Pennsylvania Department of Health
ST. JOHN NEUMANN CENTER FOR REHABILITATION & HEALTHCARE
Patient Care Inspection Results

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ST. JOHN NEUMANN CENTER FOR REHABILITATION & HEALTHCARE
Inspection Results For:

There are  152 surveys for this facility. Please select a date to view the survey results.

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ST. JOHN NEUMANN CENTER FOR REHABILITATION & HEALTHCARE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, and State Licensure Survey completed on March 8, 2024, it was determined that St. John Neumann Center for Rehabilitation and Healthcare, 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, related to the health portion of the survey process.


 Plan of Correction:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

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

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

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

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

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


Based on observation, review of facility policy and interview with facility staff, it was determined that the facility failed to provide care and services to enhance residents' dignity related to feeding residents, serving meals on disposable paperware and providing incontinent care for four of 36 Residents reviewed. (Residents R79, R4, R21, and R18).

Findings include:

A review of the facility policy and procedure, titled, "Feeding Residents," revised November 2023, states that it is the facility's policy to sit next to or face resident while feeding to promote socialization and correct feeding techniques.

Clinical record review for Resident R79 revealed that resident was admitted to the facility on September 5, 2019. Observations during the initial tour of the facility on March 5, 2024, at 10:45 a.m. in Resident R79's room revealed that resident was laying in her bed, and stated that she had to urinate. The Unit Manager, Employee E6, who was also in the room asked her to wait. Resident R79 then said, "should I go in my diaper?" The Unit Manager responded that it was okay.

Observation at 12:30 p.m. on March 5, 2024, in the 300 dining room during the lunch meal revealed a nurse aide, Employee E7, who was standing and feeding Resident R4, who was sitting at a table.

Further observation revealed that Resident R21's meal was served on a Styrofoam plate. Further review of Resident R21's record revealed no physician's order for Styrofoam or disposable plate at mealtime.

During an interview with Unit Manager, Employee E6, at 12:35 p.m. on March 5, 2024, confirmed that Resident R21 had disposable dishware on her tray, and that it was because she came from a behavioral unit.

Further observation at 12:40 p.m. on March 5, 2024, in the 300 dining room during the lunch meal revealed a nurse aide, Employee E8, who was standing and feeding Resident R18, who was sitting at a table.

Observation at 12:25 p.m. on March 6, 2024, in the 300 dining room during the lunch meal revealed a nurse aide, Employee E7, who was standing and feeding Resident R18, who was sitting at a table.

Further observation at 12:25 p.m. on March 6, 2024, in the 300 dining room during the lunch meal revealed the Unit Manager, Employee E6, who was standing and feeding Resident R4, who was sitting at a table.

Interview with the Director of Nursing (DON) and Administrator on March 7, 2024, at 2:30 p.m. confirmed the above findings.

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

28 Pa. Code: 201.29(a) Resident rights



 Plan of Correction - To be completed: 04/29/2024

1.Resident R21 was seen by rehab for eating utensils. Resident care plan updated and orders received. R79, R4 and R 18 received care and services to enhance resident's dignity related to feeding.
2.Staff Educator/Designee will Inservice Nursing on resident right to a dignified existence regarding toileting needs and feeding assistance.
3.DON/Designee will audit residents requiring assistance during meals weekly x 4weeks, monthly x2 to assure staff sit with residents 1:1 and enhance resident's dignity during feeding.
4.Audit results will be reported at QAPI meetings for further review and recommendations x2

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:

Based on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food that was palatable and served at the proper temperature for nine of 36 residents reviewed (Residents R119, R75, R31, R182, R34, R81, R85, R10, R71).

Findings include:

Review of facility policy titled, "Food Temperatures," dated February 1, 2021, revealed that "temperatures of food will be monitored to ensure safety" and that hot foods must "stay above 135 degrees Fahrenheit and cold foods stay below 41 degrees Fahrenheit during the holding and serving process."

During a group interview, held on March 7, 2024, at 10:30 a.m. with Residents R119, R75, R31, R182, R34, R81, R85, R10, R71, revealed that food is not appetizing and palatable.

Observations during lunch tray line on March 8, 2024, from 12:15 p.m. to 1:00 p.m. revealed that the fruit cups, pudding, sandwiches, and salads were prepared in bulk and observed on a rack not being chilled prior to tray assembly.

Observations during a test tray conducted with the Food Service Director (FSD), Employee E19, on March 8, 2024, at 1:04 p.m. revealed that the pudding registered at 53.4 degrees F; salad greens registered at 69.33 degrees F; turkey and cheese registered at 67.3 degrees F; fruit cup at 70.7 degrees F; fish fillet at 139.1 degrees F.

An interview with the FSD, on March 8, 2024, at approximately 1:07 p.m. confirmed that the above-mentioned food items were below and above the acceptable temperatures and therefore not palatable.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(3) Management

28 Pa. Code 211.6(f) Dietary services




 Plan of Correction - To be completed: 04/29/2024

1.The Dietary Department or designee will interview a sample of residents to determine if the food is flavorful, aesthetically pleasing, and palatable for them.
2.Dietary director will in-service cooks on conserving flavor, appearance, and palpability of food preparation.
3.The Dietary Director will educate dietary staff to hold all cold food in Ice trays or refrigerator until ready to assemble tray line.
4.The Dietician /designee will complete 5 random resident audits weekly x 4 and then monthly x2 to evaluate resident feedback.
5.Audit results will be reported at QAPI meetings for further review and recommendations monthly x2.
483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
483.45(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 facility policy, observations, and interviews with staff, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions on three of five nursing units. (700 unit, 300 unit and All Saints unit)

Findings include:

Review of facility policy titled Policy "St John Neuman Storage of Medications" revealed that the nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, sanitary, manner. Further review of this policy revealed that medications requiring refrigeration must be stored in a refrigerator looked in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be locked accordingly.

Observation of medication cart 700 third cart on March 8, 2024, at 10:10 a.m., revealed 31 unidentified looses pills in the top drawer of the cart. Interview with Licensed nurse Employee E12 at time of observation confirmed this observation.
Observation of med cart 300 second cart On March 8, 2024n at 10:40 a.m. revealed 7 loose pills in the top drawer of the cart. Interview with licensed nurse Employee E11 at time of observation confirmed this observation.

Observation of med cart on All Saint's hall cart one, revealed a small cup with unidentified pills in the top drawer. At this observation Employee E10 threw the cup out. Interview with Licensed nurse, Employee E10 at time of observation confirmed there was a small cup of pills, employee stated that the medication was only Tylenol.

Observation of the 300 nursing unit medication storage room revealed the medication refrigerator stored with insulin and vaccines also was observed as containing food, specifically cheese. Interview with Licensed nurse, Employee E11 at time of observation confirmed that the food product does not belong in the med refrigerator.


28 Pa. Code (j)(1)(4)211.9 Pharmacy Services

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








 Plan of Correction - To be completed: 04/29/2024

1.All med carts have been checked and cleaned for any loose meds or spills.
2.Staff educator/designee will in-service all licensed nursing staff on medication cart check at end of every shift and storing medications appropriately.
3.The DON/designee will complete audits weeklyx4 and then monthly x2 to assure medication carts are free of loose pills.
4.Audit results will be reported at QAPI meetings for further review and recommendations monthly x2.

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More: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.
483.45(f) Medication Errors.
The facility must ensure that its-

483.45(f)(1) Medication error rates are not 5 percent or greater;
Observations:

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater two of two residents observed for medication administration. (Resident R127, and Resident R13)

Findings include:

On March 6, 2024, at 8:34 a.m., observed that Employee E32, a Licensed Nurse, administered to Resident R127, Aspirin Enteric Coated Tablet 81 MG, one tablet. Review of physician order for Resident R127, dated September 22, 2023, revealed an order to administer Aspirin Tablet Chewable 81 MG, give 1 tablet by mouth in the morning for Coronary Artery Disease (Coronary Artery Disease Damage or disease in the heart's major blood vessels; the usual cause is the buildup of plaque; this causes coronary arteries to narrow, limiting blood flow to the heart).

Review of medical literature, in, https://newsnetwork.mayoclinic.org/discussion, revealed that with enteric-coated aspirin, research indicated that bloodstream absorption may be delayed and reduced, compared to regular aspirin absorption. Regular aspirin is quickly dissolved and absorbed in the stomach. As a result, enteric-coated aspirin may not be as effective as regular aspirin at reducing blood clot risk.

At the time of the observation, an interviewed with Licensed nurse, Employee E32, confirmed the above findings.

On March 6, 2024, at 8:54 a.m., observed that Employee E31, a Registered Nurse, administered to Resident R13, Gerikot 8.6 mg, one tablet by mouth, for constipation. Review of physician order for Resident R13, dated July 9, 2021, revealed an order to administer Senna Plus Tablet 8.6-50 MG (Sennosides-Docusate Sodium), give one tablet by mouth for constipation.

Review of medical literature, in, https://www.webmd.com/drugs/2/drug-20755/senna-plus-oral/details, revealed that Gerikot is the generic name for the medicine, named Senna, which treats occasional constipation; it works by helping the muscles in the intestines move stool. Senna Plus Tablet, 8.6-50 MG contains, two medications, namely Sennosides and docusate. Sennosides are known as stimulant laxatives; they work by keeping water in the intestines, which helps to cause movement of the intestines. Docusate is known as a stool softener; it helps increase the amount of water in the stool, making it softer and easier to pass; and Senna Plus should be taken by mouth with a full glass, or eight ounces or 240 milliliters of water.

Continued observations on March 6, 2024, at 8:54 a.m., Licensed nurse, Employee E31 administered to Resident R13, Vitamin C Tablet 250 MG (Ascorbic Acid), two tablets by mouth. Review of physician order for R13, dated June 6, 2019, revealed an order to administer Vitamin C Tablet 500 MG (Ascorbic Acid), give 2 tablet by mouth one time a day.

At the time of the observation, and interviewed with Employee E31, and confirmed the above findings.

The facility incurred a medication error rate of 10.71 %.

Pa Code:211.12(d)(1)(2)(5) Nursing Services.





 Plan of Correction - To be completed: 04/29/2024

1.An audit of all orders related to OTC medications completed.
2.Staff educator/designee will in service all licensed nursing staff on medication administration.
3.The DON/designee will complete audits weekly x4 and then monthly x2 to assure medications administered are per physician orders.
4.Audit results will be reported at QAPI meetings for further review and recommendations monthly x2.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(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, review of clinical record, review of facility policy and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and services for 3 of 36 residents reviewed (Residents R29, R60, and 195).

Findings include:

Review of facility policy for Tracheostomy care revised March 2024, revealed "Check orders for tracheostomy care. Assure an extra tracheostomy tube with inner cannula is always available for emergency replace resident bedside as ordered. Assure an Ambu bag is at resident bedside for emergency procedure as ordered."

Review of Resident R60's clinical record revealed the resident was diagnosed with tracheostomy status (procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck).

Review of Resident R60's physician's orders dated March 5, 2024, revealed the tracheostomy cuffed Shiley number 4.

Observation of Resident R60 conducted on March 5, 2023, at 11:44 a.m. with Unit manager, Employee E15, revealed no extra tracheostomy tube with inner cannula size 4 and ambu bag by resident bedside for emergency procedure.

Review of Resident R29's clinical record revealed the resident was diagnosed with tracheostomy status (procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck).

Review of Resident R29's physician's orders dated May 17, 2023, revealed the tracheostomy size 6XL shiley.

Observation of Resident R29 conducted on March 5, 2023, at 11:49 a.m. with Unit manager, Employee E15, revealed no extra tracheostomy tube with inner cannula size 6 x l and ambu bag by resident bedside for emergency procedure.

Review of Resident R195's clinical record revealed the resident was diagnosed with tracheostomy status (procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck).

Review of Resident R195's physician's orders dated September 26, 2023, revealed the tracheostomy uncuffed shiley number 6.

Observation of Resident R195 conducted on March 5, 2023, at 12:07 p.m. with Unit manger, Employee E15, revealed no extra tracheostomy tube with inner cannula size 6 and ambu bag by resident bedside for emergency procedure.

Interview with the Nursing Home Administrator, Employee E1, conducted on March 7, 2024, at 9:30 a.m. confirmed and update tracheostomy policy, that the residents on tracheostomy need to have an extra tracheostomy tube with inner cannula and ambu bag is always available for emergency replace resident bedside.

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



 Plan of Correction - To be completed: 04/29/2024

1.Extra tracheostomy with inner cannula and ambu bags placed at the bedside of R60, R29 and R 195.
2.Unit Managers audited other residents with tracheostomy to ensure extra tracheostomy with inner cannulas and ambu bags were at their bedside.
3.The policy was reviewed and updated to include ambu bag and extra trach at bedside. Staff educator/ Designee will in service license nurses on revised policy.
4.Unit Manager's obtained physician orders to include extra trach and ambu bag at bedside and to check every shift for placement. The DON /designee will complete audits weekly x 4 and then monthly x2 to assure placement of trach and ambu bag at bedside.
5.Audit results will be reported at QAPI meetings for further review and recommendations monthly x2.

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 the review of clinical records, observations, and interview with staff, it was determined that the facility failed to ensure that the resident environment was free of accident hazards related to medication administration for two out of 36 residents reviewed (Resident R147 and Resident R69) , and failed to ensure that hazardous materials were not accessible to residents on one of five nursing units. (700 unit)


Findings include:

Observation conducted on March 8, 2024, at 11:08 a.m. in the 700 unit by the nursing station shower room revealed that there was used twin blade disposable razors in the trash, on the sink and on the floor.

Interviewed conducted with the Unit manger, Register nurse, Employee E12, revealed, and confirmed that razors should not been left out or thrown out in the trash in the shower room. It must be discarded in the sharp container after being used. The Unit manger, Register nurse, Employee E12, took all of razors and discarded them in the sharp container.

Interview conducted with the Director of Nursing, Employee E2 on March 8, 2024, at 11:44 a.m. reported that razors must be discarded in the sharp container after used.

Facility policy titles medication Administration revealed that the resident may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have decision making capacity to do so safely.

Review of Resident R69's clinical record revealed that Resident R69 was admitted in to the facility on July 21, 2021 with diagnoses of chronic pulmonary disease (COPD is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), cervical disc degeneration (a condition caused by age related that compresses the spinal cord and nerves in the neck) , pneumonia (an infection that inflames the air sacs in one or both lungs), and atrial fibrillation (an abnormal heart rhythm).

Review of Resident R69's MDS (Minimum Data Set, a resident assessment, is a health status screening and assessment tool) revealed that this resident had a BIMS (brief interview for mental status 0-7 suggest severe cognitive impairment, 8-9 suggest moderate cognitive impairment and 13-15 suggest cognition is intact) score of 8 . Further review of Resident R69's physician orders revealed no orders for medication self-administration.

Observation of Resident R69 in the resident room, on March 5, 2024, at 10:40 a.m. revealed resident asleep, Resident R69 share living space with Residenst R1 and R39, one roommate watching television, the other out of the room. Observed was a small cup containing nine unidentified pills on the resident's bedside table. The licensed nurse, Employee E3 administering the medication interviewed at time of observation stated, "she can take them when she wakes up".

Further review of Resident R69's clinical record revealed the Medication Administration Record was document as the medications being given by Licensed nurse, Employee E3 were listed as Aspirin 81 milligrams (used for heart and stoke protection ), Lexapro (used to treat depression), Spironolactone (used to treat high blood pressure), Eliquis(an anticoagulant drug commonly used for atrial fibrillation), Budesonide (a corticosteroids decrease inflammation in the digestive system) , Metoprolol (beta blocker, used to treat high blood pressure), Mucinex (medication used to decrease cough and loosen mucus in the chest), Buspirone (medication to treat anxiety) and Tylenol (acetaminophen used as a pain reliever and fever reducer)

Review of Resident 147's clinical record revealed that Resident R147 revealed the resident entered the facility July 23, 2021with diagnosis of chronic obstructive pulmonary disease (COPD is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), morbid obesity(clinical sever obesity, a severe health condition), malignant neoplasm of breast(breast cancer), dermatitis( skin inflammation), major depressive disorder (a mood disorder causing a persistent feeling of sadness), hypertension (high blood pressure), atrial fibrillation(an abnormal heart rhythm), and hypothyroidism (an overactive thyroid gland producing too much hormones). Further review of Resident R147's clinical record revealed a BIMS (brief interview for mental status 0-7 suggest severe cognitive impairment, 8-9 suggest moderate cognitive impairment and 13-15 suggest cognition is intact) score of 14.

Observation of Resident 147 on March 5, 2024, at 11:10 a.m. revealed a small cup on her bedside containing pills. Interview with Resident R147 at time of observation revealed that the nurse brought then in, but this resident requires one pill to be crushed, so this resident has not taken any of her scheduled medications. Further observation revealed that Resident R147 shared the living space with Resident R 68 and Resident R112.

Further review of Resident R147's clinical records revealed the resident was ordered Amiodarone (medication used to treat irregular heartbeats) Anastrozole (used to treat breast cancer), Aspirin 81mg (used for heart and stoke protection ), Calcium (crushed, a dietary supplement), Meclizine (antihistamine used to treat nausea), multi vit (dietary supplement), Pepcid (medication used to treat stomach acid) , Senokot (a laxative used to treat constipation) Torsemide (used to reduce extra fluid in the body), Zoloft (a medication used to treat mental and mood disorders), Buspirone (medication used to treat anxiety), Celebrex (an anti-inflammatory used to treat pain), Depakote
(medication used to treat seizures and bipolar disorder), Eliquis (an anticoagulant used to treat and prevent blood clots) and Tylenol (acetaminophen used as a pain reliever and fever reducer)


Interview with Licensed nurse Employee E3, at time of observation confirmed that she left the medications on the table and exited the room.


28 Pa. Code 201.18(a)(b)(1)(3) Management


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







 Plan of Correction - To be completed: 04/29/2024

1.All shower rooms will have sharps container placed to dispose razors appropriately.
2.Unit Manager will check other shower rooms to ensure razors were disposed of appropriately and checked resident rooms to ensure no medication left at resident bedside.
3.Staff Educator will in-service all nursing staff on disposing razors into sharps containers and will in-service all licensed staff on medication administration and assuring resident takes all medications before leaving resident side.
4.DON/Designee will do random audits weekly x4 then monthly x2 to ensure that no medications are left at bedside and to verify razors disposed of appropriately.
5.Audit results will be reported at QAPI meetings for further review and recommendations monthly x2.

483.10(j)(1)-(4) REQUIREMENT Grievances:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:

Based on observations, review of documentation and interviews with residents and staff, it was determined that the facility failed to ensure that residents had access to grievance forms and access to the contact information of the grievance official on five out of five nursing units. (300-700 nursing units).


Findings include:

Observations on March 5, 2024, at 10:55 a.m. of the 700 rooms nursing units revealed that no grievance forms and box were available for residents to be able to anonymously file a grievance. In addition, there was no information made available to residents on how to contact the grievance officer. Interviewed Unit manger, Employee E15 revealed that forms were filed in the nursing station.

Continued observations on March 5, 2024 at 11:00 a.m. other nursing units revealed that no grievance forms were available for residents to be able to anonymously file a grievance. In addition, there was no information made available to residents on how to contact the grievance officer.

Interview on March 5, 2024 at 1:45 p.m. a.m. with the Director of Social Work, Employee E13, confirmed that there was no contact information posted on how to contact the grievance officer and that there were no grievance forms and box available for residents to use anonymously.


28 Pa. Code 201.18(b)(2) Management

28 Pa. Code 201.29(a)(i) Resident rights



 Plan of Correction - To be completed: 04/29/2024

1.New grievance forms, signage with Grievance Officer information and boxes were marked and placed on all units.
2.Education will be provided to all staff regarding grievance process and information. All residents will be notified regarding the process through resident council, admission process and quarterly meetings.
3.DOSS/ Designee will audit weekly x 4 and monthly x 2 to assure the information posted and forms are available for all residents.
4.Audit results will be reported at QAPI meetings for further review and recommendations x2.

483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities: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.
483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

483.24(b)(2) Mobility-transfer and ambulation, including walking,

483.24(b)(3) Elimination-toileting,

483.24(b)(4) Dining-eating, including meals and snacks,

483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
Observations:


Based on observation, review of clinical records, and staff interviews, it was determined that the facility failed to provide a communication device to maintain optimal communication for one of 36 residents reviewed. (Residents R189)

The findings include:

Observations during the screening process, on March 5, 2024, at 1:32 p.m. revealed that Resident R189 had a language communication barrier. When the surveyor approached Resident R189's room, the resident was observed laying in bed. When the surveyor requested permission to enter the room, the resident appeared anxious and voiced Nurse aide, Employee E20's name repeatedly. Further observations revealed that Resident R189 got out of bed, and roamed the hallway, anxiously calling for Employee E20.

Review of Resident R189's admission Minimum Data Set Assessment (MDS, an assessment tool selected at specific intervals to determine care needs) dated, January 17, 2023, revealed that in section A, the resident was coded, "yes" for "does the resident need or want an interpreter to communicate with a doctor or health professional?"

Review of Resident R189's care plan dated, initiated on January 20, 2023, revealed that "[Resident R189] is Creole-Speaking only." Interventions listed included a "communication board; use translation phone application to communicate with resident."

Interview with Licensed Practical Nurse, Employee E21, conducted on March 5, 2024, at 1:38 p.m. revealed that Resident R189 does not speak English and requires translation. Employee E21 further stated that employees sometimes translate for Resident R189 when they are available. Further interview confirmed that Resident R189 did not have a communication board or a phone translation line in resident's room.

Interview with Nurse aide, Employee E22, conducted on March 5, 2024, at 1:40 p.m. revealed that "it is hard to communicate with Resident R189 due to the language barrier." Further interview confirmed that the resident had no communication board or a phone translation line available in her room.

Interview with Nurse aide, Employee E20, on March 5, 2024, at 1:41 p.m. who provided direct care to Resident R189 confirmed that there is no communication board or translation line available in resident's room. Further interview with Employee E20 and Resident R189 confirmed that the resident would benefit from a communication board or a phone translation line, as Employee E20 is not always available to assist the resident with translation.

Interview conducted on March 5, 2024, at 2:57 p.m. with the Registered Dietitian, Employee E23; Speech language Pathologist, Employee E24; and Social Worker, Employee E13; confirmed that Resident R189 never had a communication board or a translation line available. This interview revealed that google translate is often used when communicating with the resident, "but is challenging because the resident has a soft voice."

Interview with the Director of Nursing, Employee E2 and Facility Administrator, Employee E1 on March 6, 2024, at approximately 2:50 p.m. confirmed the above-mentioned findings. A communication policy for non-English speaking residents was not provided during survey.

28 Pa. Code 211.10(c) Resident care policies

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







 Plan of Correction - To be completed: 04/29/2024

1.A communication policy for non-English speaking residents was established.
2.An audit was completed for resident who are non- English speaking to ensure communication devices are accessible. Any non English speaking resident found without a communication device was provided one with copies on each unit.
3.Staff Educator in-serviced all staff on ensuring that residents who are non- English speaking we use communication boards in room, nurses station and also utilize Voice Translator Intelligence Device.
4.Activities director or Designee will complete a random audit weekly x4 then monthly x2 to ensure that residents who are non- English speaking have communication boards in their rooms.
5. Audit results will be reported at QAPI meetings for further review and recommendations monthly x2.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on review of clinical records, observations, and resident and staff interviews, it was determined that the facility
failed to ensure the appropriate size of an indwelling urinary catheter was used for one of 36 residents reviewed (Resident R2).

Findings include:

Review of Physician order dated February 16, 2022, for Resident R2, indicated an order to change Foley Catheter 16fr/10cc, every one month, one time a day, starting on the 16th and ending on the 16th every month".

On March 7, 2024, at 11:39 a.m., reviewed the Foley Catheter of R2, in the presence of a Licensed Nurse, Employee E33, and observed that R2 had Foley Catheter Size 18 FR, with the Balloon Size 30 cc.

At the time of the finding, Licensed nurse, Employee E33 confirmed that Resident R2 had the incorrect catheter size.

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



 Plan of Correction - To be completed: 04/29/2024

1.R2 resident foley number was noted and placed on order to be changed monthly as ordered.
2.Unit/Manager/Designee will audit all residents with foley to assure the Foley catheter size and physicians orders are matching.
3.Staff Educator/Designee will Inservice licensed nurses on ensuring resident returning from appointments and hospital stay have the right size foley ordered.
4.DON/Designee will do random audits weekly x4 then monthly x2 to ensure foley catheter size and orders match.
5.Audit results will be reported at QAPI meetings for further review and recommendations monthly x2.

483.20(g) REQUIREMENT Accuracy of Assessments:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on clinical record review and interviews with staff, it was determined that the facility failed to accurately complete a resident assessment related to resident identification information for one of 36 residents reviewed (Resident R203).

Findings include:

Review of Resident R203's admission Minimum Data Set (MDS- assessment of resident care needs) dated January 17, 2023; modification of admission MDS, dated August 3, 2023; and quarterly MDS dated January 3, 2024, revealed that the resident's social security number was inaccurately documented on the Quarterly MDS, dated January 3, 2024, which resulted in Resident R203's MDS record being over 120 days old.

Interview with the Nursing Home Administrator, Employee E1, conducted on March 8, 2024, at 3:30 p.m. confirmed that the MDS identification information, dated January 3, 2024, for Resident R203 was coded inaccurately.

28 Pa. Code 201.14(a) Responsibility of licensee

2 Pa. Code 211.5(f) Medical records



 Plan of Correction - To be completed: 03/08/2024

I hereby acknowledge the CMS 2567-A, issued to ST. JOHN NEUMANN CENTER FOR REHABILITATION & HEALTHCARE for the survey ending 03/08/2024, AND attest that all deficiencies listed on the form will be corrected in a timely manner.
201.19(8) LICENSURE Personnel policies and procedures.:State only Deficiency.
(8) A copy of the final report received from the Pennsylvania State Police and the Federal Bureau of Investigation, as applicable, in accordance with the Older Adults Protective Services Act (35 P. S. 10225.101-10225.5102), the Adult Protective Services Act (35 P.S. 10210.101-10210.704), and applicable regulations.

Observations:

Based on review of employee personnel records and staff interview, it was determined that the facility failed to maintain required information for six of six employee records (Employee E25, E26, E27, E28, E29 and E30)

Findings include:

Review of facility documentation of newly hired staff revealed that the following employees were hired on January 4, 2023:

Employee E25 - Dietary Aide
Employee E26 - LPN
Employee E27 - RN
Employee E28 - Social Worker

Review of facility documentation of newly hired staff revealed that the following employees were hired on January 23, 2023:

Employee E29 - Housekeeper
Emplopyee E30 - CNA

None of the above employee files contained any documentation that would indicate a Pennsylvania State Police criminal background check was completed.

During an interview on March 8, 2024, at 12:25 p.m. with Nursing Home Administrator and Director of Nursing it was confirmed that the facility failed to complete a Pennsylvania State Police criminal background check, and that the facility was using a private company to perform background checks.






 Plan of Correction - To be completed: 04/29/2024

1.The facility is set up and initiated background checks to be completed by Pennsylvania State Police criminal background check for all new employees hired.
2.The NHA/designee will complete 5 random personal file audits weekly x 4 and then monthly x2 to assure background checks are completed By PA State police.
3.Audit results will be reported at QAPI meetings for further review and recommendations monthly x2.


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