Pennsylvania Department of Health
VINCENTIAN HOME
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

VINCENTIAN HOME
Inspection Results For:

There are 124 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.


VINCENTIAN HOME - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Medicaid/Medicare Recertification, State Licensure and Civil Rights Compliance survey completed on May 2, 2025, it was determined that Vincentian Home 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(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

Observations:

Based on review of facility policy, observations and staff interview, it was determined that that the facility failed to determine it was safe to self-administer medications, did not have a current order or care plan to self-administer medications, or an interdisciplinary assessment for one of five residents (Resident R302).

Findings include:

Review of the facility policy "Self-Administration of Medications by Residents" last reviewed 3/19/25, indicated self-administration of medication is the ability of a resident to take medications independently without assistance from another person. The resident shall be assessed for competency using the assessment for self-administration of medications. The results shall be documented in the resident's record and care plan. Specific orders for self-administration of medication shall be documented in the resident's medical record and care plan. Each resident's medication shall be clearly labeled by the prescribing pharmacy.

Review of the facility policy "Skin and Wound Assessment" last reviewed 3/19/25, indicated residents identified with a pressure ulcer or non-pressure related skin conditions will be monitored for evidence of further breakdown or complication. Verify a physician's order for the procedure.

Review of the facility policy "Medications Administration" last reviewed 3/19/25, indicated medications shall be administered only upon the order of physicians and physician extenders who are authorized and have been granted clinical privileges to write such orders. Licensed nurses shall administer prescribed medications, fluids and treatments.

Review of the admission record indicated Resident R302 was admitted to the facility on 4/21/25, with diagnosis that included irritable bowel syndrome (IBS- a gastro-intestinal disorder that causes abdominal pain, bloating and changes in bowel patterns), overactive bladder (sudden urges to urinate that are hard to control), and dysphagia (difficulty in swallowing).

During an interview and observation completed on 4/28/25, at 10:51 a.m. Resident R302 voiced that she has frequent episodes of incontinence and her bottom was raw, bleeding and sore. Resident 302 stated "I wash and clean myself and apply Aquaphor ointment and desitin cream", and further stated "I would like a good look over when I get my shower". The Aquaphor ointment was observed sitting next to the commode in her bathroom.

During an interview completed on 4/28/25, at 10:58 a.m. Registered Nurse (RN) Employee E1 confirmed the Aquaphor ointment was in Resident R302's bathroom and stated, "there is not a label, I think her family brought it in for her to use".

Review of Resident R302's clinical record on 4/28/25, at 11:00 a.m. failed to include orders for the Aquaphor ointment or for self-administration of medications, failed to include a care plan, or an interdisciplinary assessment.

During an interview completed on 4/30/25, at 2:43 p.m., the Director of Nursing confirmed Resident R1 did not have a current order, care plan to self-administer medications, or an interdisciplinary assessment, and that the facility failed to determine it was safe to self-administer medications for one of five residents (Resident R1).

28 Pa. Code 201. 18(b)(1) Management
28 Pa code:211.10(c)(d) Resident care policies
28 Pa Code:211.12(c)(d)(1)(2)(5) Nursing services

Plan of Correction - To be completed: 06/17/2025

Resident R302 was discharged from the facility on 5/2/25. Prior to discharge from the facility self-administration assessment was completed. Physician order obtained and care plan initiated.
The facility will act to protect residents in similar situations and will obtain orders, complete an assessment, and update the care plan to allow residents to keep, secure, and administer their meds to promote autonomy.
Measures the facility will take to ensure practice does not recur include assessing residents for Self-Administration of Medications who are eligible by the Licensed Nurse. In addition, education will be provided to all the Licensed Nurses not to leave medications with a resident who has not been assessed for Self-Administration of medications. This education will be provided by the DON/ADON/Designee.
Performance will be monitored by conducting medication administration audits with the Licensed Nurses. A minimum of 3 audits weekly for a period of four weeks, and monthly thereafter for a period of three months. Audits will be conducted by DON/ADON/Designee and results will be reported at the quarterly Quality Assurance Committee Meeting.

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 facility policy, clinical record review, and interview, it was determined that the facility failed to have physician order specifications relating to the size of indwelling catheter (a thin, flexible tube inserted into the bladder through the urethra to drain urine) and balloon inflation amount (secures catheter to bladder) for one of three residents (Resident R305).

Findings include:

Review of the facility policy " Foley Catheter Care" last reviewed 3/19/25, indicates to maintain a closed, sterile drainage system and minimize the risk of infection. Obtain physician order for foley catheter use. Include bulb and catheter size, frequency of catheter changes and catheter care instructions.

Review of Admission record indicated Resident R305 was admitted to the facility on 4/23/25, with the diagnosis of dysphagia (difficulty in swallowing), chronic kidney disease (affects the kidneys ability to filter waste), and urinary retention (bladder doesn't completely empty).

Review of Resident R305's physician orders dated 4/22/25, indicated exchange Foley catheter on the 22nd of each month and when directed by provider.

Review of Resident R305's physician orders dated 4/22/25, indicated Foley catheter bag dignity cover on at all times.

Review of Resident R305's physician orders dated 4/22/25, indicated irrigate Foley catheter with 50 milliliters (mL) Normal Saline Solution (NSS) if complete or partial occlusion suspected. May irrigate once each shift. Notify provider if irrigation ineffective. Exchange Foley if directed by provider as needed

Review of Resident R305's physician orders on 4/4/25, failed to include specifications for size and balloon inflation amount for the indwelling foley catheter.

Interview on 4/30/25, at 3:02 p.m. the Assistant Director of Nursing (ADON) Employee E7 confirmed Resident R305's clinical record failed to provide specifications for size and balloon inflation amount of the indwelling catheter and that the facility failed to have physician order specifications relating to size of an indwelling catheter and balloon inflation amount for one of three residents (Resident R305).

28 Pa. Code 201. 18(b)(1) Management.
28 Pa code:211.10(c)(d) Resident care policies.
28 Pa Code:211.12(c)(d)(1)(2)(5) Nursing services.

Plan of Correction - To be completed: 06/17/2025

Resident R305 discharged on 4/30/25 from the facility. MD issued catheter order with foley size and inflation of the balloon.
The facility will act to protect residents in similar situations by conducting reviews of foley catheter orders and ensure order contains foley size and milliliter of fluid in balloon.
Measures the facility will take to ensure practice does not recur will include educational in-services by the DON/ADON/Designee to the licensed nurses. Educational in-services will include recognition of foley catheter orders from MD and must contain foley size and inflation of balloon.
Performance will be monitored by conducting audits for foley catheter orders and MD order to contain catheter size and inflation of balloon. These audits will be conducted 3 audits weekly for a period of four weeks, and monthly thereafter for a period of three months. Audits will be conducted by DON/ADON/Designee and results will be reported to the quarterly Quality Assurance Committee Meeting.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 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 review of facility policies, observations, clinical record review, and staff, resident, and family interviews, it was determined that the facility failed to provide appropriate respiratory care for two of five residents (Residents R67 and R307).

Findings include:

Review of the facility policy "C-PAP/Bi-PAP Storage" dated 3/19/25, indicated it is the policy of the facility to store CPAP (a method of positive pressure ventilation used with patients who are breathing spontaneously) machine in a clean dry environment. When not in use, place clean mask in a plastic bag (not airtight).

Review of the facility policy "Oxygen Concentrators-Usage and Care" last reviewed 3/19/25, indicates Nasal cannulas, masks, tubing and water bottles are to be changed weekly. The water bottle and tubing are to be dated and stored in a plastic bag attached to the concentrator when not in use.

Review of the clinical record indicated that Resident R67 was admitted to the facility on 4/4/25, with diagnoses of anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), heart failure (condition where the heart muscle doesn't pump blood as well as it should), and dysphagia (difficulty swallowing).

Review of Resident R67's physician order dated 4/4/25, indicated to apply CPAP on at bedtime. Reconnect mask and tubing (mask, reservoir, and tubing cleaned every morning and allowed to air dry). Utilize pre-programmed adaptive settings calibrated by pulmonology. Fill humidification reservoir with distilled water to level indicated. The order failed to include the settings for the CPAP and a diagnosis.

Review of Resident R67's unsigned and undated baseline care plan failed to include care interventions related to the resident's CPAP.

Review of Resident R67's MDS dated 4/10/25, indicated the diagnoses were current.

Review of Resident R67's care plan dated 4/18/25, indicated to provide CPAP maintenance per protocol.

During an observation and interview on 4/28/25, at 10:31 a.m. Resident R67's CPAP mask was observed not in a bag, sitting on the bed. Resident R67 stated "I use my CPAP every night."

During an observation on 4/29/25, at 10:05 a.m. Resident R67's CPAP mask was sitting on the resident's dresser not stored in a bag.

During an observation on 4/30/25, at 9:40 a.m. Resident R67's CPAP mask was sitting on the resident's dresser not stored in a bag.

During an interview on 4/30/25, at 9:58 a.m. Registered Nurse, Employee E3 confirmed Resident R67's CPAP mask was not stored properly.

During an interview on 4/30/25, at 11:03 a.m. the Director of Nursing (DON) confirmed the facility failed to implement a baseline care plan for Resident R67's CPAP.

Review of the admission record indicated Resident R307 was admitted to the facility on 4/25/25, with the diagnosis of pneumonia (infection in the lungs), congestive heart failure (CHF- heart can ' t pump blood as well as it should) and emphysema (chronic lung disease that causes shortness of breath and damage to the lung).

During an observation completed on 4/28/25, at 10:34 a.m. Resident R307 was in bed with his oxygen on via nasal canula (flexible tubing used to deliver oxygen) the tubing failed to be labeled with a date.

During an interview completed on 4/28/25, at 10:36 a.m. LPN Employee E2 confirmed the tubing failed to be labeled with a date.

During an interview on 5/2/25, at 11:56 a.m. the Nursing Home Administrator (NHA) and DON confirmed the facility failed to provide appropriate respiratory care for two of five residents (Residents R67 and R307).

28 Pa. Code: 201.14(a) Responsibility of licensee
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Plan of Correction - To be completed: 06/17/2025

Residents have been discharged and were corrected during survey.
The facility will act to protect residents in similar situations by conducting a whole house audit of current residents receiving oxygen and CPAP/BIPAP care orders for date and initials on the oxygen tubing and humidification bottles, and all masks have a clean bag to store mask.
Measures the facility will take to ensure practice does not recur will include educational in services by the DON/ADON/Designee to the licensed nurses. Educational in-services will include that residents receiving oxygen have the date and initials on the tubing, humidification bottles, CPAP/BIPAP mask are stored in a plastic bag.
Performance will be monitored by conducting 3 audits of residents receiving oxygen have the date and initials on the tubing, humidification bottles, and storage of mask and non-used nasal cannula in a plastic bag. These audits will be conducted weekly for a period of four weeks, then monthly thereafter for a period of three months. Audits will be conducted by Infection Control Assistant/Designee and results will be reported to the quarterly Quality Assurance Committee Meeting.

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(f). 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 facility policy, clinical records, and staff interviews it was determined that the facility failed to implement pharmaceutical services to ensure accurate provision of medications for one of five residents (Resident R250).

Findings include:

Review of the facility policy, "Pharmacy Requirements" last reviewed 3/19/25, indicated regular and reliable pharmaceutical service is available to provide residents with prescriptions and non-prescriptions medications, services, and related equipment and supplies. Pharmacy services will be provided routine and timely.

Review of Residents R250's admission record indicated admission to the facility on 4/24/25, with diagnoses of anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), calculus of kidney, and Alzheimer's Disease (a progressive brain disorder that gradually destroys memory, thinking skills, and the ability to carry out daily tasks).

Review of Resident R250's physician order dated 4/24/25, indicated to administer two tablets of TheraLith XR (medication formulated to support and maintain normal urine chemistry), two times a day, related to calculus of kidney.

Review of Resident R250's April 2025 Medication Administration Record revealed the resident did not receive TheraLith as ordered from 4/24/25, through 4/28/25. A total of nine dose were missed.

Review of Resident R250's progress note dated 4/28/25, revealed the resident's TheraLith was unavailable from the pharmacy.

During an observation of a medication pass, on 4/29/25, at 10:16 a.m. Resident R250's Theralith was unavailable. Registered Nurse, Employee E10 confirmed Resident R250's TheraLith was not in stock and available for administration.

During an interview completed on 4/29/25, at 11:15 a.m. the Nursing Home Administrator (NHA) confirmed the facility failed to implement pharmaceutical services to ensure accurate provision of medications for one of four residents (Resident R250).

During an interview on 4/29/25, at 2:51 p.m. the Director of Nursing (DON) stated the pharmacy was out of stock of TheraLith and that was the reason resident did not receive the medication as ordered.

28 Pa. Code 201.14 (a) Responsibility of licensee.
28 Pa. Code 211.9 (a)(1)(k)(l)(1)(2)(3)Pharmacy services
28 Pa. Code 211.10 (c) Resident care policies.
28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Plan of Correction - To be completed: 06/17/2025

Resident R250 discharged on 5/3/25. Prior to discharge order was updated by MD, medication was obtained from pharmacy and no adverse effects occurred with resident not receiving vitamin.
The facility will act to protect residents in similar situations by reviewing admission orders of new residents and the pharmacy will notify SNF of medications not available.
Measures the facility will take to ensure practice does not recur will include educational in-services by the DON/ADON/Designee to the licensed nurses. Educational in-services will include recognition of reconciliation of admission medications, notification from pharmacy regarding medications not in stock, obtain an order from MD to hold medication until available at facility.
Performance will be monitored by conducting audits on new admission orders, notification from pharmacy, and MD order obtained. These audits will be conducted 3 audits weekly for a period of four weeks, and monthly thereafter for a period of three months.

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 review of facility policies, observations and staff interview it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of four nursing units (Building 2-2) failed to properly store medical supplies in two of five medication carts (County high hall and Country low hall ) and two of four medication rooms (Beach hall high and Country hall high).

Findings include:

Review of the facility policy "Medication Storage" last reviewed 3/19/25, indicated medications and biologicals are stored safely, securely, and properly following manufactures recommendations or those of the supplier. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medications supplies are locked or attended by persons with authorized access.

Review of the facility policy "Medication Administration" last reviewed 3/19/25, indicated the individual administering a medication shall be aware of the following information including but not inclusive to the expiration date has not been exceeded.

During an observation and interview on 4/28/25, at 10:07 a.m., Resident R254 was observed to have the following medications located on the bedside table in a tissue box.
-(1) Bottle of Systane Complete PF eye drops
-(1) Bottle of Refresh Digital PF eye drops
-(1) Ventolin HFA Inhaler 90 mcg per actuation

During an interview on 4/30/25, at 9:35 a.m. the above medications were observed again on Resident R254's bedside table in a tissue box.

During an interview on 4/30/25, at 9:38 a.m. RN, Employee E3 confirmed Resident R254's medications were not properly stored.

During an interview on 4/30/25, at 10:10 a.m. the Nursing Home Administrator confirmed the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of four nursing units (Building 2-2).

During a medication cart review on 04/29/25, at 9:18 a.m. the following was observed in the fourth drawer of the Country high hall cart:
. Two bags of suppositories comingling with oral medications.

During an interview completed on 4/29/25, at 9:58 a.m. Registered Nurse (RN) Employee E8 confirmed the two bags of suppositories were comingling with oral medications.

During a medication cart review on 4/29/25, at 9:35 a.m. the following was observed in the top drawer of the Country high hall cart:
. 1 vial of COVID 19 testing solution that failed to be labeled with an open date.

During an interview completed on 4/29/25, at 9:50 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the COVID 19 testing solution failed to be labeled with a date.

During a medication storage room observation on 4/29/25, at 9:51 a.m. the following was observed in the Country high hall medication storage refrigerator:
. Two unlabeled cold brick ice packs

During an interview completed on 4/29/25 at 9:56 a.m., LPN Employee E2 confirmed the Country high hall medication storage refrigerator contained unlabeled cold brick ice packs.

During a medication storage room observation on 4/30/25, at 9:30 a.m. the following was observed in the Beach high hall cupboard above sink:
. One box monojet 1 milliliter (ml) insulin safety syringe with the use by date 10/31/24.

During an interview completed on 4/30/25, at 9:35 a.m. LPN Employee E9 confirmed that the box of monojet 1 milliliter (ml) insulin safety syringe had a use by date of 10/31/24.

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

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

Plan of Correction - To be completed: 06/17/2025

Resident R254 discharged from the facility on 5/7/25. Prior to end of survey, resident self-administration assessment completed, and care plan updated. Resident locked meds in her beside table.
Ensure all medication carts, medication rooms, and medication refrigerator contain proper items that are dated, not expired, and all medications are stored separated and not comingling with other routes of biologicals.
Measures the facility will take to ensure practice does not recur will include educational in-services by the DON/ADON/Designee to the licensed nurses. Educational in-services will include properly storing medications, make sure items are not expired, and only medications can be stored in medications area.
Performance will be monitored by conducting audits for proper storage of biologicals that are not expired and separated by route of medications, no nonbiological stored in such deemed areas. These audits will be conducted 3 audits weekly for a period of four weeks, and monthly thereafter for a period of three months. Audits will be conducted by DON/ADON/Designee and results will be reported to the quarterly Quality Assurance Committee Meeting.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§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)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on review of facility policy, observations, and staff interviews, it was determined that that the facility failed to implement a surveillance plan for tracking, and monitoring residents who tested negative for COVID during an outbreak for six of six months (August 2024 to February 2025) and failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R67)

Review of the "Respiratory Virus Outbreak Toolkit" dated 11/14/24, indicated a case-line listing is designed to collect information about all ill cases (residents and staff) during an outbreak in a long-term care facility. It was indicated upon identification of an outbreak, use this template to collect and organize information on cases. The type of test ordered and if pathogens were detected must be recorded.

A review of the facility policy "Skin and Wound Assessment", last reviewed 3/19/25, guidelines for the application of dry, clean dressings indicates step in procedures include but not inclusive to:
. Wash and dry your hands thoroughly. Put on clean gloves.
. Clean the bedside stand. Establish a clean field.
. Place the clean equipment on the barrier. Arrange the supplies so they can be easily reached.
. Use a waste basket away from clean field.
. Remove the soiled dressing, pull glove over dressing and discard into waste basket.
. Wash and dry your hands thoroughly. Put on clean gloves
. Cleanse the wound with ordered cleanser.
. Remove your gloves, wash your hands, and apply new gloves.
. Apply the ordered dressing
. Discard disposable items including the barrier.
. Clean the bedside stand
. Remove the garbage from the waste basket.
. Wash and dry your hands thoroughly.

A review of the facility procedure "Hand Hygiene" last reviewed 3/19/25, indicates:
. Always follow standard precautions.
. Gloves shall be worn when contact with blood, bodily fluids, mucous membranes, non-intact
skin etc., is anticipated.
. Change gloves when moving from a contaminated body site to a clean body site on the same
resident.

Review of the facility's line listing for covid on 4/29/25, at 12:40 p.m. revealed the most recent COVID outbreak started on 8/27/24, and the last positive was on 3/1/25. A further review failed to include residents who tested negative.

During an interview on 4/29/25, at 12:55 p.m. the Infection Preventionist (IP), Employee E7 stated "I thought the new guidance was not to track residents who tested negative." IP, Employee E7 confirmed the facility failed to ensure residents who tested negative for COVID were included on the facility's line listing.

During an interview on 4/29/25, at 3:00 p.m. the Director of Nursing (DON) and IP, Employee E7 confirmed the facility failed to implement a surveillance plan for tracking, and monitoring residents who tested negative for COVID during an outbreak for six of six months (August 2024 to March 2025).

Review of the admission record indicated Resident R67 was admitted to the facility on 4/4/25.

Review of R67's Minimum Data Set (MDS-periodic assessment of care needs) dated 4/10/25, included diagnoses of anemia (the blood doesn't have enough healthy red blood cells), hypertension (high blood pressure), and heart failure (the heart doesn't pump blood as well as it should).

Review of Resident R67's physician order dated 4/9/25, indicates cleanse right heel with soap and water and pat dry. Apply Medi honey to wound base and cover with calcium alginate hold in place with border gauze daily and as needed

During a wound care observation on 4/30/25, at 10:57 a.m. Registered Nurse (RN) Employee E3 washed her hands, put gloves on, placed a basin that contain soapy water and wash cloth on the bed as well as dressing supplies and extra gloves. RN Employee E3 used her inner legs to hold Resident R67's right foot off the floor and removed her sock. RN Employee E3 removed soiled dressing, pulled glove over soiled dressing and placed on the bed, cleansed the wound with a washcloth removed from the basin applied Medi honey onto alginate and placed on heel and covered with border gauze. RN Employee E3 removed her gloves, placed sock back on foot. Picked up the basin containing the washcloth, removed washcloth with her hand and squeezed out the soapy water. Removed remaining items on bed, removed gown and placed into trash in the resident's bathroom and exited the room.

During an interview completed on 4/30/25, at 11:16 a.m. RN Employee E3 confirmed a clean field was not established. Pulling the glove over soiled dressing and placing onto the bed, not completing hand hygiene during the dressing change, squeezing out washcloth without gloves and not completing hand hygiene after completion of procedure and that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R67)

28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 211.12 (d)(3) Nursing Services.

Plan of Correction - To be completed: 06/17/2025

Resident R67 – continues to reside in the facility. A new dressing was applied after the dressing change observation.
Employee was counseled by the DON on the proper Clean/Dry Dressing change procedure policy for performing a dressing change.
The facility will act to protect residents in similar situations by conducting reviews of current residents with wound dressings.
Line Listing will be completed with negative results with the next outbreak. IP will complete the updated procedure.
Measures the facility will take to ensure practice does not recur will include educational in-services by the DON/ADON/Designee to the licensed nurses. Educational in-services will include to follow the Skin Assessment - Clean/Dry Dressing change procedure policy when performing a dressing change. Line listing for IP will include negative results during an outbreak.
Performance will be monitored by conducting and observing dressing changes with 2 or more licensed nurses weekly for a period of four weeks, then monthly thereafter for a period of three months. Audits will be conducted by DON/Designee and results will be reported to the quarterly Quality Assurance Committee Meeting.

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