Pennsylvania Department of Health
EMBASSY OF SAXONBURG
Patient Care Inspection Results

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EMBASSY OF SAXONBURG
Inspection Results For:

There are  102 surveys for this facility. Please select a date to view the survey results.

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EMBASSY OF SAXONBURG - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint, on March 18, 2024, it was determined that Embassy of Saxonburg 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 for the Health portion of the survey process.


 Plan of Correction:


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:

Based on clinical record review and staff interview, it was determined the facility failed to notify the physician of a change in condition for twelve of nineteen residents testing positive for Covid-19 (Resident R1, R2, R5, R7, R8, R10, R11, R12, R16, R17, R18, R19).

Findings include:

Review of the facility policy "Notification of Changes" last reviewed 2/15/23, indicate the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include but not exclusive to circumstances that require a need to alter treatment, significant change in the resident's physical, mental or psychosocial condition.

Review of Resident R1's clinical record indicated admission to facility on 9/11/20, with the diagnosis of Lymphoma (form of cancer), diabetes (high blood sugar levels) edema (swelling).

Review of facility covid line listing indicated Resident R1 tested positive for COVID-19 on 2/21/24.

Review of Resident R1's progress notes did not include information on physician notification of COVID-19 testing results.

Review of Resident R2's clinical record indicate admission to facility on 12/23/23, with the diagnosis of diabetes, Parkinson's disease (degenerative neurological disorder), hypertension (high blood pressure).

Review of facility covid line listing indicated Resident R2 tested positive for COVID-19 on 2/24/24.

Review of Resident R2's progress notes did not include information on physician notification of COVID-19 testing results.

Review of Resident R5's clinical record indicate admission to facility on 1/16/24, with the diagnosis of fracture of left femur (thigh bone), multiple sclerosis (autoimmune disease), dysphagia (difficulty swallowing).

Review of facility covid line listing indicated Resident R5 tested positive for COVID-19 on 2/16/24.

Review of Resident R5's progress notes did not include information on physician notification of COVID-19 testing results.

Review of Resident R7's clinical record indicate admission to facility on 1/12/24, with diagnosis of dementia (loss of memory), muscle weakness, gastro-esophageal reflux disease (GERD- stomach acid flows backwards).

Review of facility covid line listing indicated Resident R7 tested positive for COVID-19 on 2/16/24.

Review of Resident R7's progress notes did not include information on physician notification of COVID-19 testing results.

Review of Resident R8's clinical record indicated admission to facility on 3/3/23, with diagnosis of aphasia (loss of ability to understand or express speech), cerebral infarction (stroke), ataxia (loss of body movements).

Review of facility covid line listing indicated Resident R8 tested positive for COVID-19 on 2/22/24.

Review of Resident R8's progress notes did not include information on physician notification of COVID-19 testing results.

Review of Resident R10's clinical record indicated admission to facility on 12/25/29, with diagnosis of cerebral infarction (stroke), diabetes, aphasia (loss of ability to understand or express speech).

Review of facility covid line listing indicated Resident R10 tested positive for COVID-19 on 2/16/24.

Review of Resident R10's progress notes did not include information on physician notification of COVID-19 testing results.

Review of Resident R11's clinical record indicated admission to facility on 1/22/24, with diagnosis of diabetes, dysphagia, hypertension.

Review of facility covid line listing indicated Resident R11 tested positive for COVID-19 on 2/16/24.

Review of Resident R11's progress notes did not include information on physician notification of COVID-19 testing results.

Review of Resident R12's clinical record indicated admission to facility on 2/7/24, with diagnosis of atrial fibrillation (A-fib rapid irregular heartbeat), weakness.

Review of facility covid line listing indicated Resident R12 tested positive for COVID-19 on 2/16/24.

Review of Resident R12's progress notes did not include information on physician notification of COVID-19 testing results.

Review of Resident R16's clinical record indicated admission to facility on 8/24/22, with diagnosis of emphysema (lungs are damaged), neutropenia (low white blood cells), gastritis (inflammation of the stomach).

Review of facility covid line listing indicated Resident R16 tested positive for COVID-19 on 2/16/24.

Review of Resident R16's progress notes did not include information on physician notification of COVID-19 testing results.

Review of Resident R17's clinical record indicated admission to facility on 12/18/23, with diagnosis of diabetes, muscle weakness, hyperlipidemia (high fat in blood).

Review of facility covid line listing indicated Resident R17 tested positive for COVID-19 on 2/16/24.

Review of Resident R17's progress notes did not include information on physician notification of COVID-19 testing results.

Review of Resident R18's clinical record indicated admission to facility on 8/22/23, with diagnosis of multiple rib fractures, hyperlipidemia, hypertension.

Review of facility covid line listing indicated Resident R18 tested positive for COVID-19 on 2/18/24.

Review of Resident R18's progress notes did not include information on physician notification of COVID-19 testing results.

Review of Resident R19's clinical record indicated admission to facility on 2/13/24, with diagnosis of intercranial injury (injury of brain), GERD, hyperlipidemia.

Review of facility covid line listing indicated Resident R19 tested positive for COVID-19 on 2/18/24.

Review of Resident R19's progress notes did not include information on physician notification of COVID-19 testing results.

Interview on 3/18/24, at 2:14 p.m. the Nursing Home Administrator confirmed the facility failed to notify the physician of a change in condition for twelve of nineteen residents testing positive for COVID-19. (Resident R1, R2, R5, R7, R8, R10, R11, R12, R16, R17, R18, R19).

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

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


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

- Doctor was notified of all affected residents R1, R2, R5,R7,R8,R10,R11,R12,R16,R17,R18,R19 and their COVID-19 positive status from outbreak.
- An audit was completed of all like residents to ensure all doctor notifications were complete for residents affected by the outbreak.
- Licensed nurses and Infection Preventionist will be re-educated by DON or designee on policy for notification of any changes in condition to physician.
- All residents will be audited twice weekly for 2 weeks then weekly going forward, for any changes in condition and notification to physician being completed. Any resident that has a change in condition, will have a proper note and documentation of change with physician notification.


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on clinical record review and staff interview, it was determined the facility failed to obtain physician orders for transmission-based precautions for three of nineteen residents (Resident R1, R5, R8).

Findings include:

Review of the facility policy "Infection Prevention and Control Program" revised 8/1/23, indicates the facility has established and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines. Isolation protocol includes but not exclusive to:
- resident with an infection or communicable disease shall be placed on transmission-based precaution as recommended by current CDC guidelines.

Review of Resident R1's clinical record indicated admission to facility on 9/11/20, with the diagnosis of Lymphoma (form of cancer), diabetes (high blood sugar levels) edema (swelling).

Review of facility covid line listing indicated Resident R1 tested positive for COVID-19 on 2/21/24.

Review of Residents R1's physician orders did not include interventions for transmission-based precautions.

Review of Resident R5's clinical record indicate admission to facility on 1/16/24, with the diagnosis of fracture of left femur (thigh bone), multiple sclerosis (autoimmune disease), dysphagia (difficulty swallowing).

Review of facility covid line listing indicated Resident R5 tested positive for COVID-19 on 2/16/24.

Review of Residents R5's physician orders did not include interventions for transmission-based precautions.

Review of Resident R8's clinical record indicated admission to facility on 3/3/23, with diagnosis of aphasia (loss of ability to understand or express speech), cerebral infarction (stroke), ataxia (loss of body movements).

Review of facility covid line listing indicated Resident R8 tested positive for COVID-19 on 2/22/24.

Review of Residents R8's physician orders did not include interventions for transmission -based precautions.

Interview on 3/18/24, at 2:14 p.m. the Nursing Home Administrator confirmed the facility failed to obtain physician orders/interventions for transmission-based precautions for three of nineteen residents (Resident R1, R5, R8).

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

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


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

- No other residents were affected by this except the residents identified in the line listing kept during outbreak that did not have an order for isolation
- Licensed Nurses and Infection Preventionist will be re-educated by DON or designee on physician orders being in place for any resident needing isolation precautions for any type of required infection
- All residents with infections will be monitored twice weekly for 2 weeks, then weekly going forward, to ensure proper isolation precaution orders are in place.

Results will be reviewed in facility QAPI process

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:

Findings include:

Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide a minimum of one Nurse Aide (NA) per 12 residents on four days out of twenty-one days on the evening shift (2/26/24, 3/5/24, 3/6/24, and 3/11/24).

Review of facility census data indicated that on 2/26/24, the facility census was 58, which required five NA's during the evening shift.

Review of nursing time schedules and deployment sheets revealed four NA's provided care on evenings. No additional excess higher-level staff were documented as providing compensation.

Review of facility census data indicated that on 3/5/24, the facility census was 57, which required five NA's during the evening shift.

Review of nursing time schedules and deployment sheets revealed four NA's provided care on evening shift. No additional excess higher-level staff were documented as providing compensation.

Review of facility census data indicated that on 3/6/24, the facility census was 57, which required five NA's during the evening shift.

Review of nursing time schedules and deployment sheets revealed four NA's provided care on evening shift. No additional excess higher-level staff were documented as providing compensation.

Review of facility census data indicated that on 3/11/24, the facility census was 56, which required five NA's during the evening shift.

Review of nursing time schedules and deployment sheets revealed four NA's provided care on evenings. No additional excess higher-level staff were documented as providing compensation.

Interview with 3/18/24, at 2:14 p.m. Nursing Home Administrator confirmed facility administrative staff failed to provide a minimum of one nurse aide per twelve residents on the evening shift on four of 21 days reviewed: 2/26/24, 3/5/24, 3/6/24, and 3/11/24.



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

o Nurse supervisors, scheduler, ADON and DON will be re-educated by NHA or designee on staffing ratios per shift for CNAs
o A daily audit will be completed daily for 2 weeks and weekly thereafter by our DON or designee, of our labor meetings to review staffing and ensure ratios are being met. Meeting notes will be logged daily. Should there be call offs, proper means of filling the shifts will be carried out. Agency and in house staff will be utilized to cover any open holes/call offs so that shifts are properly filled and staffed.

Results will be reviewed in facility QAPI process

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:

Findings include:

Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse per 25 residents during the daylight shift, on one of twenty-one days (2/25/23) and failed to provide a minimum off one licensed practical nurse per 30 residents on the evening shift on one of twenty one days (3/17/24).

Review of facility census data indicated that on 2/24/24, the facility census was 57, which required three licensed practical nurses (LPN) during the daylight shift.

Review of nursing time schedules and deployment sheets revealed two licensed practical nurses (LPN) provided care.

Review of facility census data indicated that on 3/17/24, the facility census was 57, which required two licensed practical nurses (LPN) during the evening shift.

Review of nursing time schedules and deployment sheets revealed two licensed practical nurses splitting the scheduled from 2:00 p.m. to 6:00 p.m. and 6:00 p.m. to 10:00 p.m. providing care.

During an interview on 3/18/24, at 2:14 p.m. the Nursing Home Administrator confirmed that the facility failed to provide a minimum of one licensed practical nurse per 25 residents during the daylight shift, on one of twenty-one days (7/16/23) and failed to provide a minimum of one LPN per 30 residents on the evening shift on one of 21 days.



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

o Nurse supervisors, scheduler, ADON and DON will be re-educated by NHA or designee on staffing ratios per shift for LPNs
o A daily audit will be completed daily for 2 weeks and weekly thereafter by our DON or designee, of our labor meetings to review staffing and ensure ratios are being met. Meeting notes will be logged daily. Should there be call offs, proper means of filling the shifts will be carried out. Agency and in house staff will be utilized to cover any open holes/call offs so that shifts are properly filled and staffed.

Results will be reviewed in facility QAPI process


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