Pennsylvania Department of Health
WESTON REHABILITATION & NURSING CENTER
Patient Care Inspection Results

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WESTON REHABILITATION & NURSING CENTER
Inspection Results For:

There are  112 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.
WESTON REHABILITATION & NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and a Civil Rights Compliance survey completed on February 8, 2024, it was determined that Weston Rehabilitation and Nursing 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 observation, it was determined that the facility failed to store food under sanitary conditions in the kitchen.

Findings include:

A tour of the kitchen on February 6, 2024, at 10:20 a.m., revealed a bottle of vinegar on an out of service heating unit that was directly under an automatic hand sanitizer pump. The heating unit appeared worn and deteriorated. There were various particles of debris and dust under a shelf in dry storage. There was a bag of flour that was not sealed and open to air. There was a brown substance on the bottom of the reach-in freezer. There were various particles of debris on the shelf under a food preparation table. The floor and baseboards under the dish machine had an accumulation of debris.

Observation of the kitchen on February 7, 2024, at 12:11 p.m., revealed a container of sugar stored on the out of service heating unit directly under the automatic hand sanitizer pump. There was a roll of paper towels stored on the unit. There was a brown substance scattered on the wall behind the toaster. The wall at the three-compartment sink was peeling and marred. There was an accumulation of debris, which included crumbs, plastic wrap, a fork, and aluminum foil, on the floor behind the reach-in refrigerator.

28 Pa. Code 201.18(b)(3)(e)(2.1) Management.





 Plan of Correction - To be completed: 03/13/2024

1
Kitchen food storage and cleanliness deficiencies identified by the surveyor were immediately corrected throughout the kitchen.
No residents were affected secondary to findings.
Any work that required follow-up and additional time or supplies for completion were noted. These include acquiring materials and scheduling time, to by date certain, safely:
- Remove the wall-mounted hand sanitizer from the south kitchen wall
- Reconstructing a more cleanable surface over the decommissioned steam radiator
- Installing washable panels behind the 3-compartment sink and toaster
- Replacing baseboards and grouting along the wall behind the dish machine

2
A thorough cleaning and storage assessment of the kitchen and pantries was conducted, to ensure all possible areas are free of dust, debris, and hazards such as chemicals.
3
The Dietary Manager and kitchen staff were in-serviced by the Administrator regarding food safety, appropriate storage, and cleanliness of storage areas in the kitchen, pantries and refrigerators.

An audit will be conducted by the Administrator or designee of the kitchen, pantries, and refrigerators 2 times a week for 3 weeks, and once a week for 3 weeks, to ensure the facility remains in compliance with standards of professional and food safety practices.
4
Results of our kitchen and storage area audits will be reviewed, and the data submitted to the Quality Assurance and Performance Improvement Committee until necessary, to determine effectiveness, improvement, or if further measure is necessary to correct any persistence or worsening of facility compliance.

483.70(q)(1)-(5) REQUIREMENT Payroll Based Journal: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.
§483.70(q) Mandatory submission of staffing information based on payroll data in a uniform format.
Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

§483.70(q)(1) Direct Care Staff.
Direct Care Staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Direct care staff does not include individuals whose primary duty is maintaining the physical environment of the long term care facility (for example, housekeeping).

§483.70(q)(2) Submission requirements.
The facility must electronically submit to CMS complete and accurate direct care staffing information, including the following:
(i) The category of work for each person on direct care staff (including, but not limited to, whether the individual is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS);
(ii) Resident census data; and
(iii) Information on direct care staff turnover and tenure, and on the hours of care provided by each category of staff per resident per day (including, but not limited to, start date, end date (as applicable), and hours worked for each individual).

§483.70(q)(3) Distinguishing employee from agency and contract staff.
When reporting information about direct care staff, the facility must specify whether the individual is an employee of the facility, or is engaged by the facility under contract or through an agency.

§483.70(q)(4) Data format.
The facility must submit direct care staffing information in the uniform format specified by CMS.

§483.70(q)(5) Submission schedule.
The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly.
Observations:

Based on record review and interview, it was determined that the facility failed to submit direct care staffing information in the Payroll-Based Journal (PBJ) system for four of four quarters reviewed. (Quarters one, two, three, and four)

Findings include:

A review of PBJ staffing data reports revealed that the facility did not submit data for quarter two (January 1, through March 31, 2023), quarter three (April 1, through June 30, 2023), quarter four (July 1, through September 30, 2023), and quarter one (October 1, through December 31, 2023).

In an interview on February 6, 2024, at 10:04 a.m., the Administrator confirmed that the facility had not submitted staffing information in the PBJ system.

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







 Plan of Correction - To be completed: 03/13/2024

1
The facility is unable to retrospectively submit missed staffing data reports by report date of 2/14/2024.
The facility does continuously meet and mostly exceeds the minimum staffing ratio required by state regulation.
2
The Administrator, in a combined effort with the Payroll Coordinator and Corporate Office assistance, will continue to gather data as once planned, for composing it to Payroll-Based-Journal specifications for final review and submission.
The next Report-By date with the PBJ system is 5/15/2024.
3
The Administrator will be re-educated by the Operations Officer as to the importance and mandatory requirement of electronically reporting employee role and time data to the Payroll Based Journal System in a thorough, complete, and timely manner.
To serve as monitor and audit, the Operations Officer will be made aware of progress towards meeting the next Report-By date twice a week for 4 weeks, and once a week until complete submission.
4
Results of our PBJ reporting audit with related progress will be reviewed, and respective data submitted to the Quality Assurance and Performance Improvement Committee until necessary, to determine effectiveness, improvement, or if further measure is necessary to correct any persistence or worsening of facility compliance.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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(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 review of facility policy, review of manufacturer instructions, observation, and staff interview, it was determined that the facility failed to properly store and label medications in two of two medication carts. (East and West unit medication carts)

Findings include:

Review of the facility policy entitled, "Storage and Expiration Dating of Medications, Biologicals," last reviewed November 21, 2023, revealed that all drugs were to be stored and administered in compliance with state and federal regulations. Once any medication or biological package was opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container when the medication had a shortened expiration date once opened. Medications were to be administered from containers labeled with an expiration date when applicable.

Review of manufacturer instructions revealed the following:

Latanoprost eye drops were to be discarded six weeks after opening. Refresh eye drops were to be discarded 90 days after opening. Insulin glargine and Novolog solution pens were to be discarded 28 days after opening. Advair Diskus inhalers were to be discarded one month after opening. Albuterol sulfate inhalers were to be discarded one year after opening.

Observation of the West unit medication cart on February 7, 2024, at 11:00 a.m., revealed the following:

There was an open bottle of latanoprost eye drops that was not labeled with an open date. There were three open bottles of Refresh eye drops that were not labeled with an open date. There was one insulin glargine solution pen that was open and not labeled with an open date. There was one open Advair Diskus inhaler that was not labeled with an open date. There were two albuterol sulfate inhalers that were open and not labeled with an open date.

Observation of the East unit medication cart on February 7, 2024, at 2:27 p.m. revealed the following:

One Novolog (insulin) solution pen that was open and not labeled with an open date.

In an interview on February 8, 2024, at 9:30 a.m., the Administrator stated that staff were to label all medications with open and expiration dates, and all expired medications were to be removed from the medication carts.

28 Pa. Code 211.12 (d)(1)(2)(5) Nursing services.






 Plan of Correction - To be completed: 03/13/2024

1
Medication labeling deficiencies identified by the surveyor, were immediately corrected on both the East and West medication carts and in the medication room where applicable.
Findings did not result in any harm to a resident.
2
A complete audit of the medication room, East and West medication carts, to include the treatment cart, was conducted to ensure no other resident medication was not labeled/dated properly.
3
Nurse staff were in-serviced by the Director of Nursing regarding labeling and dating of medication per professional practice, as well as federal, state, and pharmacy guidelines.

An audit of medication labeling and dating of the medication carts, medication room, and treatment cart will be conducted by the Director of Nursing or designee, 3 time a week for 2 weeks, twice a week for 2 weeks, and once a week for 4 weeks to ensure the facility remains in compliance with labeling and dating standards and guidelines.
4
Results of our medication labeling and dating audits will be reviewed, and the data submitted to the Quality Assurance and Performance Improvement Committee until necessary, to determine effectiveness, improvement, or if further measure is necessary to correct any persistence or worsening of facility compliance.
§ 201.19(3) LICENSURE Personnel policies and procedures.:State only Deficiency.
(3) Documentation of credentials, which shall include, at a minimum, current certification, registration or licensure, if applicable, for the position to which the employee is assigned.

Observations:


Based on a review of facility files and staff interview, it was determined that the facility failed to request a verification of registration status for two employees of four reviewed. (Nurse Aides (NA) 1 and 3)

Findings include:

NA 1 was employed with a start date of January 3, 2024. A review of NA 1's employee file revealed no evidence that the employee's registration status was verified with the Pennsylvania Nurse Aide Registry prior to that date.

NA 3 was employed with a start date of January 12, 2024. A review of NA 3's employee file revealed no evidence that the employee's registration status was verified with the Pennsylvania Nurse Aide Registry prior to that date.

In an interview on February 8, 2024, at 2:48 p.m., the Administrator confirmed that the Pennsylvania Nurse Aide Registry verifications for NA 1 and NA 3 had not been conducted prior to their start dates.



 Plan of Correction - To be completed: 03/13/2024

1
NA-1 and NA-3 Registration Status verifications identified by the surveyor, were accomplished prior to submitting results for his review.
Results for both were that of: Active
2
An NA Registration Status audit will be conducted by the Human Resources department or designee, to ensure no NA practices with less than the minimum status required.
3
The Human Resources department will be re-educated by the Operations Officer as to the importance of NA Registration Status verifications, in print and filed, via the State Registry system, to take place PRIOR to an employee's start date.
An audit of employee files will be conducted by the Corporate Office or designee to ensure compliance is maintained with verifying NA Registration Status' for new employees once a week for 4 weeks, and biweekly for 2 weeks.
4
The results of the NA Registration Status audits will be reviewed, and respective data submitted to the Quality Assurance and Performance Improvement Committee until necessary, to determine effectiveness, improvement, or if further measure is necessary to correct any persistence or worsening of facility compliance.


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