Pennsylvania Department of Health
RENAISSANCE HEALTHCARE & REHABILITATION 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

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
RENAISSANCE HEALTHCARE & REHABILITATION CENTER
Inspection Results For:

There are  94 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.
RENAISSANCE HEALTHCARE & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, and State Licensure Survey completed on December 15, 2023, it was determined that Renaissance Healthcare & Rehabilitation Center, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.


 Plan of Correction:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:
Based on observations and interviews with staff, it was determined that the facility failed to promote care for residents that maintains or enhances dignity and respect related to dining for two of two dining rooms observed. (First floor and second floor dining rooms.)

Findings include:

Observations of lunch dining on the first-floor dining room, on December 12, 2023, at 12:32 p.m. revealed the following:

A table with four residents seated; two residents were served a meal at 12:36 p.m. and consumed 100% of their meal meanwhile two other residents were waiting to be served a meal. Resident R109 stated, "I don't know why I always get my food last." Further observations revealed the residents' meal tray arrived at 12:54 p.m.

Observations of lunch dining on the second-floor dining room, on December 13, 2023, at 12: 19 p.m. revealed the following:

16 out of 16 residents were dressed in aprons without permission.

A table with four residents seated; one resident was served a meal at 12:34 p.m.; another resident was served a meal at 12:50 p.m.; and two residents were served at 12:55 p.m.

A table with two residents seated; one resident was served a meal at 12:34 p.m. and the other resident was served at 12:51 p.m.

A table with two residents seated; one resident was served a meal at 12:37 p.m. and the other resident was served at 12:54 p.m.

A table with three residents seated; one resident was served a meal at 12:42 p.m.; another resident was served a meal at 12:49 p.m.; and two residents were served at 1:00 p.m.

Interview with the assistant administrator, Employee E3, on December 15, 2023, at 12:39 confirmed the above-mentioned findings. Employee E3 stated that this has been an ongoing problem at the facility.


28 Pa. Code 201.29(d) Resident Rights



 Plan of Correction - To be completed: 01/30/2024

Facility can not retroactively correct the dignity citation for the cited residents.

The Director of Staff Development or designee will re-inservice the RN, LPN, and C.N.A. staff regarding the Dignity Policy with an emphasis on ensuring that residents who are seated together at a table will receive their meals at the same time and also residents will be asked for the residents' permission prior to donning an apron.

Random dignity audits will be performed by the Director of Nursing or designee to ensure that residents who are seated together at a table will receive their meals at the same time and also residents will be asked for the residents' permission by the staff prior to donning an apron. Audits will be completed weekly x 4 and monthly thereafter for 90 days. Results of the audits will be forwarded to the QAPI Committee for review and recommendations and to determine the need for further audits and/or action plans.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
§483.60(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 observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Findings include:

A review of undated facility policy titled, "Labeling and Dating Inservice," indicated that "all foods should be dated upon receipt before being stored. Food labels must include the item name; the date of preparation/receipt/removal from freezer; and "use by" date ..."

A tour of the Food Service Department was conducted on December 12, 2023, at 9:35 a.m. with Employee E5, Food Service Director (FSD), revealed the following concerns:

Observations throughout the foodservice department, including the main kitchen area, dish room, pantry, and other common areas revealed the floors were dirty with food crumbs, crevices in the floor tile were filled with debris.

Observations of the walk-in refrigerator revealed the following items were opened, unlabeled, and undated: sour cream; Swiss cheese, mozzarella cheese; two pork sausage bulk links; turkey roast; and ham.

Interview with the FSD on December 12, 2023, at 9:10 confirmed that he was not aware of how long the food items have been in the fridge due to improper dating and labeling upon receipt before being stored; and that the grime on the floor was a result of not maintaining the kitchen floors over several days/weeks.

28 Pa. Code 201.14(a) Responsibility of licensee



 Plan of Correction - To be completed: 01/30/2024

The sour cream, swiss cheese, mozzarella, two pork sausage links, turkey roast, and ham were all discarded immediately. The floors and the crevices were cleaned to remove dirt and debris.

Dietary staff was re-inserviced for proper cleaning schedules, labeling and dating, and food storage.

Dietary manager or designee will audit cleaning schedules and kitchen for dirt and debris daily for one month and then weekly for two months.

Dietary manager or designee will audit kitchen refrigerators for proper food storage, and labeling and dating daily for one month and then weekly for two months.

Administrator or designee will audit cleaning schedules and kitchen for dirt and debris daily for one month and then weekly for two months. Any findings will be reported to the monthly QAPI meeting for further recommendations.

Administrator or designee will audit kitchen refrigerators for proper food storage, and labeling and dating daily for one month and then weekly for two months. Any findings will be reported to the monthly QAPI meeting for further recommendations.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on a review of clinical records, facility policies and facility documentation, and interviews with staff, it was determined that the facility failed to review and revise a comprehensive person-centered plan of care in a timely manner, for one of 26 clinical records reviewed (Residents R19).

Findings include:

Review of facility policy, "Care Plans, Comprehensive Person-Centered," revised December 2016, revealed, "Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change."

Observations conducted on the first-floor nursing unit on December 12, 2023, at 1:17 p.m. revealed that Resident R19 had dentures placed on her table stand. Interview with the resident at the time of the observation revealed that Resident R19's dentures are no longer fitting, and that she has had a hard time chewing for months.

Review of Resident R19's dental records dated, May 30, 2023, revealed that Resident R19's edentulous ridge (the raised part of the alveolar process after teeth have been removed) was "moderate" and that she was recommended "full lower dentures". Further review revealed that Resident R19 required a "full mouth x-ray series" and was listed as "priority."

Further review of Resident R19's dental records dated, July 17, 2023, revealed that Resident R19 was not wearing her lower dentures due to "poor edentulous ridge" ad that she required "continued exams."

Review of Resident R19's care plan dated March 10, 2014, revealed that the resident was care planned for "self-care deficit (dressing, grooming, bathing, and hygiene needs)" and that the resident required help with removing her dentures at night for cleaning and inserting them in the morning.

Resident R19's care plan revealed lack of updated plan pertaining to no longer fitting dentures.

Interview conducted with the Registered Dietitian, Employee E4, on December 15, 2023, at 10:53 a.m. confirmed that Resident R19's care plan should have been updated to reflect the resident's poor oral status and required care. Employee E4 acknowledged that care plan interventions including close monitoring of Resident R19's eating habits, risk of choaking, and weight loss should have been implemented.

28 Pa. Code 211.11(b)(c) Resident care plan

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services



 Plan of Correction - To be completed: 01/30/2024

Resident R 19's care plan has been revised.

Current residents who require dentures will be audited by the Registered Dietician or designee to ensure that care plan revisions have been completed if applicable.

The Director of Staff Development or designee will re-inservice the Registered Dietician regarding the policy Care Plans, Comprehensive Person –Centered. The focus of the inservice will be to ensure that the Registered Dietician completes care plan revisions for those residents who require dentures if applicable.

The Registered Dietician or designee will audit to ensure that care plan revisions are completed if applicable for those residents who require dentures weekly x 4 weeks and then monthly thereafter for 90 days. Results of the audits will be forwarded to the QAPI Committee for review and recommendations and to determine the need for further audits and /or action plans.

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program: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.
§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:

Based on a review of the facility's infection control policies and procedures and clinical records and staff interview, it was determined the facility failed to consistently implement an antibiotic stewardship program and maintain a system to effectively monitor antibiotic usage for one of six sampled residents for unnecessary medication usage (Resident R86).


Findings include:

A review of facility policy entitled "Infection Prevention and Control Plan" last reviewed October 2023, revealed "The facility assures there is an infection control program that is effective for investigating, controlling and preventing infections. This facility will assign an infection control coordinator to collect data, monitor, analyze, and make recommendations. The data will be submitted to the AQPI committee monthly."

Review of infection control protocols submitted by the facility during the survey revealed that the facility followed McGeer's Criteria to evaluate and monitor the use the use of antibiotics.

Review of physician orders for Resident R86 dated November 18, 2023, revealed medication orders for Cephalexin (Antibiotic medication) 500 milligrams (mg) one tablet four times a day for cellulitis.

Review of Medication Administration Record for Resident R86 for the month of November 2023 revealed that the resident received Cephalexin from November 18, 2023 to November 29, 2023.

A review of facility infection surveillance for the month of November 2023 revealed that the facility did not include Resident R86's antibiotic use for review.

Interview with the Infection Control Nurse, Employee E9, on December 15, 2023, at 11:10 a.m. stated facilities antibiotic stewardship program included the use of surveillance and tracking form for antibiotics ordered. Facility did not use any other documentation for antibiotic stewardship usage. Facility followed McGreer's Criteria for antibiotic stewardship, however did not document the evaluation based on the criteria.

Continued interview with Infection Control Nurse, Employee E9 confirmed that the facility did not review and monitor Resident R86's antibiotic usage from November 18, 2023 to November 29, 2023, for appropriate use of antibiotics.

28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

28 Pa. Code 211.2(d)(3)(5) Medical Director

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




 Plan of Correction - To be completed: 01/30/2024

The facility can not retroactively correct the antibiotic stewardship usage for the cited resident.
Current residents who received antibiotic medication from 12/1/23 will be audited to ensure that they are included in the infection surveillance and tracking form and that they are monitored and evaluated for appropriate use of antibiotics.

The Assistant Director of Nursing or designee will re-inservice the Director of Infection Control regarding the need to ensure that residents who receive antibiotic medication are included in the infection surveillance and tracking form and that they are monitored and evaluated for appropriate use of antibiotics.

The Assistant Director of Nursing or designee will audit the residents who receive antibiotic medication to ensure they are included in the infection surveillance and tracking form and that they are monitored and evaluated for appropriate use of antibiotics weekly x 4 and then monthly thereafter. The results of the audits will be submitted to the QAPI Committee for review and recommendations and to determine the need for additional audits and/or action plans.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly: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.
§483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:

Based on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed properly.

Findings include:

An initial tour of the Food Service Department conducted on December 12, 2023, at approximately 9:35 a.m. with the Food Service Director (FSD), Employee E5, revealed the following concerns in the outdoor garbage and receiving area:

Debris and plastics (cups, lids, dirty gloves, condiment packets, saran wrap) was observed around the trashcan area.

Observations revealed piles of spoiled fruit droppings (premature shedding of fruit from a tree before fully ripe) throughout the receiving and garbage area with unpleasant odors, which created an unsafe and unsanitary environment in the main food receiving area.

Interview on December 12, 2023, at approximately 9:45 a.m. with the FSD confirmed the above-mentioned findings and acknowledged that the current receiving, and dumpster area was unsafe and allowed pest harborage (conditions or place where pests can obtain water or food, nest, or obtain shelter).

29 Pa. Code 201.18 (b)(1) Management



 Plan of Correction - To be completed: 01/30/2024

The debris and plastics were removed around the trashcan area immediately. The "fruit" from the tree was cleaned and removed from the garbage and receiving area.

Dietary staff was re-inserviced for proper cleaning schedules to include the garbage and receiving areas.

Dietary manager or designee will audit cleaning schedules and garbage and receiving areas daily for one month and then weekly for two months.

Administrator or designee will audit cleaning schedules and garbage and receiving areas daily for one month and then weekly for two months. Any findings will be reported to the monthly QAPI meeting for further recommendations.

483.60(e)(1)(2) REQUIREMENT Therapeutic Diet Prescribed by Physician: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.
§483.60(e) Therapeutic Diets
§483.60(e)(1) Therapeutic diets must be prescribed by the attending physician.

§483.60(e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law.
Observations:

Based on observations, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure therapeutic diets were served per physician orders for three of 26 residents reviewed (Residents R36, R31 and R71).

Findings include:

A review of facility policy titled, "Therapeutic Diets," revised October 2017, indicted that therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care.

Review of Resident R36's clinical records revealed a physician order dated, June 26, 2023, for a therapeutic diet, "Puree texture, nectar consistency."

A review of Resident R36's Speech Language Pathology discharge recommendations dated, September 14, 2023, revealed Resident R36 was recommended "Nectar Thick Liquids."

A review of Resident R31's Speech Language Pathology discharge recommendations dated, October 23, 2023, Resident R31 was recommended "Nectar Thick Liquids."

A review of Resident R31's clinical records revealed a physician's order dated, November 3, 2023, for a therapeutic diet, "pureed texture, Nectar consistency."

A review of Resident R71's clinical record revealed a physician order dated, September 9, 2023, for a therapeutic diet, "pureed texture, nectar consistency."

First floor dining observations conducted on December 12, 2023, at 12:33 p.m. revealed the following:

Resident R36's meal slip indicated that Resident R36 was to receive "Nectar thickened Hot Coffee." Observations revealed that Resident R36 received coffee, regular consistency. Interview with the Nurse aide, Employee E6, revealed that he was unaware that the resident's coffee was regular consistency and confirmed that Resident R36 had not received all thickened liquids according to the prescribed therapeutic diet.

Second floor dining observations conducted on December 13, 2023, at 12:45 p.m. revealed the following:

Resident R31 was observed drinking water, regular consistency. Observations of meal slip revealed Resident R31 was to receive "Nectar Thickened Liquids." Interview with Nurse aide, Employee E7 at approximately 12:50 p.m.confirmed this finding.

Further observations revealed Resident R71's meal slip indicated that the resident was to receive "nectar thickened liquids." Interview with Nurse aide, Employee E8, who was assisting Resident R71, at 12:52 p.m. revealed she was not ware Resident R71's milk was regular consistency and confirmed that thickened beverages were not provided for resident as ordered.

28 Pa. Code 211.6(c) Dietary services

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





 Plan of Correction - To be completed: 01/30/2024

R36 regular consistency coffee was removed and was given the prescribed consistency coffee immediately. R31's regular consistency water was removed and was given the prescribed consistency water immediately. R31 did not have any adverse reactions. R71's regular consistency milk was removed and given the prescribed consistency coffee immediately.

Dietary Manager will complete an audit to ensure that meal tickets match the prescribed beverage consistency.

Dietary Staff will be re-inserviced on diet consistencies for the beverages that are placed on the tray to match the meal ticket consistency.

Nursing staff will be re-inserviced on diet consistencies for residents that need thickened liquids have the prescribed beverage on the resident's tray.

Dietary manger or designee will inspect thickened beverage consistencies weekly for 3 months to match the meal ticket consistency with the beverage on the tray.

Administrator or designee will randomly inspect trays for thickened liquids to match the meal ticket consistency monthly for 3 months. Any findings will be reported to the monthly QAPI for further recommendations.

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 observation, staff interview, review of facility documents and review of facility policy, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards for one of two medication rooms observed (second floor medication room).

Findings include:

Review of facility policy on controlled substances revealed that under section "Policy Statement", the facility shall comply with all laws and regulations and other requirements related to storage, disposal and documentation of scheduled II and another controlled substances. Under section "Policy Interpretation and Implementation", #3. Controlled substances must be, counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record. #4. If the count is correct, an individual resident controls substance record must be made for each resident who will be receiving a controlled substance. Do not enter more than one prescription per page. This record must contain: a. Name of the resident, b. Name and strength of the medication, c. Quantity received, d. Number on hand, e. Name of Physician, f. Prescription number, g. Name of Issuing Pharmacy, h. Date and time received, i. Time of administration, j. Method of administration, k. Signature of person receiving medication and l. Signature of nurse administering medication. #5. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. #9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies through their Director of Nursing services.

Observation of the second-floor medication room with Employee E12 conducted on December 13, 2023, at 12:03 pm revealed that the medication room had a lock. Interview with Employee E12 conducted at the time of the observation revealed that only the charge nurses have the key to the medication room.

Observation of the medication refrigerator in the second-floor medication room revealed that the refrigerator did not have a lock.

Further observation of the refrigerator revealed a locked transparent plastic box labelled two south containing 2 bottles of liquid Morphine Sulfate and a bottle of Liquid Lorazepam.

Further observation revealed that the screw attaching the box to the inside of the refrigerator broke off from the refrigerator and the box was not affixed to the refrigerator.

Interview with Licensed nurse, Employee E12 conducted at the time of the observation confirmed that the screw attaching the box to the inside of the refrigerator broke off from the refrigerator and the box was not affixed to the refrigerator.

Interview with Licensed nurse, Employee 12 conducted at the time of the observation confirmed that the box containing 2 bottles of Morphine Sulfate and a bottle of 30 ml of Lorazepam 2mg/ml has broken off from the refrigerator and that it was not permanently affixed to the refrigerator.

Licensed nurse, Employee E12 then left the medication room and Licensed nurse, Employee E 13 came in to complete with observation with surveyor.

Further observation of the second-floor medication room with Licensed nurse, Employee E13 confirmed that the medication refrigerator in the second-floor medication room contained a locked box labelled two south containing 2 bottles of Morphine Sulfate and a bottle of liquid Lorazepam and that the box was not affixed to the refrigerator.

Further interview with Licensed nurse, Employee E13 confirmed that the screw attaching the box to the inside of the refrigerator broke off from the refrigerator and the box was not affixed to the refrigerator and that the screw attaching the box to the inside of the refrigerator broke off from the refrigerator and the box was not affixed to the refrigerator.

Observation of bottle #1 conducted with Licensed nurse, Employee E13 revealed that bottle #1 of Morphine Sulfate was labelled with Resident R4's name. Further, it was labelled "Morphine Sulfate Solution 100 ml/5ml solution, quantity 30, light blue, solution raspberry.

Further observation revealed that there was 30 ml of liquid inside bottle #1

Observation of bottle #2 conducted with Employee E13 revealed that bottle #2 of Morphine Sulfate was labelled with Resident R4's name. Further, it was labelled "Morphine Sulfate 20 mg/ml concentrate Generic for Roxanol, 0.25 ml, quantity 15 and with date July 13, 2023

Further observation revealed that there was 15 ml of liquid inside bottle #2.

Observation of bottle #3 conducted with Employee E13 revealed that the bottle #3 was labelled with Resident R4's name. Further, it was labelled Lorazepam Oral Concentrate 2mg/ml.

Further observation revealed that there was 30 ml of liquid inside bottle #3.

Interview with Employee 13 conducted at the time of the observation confirmed that the above observation.

Follow-up observation of the second-floor medication room conducted on December 14, 2023, at 9:30 am with Licensed Nurse, Employee E14 revealed that the medication refrigerator did not have a lock. Further observation revealed that the medication refrigerator contained a locked box labelled two south containing 2 bottles of liquid Morphine Sulfate and a bottle liquid Lorazepam

Further observation revealed that the box was temporarily attached to the inside wall of the refrigerator using a black tape. Further, the box was falling out of the inside wall of the refrigerator and a gray putty like material was observed between the inside wall of the refrigerator and the box attach the box into the inside of the refrigerator. Further observation revealed that the putty like material was soft with the consistency of a playdough. Further, the box containing two bottles of liquid Morphine Sulfate and one bottle liquid Lorazepam can be easily pulled off from the inside of the refrigerator and was not permanently affixed to the inside of the refrigerator.

Interview with Employee 13 conducted at the time of the observation confirmed that that the box was temporarily attached to the inside wall of the refrigerator using a black tape. Further, the box was falling out of the inside wall of the refrigerator and a gray putty like material was observed between the inside wall of the refrigerator and the box attach the box into the inside of the refrigerator. Further observation revealed that the putty like material was soft with the consistency of a playdough. Further, the box containing two bottles of liquid Morphine Sulfate and one bottle liquid Lorazepam can be easily pulled off from the inside of the refrigerator and was not permanently affixed to the inside of the refrigerator.

The box containing 2 bottles of liquid Morphine Sulfate and a bottle liquid Lorazepam was not permanently affixed to the unlocked refrigerator from the time of the initial observation (December 13, 2023) through the time of the follow-up observation (December 14, 2023).

28 Pa. Code 201.14(a) Responsibility of licensee


28 Pa. Code. 211.12(c) Nursing services

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



 Plan of Correction - To be completed: 01/30/2024

The locked narcotic box has been re-attached to the Second Floor Medication Room refrigerator.
The locked narcotic box on the First Floor Medication Room refrigerator has been audited to ensure that it is attached.

The Director of Staff Development or designee will re-inservice RN and LPN staff regarding the need to notify the Director of Nursing if the locked narcotic box is not securely attached in the Medication Room refrigerators.

The Director of Nursing or designee will audit the locked narcotic boxes to ensure they are securely attached in the Medication Room refrigerators weekly x 4 and then monthly thereafter. The results of the audits will be forwarded to the QAPI Committee for further review and recommendations and to determine the need for further audits and/or action plans.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 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 a review of facility documents, observations, and interviews with staff, it was determined that the facility did not establish a system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation for one resident and failed to provide necessary pharmaceutical services for one of five residents reviewed. (Resident R86 and Resident R4).


Findings include:

Review of facility policy on controlled substances revealed that under section "Policy Statement", the facility shall comply with all laws and regulations and other requirements related to storage, disposal and documentation of scheduled II and another controlled substances. Under section "Policy Interpretation and Implementation", #3. Controlled substances must be, counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record. #4. If the count is correct, an individual resident controls substance record must be made for each resident who will be receiving a controlled substance. Do not enter more than one prescription per page. This record must contain: a. Name of the resident, b. Name and strength of the medication, c. Quantity received, d. Number on hand, e. Name of Physician, f. Prescription number, g. Name of Issuing Pharmacy, h. Date and time received, i. Time of administration, j. Method of administration, k. Signature of person receiving medication and l. Signature of nurse administering medication. #5. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. #9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies through their Director of Nursing services.

Review of second floor narcotic book revealed that there were two narcotic accountability sheets for liquid morphine sulphate for Resident R4.

Review of the first narcotic accountability for a Morphine Sulphate for Resident R4 conducted with Employee E13 revealed that the page was numbered 70. Further, the following were written on the accountability sheet. Resident's name: Resident R4, Drug dosage: 0.25 milliliters (ml) (morphine sulphate), Direction: 0.25 ml every 3 hours for pain or SOB (shortness of breath) . Further review revealed that on July 10 (no year was indicated), 30 ml was the amount left.

Review of the second narcotic accountability for a Morphine Sulphate for Resident R4 conducted with Employee E13 revealed that the page was numbered 72. Further, the following were written on the accountability sheet: Resident's name: Resident R4, Drug dosage: 0.25ml (morphine sulphate), Direction: 0.25 ml every 3 hours for pain or SOB. Further review revealed that on July 14 (no year was indicated), at 9am, 30 was the amount left.

Observation of the medication refrigerator in the second-floor medication room with Employee E13 conducted on December 13, 2023, at 12:03 pm revealed a box containing two bottles of liquid Morphine Sulfate.

Observation of bottle #1 conducted with Employee E13 revealed that bottle #1 of Morphine Sulfate was labelled with Resident R4's name. Further, it was labelled "Morphine Sulphate Solution 100 ml/5ml solution, quantity 30, light blue, solution raspberry.

Further observation revealed that there was 30 ml of liquid inside bottle #1

Observation of bottle #2 conducted with Employee E13 revealed that the second bottle of Morphine Sulfate was labelled with Resident R4's name. Further, it was labelled "Morphine Sulphate 20 mg/ml concentrate Generic for Roxanol, 0.25 ml, quantity 15 and with date July 13, 2023

Further observation revealed that there was 15 ml of liquid inside bottle #2.

The above observation revealed that there was a discrepancy between the 15 ml. of Morphine Sulphate in bottle #2 and the documentation on the morphine sulphate accountability sheet.

Interview with Licensed nurse. Employee E13 conducted at the time of the observation confirmed that that bottle #1 labelled "Morphine Sulphate Solution 100 ml/5ml (20 mg/ml) for Resident R4 had 30 ml of liquid inside bottle #1 and that bottle #2 was labelled "Morphine Sulphate 20 mg/ml concentrate Generic for Roxanol had 15 ml of liquid inside bottle #2.

Further interview with Licensed nurse, Employee E13 also confirmed that there was a discrepancy between the 15 ml. of Morphine Sulphate in bottle #2 and the documentation on the morphine sulphate accountability sheet.

This discrepancy was not identified during the shift-to-shift count from July 14, 2023, to December 13, 2023.

Review of physician orders for Resident R86 dated November 18, 2023, revealed medication orders for Cephalexin (Antibiotic medication) 500 mg one tablet four times a day for cellulitis.

Review of medication administration record (MAR) for Resident R86 for the month of November 2023 revealed that the resident did not receive Cephalexin on November 18, 2023, at 1:00 p.m., November 19, 2023, at 1:00 p.m. and 5:00 p.m. and November 28, 2023, at 9:00 p.m. The MAR documentation revealed that the medication was not available to be administered.

Interview with the Assistant Director of Nursing, Employee E3, on December 15, 2023, at 11:10 a.m. confirmed that the medication was not administered as ordered and the medication was not available from the pharmacy.

28 Pa. Code 201.18(b)(2) Management

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


28 Pa. Code 211.12(d)(1)(3)(5) Nursing services




 Plan of Correction - To be completed: 01/30/2024

Resident R 4's narcotic inventory was corrected at the time of the discovery. Resident R86's physician was made aware that the antibiotic medication was not available to be administered.

The narcotic inventory and the narcotic accountability sheets were audited to ensure that were no discrepancies. Current residents who received antibiotic medication from 12/1/23 will be audited to ensure that medication was available and administered as ordered.

The Director of Staff Development or designee will re-inservice the RN and LPN staff regarding the Controlled Substances Policy with a focus on ensuring that the narcotic inventory matches the narcotic accountability sheets. The Director of Staff Development or designee will re-inservice the RN and LPN staff regarding the need to ensure that antibiotic medication is available from the pharmacy and administered as ordered.

The Director of Nursing or designee will audit the narcotic inventory and the narcotic accountability sheets to ensure there are no discrepancies weekly x 4 and then monthly thereafter for 90 days. The results of the audits will be forwarded to the QAPI Committee for additional review and recommendations and to determine the need for further audits and/or action plans.

The Director of Nursing or designee will perform random audits for those residents on antibiotic medication to ensure that the medication is available and administered as ordered weekly x 4 and then monthly thereafter for 90 days. The results of the audits will be forwarded to the QAPI Committee for additional review and recommendations and to determine the need for further audits and/or action plans.

483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on interviews with staff and review of the clinical record, it was determined that the facility failed to ensure that that residents received treatment and care in accordance with professional standards of practice related to failing to ensure that recommendations from the resident's cardiologist recommendations were followed for one out of 26 residents reviewed (Resident R24).

Findings include:

Review of the December 2023 physician orders for Resident R24 indicated that the resident was admitted into the facility on December 23, 2022, and had diagnoses of diabetes (a condition that related to an individual having blood sugar that is too high); hypertension (high blood pressure) and difficulty in walking.

Review of the resident's Quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated December 1, 2023 indicated that the resident was cognitively intact.

Review of a consultation dated November 28, 2023, from the resident's cardiologist appointment on the referenced day, documented that the resident had a diagnosis of chronic systolic heart failure (a condition in which an individual's left ventricle of the heart is weak and cannot pump blood efficiently). Continued review of the consultation included the following "Daily Goals" that the cardiologist made for Resident R24's care which included being weighed daily, and notifying the cardiologist if his weight increased 2-3 pounds overnight, or if his weight increased to 3-5 pounds within a week. The other "Daily Goals" made after the consultation instructed the resident to limit his salt intake to 1500-2000 milligrams per a day to prevent fluid retention, instructing the resident to limit his fluid intake to no more than 64 ounces of fluid each day, in addition to instructing the resident to exercise for a limited amount of time each day.

During an interview with Resident R24 on December 12, 2023, at 2:14 p.m. Resident R24 was observed on his bed eating with 2 bottles of water on his bed that were 16.9 ounces each. Four cases of water were also observed on the side of the resident's bed, in the corner, next to his window. Resident R24 was asked if he got his weight taken every day at the facility and he replied "no." During the interview the resident was also asked if the fluid he drank each day was limited by a certain amount, and Resident R24 reported that he received a kidney transplant "years ago," and "as far as I know, I can drink as much as I want to drink each day."

Review of the resident's clinical record did not show evidence that the facility acknowledged/followed up with any of the recommendations that were made by the cardiologist to ensure continued appropriate care, services treatment and monitoring related to his heart failure condition that he was seeing the cardiologist for.

During an interview with Employee E12 on December 13, 2023 at 10:55 a.m. it was confirmed that there was no documentation to show evidence that the facility ensured that the recommendations of the cardiologist were followed through with, and if not, a valid reason provided.

28 Pa. Code:201.18(b)(1)(3) Management.

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




 Plan of Correction - To be completed: 01/30/2024

Resident R 24's cardiology consult was reviewed by the physician and new orders were initiated on 12/13/2023.

Current residents with out of facility consults since 12/1/23 have been audited to ensure that recommendations are reviewed with the physician and new orders initiated if they are approved by the physician.

The Director of Staff Development or designee will re-inservice RN and LPN staff to ensure that residents with out of facility consults have had the consult reviewed by the physician and new orders initiated if they are approved by the physician.

The Director of Nursing or designee will complete random audits for those residents who have out of facility consults to ensure that the consult has been reviewed by the physician and new orders initiated if they are approved by the physician. Audits will be completed weekly x 4 and then monthly thereafter for 90 days. Results of the audits will be forwarded to the QAPI Committee for review and recommendations and to determine the need for further audits and/or action plans.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on observation, staff interviews, review of facility policy, and review of clinical records, it was determined that the facility failed to follow physician orders for oxygen administration for two of 26 residents observed. (Resident R79 and Resident R42).

Findings include:

Review of facility policy on Oxygen Administration revealed that under section "Purpose" revealed that the purpose of this procedure is to provide guidelines for safe oxygen administration. Under section "Steps in the Procedure"# 8. Turn on the Oxygen. Unless otherwise ordered, start the flow of Oxygen at the rate of 2 to 3 liters per minute. #10. Adjust the flow of Oxygen device so that it is comfortable for the resident and proper flow of Oxygen is being administered.

Review of Resident R79's physician's order dated February 9, 2023, revealed an order for Oxygen orders 2 liters/minute, via nasal canula, continuous oxygen every shift.

Observation of Resident R79 conducted on December 12, 2023, at 10:18 am during the tour of the second floor revealed that Resident R79 was on oxygen concentrator via nasal cannula at 3.5 liters/minute.

Further observation revealed that the oxygen tubing attached from Resident R79's nasal cannula to the oxygen concentrator did not have a date affixed on it.

Review of Resident R79's clinical record revealed an order for Oxygen orders- 2Liters perminute, via nasal canula, continuous oxygen every shift for SOB (shortness of breath).

Follow-up observation on Resident R79 conducted on December 13, 2023, at 8:35 am revealed that Resident R79 was on oxygen concentrator at 3.5 liters/minute.

Interview with Nurse Supervisor Employee E12 conducted at the time of the observation confirmed that Resident R79 was on oxygen Concentrator via nasal cannula at 3.5 liters/minute.

Further, Employee E12 also confirmed that Resident R79's order was for 2 liters of Oxygen. Employee E12 adjusted Resident R79's Oxygen rate from 3.5 liters to 2 liters. Employee E12 adjusted the Oxygen flow rate from 3.5 liters/minute to 2 liters/minute.

Review of the December 2023 physician orders for Resident R42 included the following diagnosis: bipolar (a mental health condition that causes extreme mood swings between emotional highs and lows); dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and diabetes (a condition that related to an individual having blood sugar that is too high).

Review of the Resident R42 December 2023 physician orders included a physician's order with a start date of December 12, 2023 for nursing staff to administer 2 liters of oxygen to the resident to treat his shortness of breath.

During an observation in Resident R42's room on December 12, 2023 at 1:13 p.m. Resident R42's oxygen concentrator was observed as administering 2.75 liters of oxygen.
During an observation with Employee E16 in Resident R42's room on December 12, 2023 at 1:15 p.m. Employee E16 was confirmed that the resident was not receiving the correct amount of oxygen, as ordered by the physician.

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





 Plan of Correction - To be completed: 01/30/2024

Resident R 79's oxygen was adjusted as ordered and the oxygen tubing was replaced and dated and labeled. Resident R 42's oxygen was adjusted as ordered.
Current residents who require oxygen have been audited to ensure that they are receiving oxygen as ordered by the physician and that the oxygen tubing was dated and labeled.

The Director of Staff Development or designee will re-inservice the RN and LPN staff that residents receiving oxygen must have their oxygen administered as ordered by the physician and their oxygen tubing dated and labeled appropriately.

The Director of Nursing or designee will audit residents who receive oxygen weekly x 4 and then monthly thereafter for 90 days to ensure that residents are administered oxygen as ordered by the physician and that their oxygen tubing is labeled and dated appropriately. The results of the audits will be forwarded to the QAPI Committee for further review and recommendations and to determine the need for further audits and/or action plans.

483.35(g)(1)-(4) REQUIREMENT Posted Nurse Staffing Information: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.
§483.35(g) Nurse Staffing Information.
§483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

§483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.

§483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

§483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.
Observations:

Based on observation and staff interview, it was determined that the facility failed to accurately display facility daily nurse staffing hours as required for one of four days.

Findings Include:

On September 15, 2023, at 11:04 a.m. observations at the front receptionist desk revealed staffing data was posted for the previous day, December 13, 2023. Further observation revealed that the staffing indicated the projected number of staff, but the actual number was left blank.

Further observations in the lobby area, including the front and back doors of the facility, the first and second- floor nursing units failed to reveal posted staffing data.

Interview with the facility receptionist, Employee E10, on December 15, 20253 at approximately 11:06 a.m. confirmed the above-mentioned findings, that there was no staffing data posted anywhere in the lobby area.

Interview with the first-floor unit manager, Employe E17, on December 15, 2023, at approximately 11:10 a.m. confirmed that there was no staffing data posted on the first floor.

Interview with he first floor Unit Manager, Employee E18, revealed that the staffing person would be responsible to ensure that the staffing data is posted.

28 Pa. Code 211.12 (d)(1)(3)(4) Nursing services



 Plan of Correction - To be completed: 01/30/2024

The daily staffing postings were updated immediately.

The Staffing Coordinator has been re-inserviced to ensure daily staffing postings are updated daily and posted at each nurses station and at reception.
Staffing Coordinator will ensure daily staffing postings are updated daily and posted at each nurses station and at reception.

Administrator or designee will periodically inspect nurses stations and reception to ensure that daily staffing postings are updated and available for two weeks. Any findings will be reported to the QAPI meeting for further recommendations.

§ 201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on staff interviews and review of facility infection control documentations, it was determined that the facility failed to ensure compliance with the requirements of the "Medical Care Availability And Reduction Of Error (Mccare) Act - Reduction And Prevention Of Health Care-Associated Infection And Long-Term Care Nursing Facilities Act Of Jul. 20, 2007, P.L. 331, No. 52 " .

Findings include:

The Act 52, "Medical Care Availability And Reduction Of Error (Mccare) Act - Reduction And Prevention Of Health Care-Associated Infection And Long-Term Care Nursing Facilities Act Of Jul. 20, 2007 ", indicated that a health care facility should develop and implement an internal infection control plan that should be established for the purpose of improving the health and safety of residents and health care workers and should include a multidisciplinary committee including a representative from each of the following, if applicable to the specific health care facility:

(i) Medical staff that could include the chief medical officer or the nursing home medical director
(ii) Administration representatives that could include the chief executive officer, the chief financial officer, or the nursing home administrator
(iii) Laboratory personnel
(iv) Nursing staff that could include a director of nursing or a nursing supervisor
(v) Pharmacy staff that could include the chief of pharmacy
(vi) Physical plant personnel
(vii) A patient safety officer
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility.

Review of the monthly attendance sheets for the Infection Control Committee dated February 2023 through November 2023 revealed that the medical director and a community member was not included in the committee.

During an interview on December 15, 2023 at 12:00 p.m.. Employee 3, Assistant Director of Nursing, confirmed that the Infection Control Committee did not include a community representative and medical director as required in accordance with Act 52.




 Plan of Correction - To be completed: 01/30/2024

Facility can not retroactively correct the deficient practice.
The Assistant Director of Nursing will re-inservice the Director of Infection Control will ensure attendance and the required signature on the sign-in sheet of the Medical Director and a Community Member for the Infection Control Committee.

The Director of Nursing or designee will audit the attendance and the required signature on the sign-in sheet of the Medical Director and a Community Member for the Infection Control Committee monthly x 3 months. Results of the audit will be submitted to the QAPI Committee for review and additional recommendations and to determine the need for further audits and/or action plans.


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

Visit the PA Power Port