Pennsylvania Department of Health
BETHLEHEM NORTH SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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BETHLEHEM NORTH SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

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BETHLEHEM NORTH SKILLED NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and a Civil Rights Compliance survey completed February 16, 2024, it was determined that Bethlehem North Skilled 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(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on facility policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess and implement safety measures related to smoking for one of one sampled residents who smoke. (Resident 31)

Findings include:

Review of the facility policy entitled, "Smoking," last reviewed August 7, 2023, revealed that smoking would be permitted in designated areas and that residents would be assessed on admission, quarterly, and with change in condition for the ability to smoke safely and, if necessary, would be supervised.

Clinical record review revealed that Resident 31 had diagnoses that included diabetes, chronic obstructive pulmonary disease, and an amputation of the left leg below the knee. According to the Minimum Data Set assessment, dated November 2, 2023, the resident had no cognitive impairment. In an interview on February 15, 2024 at 8:44 a.m., Resident 31 reported smoking on a regular basis. Observations on February 15, 2024, at 11:05 a.m. and 2:55 p.m., revealed Resident 31 outside the front of the building smoking. There was no documentation in the clinical record to support that the resident's smoking safety was evaluated by the facility. In an interview on February 16, 2024, at 9:09 a.m., the Director of Nursing confirmed that Resident 31 had not been assessed for safety related to smoking.

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




 Plan of Correction - To be completed: 03/05/2024

1.The facility is a smoke- free campus, however those residents who smoked prior to the transition have been grandfathered in and allowed to continue to smoke. Resident 31 cannot be assessed retroactively from the time of admission for smoking safety. The resident will be assessed per policy including quarterly and with change in condition for the ability to smoke safely and if necessary will be supervised.

2.New admissions that enter the facility are notified of our smoke-free status and are not allowed to smoke. Current grandfathered residents who smoke will be identified and will be assessed per policy by nursing for smoking safety.

3. Education will be conducted by the nurse educator to ensure that all smoking residents are assessed initially then quarterly and with change of condition to ensure smoke safety and supervised as needed.

4. Audits of smoking assessments will be conducted by the DON or designee weekly x two (2) weeks and then quarterly for one (1) quarter to ensure compliance. Any identified trends will be reported to QAPI for review and recommendation.



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