Pennsylvania Department of Health
WALLINGFORD 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

WALLINGFORD SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

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WALLINGFORD 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 February 20, 2024, at Wallingford Skilled Nursing and Rehabilitation identified deficient practice related to the reported complaint allegations under the 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 as they relate to the Health portion of the survey process.

Plan of Correction:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

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 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based on review of facility policy and facility documentation, and staff interview, it was determined that the facility failed to ensure one of three residents reviewed was free from abuse (Resident CL1).

Findings include:

Review of facility policy, "Abuse Prohibition," last reviewed October 24, 2022, revealed that "Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient property, and exploitation for all patients."

Review of Resident CL1's clinical record revealed the resident was admitted to the facility on January 10, 2024, with a diagnosis of lung cancer with metastasis to the brain and expired on January 23, 2024.

Review of Resident CL1's comprehensive Minimum Data Set (MDS - periodic assessment of resident care needs) dated January 16, 2024, revealed the resident's Brief Interview for Mental Status (BIMS) score was 13, indicating the resident was cognitively intact.

Review of Resident CL1's roommate's clinical record, Resident CL2, revealed a comprehensive MDS dated January 9, 2024, with a BIMS score of 15, indicating that the resident was cognitively intact. Further review of Resident CL2's clinical record revealed the resident was discharged home on January 26, 2024.

Review of information submitted by the facility revealed that on January 13, 2024, at approximately 2:00 a.m., Resident CL1 was attempting to call a family member. Licensed Nurses Employees E4 and E5 entered the room at the time. Employee E4 grabbed the phone from the resident and threw it against the nightstand, breaking it. Resident CL2 was awake at the time and witnessed the interaction.

Interview with Employee E6 on February 20, 2024, at approximately 1:00 p.m. revealed the employee was the Manager on Duty on January 13, 2024. Employee E6 revealed that Resident CL1's family member reported the incident to her after visiting the resident. Employee E6 and Licensed Nurse Employee E7 went to the residents' room and interviewed Residents CL1 and CL2 and noted that the resident's phone was broken. Employee E6 stated that Employees E4 and E5 were suspended on January 13, 2024, following the abuse allegations.

Further review of facility investigation revealed the phone was later fixed by Employee E8.

Review of witness statement from Resident CL1 from January 13, 2024, revealed: "Around 2:30 in the morning I was trying to make a phone call and a different nurse came in ...who grabbed by house phone from me slammed it on my table and told me I was not allowed to make calls at that time of the morning."

Review of witness statement from Resident CL2 from January 13, 2024, revealed: "Around 2am she (my roommate) tried to make a call and another ...nurse ...came in, snatched her phone and slammed it on the table and told her she wasn't allowed to call her sister."

Interview with the former Nursing Home Administrator (NHA), Employee E3, on February 20, 2024, at approximately 12:00 p.m. revealed licensed nurse Employee E4 was terminated on February 1, 2024, for not allowing Resident CL1 to call family and breaking the phone, and licensed nurse Employee E5 was terminated on February 1, 2024, for witnessing the interaction and not stopping it or reporting it.

Interview with the current NHA and Director of Nursing on February 20, 2024, at approximately 3:30 p.m. confirmed the above findings.

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

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

28 Pa. Code 211.10(c)(d) Resident care policies.

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

Plan of Correction - To be completed: 04/15/2024

Investigation initiated for resident CL1 allegation of abuse. Identified perpetrators were suspended during the investigation and later terminated based on the outcome.

All resident concerns, grievances and allegations of abuse/neglect will be reviewed at Morning Meeting for follow-up.

Staff will be re-educated on abuse policy and the reporting requirements.

Weekly audits of any allegations of abuse/neglect to be completed weekly for the next three months. QAPI committee will determine the need for further audits.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(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 review of nursing time schedules, it was determined that the facility administrative staff failed to provide a minimum of one nurse aide per 12 residents during the day, one nurse aide per 12 residents during the evening, and one nurse aide per 20 residents overnight on nine days for three weeks' staffing reviewed (Weeks of December 24, 2023, January 7, 2024, and February 11, 2024).

Review of the staffing for the weeks of December 24, 2023, January 7, 2024, and February 11, 2024 revealed the following dates and shifts did not meet the minimum requirements for nurse aide staffing ratios:

December 24, 2023, on the day, evening, and night shifts
December 25, 2023, on the day and evening shifts
December 26, 2023, on the night shift
December 27, 2023, on the day and evening shifts
December 28, 2023, on the evening shift
January 7, 2024, on the day and evening shifts
January 9, 2024, on the evening shift
January 11, 2024, on the evening shift
January 12, 2024, on the day, evening, and night shifts

Interview with the Nursing Home Administrator and Director of Nursing on February 20, 2024, at approximately 3:30 p.m. confirmed the above findings.

Plan of Correction - To be completed: 04/15/2024

No residents were adversely impacted due to the HPPD and nursing aide assignment.

The Staffing Scheduler, Director of Nursing, and Nursing Home Administrator meet each morning to review the projected HPPD for the upcoming days and to review the staffing ratios each day.

Our staff will be contacted to pick up extra shifts as necessary. Also, nursing agencies will be used to ensure that we have the correct staffing ratios.

Audits will be conducted by the Nursing Home Administrator or designee daily for the next three months to ensure that we are meeting the staffing ratio requirements. Results of the audits will be forwarded to the QAPI committee for review and recommendations.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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 review of nursing time schedules, it was determined that the facility administrative staff failed to provide a minimum of one Licensed Practical Nurse (LPN) per 25 residents during the day shift, one LPN per 30 residents during the evening shift, and one LPN per 40 residents on the night shift for six days for three weeks' staffing reviewed (Weeks of December 24, 2023, January 7, 2024, and February 11, 2024.)

Findings include:

Review of the staffing for the weeks of December 24, 2023, January 7, 2024, and February 11, 2024 revealed the following dates and shifts did not meet the minimum requirements for LPN staffing ratios:

December 26, 2023, on the day and night shifts
January 8, 2024, on the day and evening shifts
January 13, 2024, on the evening and night shifts
February 11, 2024, on the day and evening shifts
February 12, 2024, on the day shift
February 16, 2024, on the day shift

Interview with the Nursing Home Administrator and Director of Nursing on February 20, 2024, at approximately 3:30 p.m. confirmed the above findings.

Plan of Correction - To be completed: 04/15/2024

No residents were adversely impacted due to the HPPD and nursing assignments.

The Staffing Scheduler, Director of Nursing, and Nursing Home Administrator meet each morning to review the projected HPPD for the upcoming days and to review the staffing ratios each day and shift.

Our staff will be contacted to pick up extra shifts as necessary. Also, nursing agencies will be used to ensure that we have the correct staffing ratios.

Audits will be conducted by the Nursing Home Administrator or designee daily for the next three months to ensure that we are meeting the staffing ratio requirements. Results of the audits will be forwarded to the QAPI committee for review and recommendations.

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Observations:
Based on review of nursing time schedules, it was determined that the facility administrative staff failed to provide a minimum of one Registered Nurse (RN) per 250 residents during the evening shift for two days for three weeks' staffing reviewed (Weeks of December 24, 2023, January 7, 2024, and February 11, 2024.)

Findings include:

Review of the staffing for the weeks of December 24, 2023, January 7, 2024, and February 11, 2024 revealed the following dates did not meet the minimum requirements for RN staffing ratios for the evening shift:

January 7, 2024
January 11, 2024

Interview with the Nursing Home Administrator and Director of Nursing on February 20, 2024, at approximately 3:30 p.m. confirmed the above findings.

Plan of Correction - To be completed: 04/15/2024

No residents were adversely impacted due to the HPPD and nursing assignment.

The Staffing Scheduler, Director of Nursing, and Nursing Home Administrator meet each morning to review the projected HPPD for the upcoming days and to review the staffing ratios each day and shift.

Our staff will be contacted to pick up extra shifts as necessary. Also, nursing agencies will be used to ensure that we have the correct staffing ratios.

Audits will be conducted by the Nursing Home Administrator or designee daily for the next three months to ensure that we are meeting the staffing ratio requirements. Results of the audits will be forwarded to the QAPI committee for review and recommendations.

§ 211.12(i)(1) LICENSURE Nursing services.:

(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 facility staffing data, it was determined that the facility failed to ensure the total number of general nursing care hours provided in each 24-hour period be a minimum of 2.87 hours per patient day (PPD) for five days of three weeks reviewed (Weeks of December 24, 2023, January 7, 2024, and February 11, 2024).

Findings include:

Review of facility staffing sheets revealed the following dates were below 2.87 hours PPD:

December 24, 2023 with a PPD of 2.59
December 25, 2023 with a PPD of 2.73
January 7, 2024 with a PPD of 2.59
February 11, 2024 with a PPD of 2.44
February 17, 2024 with a PPD of 2.58

The facility staffing PPD being below the state minimum requirements was confirmed by the Nursing Home Administrator and Director of Nursing on February 20, 2024, at approximately 3:30 p.m.

Plan of Correction - To be completed: 04/15/2024

No residents were adversely impacted due to the staffing HPPD.

The Staffing Scheduler, Director of Nursing, and Nursing Home Administrator meet each morning to review the projected HPPD for the upcoming days to ensure regulatory compliance.

Our staff will be contacted to pick up extra shifts as necessary. Also, nursing agencies will be used to ensure that we have the correct hours of direct resident care for each resident of the facility.

Audits will be conducted by the Nursing Home Administrator or designee daily for three months to ensure that we are meeting the HPPD requirements. Results of the audits will be forwarded to the QAPI committee for review and recommendations.

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