Pennsylvania Department of Health
GLEN BROOK REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GLEN BROOK REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are 131 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.


GLEN BROOK REHABILITATION AND HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated complaint survey completed on February 28, 2024, it was determined Glen Brook Rehabilitaion and Healthcare Center 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:

483.10(j)(1)-(4) REQUIREMENT Grievances:

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.

§483.10(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

Observations:
Based on a review of grievances lodged with the facility and select facility policy and resident and staff interviews it was determined that the facility failed to demonstrate timely and adequate efforts to resolve resident grievances for two residents out of 16 sampled. (Resident 2 and 11)

Findings include:

A review of facility policy entitled "Resident and Family Grievances" revealed the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. The staff will forward the grievance form to the grievance official as soon as practicable. The grievance official takes steps to resolve the grievance and record information about the grievance and those actions on the grievance form. In accordance with the residents right to retain a written decision regarding his or her grievance, the grievance official will issue a written decision of the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum, the date the grievance was received, the steps taken to investigate the grievance, a summary of pertinent findings or conclusions regarding the resident's concerns, a statement to whether the grievance was confirmed or not confirmed, any corrective action taken by the facility as a result of the grievance, and the date the written decision was issued.

A review of a grievance lodged by Resident 2 dated January 28, 2024, which was requested for review during the recent survey at the facility, completed on February 6, 2024, but not provided at the time of request, revealed that the resident expressed a concern with staff not answering call bells in a timely manner and that the nurse aides sit in a back room on their phones. The grievance indicated that the resident felt that the facility should restrict phone usage to break times so residents are taken care of.

According to the grievance form, the facility noted that the resident's complaint was resolved on February 1, 2024. However, there was no documented evidence that the resident had been informed of the outcome of the grievance. The resident did not sign off that he received the facility's response or was aware of the actions taken by the facility to resolve his grievance. There was no documented evidence that the facility educated staff on use of their personal cell phones while on duty.

An interview with Resident 2 on February 28, 2024, at 10:15 AM revealed that the resident stated that his concerns were not yet resolved. The resident stated the wait times for staff to respond to call bells and provide requested care, remains a problem. The resident stated that it still takes up to 45 minutes for staff to respond to his call bell and meet his needs for assistance. The resident confirmed that the facility did not provide him written details of the outcome of his grievance and no one had asked him if he was satisfied with the outcome or if he still had concerns.

A review of a grievance filed on behalf of Resident 11 dated January 29, 2024, which was also requested for review during the survey ending February 6, 2024, but not provided upon request at that time, revealed that the resident's daughter had concerns with a small box cutter type knife found in her mother's bed. The resident's daughter questioned how the small knife ended up in her mother's bed and was concerned that her mother could have been hurt.

According to the grievance form, this complaint was resolved on February 2, 2024. However, there was no indication that the resident's daughter or the resident had been informed of the outcome, as the area of the form indicating notification of the representative was blank. Neither the resident nor the resident's daughter signed the form to acknowledge their receipt of the facility's response to the complaint and awareness of the actions taken to resolve the complaint.

An interview with Resident 11 on February 28, 2024, at approximately 10:30 AM revealed the resident was asked if she recalled the incident when a small blade was found in the resident's bed. The resident shook her head "yes." When asked if anyone came back to speak with her about how the blade ended up in her bed or what the facility did to correct these concerns, the resident shook her head "no."

During an interview with the Nursing Home Administrator (NHA) on February 28, 2023, at approximately 4:00 PM, the NHA was unable to provide documented evidence that the facility followed-up, in a timely manner, with the residents and/or their representatives to inform them of the outcome of their grievance and ascertain the effectiveness of the facility's efforts in resolving their complaints.

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

28 Pa. Code 201.29 (a) Resident rights

Plan of Correction - To be completed: 03/15/2024

F0585 (Grievances)

Resident 2, and resident 11 grievances were reviewed to assure resolution.

Social Service/designee followed up the residents / resident representative on the outcome of the grievances.

The facility has determined that all residents could be potentially affected.

The staff educator/designee will provide education to the grievance official, Administrator/DON/department heads on the facility grievance policy and procedures and the importance of adequately making efforts to resolve grievances timely.

Grievances will be reviewed in stand up meeting for completion.

The NHA/designee will review grievance forms to assure that the facility provided evidence of timely follow up to residents/representatives the outcome related to the grievances Audits will be done weekly for 4 weeks, then monthly for 2 months or until compliance is sustained.
Date of Compliance 3.15.2024

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on observation and staff interview, it was determined that the facility failed to adhere to expiration dates on pharmacy products stored in the central supply room.

Findings include:

Observations of the facility's central supply room on February 28, 2024, at 11:15 AM revealed one box, containing 5 bottles of Glucerna tube feeding, and another box containing 6 bottles, both had expired in November 2023.

There were 2 bags Nova Source Renal tube feeding formula that expired May 4, 2023.

16 bottles of hand sanitizer expired in June 2022.

An interview with Employee 5, clinical consultant ,on February 28, 2024, at the time of the observation confirmed the pharmacy products, enteral tube feeding formulas had expired .

28 Pa. Code 211.9 (k) Pharmacy Services

Plan of Correction - To be completed: 03/15/2024

F0761 (label/ storage of drugs and biologicals)

The facility central supply room was checked for expired products. All expired products were removed and disposed of properly.

The central supply room was checked on 3/9/24 to assure that there were no expired pharmacy products stored.

The Nursing home administrator/ designee will educate the central supply coordinator on routinely checking the central supply room to assure that no expired products exist.

The central supply clerk will review weekly with delivery of new supplies, and rotation of older supplies and remove any noted expired supplies.

The nursing home administrator/ designee will complete random audits of the central supply room to assure supplies are not expired and are properly stored.

Audits will be completed weekly times for 4 weeks, then monthly for 2 months or until substantial compliance is met.

Date of compliance 3.15.2024

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on a review of clinical records and select facility policy and resident and staff interviews it was determined that the facility failed to provide timely care and necessary resident care supplies for effective incontinence management for one resident out of 16 sampled (Resident 2).

Findings included:

A review of a facility policy entitled "Urinary and Bowel Incontinence" last reviewed by the facility on October 3, 2023, indicated that it was the policy of the facility that once a resident was identified as incontinent, staff would develop a plan of care to manage issues with incontinence and provide the appropriate treatment and services to meet the resident's toileting needs.

A review of Resident 2's clinical record revealed that the resident was admitted to the facility on July 6, 2022, with diagnoses that included diabetes, congestive heart failure and above the knee amputation of the right leg and below the knee amputation of the left leg.

The resident's plan of care for ADL (activities of daily living include bathing, dressing, combing hair, etc.) assistance initiated July 7, 2022, and revised November 12, 2023, indicated that Resident 2 had an ADL self-care deficit related to an amputation of the right leg and a below the knee amputation of the left leg with a noted goal that the resident would have his personal ADL needs met with the assistance of staff, while promoting his highest level of functioning and dignity. Resident 2 required two-persons assist for personal care and hygiene with planned interventions that included the use of a mechanical Hoyer lift with use of an amputee/shower sling for all transfers.

The resident's care plan for the problem of bowel incontinence initiated July 11, 2023, indicated that the resident would be maintained in a clean, and dry, and dignified state as possible. Planned bowel incontinence interventions were to check the resident every two-hours and as required for incontinence and to wash, rinse, and dry perineum (is the space between the anus and the genitals) and to apply barrier cream after each episode, change clothing as needed (PRN) after incontinence episodes, and to use disposable briefs for containment and dignity.

During an interview with Resident 2 on February 28, 2024, at 10:25 a.m., the resident stated that on Sunday February 11, 2024, he sat in a soiled brief with feces for over two hours, from 7:15 a.m. until 9 a.m. and was very uncomfortable and itchy. The resident stated that the nurse aides could not locate any of his proper sized bariatric briefs, "the package with the white colored coding on the packaging." Resident 2 reported that he sat without a brief on due because there were no bariatric briefs available at the facility. Resident 2 relayed that the staff didn't locate bariatric sized briefs until the second shift on Sunday, February 11, 2024, "the aides found briefs with the green color coded on the packaging and were a size smaller than what I needed. The aides left the brief closures opened because they (briefs) didn't fit around my belly."

An observation of Resident 2's closet revealed that the green color smaller sized briefs were present and not the properly sized white bariatric briefs the resident required.

An interview with Employee 1, a nurse aide (NA), on February 28, 2024, at 10:35 a.m., confirmed that the facility did not have the correct sized briefs available for Resident 2. Employee 1 stated that the facility frequently runs out of bariatric incontinence briefs and that staff must search throughout the building for briefs and other supplies.

During an interview with the Director of Nursing (DON) on February 28, 2024, at 2:15 p.m., revealed that there were occasions that management staff had to go to a local store to purchase several packages of assorted sized incontinence briefs because the facility's runs out. The DON confirmed that the correct sized incontinence bariatric briefs were not consistently available for Resident 2 and that he should not have had to sit in feces or wear briefs that did not fit him properly. The DON also confirmed that the facility did not have a functioning system, par level, to assure consistently availability of incontinence briefs prior to stock depletion.

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

28 Pa. Code 201.14 Supplies

Plan of Correction - To be completed: 03/15/2024

F0690 (Bowel/ Bladder Incontinence, Catheter, UTI)

1. Resident 2 was provided a package of appropriate size incontinent briefs.
2. The facility has determined that residents who are incontinent of bowel and/or bladder
have the potential to be affected.

3. Residents who utilize incontinence briefs were reviewed to assure that facility had
adequate amount of incontinence briefs per sizing available for resident care. The facility central supply coordinator was educated by NHA/designee on assuring that adequate amounts of incontinence briefs are ordered weekly based on facility needs. The staff educator/designee provided education to direct care staff (CNa's) on the facility procedures to obtain necessary supplies/incontinence briefs for resident care and reporting of any issues to Unit manager/supervisor timely.

4. Unit manager / designee will complete visual audits and random resident / interviews to assure that incontinence briefs are available to meet resident care needs. Audits will be completed weekly for 4 weeks, then monthly for 2 months or until compliance is
sustained.

5. Date of Compliance 3.15.2024

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

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.

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to consistently provide residents dependent on staff for assistance with activities of daily living, the necessary services to maintain good personal hygiene by failing to provide showers as scheduled for one resident out of 16 residents sampled (Resident 2).

Findings include:

A review of Resident 2's clinical record revealed that the resident was admitted to the facility on July 6, 2022, with diagnoses that included diabetes, congestive heart failure (CHF - heart disease that affects pumping action of the heart muscles that causes fatigue, shortness of breath) and above the knee amputation of the right leg and below the knee amputation of the left leg

The resident's plan of care for ADL (activities of daily living include bathing, dressing, combing hair, etc.) assistance initiated on July 7, 2022, and revised on November 12, 2023, indicated that Resident 2 had an ADL self-care deficit related to an amputation of the right leg and below the knee amputation of the left leg with a noted goal to that the resident would have his personal ADL needs met with the assistance of staff, while promoting his highest level of functioning and dignity. The resident's care plan indicated that the resident two-person assistance for personal care and hygiene with planned interventions that included to use a mechanical Hoyer lift with use of amputee/shower sling for all transfers.

Resident 2's nurse aide tasks indicated that the resident was to be showered every Wednesday during the 3 PM to 11 PM shift and Saturday 7 AM to 3 PM shift.

During an interview with Resident 2 on February 28, 2024, at 10:15 a.m., the resident stated that the specialized bariatric shower sling for bilateral amputees he requires for transfers has been missing from his room since early January 2024. He stated that staff have not been able to locate his shower sling for a few months and that the specialty sling was being used to shower him, but then that sling would get wet and would need to be sent to laundry to be cleaned and then unavailable for staff to use to get him out of bed. Resident 2 reported that he would like to get a shower and be able to get out of bed when desired, but it hasn't been possible because his specialized bariatric amputee sling has had not been available for staff to use to safely transfer him.

An interview with Employee 1, a nurse aide (NA), on February 28, 2024, at 10:25 a.m., confirmed that Resident 2's specialized bariatric amputee sling required for his showers and Hoyer transfers is unavailable. Employee 1 stated that the nurse aides had to search the laundry department in an attempt to locate them in an attempt accommodate the resident's shower schedule and his desire to get out of bed. Employee 2 indicated that slings were not always being returned from laundry.

A review of Resident 2's task summary report dated January 2024, revealed that the resident received four out of eight planned showers during the month of January 2024.

The resident's task summary dated through survey ending February 28, 2024, revealed that the resident received three out of eight planned showers to date.

During an interview with the Director of Nursing (DON) on February 28, 2024, at 2:00 p.m., the DON stated that it is facility's policy to provide residents with two showers per week, and bed baths as needed between planned showers or at the resident's request. The DON reported that Resident 2 required transfers with two-staff via mechanical Hoyer lift and a specialized bariatric amputee sling for all transfers and for showers. The DON stated that she was unaware that Resident 2's bariatric shower sling was not available for staff to use to shower the resident as scheduled. The DON confirmed that the resident didn't receive his planned showers due to the required bariatric amputee shower sling being unavailable.

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

Plan of Correction - To be completed: 03/15/2024

F0677 (ADL Care Provided for Dependent Residents)

1. Resident 2's bariatric shower sling was located in the laundry room. Resident was offered
and provided a shower.

2. The facility has determined that residents who require mechanical lift for showers could
be potentially affected.

3. The Staff educator /designee will provide direct care staff (CNa's) in-service education
on assuring that residents are provided showers based on their plan of care and
procedures are followed to obtain necessary equipment and reporting of any issues to Unit manager/supervisor.

4. Unit manager/ designee will complete audits of tasks related to showers to assure that
showers are being offered and any refusals are not related to unavailability of necessary
equipment. Audits will be completed weekly for 4 weeks, then monthly for 2 months or
until compliance is sustained.

5. Date of compliance 3.15.2023

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

§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 review of clinical records and select facility policy and resident and staff interview it was determined that the facility failed to implement pharmacy procedures to consistent availability of routine prescribed medications for one of 16 residents reviewed (Resident 8).

Findings include:

A review of the facility's policy titled "Ordering and Receiving Non-Controlled Medications" provided by facility on February 28, 2024, indicated that repeat medications (refills) are written on a medication reorder form or by peeling the reorder tab from the prescription label and placing it in the appropriate area on the medication reorder form provided by the pharmacy, or requested via the facility's EHR (Electronic Health Record) system.

Resident 8 was admitted to the facility on July 29, 2023, with diagnosis to include diabetes with hyperglycemia (high blood sugar), and hypertension (elevated blood pressure).

Review of current physician orders for Resident 8 revealed an order for Novolin 70/30 subcutaneous suspension (70-30) 100 unit/ml (Insulin NPH Isophane & Reg (Human)), inject 28 unit subcutaneously in the morning for DM (diabetes mellitus) and an order for Novolin 70/30, inject 15 units subcutaneously in the evening.

During an interview with Resident 8 on February 28, 2024, at 12:10 PM, she expressed concern and fear that she would miss her evening dose of insulin. She reported that she has been a resident at the facility for 7 months and the facility has "completely run out of my insulin 3 times and they ask me to call my son to bring in my insulin from home. Today, the nurse said they ran out and could my son bring it in." Resident 8 expressed frustration that she does not understand how the facility keeps running out, why an order is not placed before they run out, and why they cannot order it from local pharmacy instead of asking her to call her son. The resident reported she no longer has any insulin at home because her son bought in all she had the other times the facility ran out. She stated, "I've asked them before why they can't order it from the local pharmacy, and they tell me they have to get from a pharmacy in New Jersey."

During an interview with Employee 6 (licensed practical nurse) on February 28, 2024, at approximately 12:20 PM, she confirmed that she administered the last dose of Residents 8's insulin available in the facility during her morning medication pass this date. She confirmed that she asked the resident if she had more insulin at home and if she could contact her son to bring it in. Employee 6 stated she messaged her supervisor regarding Resident 8 being out of insulin.

During an interview with the Director of Nursing (DON) on February 28, 2024, at 2:25 PM she confirmed that when medications are low, staff should reorder medications through PCC (Point Click Care -electronic healthcare software provider). She confirmed that facility staff failed to follow the facility policy for reordering medications and that the facility failed to ensure consistent availability of a prescribed medication for Resident 8.

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

28 Pa. Code 211.9 (a)(1)(k) Pharmacy services

Plan of Correction - To be completed: 03/15/2024

F0755 (Pharmacy Services) Rejected

Resident 8's insulin was obtained from pharmacy and had no negative outcome.
The facility has determined that residents have the potential to be affected. Staff Educator / designee educated the licensed nursing staff on the facility pharmacy procedures for ordering/reordering routine prescribed medications.
Licensed nursing staff will order medications when there are 8 doses available. The nurse will management team will review and address pharmacy order alerts in PCC.

Director of nursing / designee will review resident clinical records to assure that prescribed medications are available for administration Audits will be completed daily x 7 days, then weekly for 4 weeks, then monthly for 2 months or until compliance is sustained.

Date of compliance 3.15.2024

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ:

§483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Observations:

Based on observation and staff interview, it was determined that the facility failed to store resident care supplies in a sanitary environment and manner in the central supply room.

Findings included

Observations of the facility's central supply room on February 28, 2024, at 11:15 AM revealed paper litter, dirt, and debris scattered about the floor of the room.

There were boxes of personal care supplies directly on the floor, including bags of clean incontinence briefs, boxes of skin and hair cleanser.

An oxygen tubing and mask kit was observed on the floor.

A skin stapler remover kit was observed on the floor.

A foam dressing kit and a piston syringe was observed on the floor.

Outside the central supply room, there were 20 boxes of clean incontinence briefs on the floor.

An interview with Employee 5 clinical consultant on February 28, 2024, at the time of the observation confirmed the supplies were not stored appropriately.

During an interview with the DON (Director of Nursing) on February 28, 2024 at approximately 4:00 PM revealed the central supply room is to be maintained in a sanitary manner.

28 Pa. Code 201.18 (e)(2.1) Management

Plan of Correction - To be completed: 03/15/2024

F0921 (Safe / Functional / Comfortable Environment)

The Central supply room was cleaned all paper litter, dirt and debris that was scattered about the floor was removed.

The boxes of personal care supplies and medical equipment were removed from the floor and stored properly or disposed of as appropriate. Supplies that were stored outside of the supply room were relocated and stored properly.

The central supply room was checked on 3/9/24 to assure that resident care supplies were stored in a sanitary manner and environment.

The Nursing Home administrator/ designee will educate the Central Supply coordinator on assuring that resident care supplies are stored in a sanitary manner and environment.

The Nursing Home administrator/ designee will educate housekeeping staff on assuring that the central supply room is maintained in a sanitary manner and environment.
House Keeping Services will add central supply to their weekly cleaning schedule.

The Nursing home administrator / designee will preform random audits of the central supply room to assure that it is maintained in a sanitary manner.

Audits will be completed weekly for 4 weeks, then monthly for 2 months or until substantial compliance is met.

Date of compliance 3.15.2024

§ 204.14 LICENSURE Supplies.:

Adequate supplies shall be available at all times to meet the residents' needs.

Plan of Correction - To be completed: 03/15/2024

P 2920 Supplies Rejected/ Updated

Resident 2 provided the appropriate supplies needed for care.

Par levels for supplies such as cleaning wipes and incontinence briefs will be identified and in place by 3.15.2024.

The central supply coordinator will review supplies of cleaning wipes and incontinence briefs in the central supply room to assure that supplies are available based on established par levels.

Par levels will be reviewed by central supply coordinator weekly or as needed for increase/ decrease in census.

Central supply coordinator/designee will conduct audits of central supply room to assure cleaning wipes and incontinence briefs are available based on established par levels.
Any issues identified will be addressed to the nursing home administrator. Audits will be conducted weekly for 4 weeks then monthly for 2 months or until substantial compliance is met.

Date of compliance 3.15.2024

§ 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 a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for two shifts out of 63 reviewed (2/13/24 and 2/14/24).

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:12 on the day and evening shift based on the facility's census.

February 13, 2024 - 14.93 nurse aides on the day shift, versus the required 15.33 for a census of 184.

February 14, 2024 - 14.40 nurse aides on the evening shift, versus the required 15.25 for a census of 183.

An interview with the Nursing Home Administrator on February 29, 2024, at approximately 3:45 PM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates.

Plan of Correction - To be completed: 03/15/2024

P 5510 (Nursing Services) Rejected/ Updated

The facility cannot retroactively correct this issue. No residents were negatively affected. All care was provided.

Daily staffing sheet was reviewed on 3/9/2024 to ensure minimum nurse aide staff to resident ratio was met.
The Regional HR consultant/designee will educate the staff scheduler on reviewing daily staffing schedule to ensure minimum nurse aide staff to resident ratio is being met.

NHA/DON /designee will review during daily staffing meeting the daily staffing schedules to ensure minimum nurse aide staff to resident ratio are being met.
The facility continues to hire open positions & prn staff, offer incentive for shifts picked up and continue to utilize agency to meet minimum nurse aide staff to resident ratio.

The staffing coordinator will update the NHA and DON on any staffing needs that arise throughout the day. During off shifts the nurse supervisor will address staff call off that arise and communicate any concern with the NHA/ DON.

Date of compliance 3.15.2024

§ 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 a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for 3 shifts out of 63 reviewed (2/9/24, 2/12/24, 2/14/24).

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1 per 40 residents overnight based on the facility's census.

February 9, 2024 - 4.27 LPNs on the night shift, versus the required 4.88 for a census of 183.
February 12, 2024 - 4.27 LPNs on the night shift, versus the required 4.91 for a census of 184.
February 14, 2024 - 4.27 LPNs on the night shift, versus the required 4.85 for a census of 182.

An interview with the Nursing Home Administrator on February 29, 2024, approximately 3:45 PM, confirmed the facility had not met the required LPN to resident ratios on the above dates.

Plan of Correction - To be completed: 03/15/2024

P 5530 (Nursing Services) Rejected / Updated

The facility cannot retroactively correct this issue. No residents were negatively affected.

The daily staffing sheet was reviewed on 3/9/2024 to ensure that minimum licensed practical nurse staff to resident ratio was met.

The Regional HR consultant/designee will educate the staff scheduler on reviewing daily staffing schedule to ensure minimum licensed practical nurse staff to resident ratio is being met.

NHA/DON / designee will review during daily staffing meeting the daily staffing schedules to ensure minimum licensed practical nurse staff to resident ratio are being met.

The facility continues to hire open positions & prn staff, offer incentive for shifts picked up and continue to utilize agency to meet minimum licensed practical nurse staff to resident ratio.

The staffing coordinator will update the NHA and DON on any staffing needs that arise throughout the day.

During off shifts the nurse supervisor will address staff call off that arise and communicate any concern with the NHA/ DON.

Date of compliance 3.15.2024

§ 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 a review of nurse staffing, resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily on two of 21 days reviewed (2/13/24 and 2/14/24).

Findings include:

A review of the facility's staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident:

February 13, 2024 -2.78 direct care nursing hours per resident
February 14, 2024 -2.77 direct care nursing hours per resident

An interview with the Nursing Home Administrator on February 29, 2024, at approximately 3:45 PM confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Plan of Correction - To be completed: 03/15/2024

P5630 (Nursing Services)

The facility cannot retroactively correct this issue. No residents were negatively affected.

The daily staffing sheet was reviewed on 3/9/2024 to ensure that minimum general nursing care hours to resident was met.

The Regional HR consultant/designee will educate the staff scheduler on reviewing daily staffing schedule to ensure minimum general nursing care hours to resident are being met.

NHA/DON / designee / will review during daily staffing meeting daily staffing schedules to ensure minimum general nursing care hours to resident are being met.

The facility continues to hire open positions & prn staff, offer incentive for shifts picked up and continue to utilize agency to meet general nursing care hours.

The staffing coordinator will update the NHA and DON on any staffing needs that arise throughout the day. During off shifts the nurse supervisor will address staff call off that arise and communicate any concern with the NHA/ DON.

Date of compliance 3.15.2024

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement