Pennsylvania Department of Health
ST. IGNATIUS NURSING & REHAB CENTER
Patient Care Inspection Results

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ST. IGNATIUS NURSING & REHAB CENTER
Inspection Results For:

There are  133 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.
ST. IGNATIUS NURSING & REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on April 5, 2024, it was determined that St. Ignatius Nursing and Rehab Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.



 Plan of Correction:


483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination: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(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:


Based on review of clinical records, and interviews with resident and staff, it was determined that the facility did not ensure one resident's rights were exercised related to scheduled dialysis appointments for one of 27 resident records reviewed (Resident R22).

Findings include:

Review of Resident R22's clinical record revealed the resident was admitted to the facility on December 19, 2019, independent in making personal decisions, diagnosed with End Stage Renal Disease (kidney failure) and Chronic Obstructive Pulmonary Disease (COPD a lung disease).

During an interview with Resident R22 on April 2,2024 at 11:30 a.m. stated that resident went to Dialysis (treatment for kidney failure) three times a week. She stated she used to go early in the morning and enjoyed the earlier schedule much more but the facility changed it to later in the day.

Interview with the Director of Nursing (DON) on April 4, 2024 at 1:00 p.m. stated, "We changed Resident R22's dialysis time because she needed an escort and she agreed to the change. It was confirmed the DON did not have documented evidence that supported the mutual agreement."

28 Pa Code 211.5(f)(ii) Medical records







 Plan of Correction - To be completed: 05/13/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

It is the goal of STINRC to ensure Resident Rights are exercised such as in the scheduling of standing dialysis appointments.

Resident R 22 agreed to the change in time for dialysis treatment; however, the conversation supporting mutual agreement was not documented.

In the future, all conversations concerning changes in time or place of standing appointments will be documented in the Resident's medical record.

Residents with standing outside appointments will be interviewed and the conversation documented to ensure Resident Rights to self-determination are maintained.

An audit of Residents with outside standing appointments has been completed by the DON or designee.

Nursing Staff will be in-serviced on Resident Rights/Self Determination with an emphasis on Resident choice.

Resident Rights/Self Determination compliance will be monitored by the DON and Director Social Services during daily rounds.

A weekly audit X 4 of Residents with outside standing appointments will be completed by the DON or designee.

The results of such audits will be brought to the QAPI meeting for review and resolution.

483.25(h) REQUIREMENT Parenteral/IV Fluids: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(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:

Based on observations, review of clinical records, facility policies and procedures, and interviews with staff and resident, it was determined that the facility failed to provide adequate treatment and care for a mid line catheter in accordance with professional standards of practice for one of one resident with midline reviewed (Resident R113).

Findings include:

Review of facility policy, "PICC, Central Line and Perpheral Line Dressing Changes" dated July 2019 revealed that "Central venous access devise and midline dressing changes will be done at established intervals and immediately if the integrity of the dressing is compromised, if moisture drainage or blood is present or for futher assessment if infection is suspected. Transparent semi-permeable membrane dressing are changed every 7 days and PRN."

Observation of Resident R113 on April 2, 2024, at 12:14 p.m, revealed that the resident had a right upper extremity mid line insertion. There was documentation on the dressing to indicate the date and time the dressing last changed was March 29, 2024.

Review of clinical record for Resident R113 revealed that the resident was admitted to the facility on March 13, 2024.

Review Resident R113's physician order dated March 29, 2024, revealed an order to change PICC line dressing as soon as possible weekly.

A review of the treatment administration record (TAR) for the month of March 2024 indicated that order was signed off by the staff on March 29, 2024. Continued review of the TAR revealed that the PICC line dressing was not changed from March 13, 2024, to March 29, 2024.

An interview with Director of Nursing, Employee E2, on April 5, 2024, at 11:00 a.m. confirmed that that the PICC line dressing change was not completed from March 13, 2024 to March 29, 2024.

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

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

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

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



 Plan of Correction - To be completed: 05/13/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

It is the goal of STINRC to provide adequate treatment and care for mid-line catheters following professional standards.

Resident R 113 treatment and care were provided care immediately after identification. The surveyor later the same day verified the care was completed.

Central Venous access devices and midline dressing changes will be provided at established intervals and immediately if needed per the facility policy.

An audit of Residents with PICC lines, central lines, and peripheral lines dressings has taken place by nursing. Any care needs identified were addressed immediately.

Nursing Staff has been in-serviced on PICC lines, central lines, and peripheral lines dressings to ensure quality care is provided according to policy.

PICC lines, central lines, and peripheral lines dressings care will be monitored by the DON and United Managers during daily rounds.

A weekly audit X 4 of Residents with PICC lines, central lines, and peripheral lines dressings care to be completed by the DON or designee.

The results of such audits will be brought to the QAPI meeting for review and resolution.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on observation, clinical record review and interview with staff, it was determined that the facility did not ensure to administer oxygen therapy in accordance with professional standards of practice related to for two of 28 residents reviewed (Resident R18 and R22).

Findings include:

Review of facility's policy titled 'Oxygen Administration,' revised on August 2000, states "nasal cannula or mask and oxygen tubing must be dated and changed weekly."

Review of R18's clinical records revealed diagnosis of chronic obstructive pulmonary disease, high blood pressure, heart disease, kidney disease - stage 3.

Observations of R18 on third floor unit, on April 2, 2024 at 11:31 am revealed oxygen tubing dated February 17, 2024; finding confirmed by licensed nurse, employee E3.

Review of Resident R22 clinical record revealed the resident was admitted to the facility on December 19, 2019 diagnosed with End Stage Renal Disease (kidney failure) and Chronic Obstructive Pulmonary Disease (COPD a lung disease). Further review of the resident's clinical chart revealed an order for 3 liters of oxygen.

On April 2, 2024 at 2:30 p.m. with Licensed Practical Nurse, (LPN) Employee E6 observed that Resident R22's oxygen condenser was not clean. Observed was a thick gray coating that appeared to be dust covering the filter.


28 Pa Code 211.10(c) Resident Care Policies

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






 Plan of Correction - To be completed: 05/13/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

It is the goal of STINRC to ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, are provided consistent with professional standards and practices.
Resident R 18 nasal cannula and tubing were changed and dated.

Resident R-22 oxygen concentrator was taken out of service and was scheduled for preventative maintenance.

Nursing audited Residents with orders for oxygen all supplies were checked for date and equipment was checked for cleanliness. Any findings were addressed immediately by the nursing and maintenance staff.

Nursing and Maintenance Staff have been in serviced on proper usage and storage of oxygen supplies and preventative maintenance on oxygen concentrators.

Compliance will be monitored by the DON and Maintenance Director during daily rounds.

A weekly audit X 4 of Residents with oxygen orders will be completed by the DON or designee.

The results of such audits will be brought to the QAPI meeting for review and resolution.

483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on review of facility policy, review of clinical documentation, and interviews with staff, determined the facility failed to ensure residents who require dialysis receive such services, consistent with professional standards of practice, and the comprehensive person-centered care plan, by failing to provide dialysis treatment and medication as ordered for one of 34 resident records reviewed (Resident R22).

Findings included:

Review of the facility's policy titled, " Dialysis Care Policy" stated it is the facility's policy to coordinate dialysis care and services for residents receiving dialysis in a comprehensive manner and coordination of services between the facility and the dialysis center to maintain continuity of care.

Review of Resident R22's clinical record revealed the resident was admitted to the facility on December 19, 2019, independent in making personal decisions, diagnosed with End Stage Renal Disease (kidney failure) and received hemodialysis.

Review of Resident R22's nursing progress notes revealed on March 15, 2024, the resident missed her scheduled dialysis because she did not have an escort.

Further review of Resident R22's nursing progress notes dated March 22, 2024 stated the nurse was unable to give the resident medications scheduled for 10:00 a.m., and 2:00 p.m. because the resident was at dialysis.

The above was confirmed with the Director of Nursing on April 4, 2024 at 10:00 a.m.

28 Pa Code 211.12(c) Resident care policies

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







 Plan of Correction - To be completed: 05/13/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

It is the goal of STINRC to ensure that residents who require dialysis receive such services, consistent with professional standards of practice.

Resident R 22 missed her dialysis appointment due to a communication breakdown.

STINRC's revised Dialysis policy includes contingency planning should an escort not be available.

Resident R-22 medication schedule was changed by the physician to accommodate her dialysis schedule.

There are no other Resident's on Dialysis at STINRC at this time. Due to the number of competing facilities offering on-site dialysis STINRC has not been receiving referrals for dialysis patients.

The Social Services Director will monitor/audit Resident R 22 dialysis trips weekly X 4 to ensure STINRC is in compliance.

Results of the audit will be brought to the QAPI Committee for review and resolution.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/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.
483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:


Based on review of facility policy, review of clinical records, and interview with staff, it was determined the facility did not ensure to provide pharmaceutical services to meet resident's needs including acquiring, receiving, and administering medications for three of 28 residents reviewed. (Residents R32, R35, and R97)

Findings include:

Review of facility's policy titled 'Medication Administration,' revised on May 2020, indicates that "drugs are to be administered in accordance with the written orders of the attending physician. When a resident's medication has not been delivered from pharmacy; the licensed nurse should immediately notify the pharmacy and notify a unit manager or nursing supervisor to obtain the medication from the medication dispense."

Review of Resident R32's April 2024 physician orders revealed an order for Aspirin 81 milligrams (mg) delayed release to be administered once a day at 9:00 a.m. Continued review of phycisian orders revealed an order for Nifedipine 60mg extended release to be administered once a day at 9:00 a.m.

Observations during medication administration on second floor unit, on April 2, 2024 at 9:50 a.m. with licensed nurse, Employee E4, revealed that pharmacy delivered double dose of Aspirin 81 mg and double dose of Nifedipine 60 mg.

Resident R35 was admitted to the facility diagnosed with benign prostate hyperplasia, high blood pressure and an overactive bladder.

Review of Resident R35's progress noted revealed a new order for the medication Mirabegron 25 mg, give daily for the diagnosis of overactive bladder to start on December 7, 2023. Continue review of Resident R35 clinical record revealed nursing note dated, December 10, 2024. revealed the resident's medication had not been administered because. "meds are not available, pharmacy called." Review of the medication administration record revealed the medication was not administered on December 7,8,9,and 10, 2023.

On April 4, 2024, at 10:32 a.m. during an interview with the Director of Nursing confirmed the medication was not given as ordered.

Review of Resident R97's April 2024 physician orders revealed an order for Guaifenesin tablet extended release, 600 mg to be administered every 12 hours at 9:00 a.m. and 9:00 p.m.

Observations during medication administration on April 3, 2024 at 10:26 a.m., with Licensed nurse, Employee E5, on third floor unit, revealed that medication was not available to be administered to Resident R97.



28 Pa Code 211.9(a)(1) Pharmacy Services

28 Pa Code 211.9(d) Pharmacy Services

28 Pa Code 211.12(d)(1) Nursing Services





 Plan of Correction - To be completed: 05/13/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

It is the goal of STINRC to ensure the facility provides pharmaceutical services to meet resident's needs including acquiring, receiving, and administering medications.

Resident's R 32, R 35, and R 97 medication regimes have been reviewed to ensure the timely administration of medications.

The pharmacy has been formally notified concerning the unacceptable customer serve STINRC and our Residents have been receiving.

The pharmacy has adjusted some of their internal and delivery processes to ensure medication is received at STINRC on a timely basis.

The amount of medication placed in the automated medication machine has increased and change to better reflect the needs of our Resident population.

The NHA will monitor the performance of the pharmacy to ensure the services meet the needs of the Residents.

The 3-11 Nursing Supervisor will audit 50% X 2 weeks of new pharmacy orders delivered to ensure the proper medication is packaged and received.

The results of the audit will be brought to the QAPI committee for review and resolution.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

483.45(c)(2) This review must include a review of the resident's medical chart.

483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on review of facility policies, clinical records and interviews with staff, it was determined that the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that included time frames for the different steps in the medication regimen review process and act on irregularities reported by the licensed pharmacist during monthly drug regimen reviews in a timely manner for one of five residents reviewed related to medication regimen reviews (Residents R55).

Findings include:

1. Review of facility policy "Medication Regimen Review" dated April 2024 revealed that "Medication Regimen Review (MRR) is a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication. The review includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities, and collaborating with other members of the interdisciplinary team. The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and the reports must be acted upon.
a. Irregularities include, but are not limited to, any drug that meets the criteria for unnecessary drugs.
b.Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
c.The attending physician must document in the resident' medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record."
Upon completion of the MRR, the facility designee and/or physician, will respond to the recommendations in a timely manner.
If the pharmacist should identify an irregularity and communicates to the facility that it requires urgent action to protect a resident, it will be acted upon immediately. "

Continued review of facility policy revealed that there was no timeframe set to complete the physician and facility response to the pharmacy consultant recommendation/report.

Review of Resident R55's Medication Regimen Review report, dated November 29, 2023, revealed that the pharmacist made a recommendation, to evaluate the current dose of Seroquel 12.5 once daily which the resident had been taking since June 2023 and consider dose reduction.

Further review of the report revealed that the recommendation was addressed on January 18, 2024.

Review of another Medication Regimen Review report Resident R55's, dated November 29, 2023, revealed an recommendation to add a stop date for an as needed Buspar (a psychotropic medication). As needed psychotropic need a 14 day stop date.

Further review of the report revealed that this recommendation was addressed until on January 18, 2024.

Review of Resident R55's Medication Regimen Review report, dated February 28, 2024, revealed a recommendation to discontinue as needed medication which was not administered since December 1.

Further review of the report revealed that this recommendation was addressed unitl on March 14, 2024.


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

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

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







 Plan of Correction - To be completed: 05/13/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

It is the goal of STINRC to develop and maintain policies and procedures for the monthly drug regime review that includes time frames for the different steps in the medication regimen review process.

Resident's R 55 monthly medication regime review was signed and acted on at the time of the survey.

The Medical Director notified all attending physicians of the importance of responding to the Pharmacists' monthly recommendations in a timely manner.

Nursing has audited all completed monthly Pharmacist reviews to ensure physician compliance.

The Pharmacist recommendations will be reviewed/audited weekly X 4 at the weekly clinical meeting which is attended by the Medical Director.

Results of the audit will be brought to the QAPI committee for review and resolution.


483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations: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(d) Influenza and pneumococcal immunizations
483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to offer and/or provide the pneumococcal immunization to two of five residents reviewed (Resident R18 and R33).

Findings include:

Review of an undated facility policy "Pneumococcal Vaccine: dated revealed that "Upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated will be offered the vaccine unless medically contraindicated or the resident has already been vaccinated. "

Review of Resident 117's immunization records revealed no evidence that the resident received the pneumococcal vaccine, or the facility offered the pneumococcal vaccine.

Review of clinical record revealed that the resident was 66 years of age.

Review of R83's immunization records revealed no evidence that the resident received the pneumococcal vaccine, or the facility offered the pneumococcal vaccine.

Review of clinical record revealed that the resident was 85 years of age.

Review of clinical record for Resident R117 and R83 revealed no documented contraindication to immunization.

Interview with the Director of Nursing, Employee E2, on April 5, 2024, at 11:00 a.m., confirmed that there was no documented evidence that Resident R117 and R83, received pneumococcal vaccine or the facility offered the pneumococcal vaccine.

28 Pa Code: 201.14 (a) Responsibility of licensee

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

28 Pa Code: 211.15 (f) Clinical records

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



 Plan of Correction - To be completed: 05/13/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

It is the goal of STINRC to offered/or provide the pneumococcal immunization to all Resident's in a timely manner.

Resident's R 18 and R33 were offered/or provided the pneumococcal immunization during the survey.

The Infection Preventionist has audited Resident's medical records to ensure compliance with STINRC's pneumococcal immunization policy.

The Infection Preventionist will add this to the yearly reporting schedule to ensure compliance.


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

Observations:

Based on a review of nursing schedules, staffing information provided by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 12 residents on the day shift and one nurse aide per 12 residents on evening shift and nurse aide per 20 residents on night for eight of 21 days. (November 19, 23, 25, 26, 2023; December 31, 2023, March 29, 30, and April 1, 2024)

Findings Include:

Review of facility census data indicated that on November 19, 2023, the facility census was 150, which required 12.50 (150 residents divided by 12) NA's during the day shift. Review of the nursing time schedules revealed 12 NA's provided care on the day shift on November 19, 2023. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on November 25, 2023, the facility census was 149, which required 12.42 (149 residents divided by 12) NA's during the day shift. Review of the nursing time schedules revealed 12 NA's provided care on the day shift on November 25, 2023. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on November 23, 2023, the facility census was 148, which required 12.33 (148 residents divided by 12) NA's during the evening shift. Review of the nursing time schedules revealed 12 NA's provided care on the evening shift on November 23, 2023. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on December 26, 2023, the facility census was 135, which required 11.25 (135 residents divided by 12) NA's during the day shift. Review of the nursing time schedules revealed 10 NA's provided care on the day shift on December 26, 2023. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on December 31, 2023, the facility census was 132, which required 11 (132 residents divided by 12) NA's during the evening shift. Review of the nursing time schedules revealed 10 NA's provided care on the evening shift on December 31, 2023. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 30, 2024, the facility census was 136, which required 11.33 (136 residents divided by 12) NA's during the day shift. Review of the nursing time schedules revealed 10 NA's provided care on the day shift on March 30, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 29, 2024, the facility census was 136, which required 11.33 (136 residents divided by 12) NA's during the evening shift. Review of the nursing time schedules revealed 8 NA's provided care on the evening shift on March 29, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on April 1, 2024, the facility census was 136, which required 11.33 (136 residents divided by 12) NA's during the evening shift. Review of the nursing time schedules revealed 8 NA's provided care on the evening shift on April 1, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

This information wa provided during an interview with the Director of Nursing Home on April 5, 2024, at 1:30 p.m.







 Plan of Correction - To be completed: 05/13/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

The electronic staffing worksheet has been revised. Staffing will be reviewed by the DON and NHA to ensure compliance.

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