Pennsylvania Department of Health
INNERS CREEK SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

INNERS CREEK SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 141 surveys for this facility. Please select a date to view the survey results.

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INNERS CREEK SKILLED NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Findings of an abbreviated complaint survey completed on March 7, 2024, at Inners Creek Skilled Nursing And Rehabilitation Center identified that the facility 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.

Plan of Correction:

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 observation, review of facility policy, and staff interview it was determined that the facility failed to provide food and beverage that were at a safe and appetizing temperature for one of one meal observed on the short-stay rehabilitation unit.

Findings include:

Food and Nutrition Services Policies and Procedures Food service Quality Indicators Policy, revised May 1, 2023, read, in part, foods are served at temperatures appropriate for food safety and palatability.

Review of the Food and Nutrition Services Test Tray evaluation form, revised May 1, 2023, documented that hot entrstarches ,vegetables and hot beverages should be greater than 140 degrees Fahrenheit, milk should be at or below 45 degrees Fahrenheit, and cold beverages and desserts should be at or below 55 degrees Fahrenheit.

Review of the Resident Council meeting minutes for January and February 2024, revealed ongoing concerns with the quality and the temperature of food during mealtimes.

A test tray was completed on March 6, 2024, on the short-stay rehabilitation unit. Test tray temperatures were taken by Registered Dietitian (RD) on March 6, 2024, at 12:35 PM, and revealed the following:
Chicken breast - 139 degrees Fahrenheit, not acceptable temperature
Mashed potatoes - 138 degrees Fahrenheit, not acceptable temperature
Mixed vegetables - 129 degrees Fahrenheit, not acceptable temperature
Ambrosia - 55 degrees Fahrenheit, palatable
Orange juice - 55 degrees Fahrenheit, palatable
Coffee - 124 degrees Fahrenheit, not acceptable temperature (coffee temperature tested in the kitchen during tray line service at 12:45 PM).

During an interview with Employee 1 (Registered Dietitian (RD)) on March 6, 2024, at 12:40 PM and 1:30 PM it was revealed that the hot foods should be warmer and the cold items cooler.

Observation in the kitchen on March 6, 2024, at 12:45 PM revealed the lunch meal was being served off the tray line. The middle well on the steam table was not functioning, and was utilized to hold the chicken during meal service.

During an interview with the Nursing Home Administrator on March 6, 2024, at approximately 3:30 PM, it was revealed that the food and beverage temperatures during the test tray weren't acceptable, and that maintenance was informed about the steamtable well that wasn't functioning and was in the process of repairing it.

28 Pa. Code 201.18(b)(1)(3) Management.
28 Pa. Code 201.14(a) Responsibility of licensee.

Plan of Correction - To be completed: 04/16/2024

1.) Facility cannot retroactively fix the food tray that was cited during the survey.

2.) The Maintenance Director repaired the steam well on 3/15/24 and checked to validate all steam wells were operating at optimal function. The Dining Services Manager/designee will reeducate the dining services team on the Food and Nutrition Services Policy and Procedure Food Service Quality Indicators Policy. The dining services manager/designee will also reeducate the dining services team on tray delivery times to ensure trays are delivered in a timely manner to uphold temperatures.

3.) The Dining Services Manager/designee will utilize the Food and Nutrition Services Test Tray evaluation form to test 5 trays per week for 4 weeks.

4.) Test Tray results will be reported to the Quality Assurance Performance Improvement Committee for further review and recommendation.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

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

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

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

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

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

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

Observations:

Based on clinical record review, and staff interviews it was determined that the facility failed to provide pharmaceutical services to assure the accurate acquiring, receiving, dispensing, and administration of drugs to meet the needs of each resident for one of 6 residents reviewed (Resident 4).

Findings include:

Review of Resident 4's clinical record revealed diagnoses that included: Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), hypertension (high blood pressure), and depression (feelings of severe despondency and dejection).

Further clinical record review revealed Resident 4 was admitted to the facility on February 20, 2024.

Review of Resident 4's physician orders, medication administration record and progress notes revealed the following medications weren't administered on the following dates and times: Carbidopa-Levodopa Oral Tablet 25-100 MG, 1 tablet by mouth four times a day (scheduled to be administered 7:30 AM, 11:30 AM, 4:30 PM, 9:30 PM and as needed) for Parkinson's, ordered on February 20, 2024, to start February 20, 2024. The medication was documented as administered on February 20, 2024 at 9:30 PM, however the subsequent dose on February 21, 2024 at 7:30 AM wasn't administered and was documented as pending pharmacy delivery; Carvedilol Oral Tablet 6.25 MG, 6.25 mg two times a day (scheduled to be administered 8:00 AM and 8:00 PM) for hypertension, ordered February 20, 2024, to start February 20, 2024. The medication was documented as not administered February 20, 2024, at 8:00 PM due to pending pharmacy delivery; and Mirtazapine Oral Tablet Disintegrating 15 mg by mouth one time a day (scheduled to be administered 8:00 PM) for depression, ordered on February 20, 2024, to start February 20, 2024. The medication was documented as not administered on February 20, 2024, at 8:00 PM due to pending pharmacy delivery.

Review of the facility's stocked medications in Omnicell (on-site automated system for medication storage and dispensing) revealed it included the following medications: Mirtazapine (medication used to treat depression) 7.5 milligrams (mg-unit of measure); carvedilol (medication use to treat hypertension) 3.125 mg; and carbidopa-levodopa (medication used to treat Parkinson's) 25-100mg tablet.

The facility failed to administer the aforementioned medications to Resident 4 that were available in the Omnicell.

During an interview with the Nursing Home Administrator on March 7, 2024, at 2:00 PM it was revealed that the aforementioned medications should have been administered to Resident 4 utilizing the Omnicell stock.

28 Pa. Code 211.9(1) Pharmacy services.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 04/16/2024

1.) Facility cannot retroactively fix the pharmacy delay for resident 4.

2.) Licensed staff are following the facility's guidelines and current residents are receiving ordered medication and notifying physicians if not available for guidance. A Comprehensive review of all new admissions within the last 30 days will be completed to ensure all medications were available and given.

3.) The Director of Nursing/designee will educate licensed staff on F-0755 Pharmacy Services, facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement. The Director of Nursing/designee will also educate licensed staff on the facility protocol of obtaining the medications through Omni cell or utilizing the 24 hour pharmacy service through the agreement with Omnicare.

4.) Director of Nursing/designee will audit new admissions weekly x4 to ensure they receive ordered medication and also to ensure they are available in a timely manner. Audit results will be reported to the Quality Assurance Performance Improvement Committee for further review and recommendation.

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