortages:

On 5/11/24, the census was 137, which required 3.65 LPN's during the night shift. Review of the nursing time schedules revealed 3.40 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 5/12/24, the census was 136, which required 3.63 LPN's during the night shift. Review of the nursing time schedules revealed 2.57 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 5/14/24, the census was 137, which required 3.65 LPN's during the night shift. Review of the nursing time schedules revealed 2.67 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

During an interview on 5/31/24, at 10:45 a.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum of one LPN per forty residents during the night shift on 3 of 21 days.

Plan of Correction - To be completed: 07/08/2024

Nursing administration reviewed the dates of 5/11, 5/12 and 5/14 that the license practical nurse ratio was below the minimum of 1:40 residents on the night shift. There were no identified adverse effects relating to residents regarding the deficiency in licensed nurse ratio. The hours per patient day on the dates identified were 3.27, 3.28 and 3.6 which is well above the state minimum of 2.87. Nursing administration and the scheduling team meets daily to review staffing, ratios, and census to make every effort to secure the staffing needed to meet the state's regulatory requirement. The team reviews census, patient care needs, and available nursing staff including current staff and agency staff to ensure we are meeting the needs of the residents. The nursing administration team works diligently and creatively to recruit for our open positions and incentivize the appropriate team members to fill our open shifts. The team utilizes staffing incentives for current team members who help to fill open shifts. The team also reaches out to our contracted agencies to find the appropriate agency staff to fill shifts that remain open. Management nurses are on call to respond to staffing shortages. NHA/DON or designee will complete a weekly audit and do everything possible to meet the licensed nurse requirement that became effective on July 1, 2023. The audit will be completed weekly for four weeks. Results will be reviewed at QAPI to determine if further audits or education are necessary.

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