Pennsylvania Department of Health
GARDEN SPRING NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GARDEN SPRING NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 214 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


GARDEN SPRING NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated survey in response to two complaints completed on August 8, 2024, it was determined that Garden Spring Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of five sampled residents. (Resident 1)

Findings include:

Clinical record review revealed that Resident 1 had diagnoses that included gastroesophageal reflux disease (acid reflux), pain, and neuropathy (nerve damage). Physician's orders dated July 26, 2024, directed staff to administer Acetaminophen (a medication for pain) and gabapentin (a medication for nerve pain) at 6:00 a.m. daily. A physician's order dated July 27, 2024, directed staff to administer omeprazole (a medication to treat acid reflux) at 6:00 a.m. daily. There was no evidence that the medications were offered or administered on August 7, 2024, per the physician's orders.

In an interview on August 8, 2024, at 2:07 p.m., the Director of Nursing confirmed there was no evidence that the medications were administered per the physician's orders.

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

Plan of Correction - To be completed: 09/03/2024

1. Resident 1 had no adverse effects. MD was notified and no new orders were obtained.
2. Full house missed meds audit completed on 8/14/2024
3. House education to RN and LPN staff will be completed by 8/24/24 on ensuring that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan and the residents choice. In the event of electronic software being down, paper medical administration records and treatment administration records will be available on each nurses station.
4. Systematic audits to be conducted weekly for 4 weeks and then monthly for 3 months and brought to QA&A committee for review and recommendations.
5. Facility compliance date 9/03/2024

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More:

§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 facility policy review, observation, and staff interview, it was determined that the facility failed to maintain a medication error rate of less than five percent (%) on one of five nursing units. (Section 2)

Findings include:

A review of the facility policy entitled, "Administering Medications," last reviewed September 2023, revealed that Medications were to be administered in accordance with the prescriber's orders, which included any required timeframe. Medications were to be administered within one hour of their prescribed time.

Clinical record review revealed that Resident 2 had diagnoses that included major depressive disorder and multiple sclerosis. A review of physician's orders dated June 29, 2018, June 9, 2021, March 28, 2023, and August 5, 2024, revealed that staff were to administer the following medications at 8:00 a.m. daily: vitamin D3 1000 international units (IU), Zeposia 0.92 milligrams (mg), escitalopram 20 mg, and Bactrim 160 mg. Observation of the medication pass on August 8, 2024, revealed that licensed practical nurse (LPN) 1 did not administer the medications until 9:30 a.m.

Clinical record review revealed that Resident 3 had diagnoses that included depression, allergies, hypertension (high blood pressure), and pain. A review of physician's orders dated April 12, 2024, April 24, 2024, May 16, 2024, July 11, 2024, July 16, 2024, and July 30, 2024, revealed that staff were to administer the following medications at 8:00 a.m. daily: cholecalciferol (vitamin D) 50 micrograms (mcg), bupropion (a medication for depression) 300 mg , lidocaine patch 4 % to the right knee, fluticasone propionate (a medication for allergies) 50 mcg, sertraline (a medication for depression) 75 mg, and lisinopril (a medication for high blood pressure) 5 mg. Observation of the medication pass on August 8, 2024, revealed that LPN 1 did not administer the medications until 9:40 a.m.

Observation during the medication pass on August 8, 2024, from 9:30 a.m. to 9:40 a.m., revealed 28 opportunities with 10 errors which resulted in a medication error rate of 35.7%.

In an interview on August 8, 2024, at 2:10 p.m., the Director of Nursing confirmed that the medications should have been adminstered by 9:00 a.m.

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

Plan of Correction - To be completed: 09/03/2024

1. Resident 2 and 3 had no adverse reaction, MD notified and no new orders were obtained.
2. Full house audits of late meds completed on 8/14/2024.
3. House education to RN and LPN staff will be completed by 8/24/24 on ensuring that medication be given timely based on physician order.
4. Systematic audits to be conducted weekly for 4 weeks and then monthly for 3 months and brought to QA&A committee for review and recommendations.
5. Facility compliance date 9/03/2024.

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