Pennsylvania Department of Health
SLATE BELT HEALTH & REHABILITATION CENTER
Patient Care Inspection Results

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SLATE BELT HEALTH & REHABILITATION CENTER
Inspection Results For:

There are  121 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.
SLATE BELT HEALTH & 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, a Civil Rights Compliance survey, and an Abbreviated survey in response to a complaint completed February 2, 2024, it was determined that Slate Belt Health 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:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department.

Findings include:

Review of the facility's policy entitled, "Use-By Guide-Quick Reference," last reviewed March 16, 2023, revealed that the use-by date marked on a container should be followed and that time/temperature control for safety directed that foods (milk and meat items) would not be held more than seven days.

Review of the facility's policy entitled, "Storage of Dry Food Policy," last reviewed March 16, 2023, revealed that containers holding food removed from the original packaging were to be labeled and dated.

Observation during the kitchen tour on January 30, 2024, at 9:40 a.m., revealed the following:

In the dessert cooler, there was a pitcher of water with lemon slices in it and six small dishes of various salad dressings that were not dated. There was a container of frosting that was dated January 18, 2024.

In the cook's cooler, there was an open container of cottage cheese with a use-by date of January 12, 2024. There was a package of sliced cheese and a bag of bread with illegible dates noted. There was a container of mozzarella cheese that was dated January 3, 2024. There was a large pan of chocolate mousse that was not labeled or dated. There were three packages of angel food cake and four bags of bread slices that were not dated.

In the trayline cooler #1, there was a small cup of milk that was not dated. In trayline cooler #2, there was a pitcher of honey thick milk that was dated January 19, 2024, and 14 cups of milk that were not dated. In the walk-in cooler, there were 24 cartons of chocolate milk with a use-by date of January 28, 2024.

In dry storage, there were two bins of white substances that were not labeled or dated. One bin had white food debris covering the top of the lid.

The dish machine required a chemical solution to sanitize the dishware and when measured, the sanitizing solution did not meet the required parts per million to sanitize dishes.

In an interview on January 30, 2024, at 11:00 a.m., the Registered Dietitian confirmed that the food items should have been labelled and dated and were not, the expired items should have been removed, and that during observation the dish machine was not properly sanitizing dishes.

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











 Plan of Correction - To be completed: 02/23/2024

1. All expired and unlabeled foods have been removed. On 1/31/2024 the dishwasher/dish machine vendor was onsite and maintenance completed and confirmed the chemical solution to sanitize the dishware met the required parts per million to sanitize dishware.

2. To identify others that can be affected, the Dietary Manager completed an audit to ensure all foods are labeled and expired foods have been discarded. As of the dishwasher/dish machine, produces the appropriate chemical solution to sanitize dishware. A new high temperature dishwasher/ dish machine was ordered.

3. To prevent this from reoccurring, the dietary director and dietary staff were educated on the importance of following the food policy regarding labeling kitchen items and discarding food in a timely manner. The dietary director and dietary staff were educated on the proper parts per million chemical solution necessary for sanitizing dishware using the current low-temp dishwasher/ dish machine along with how to test the solution to ensure the chemical solution is adequate. A new high temperature dishwasher/ dish machine was ordered.

4. To monitor and maintain, the Dietary Manager/designee will audit labeled kitchen foods 3 times weekly times four weeks then monthly times two to ensure that no expired foods are being used and all foods in dietary department are being labeled. The dietary director/designee will test the current low-temp dishwasher/dish machine chemical solution daily before use to ensure dishware are properly sanitized. Testing procedures will continue until the new high temperature dishwasher/ dish machine is installed and functioning.

5.Results will then be forwarded to QAPI for review and further recommendations.

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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify the resident's physician of an incident for two of 23 sampled residents. (Residents 75, 109)

Findings include:

Review of the facility policy entitled, "Resident Change in Condition," last reviewed March 16, 2023, revealed that the physician would be notified as soon as the nurse identified a change in condition, accident, or incident. The nurse would record the notification in the resident's health record.

Clinical record review revealed that Resident 75 was admitted to the facility on April 23, 2023, with diagnoses that included muscle weakness, senile degeneration of the brain, and repeated falls. Review of a nurse's noted dated November 30, 2023, revealed that Resident 75 had a fall. There was no documented evidence that the resident's physician was notified of the fall.

In an interview on February 2, 2024, at 9:42 a.m., the Regional Nurse confirmed that there was no documented evidence that the resident's physician was notified of the fall.

Clinical record review revealed that Resident 109 was admitted to the facility on January 20, 2024, with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction (weakness or paralysis after a stroke), low back pain, anxiety, and depression. Review of a nurse's noted dated January 31, 2024, revealed that Resident 109 was found in possession of unmarked pills, empty medication bottles, medication bottles containing pills, and empty medication cards. There was no documented evidence that the resident's physician was notified of the incident per facility policy.

In an interview on February 2, 2024, at 9:30 a.m., the Regional Nurse confirmed that there was no documented evidence that the resident's physician was notified at the time of the incident.

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




 Plan of Correction - To be completed: 02/23/2024

1.Unable to correct for resident 75 and 109
2.To identify other residents that have the potential to be affected, the DON/designee reviewed the last 7 days of incidents to ensure there is documentation of timely MD notification
3.To prevent this from reoccurring, the DON/designee educated licensed nurses on the change in condition policy ensuring that MD notification is completed timely and documented in the medical record
4.To monitor and maintain ongoing compliance, the DON/designee reviewed incidents weekly x 4 then monthly x 3 to ensure md notification is completed
5.Results of the audits will then be forwarded to facility QAPI for further review and recommendations.

483.25(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of 23 sampled residents. (Resident 3)

Findings include:

Review of the facility policy entitled, "Pain Management," last reviewed March 16, 2023, revealed that non-pharmacological interventions would be attempted prior to the administration of an as needed pain medication. Interventions for pain would be monitored for effectiveness in the electronic medication record.

Clinical record review revealed that Resident 3 had diagnoses that included rheumatoid arthritis and muscle weakness. A physician's order dated January 15, 2024, directed staff to administer the narcotic pain medication, oxycodone, every four hours as needed for pain rated at four through seven of ten. Review of the care plan revealed the resident had chronic pain and interventions included that staff offer relaxation techniques to assist with pain control. Review of the January 2024, Medication Administration Record revealed that the resident received the as needed oxycodone 37 times without evidence to support that non-pharmacological interventions were offered prior to the administration of the as needed pain medication.

In an interview on February 3, at 9:42 a.m., the Regional Nurse confirmed that there was no documented evidence staff offered non-pharmacological interventions prior to the administration of the as needed pain medication.

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




 Plan of Correction - To be completed: 02/23/2024

1. Unable to correct for resident #3
2. To identify other residents that have the potential to be affected, the DON/designee reviewed 72 hours of PRN pain medication to ensure NPI were documented prior to administration of medication.
3. To prevent this from reoccurring, the DON/designee educated licensed nurses on the pain management policy and added the NPI to MD orders ensuring NPI are offered and documented prior to the administration of a PRN pain medication.
4. To monitor and maintain ongoing compliance, the DON/designee will review 10 residents weekly x 4 then monthly x 2 to ensure that NPI are being offered and is being documented prior to administration of a PRN pain medication.
5. Results of the audits will then be forwarded to facility QAPI for further review and recommendations.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs as identified in the comprehensive assessment for one of 23 sampled residents. (Resident 67)

Findings include:

Clinical record review revealed that Resident 67 was admitted to the facility on December 26, 2023, with diagnoses that included hallucinations and dementia with mood disturbances, anxiety, and behavior disturbances. The Minimum Data Set assessment Care Area Assessment (CAA) summary dated December 30, 2023, noted that the resident's psychotropic drug use was to be addressed in the care plan. There was no documented evidence that interventions to address Resident 67's psychotropic drug use were included in the care plan.

In an interview on February 2, 2024, at 9:40 a.m., the Regional Nurse confirmed that there was no documented evidence that the identified care area (psychotropic drug use) was addressed in Resident 67's current care plan.

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







 Plan of Correction - To be completed: 02/23/2024

1. Resident 67's care plan was updated to include the use of a psychotropic medication.
2. To identify other residents that have the potential to be affected, the DON/designee reviewed residents who have triggered a CAA to ensure the care plan reflects evidence of interventions.
3. To prevent this from reoccurring, the DON/designee educated that if a CAA is triggered then it will be reflected in the care plan and an appropriate intervention is in place and that the IDT is made aware of the intervention.
4. To monitor and maintain ongoing compliance, the MDS coordinator/designee will review 5 residents weekly x 4 then monthly x 2 who trigger a CAA to ensure that an intervention is placed into the care plan.
5. Results of the audits will then be forwarded to facility QAPI for further review and recommendations.


483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.
Observations:

Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to obtain reference checks prior to the start of employment for five of five newly hired employees. (Employees 1, 2, 3, 4, and 5)

Findings include:

Review of the facility policy entitled, "Pennsylvania Resident Abuse," last reviewed March 16, 2023, revealed that the facility prohibited abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. The facility was to implement an abuse prohibition program by screening potential hires, including obtaining references from two prior employers from an applicant.

Review of the personnel files for newly hired employees revealed the following: Employee 1 started on September 25, 2023, Employees 2 and 3 started on October 23, 2023, and Employees 4 and 5 started on November 13, 2023. For all five new hires, there was no documented evidence that reference checks were obtained through the screening process.

In an interview on February 2, 2024, at 9:45 a.m., the Regional Nurse stated that reference checks were to be obtained through the screening process prior to hire. The Regional Nurse further stated that there was no documented evidence that reference checks were obtained for Employees 1, 2, 3, 4, and 5.

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

28 Pa. Code 201.19 Personnel policies and procedures.



 Plan of Correction - To be completed: 02/23/2024

1.Facility cannot retroactively correct.
2.To identify others who have the potential to be affected, the HR Director completed an audit to ensure evidence of new hire in last 30 days have reference checks completed.
3.To prevent this from reoccurring, the NHA educated the HR Director on the PA abuse policy and screening new hires by Generally attempt to obtain references from 2 prior employers for an applicant.
4.To monitor and maintain ongoing compliance, the NHA/designee will review new hire applications weekly x4 then monthly x 2 to ensure reference checks were obtained from 2 prior employers
5. Results of the audits will then be forwarded to facility QAPI for further review and recommendations.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident's representative(s) of transfer and the reasons for the move in writing for three of 23 sampled residents. (Residents 3, 57, 72)

Findings include:

Clinical record review revealed that Resident 3 was transferred to and admitted to the hospital on November 28, 2023, after a change in condition. There was no documented evidence that the resident's responsible party was provided with written information regarding the resident's transfer to the hospital.

Clinical record review revealed that Resident 57 was transferred to the hospital on January 14, 2024, after a change in condition. There was no documented evidence that the resident's responsible party was provided written information regarding the resident's transfer to the hospital.

Clinical record review revealed that Resident 72 was transferred to the hospital on January 9, 2024, after a change in condition. There was no documented evidence that the resident's responsible party was provided written information regarding the resident's transfer to the hospital.

In an interview on February 2, 2024, at 10:30 a.m., the Administrator confirmed that written transfer information, including the reasons for the move, was not provided to residents' representative(s).


 Plan of Correction - To be completed: 02/23/2024

1.Unable to correct for resident 3,57,72.
2.To identify other residents that have the potential to be affected, the DON/designee reviewed 2 weeks of transfers to ER to ensure resident representative were provided written education regarding transfer to ER.
3.To prevent this from reoccurring, the licensed nurses and SSD were educated on the transfer/discharged requirements and written notification to resident representative written education regarding the residents transfer to the hospital.
4.To prevent this from reoccurring, the DON/designee reviewed transfers to ER weekly x 4 then monthly x 2 to ensure all required documentation is completed
5.Results of the audits will then be forwarded to facility QAPI for further review and recommendations.


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