Pennsylvania Department of Health
LOCK HAVEN REHABILITATION AND SENIOR LIVING
Patient Care Inspection Results

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LOCK HAVEN REHABILITATION AND SENIOR LIVING
Inspection Results For:

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LOCK HAVEN REHABILITATION AND SENIOR LIVING - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to four Complaints, completed on March 26, 2024, it was determined that Lock Haven Rehabilitation and Senior Living 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.



 Plan of Correction:


483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:

Based on review of clinical records and resident and staff interview, it was determined that the facility failed to ensure accurate and complete clinical documentation for three of 17 residents reviewed (Residents 2, 8, and 10).

Findings include:

Interview with Resident 8, on March 26, 2024, at 9:15 AM revealed that she continues to have issues with staff not "washing her up" in the mornings. Resident 8 indicated that she is incontinent overnight, and that nursing staff will not wash her properly in the morning but only hand her a washcloth and tell her to wash her face, then dress her. Resident 8 indicated that it happened this morning and keeps happening.

Review of a grievance filed February 20, 2024, indicated that Resident 8 was not "washed" and that the nurse only dressed her. A grievance filed on March 19, 2024, again indicated that Resident 8 "laid in piss all night" and that she was not washed up this morning and that it "has been happening all week."

Review of Resident 8's clinical record revealed no documented evidence to indicate that AM care (morning care provided to get them ready for the day) is being provided. Morning care can include bathing, dressing, brushing teeth, etc. There was no documented evidence in Resident 8's clinical record to indicate that the facility made any changes to her plan of care to ensure that AM care was being provided.

Review of Resident 2's clinical record revealed a nursing intervention for Resident 2 to receive a weekly shower on Tuesdays. Review of Resident 2's shower completions from February 27, 2024, to March 26, 2024, revealed two showers were documented as "not applicable" and two showers were marked as "no." There was no documented evidence to indicate that Resident 2 received a shower in the last month.

Review of Resident 10's clinical record revealed a nursing intervention for nursing staff to complete a shower every Tuesday. Review of Resident 10's shower completions from February 29, 2024, to March 26, 2024, revealed no documented evidence to indicate nursing staff completed a shower for her.

Interview with the Administrator and Employee 4, assistant director of nursing, on March 26, 2024, at 2:30 PM confirmed the above findings.

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


 Plan of Correction - To be completed: 04/30/2024

The nursing assistant documentation of activities of daily living care to be provided for resident's 2, 8, and 10 have been reviewed and updated to ensure proper documentation by the nursing staff.

All residents have the potential to be affected.

Nursing assistant documentation for all residents will be reviewed and updated as necessary to ensure shower/bath, and other activities of daily living care provided, is able to be properly documented in the electronic health record.

All nursing staff will be reeducated regarding providing and documenting resident specific activities of daily living, including shower/bath.

Resident grievances are reviewed at daily interdisciplinary team meeting and passed on the appropriate department for follow up and resolution. Grievance forms are then returned to the Grievance Officer to ensure the issue had been resolved.

Director of Nursing or designee will audit eight randomly selected resident records weekly x 4, then monthly x 3, for completion of documentation of activities of daily living care provided.

483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program: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.
483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.
Observations:

Based on observation, review of pest control logs, and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program on one of three nursing units (Unit Three, Residents 1 and 3).

Findings include:

Interview with Resident 1 on March 26, 2024, at 9:30 AM revealed that he sees mice come in his room all the time. Resident 1 indicated that the mice enter his room from the hallway.

Interview with Employee 1, licensed practical nurse, on March 26, 2024, at 9:40 AM confirmed that staff are seeing mice on Unit Three "all the time" and mostly "at night."

Review of the facility's pest control logs revealed that a contracted company is coming in monthly. The pest control being completed monthly is spraying the baseboards in the kitchen and basement and placing exterior bait stations. There was no evidence to indicate that the pest control company was providing interior pest control to eradicate mice.

Interview with Employee 2, director of maintenance, on March 26, 2024, at 10:00 AM confirmed that the facility has not spoken to the pest control company regarding the mice problem inside the building. Review of a handwritten "log" revealed how many traps the facility placed and how many mice were "caught." Since February 13, 2024, the facility placed 28 traps, and have caught seven mice, mainly on Unit Three. Employee 2 confirmed that the mice problem continues to be an issue and has not contacted the pest control company for advice.

A grievance filed February 19, 2024, revealed that Resident 3's room contained "many fruit flies." The grievance indicated that the room "was treated for fruit flies." Prior to the surveyors questioning, there was no documented evidence to indicate when the room was treated, who treated the room, what product was used to treat the room, or follow up to ensure the treatment worked. Interview with Employee 3, environmental services director, on March 26, 2024, at 1:35 PM confirmed this information.

28 Pa. Code 201.14(a) Responsibility of licensee

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


 Plan of Correction - To be completed: 04/30/2024

A tamper proof rodent bait station was placed in the room of resident 1 and the room of resident 3 was checked to ensure there was no longer a concern regarding fruit flies.

All residents have the potential to be affected.

A representative of the pest control company visited the facility, reviewed the log of where mice had been seen recently, and installed tamper proof bait stations in those areas.

A log has been developed for documenting any concerns regarding pests, what action was taken by facility staff to address the concern, and the resolution of the concern. The log will be reviewed monthly by a representative from the pest control company to look for patterns and provide alternative treatments for any ongoing concerns.

The Administrator or designee will audit the logbook to ensure concerns are being addressed weekly x 4, then monthly x 3 months. Results of the audits will be submitted to the Quality Assurance Committee.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
483.12(b) The facility must develop and implement written policies and procedures that:

483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

483.12(b)(3) Include training as required at paragraph 483.95,

483.12(b)(4) Establish coordination with the QAPI program required under 483.75.

483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.
Observations:

Based on review of select policies and procedures and staff interview, it was determined that the facility failed to implement their abuse policy regarding reporting to the proper state agencies for misappropriation of resident property for five of 17 residents reviewed (Residents CR1, 4, 5, 6 and 7).

Findings include:

The policy entitled "Abuse," last reviewed on July 6, 2023, indicates that the facility will ensure that all alleged violations involving misappropriation of resident property are reported immediately to the state survey and certification agency. Further reporting to law enforcement agencies will be initiated for misappropriation of resident funds and/or property.

Interview with Employee 4, assistant director of nursing, on March 26, 2024, at 8:45 AM confirmed that the facility just recently investigated an incident where a large number of narcotics went missing.

Review of the facility's investigation indicated that on February 19, 2024, it was noted that 60 tablets of Resident 7's hydrocodone/acetaminophen (a narcotic pain reliever) and 60 tablets of Resident 4's Oxycodone (a narcotic pain reliever) was missing from the medication carts. On February 20, 2024, it was noted that Resident 5 had 120 tablets of Oxycodone missing from the medication cart. Further investigation revealed that Resident CR1 and Resident 6 were both was missing 60 tablets of Oxycodone. In total, the facility determined that 360 tablets of narcotic pain relievers went missing.

There was no documented evidence in the facility's investigation to indicate that the Pennsylvania Department of Health was notified of the misappropriation of narcotics for Resident CR1, 4, 5, 6, and 7. The facility also did not notify local law enforcement until February 22, 2024, three days after the initial discovery of missing narcotics.

Interview with the Administrator and Employee 4 on March 26, 2024, at 2:00 PM revealed that since the missing narcotics were replaced, the facility felt that they did not have report the incident to the Pennsylvania Department of Health.

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

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


 Plan of Correction - To be completed: 04/30/2024

The corrections set forth in this document do not constitute admission or agreement by the provider of the true facts alleged, or the conclusions set forth, in the statement of deficiencies. The plan of correction is prepared solely because it is required by provisions of Federal and State law.

The missing medications for Residents CR1, 4, 5, 6, and 7 were replaced at no cost to the resident.

All residents have the potential to be affected.

The procedure for shift-to-shift narcotic counting has been updated and implemented to ensure an accurate count for all resident's narcotics.

A report of misappropriation of narcotics was submitted to the PA Department of Health.

Nursing administration will be reeducated regarding the proper reporting of possible misappropriation of resident's personal belongings or medications to the PA Department of Health, local law enforcement, and the Area Office of Aging.

Resident Incident Reports are reviewed at the morning Interdepartmental Team Meeting to ensure any potential misappropriation is investigated and, if appropriate, properly reported.

The Administrator or designee will audit the Resident Incident Reports weekly x 4, then monthly x 3, to ensure any misappropriation has been properly reported. Results of the audits will be submitted to the Quality Assurance Committee.

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 staffing hours and staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents during the day and evening shifts for 17 of the 21 days reviewed and one nurse aide per 20 residents during the night shifts for eight of the 21 days reviewed.

Findings include:

A review of nursing care hours provided by the facility from February 25, 2024, through March 16, 2024, revealed the following on the day shift:

March 2, 2024, census of 139 with 11.10 NAs, required 11.58 NAs
March 10, 2024, census of 139 with 11 NAs, required 11.58 NAs

A review of nursing care hours provided by the facility from February 25, 2024, through March 16, 2024, revealed the following on the evening shift:

February 25, 2024, census of 138 with 10.80 NAs, required 11.50 NAs
February 26, 2024, census of 139 with 10.70 NAs, required 11.58 NAs
February 27, 2024, census of 137 with 10.75 NAs, required 11.42 NAs
February 28, 2024, census of 139 with 10.63 NAs, required 11.58 NAs
February 29, 2024, census of 139 with 11.50 NAs, required 11.58 NAs
March 1, 2024, census of 139 with 11 NAs, required 11.58 NAs
March 2, 2024, census of 139 with 11.30 NAs, required 11.58 NAs
March 3, 2024, census of 139 with 10.30 NAs, required 11.58 NAs
March 4, 2024, census of 139 with 11 NAs, required 11.58 NAs
March 5, 2024, census of 139 with 11.40 NAs, required 11.58 NAs
March 6, 2024, census of 138 with 10.75 NAs, required 11.50 NAs
March 7, 2024, census of 138 with 11.25 NAs, required 11.50 NAs
March 8, 2024, census of 140 with 10.75 NAs, required 11.67 NAs
March 9, 2024, census of 139 with 10.50 NAs, required 11.58 NAs
March 12, 2024, census of 135 with 10 NAs, required 11.25 NAs
March 13, 2024, census of 135 with 10 NAs, required 11.25 NAs

A review of nursing care hours provided by the facility from February 25, 2024, through March 16, 2024, revealed the following on the night shift:

February 26, 2024, census of 139 with 6 NAs, required 6.95 NAs
February 27, 2024, census of 137 with 6 NAs, required 6.85 NAs
February 29, 2024, census of 139 with 5.50 NAs, required 6.95 NAs
March 3, 2024, census of 139 with 6.60 NAs, required 6.95 NAs
March 4, 2024, census of 139 with 6 NAs, required 6.95 NAs
March 5, 2024, census of 139 with 6 NAs, required 6.95 NAs
March 8, 2024, census of 140 with 6 NAs, required 7 NAs
March 11, 2024, census of 135 with 6 NAs, required 6.75 NAs

Interview with the Administrator on March 26, 2024, at 2:15 PM confirmed the above findings.


 Plan of Correction - To be completed: 04/30/2024

Administrative, nursing leadership and nursing scheduler meet daily to review future schedules, troubleshoot areas of concern and discuss possible solutions for any days/shifts that do not meet the required staffing ratios.

Schedule adjustments will be made as needed via schedule changes, utilizing temporary agency staff, offering bonuses, and utilizing administrative nursing staff.

Facility Administration will meet weekly via phone with the Regional Administrator and Corporate HR Director to review recent hires, terminations and employee recruitment efforts and plan future recruitment and retention events.

The Director of Nursing or designee will in-service the Nursing Scheduler and Nursing Supervisors on the staffing scheduling tool and the need to maintain staffing ratios each shift.

The Administrator or designee will audit the staffing schedule daily to ensure there are adequate staffing ratios weekly x 4, The Administrator or designee will audit the staffing schedule daily to ensure there are adequate staffing ratios weekly x 4, then monthly x 3 months. Results of the audits will be submitted to the Quality Assurance Committee

211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift for 11 of the 21 days reviewed and one LPN per 30 residents during the evening shift for 11 of the 21 days reviewed.

Findings include:

A review of nursing care hours provided by the facility from February 25, 2024, through March 16, 2024, revealed the following on the day shift:

February 25, 2024, census of 138 with 5.20 LPNs, required 5.52 LPNs
February 26, 2024, census of 139 with 5.50 LPNs, required 5.56 LPNs
February 28, 2024, census of 139 with 5.50 LPNs, required 5.56 LPNs
February 29, 2024, census of 139 with 5.50 LPNs, required 5.56 LPNs
March 1, 2024, census of 139 with 4.50 LPNs, required 5.56 LPNs
March 2, 2024, census of 139 with 5.40 LPNs, required 5.56 LPNs
March 3, 2024, census of 139 with 5.30 LPNs, required 5.56 LPNs
March 5, 2024, census of 139 with 5.30 LPNs, required 5.56 LPNs
March 8, 2024, census of 140 with 5.00 LPNs, required 5.60 LPNs
March 9, 2024, census of 139 with 5.30 LPNs, required 5.56 LPNs
March 11, 2024, census of 135 with 5 LPNs, required 5.40 LPNs

A review of nursing care hours provided by the facility from February 25, 2024, through March 16, 2024, revealed the following on the evening shift:

February 26, 2024, census of 139 with 4.20 LPNs, required 4.63 LPNs
February 29, 2024, census of 139 with 4.00 LPNs, required 4.63 LPNs
March 1, 2024, census of 139 with 4.00 LPNs, required 4.63 LPNs
March 2, 2024, census of 139 with 4.30 LPNs, required 4.63 LPNs
March 7, 2024, census of 138 with 4 LPNs, required 4.60 LPNs
March 8, 2024, census of 140 with 4.50 LPNs, required 4.67 LPNs
March 9, 2024, census of 139 with 4.20 LPNs, required 4.63 LPNs
March 11, 2024, census of 135 with 4 LPNs, required 4.50 LPNs
March 12, 2024, census of 135 with 4.30 LPNs, required 4.50 LPNs
March 15, 2024, census of 134 with 4 LPNs, required 4.47 LPNs
March 16, 2024, census of 132 with 4 LPNs, required 4.40 LPNs

Interview with the Administrator on March 26, 2024, at 2: 15 PM confirmed the above findings.


 Plan of Correction - To be completed: 04/30/2024

Administrative, nursing leadership and nursing scheduler meet daily to review future schedules, troubleshoot areas of concern and discuss possible solutions for any days/shifts that do not meet the required staffing ratios.

Schedule adjustments will be made as needed via schedule changes, utilizing temporary agency staff, offering bonuses, and utilizing administrative nursing staff.

Facility Administration will meet weekly via phone with the Regional Administrator and Corporate HR Director to review recent hires, terminations and employee recruitment efforts and plan future recruitment and retention events.

The Director of Nursing or designee will in-service the Nursing Scheduler and Nursing Supervisors on the staffing scheduling tool and the need to maintain staffing ratios each shift.

The Administrator or designee will audit the staffing schedule daily to ensure there are adequate staffing ratios weekly x 4, The Administrator or designee will audit the staffing schedule daily to ensure there are adequate staffing ratios weekly x 4, then monthly x 3 months. Results of the audits will be submitted to the Quality Assurance Committee

211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure the total of nursing care hours provided in each 24-hour period was a minimum of 2.87 hours per patient day (PPD), effective July 1, 2023, for four of 21 days reviewed.

Findings include:

Review of nursing staff care hours for February 25, 2024, through March 16, 2024, revealed that the facility failed to meet the minimum hours per patient day for the following days:

February 25, 2024, 2.78 hours PPD
March 2, 2024, 2.75 hours PPD
March 3, 2024, 2.75 hours PPD
March 9, 2024, 2.80 hours PPD

It is noted that each of the dates listed above is staffing for a weekend shift.

Interview with the Administrator on March 26, 2024, at 2:15 PM confirmed the above findings.


 Plan of Correction - To be completed: 04/30/2024

Administrative, nursing leadership and nursing scheduler meet daily to review future schedules, troubleshoot areas of concern and discuss possible solutions for any days/shifts that do not meet the required total hours of nursing care provided in a 24 period.

Schedule adjustments will be made as needed via schedule changes, utilizing temporary agency staff, offering bonuses, and utilizing administrative nursing staff.

Facility Administration will meet weekly via phone with the Regional Administrator and Corporate HR Director to review recent hires, terminations and employee recruitment efforts and plan future recruitment and retention events.

The Director of Nursing or designee will in-service the Nursing Scheduler and Nursing Supervisors on the staffing scheduling tool and the need to maintain total hours of nursing care provided in a 24 period.

The Administrator or designee will audit the staffing schedule daily to ensure there are the required total hours of nursing care provided in a 24-hour period weekly x 4, then monthly x 3 months. Results of the audits will be submitted to the Quality Assurance Committee


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