Pennsylvania Department of Health
WESLEY ENHANCED LIVING AT STAPELEY
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WESLEY ENHANCED LIVING AT STAPELEY
Inspection Results For:

There are 137 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.


WESLEY ENHANCED LIVING AT STAPELEY - 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, State Licensure Survey and an Abbreviated survey in response to a complaint, completed on August 9, 2024, it was determined that Wesley Enhanced Living at Stapeley, 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, Commonwea,th of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency 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 environmental observations of the food and nutrition department, interviews with staff and reviews of policies and procedures, it was determined that foods were not being stored, prepared, distributed and served in accordance with professional standards for food service safety.

Findings include:

Review of the undated dietary policy titled cleaning of the main kitchen revealed that it was the responsibility of the dietary employees to ensure that food service equipment, housekeeping of the physical environment of the kitchen was cleaned and sanitized routinely. The dietary staff were responsible to report any maintenance issues to the maintenance department for repairs of equipment and structural adjustments.

An environmental tour of the main kitchen where foods and beverages were being prepared, stored and distributed to the satellite kitchenettes on the firsrt floor and second floor nursing units revealed the following:

The main kitchen environmental tour was completed with the director of dietary services, Employee E5 10:00 a.m., on August 5, 2024 and 9:30 a.m., on August 6, 2024. Interview with the director of dietary, Employee E5, at 10:30 a.m., on August 6, 2024 confirmed the lack of routine implementation of proper sanitation and food handling to prevent foodborne illness.

Observations of the three compartment sink area where racks of cleaned dishes were being stored for cooking and food preparation revealed light fixtures and ceiling tiles that were heavily soiled with dust, dirt and food debris. A majority of the ceiling tiles contained brown stained and water damage. The area was dim and missing overhead lighting. The light screenscontained a collection of dead common household pests (roaches).

The fan blowing directly on cleaned pots, pans, trays and dishes was heavily soiled with dirt and dust. The ceiling vent in this area was heavily soiled with dust and dirt.

The wall area surrounding the three compartment sink was soiled with dried food debris. The sink garbage disposal for food scraps and kitchen waste was consistenly running spewing water into the sink and sorting area for cleaned dishes. There was no lid/cover for the garbage disposal while in use.

The floor area underneath the three compartment sink, garbage disposal and large racks of cleaned dishes was covered with water. The floor drains contained a build-up of food debris and dirt which was obstructing the floor of water into the drain.

The metal door leading directly outside the facility to the trash and refuse area was was not sealing completely. The threshold of the door upon closing left a one inch air gap and easy access to the building for common household pests and rodents. The dry food stage area was located adjacent to the unsealed doors. The entrance to the main kitchen of the food and nutrition department was located near the improperly installed doorway.

28 PA. Code 201.14(a) Responsibility of licensee

28 PA. Code 201.18(b)(1)(2.1) Management

28 PA. Code 211.6(f) Dietary services

Plan of Correction - To be completed: 09/20/2024

A. Pot room, sink, walls, and cleaning were cleaned and tiles replaced as needed.
B. Procedure for proper cleaning of the room was reviewed with Dining utility workers.
C. GM created daily check list for the room
D. GM or designee will monitor check list and room daily x 2 weeks, weekly x 4 four weeks with results of audits reported through CQI process.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

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(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on environmental observations of two of thirty-six resident rooms, reviews of policies and procedures, interviews with staff and residents, it was determined that the facility failed to ensure reasonable care for the protection of resident's property from loss or theft for two of 22 residents reviewed. (Resident R88 and Resident R27)

Findings include:

Review of the policy titled Abuse: zero tolerance dated February 25, 2009 revealed that it was the responsibility of the administrator to create an atmosphere at the facility in which abuse of any nature toward or by a resident, co-worker, visitor or service provider was not acceptable behavior. The policy indicated that the definition of abuse included but was not limited too misappropriation of property. Misappropriation of property was the deliberate misplacement, exploitation, or wrongful (temporary or permanaent) use of a resident's belongings or funds without the resident's consent. The policy also indicated that the facility was responsible for investigation to determine the causative factor of the missing personal property. The facility was also responsible for listing the amount of money missing, staff who would have had access to the money, when the money was last seen and where the money was usually kept.

Review of the policy titled room furnishings dated August 8, 2024 revealed that the facility was responsible for providing each resident with a drawer or cabinet in their room that could be locked.

Clinical record review for Resident R88 revealed a quarterly assessment MDS (an assessment of care needs) dated May 2, 2024 that indicated that this resident was cognitively intact. The assessment also indicated that Resident R88 had no functional limitations in range of motion of the upper extremities.

Review of information reported to the State Survey agency dated May 16, 2027 indicated that Resident R27 reported to staff that she was missing money from her wallet. A total of $110.00 was missing on May 16, 2024, after she returned to the facility from the dialysis center.

Interview with Resident R27 at 10:00 a.m., on August 9, 2024 confirmed that money in an amount of $110.00 dollars was never returned to her. Further interview with Resident R27 revealed that she was not offered or provided with a drawer or cabinet inside her room that could be locked to secure her personal property.

Observations of Resident R27's bedroom revealed that this resident did not have a drawer or cabinet that could be secured for storing personal belongings.

Interview with the Social Worker, Employee E12 at 10:30 a.m., on August 8, 2024 confirmed that Resident R27 was not offered or provided furniture in her room that could be locked or secured to safeguard personal property (money).

Review of a report submitted to the State Survey Agency dated June 16, 2024 indicated that Resident R88 reported to staff that he was missing money from his desk drawer inside his room. Resident R88 reported that a total of $30.00 dollars had been removed from his desk.

Observations of resident R88's bedroom revealed a piece of furniture that he brought into the facility from home. This desk was not able to be locked. There was no furniture provided by the facility inside the resident's room that had a locking drawer or cabinet to secure personal belongings (money).

Interview with resident R88 at 9:30 a.m., on August 9, 2024 revealed that the resident was never offered a drawer or cabinet inside his room to safeguard his belongings.

Interview with the Social Worker, Employee E7, at 11:00 a.m., on August 9, 2024 confirmed that Resident R88 had not been offered or provided a locked drawer or cabinet in his room to secure his personal belongings.

28 PA. Code 211.10(a)(b)(c)(d) Resident care policies

28 PA. Code 201.29(a)(b)(c) Resident rights

28 PA. Code 205.72 Furniture

Plan of Correction - To be completed: 09/20/2024

A. Locks were placed in resident's bedside table and residents were given keys
B. Room readiness check will occur for locked drawer and key
C. DON or designee will complete Room Audits weekly x4 and monthly x2
D. Results will be reported through CQI process

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

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

Observations:

Based on observation, clinical record review and interviews with staff, it was determined that the facility failed to develop a comprehensive person-centered care plan related to edema for one of 22 resident records reviewed (Resident R42).

Findings include:

Review of Resident R42 quarterly MDS (Minimum Data Set, an assessment of residents' needs) dated May 14, 2024, assessed the resident with severe, cognitive impairment, physical impairments to one side of the resident's upper and lower body, dependent on staff for wheelchair mobility, toileting, personal hygiene, and bathing. The MDS contained diagnosis of high blood pressure, Peripheral vascular disease (restricted blood flow to the lower extremities) Diabetes Mellitus (lack of insulin needed to send glucose to cells, leading to high blood sugar) Cerebrovascular Accident (stroke) and clinically depressed.

Review of Resident R42's nursing progress notes noted the resident's right hand first appeared swollen on January 20, 2024. Physician orders dated March 9, 2024, instructed to elevate the resident's right upper extremity at all times for edema (swelling cause by ex excessive fluid accumulation).

On August 5, 2024, at approximately 12:00 p.m. it was observed with Licensed Practical Nurse (LPN) Employee E13 that Resident R42 was in bed with her right arm by her side not elevated. The LPN confirmed orders to elevate the resident's right arm due to edema.

Further review of Resident R42's clinical record revealed the facility failed to develop a plan of care for the resident's edema including intervention that included elevating the extremity .

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

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

Plan of Correction - To be completed: 09/20/2024

A. Edema and risk of impaired skin care plans will be created for residents with edema.
B. Audit care plans on residents with edema. Review orders for edema and create a care plan.
C. Education will be provided to identify any edema during skin checks, notify physician, place any orders for edema management and create care plan.
D. DON or designee will audit edema care plans weekly x 4, monthly x 2 with results reported through CQI process

483.25 REQUIREMENT Quality of Care:

§ 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 review of clinical records and interviews with staff, it was determined that the facility failed to ensure a neurological assessments were completed and to obtain orders for the use of a hand splint for two of 22 residents records reviewed (Resident R85 and Resident R42).

Findings include

Review of Resident R85's quarterly MDS (an assessment of residents' needs) dated June 24, 2024, was assessed as severely, cognitively impaired with unwanted physical and verbal behaviors to others The same MDS indicated the resident required supervision from staff for walking, using a cane or walker for ambulating.

Review of Resident R85's care plan revealed he was a high risk for falls due to his impaired cognition and at risk for bleeding due to his diagnosis of Atrial fibrillation (irregular heartbeat with increased risk of blood clots and stroke). The resident was ordered Eliquis, an anticoagulant (blood thinner) medication used to decrease the risk of stroke. Care plan interventions included to monitor for bruising and or bleeding, and any decline in function and to notify the physician as needed.

Interview with the facility's Medical Director on August 8, 2024, explained there is an increased risk of bleeding when you are on an anticoagulant. Not every fall or an unwitnessed fall (potential head injury) immediately needs to go to the hospital. Nurses are instructed to perform Neurological assessments that start immediately after the fall occurs. This is done numerous times in the first 24 hours and if neurological changes are seen, they would contact the doctor for further instructions.

Further review of Resident R85's clinical record revealed on the following dates July 21, April 30, 29, and February 4, 2024, the resident experienced "Unwitnessed falls" and no evidence of the neurological assessments were completed by nursing.

On August 8, 2024, at 1:00 p.m. the Director of Nursing and the Nursing Home Administrator were requested neurological assessments for the above dates, and revealed no further documented evidence the assessments were completed.

Review of Resident R42's quarterly MDS (Minimum Data Set, an assessment of residents' needs) dated May 14, 2024, assessed the resident with severe cognitive impairment, physical impairments to one side of the resident's upper and lower body, dependent on staff for wheelchair mobility, toileting, personal hygiene, and bathing. The same MDS indicated the resident was diagnosed with high blood pressure, Peripheral vascular disease (restricted blood flow to the lower extremities) Diabetes Mellitus (lack of insulin needed to send glucose to cells, leading to high blood sugar) Cerebrovascular Accident (stroke) and clinically depressed.

On August 5, 2024, at 12:00 p.m., it was observed with Licensed Practical Nurse (LPN) Employee E13, Resident R42 had a splint on her left hand.

Review of Resident R42's physician order revealed the order for the resident's splint was discontinued and no evidence of an active order was found.

On August 7, 2024, at 2:30 p.m. the Nursing Home Administrator confirmed the facility failed to obtain an order for Resident R42's splint and no evidence the skin was being assessed while in use.

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

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

Plan of Correction - To be completed: 09/20/2024

A. All unwitnessed falls will require neuro checks. All applications of splints must have an order and be care planned
B. Audit every fall for neuro checks. Audit what current residents require a splint
C. Education will be provided on splints require an order and are care planed. Educate on the falls checklist and neuro exams to ensure neuro checks have been started and completed. Educate on all applications of splints need to have an ordered and are care planned.
D. DON or designee will audit fall reports and splints weekly x 4, then monthly x 2 with results reported through CQI process.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on review of clinical records, review of facility documentation and interviews with staff, it was determined that the facility did not ensure that each resident received adequate supervision to prevent a resident from falling out of the bed during personal care for one of 22 records reviewed (Resident R38).

Findings include:

Review of Resident R38's clinical record revealed that the resident was admitted to the facility on March 21, 2023 with the diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side Muscle weakness or partial paralysis can't get rid off on one side of the body that can affect the arms, legs, and facial muscles); dysphagia (difficulty swallowing); muscle weakness and morbid obesity;

Review of Facility Policy, "Turning A Resident on His/Her Side Away From You" undated, Purpose: The purposes of this procedure are to provide comfort to the resident, to prevent skin irritation and breakdown, and to promote good body alignment. Preparation: Review the resident's care plan to assess for any special needs of the resident.

Review of the quarterly Minimum Data Set- (a periodic review of residents needs) dated May 13, 2024, indicated that the resident was cognitively impaired and is rarely understood. Further review revealed that the resident was dependent (helper does all of the effort) for rolling left and right (the ability to roll from lying on back to left and right.) Functional status for bed mobility indicates extensive assistance with two persons physical assist.

Review of Resident R38's plan of care dated March 16, 2024 revealed: "I have an ADL (activity of daily living) deficit due to CVA (cerebral vascular disease) with right sided hemiplegia. I will be kept clean with dignity maintained. Staff will assist X 2 when providing care."

Review of nurse progress note dated May 20, 2024 revealed Employee 21, " Resident fell from bed. Small amount of blood around mouth was wiped away. Resident complained of pain in the face and right leg. Resident was assisted back to bed via hoyer. Resident was assessed. NP (Nurse practitioner) and family notified. Physician and NP in agreement to administer tylenol and begin neuro-checks (a neurological exam is a series of tests and questions that assess a person's nervous system, including the brain, spinal cord and nerve function).
Continued review revealed ...that Resident R38 will receive a bariatric bed."

Review of facility documentation, "Fall Investigation" revealed Employee E20, nurse aide, note: " I turned her on her left side and she went straight on the floor. Resident did not hit her head. She was face down lying on the floor."

Interview on August 6, 2024 at 10:00 am. with Employee E2, Director of Nursing revealed, "That staff member is no longer employed here. Employee was terminated."

Interview on August 6, 2024 at 10:30 a.m. with Employee E18, Second Floor Unit Manager, revealed "I conducted a re-education with our staff. We placed this resident on paired care. Residents who are on paired care will be placed on resident's dashboard."

The facility failed to ensure that Resident R38 was provided with two persons physical assist during personal care.

28 Pa. 28 Code 201.14 (c) Responsibility of Licensee

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

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

Plan of Correction - To be completed: 09/20/2024

A. All Employees were re-educated on proper following of the care plan
B. We will identify residents requiring assistance and review their ADL care plans
C. Create a SQAPE project to include a multidisciplinary team to understand how we communicate an increase or decrease in ADL' s and care plan management with the changes.
D. DON or designed will audit ADL care plans weekly x 4, then monthly x 2 with results reported through CQI process

483.50(b)(1)(i)(ii) REQUIREMENT Radiology/Other Diagnostic Services:

§483.50(b) Radiology and other diagnostic services.
§483.50(b)(1) The facility must provide or obtain radiology and other diagnostic services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(i) If the facility provides its own diagnostic services, the services must meet the applicable conditions of participation for hospitals contained in §482.26 of this subchapter.
(ii) If the facility does not provide its own diagnostic services, it must have an agreement to obtain these services from a provider or supplier that is approved to provide these services under Medicare.

Observations:

Based on review of clinical records, interviews with resident and staff, and facility policy. it was determined that the facility failed to obtain services in a timely manner when the facility could not obtain these services on site to meet the needs of one of 22 resident records reviewed (Resident R62).

Findings included:

Review of facility policy and protocol for labs and diagnostic test results reviewed in November 2018, revealed the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility.

Review of Resident R62's Admission's MDS (an assessment of residents' needs) dated May 16, 2024 assessed the resident as alert and oriented, independent of making daily life decisions diagnosed with a fracture, coronary heart disease, high blood pressure, diabetes mellitus (lack of insulin needed to send glucose to cells, leading to high blood sugar), cerebral vascular accident (stroke) with one sided weakness, one unstageable pressure ulcer due to a device found on admission,

Interview with Resident R62 on August 6, 2024 at 2:12 p.m. indicated at home she fell and broke her ankle in two places. The resident stated, "I didn't know it but when I fell I had a heart attack. While I was in the hospital from the fall, I had a stroke. I wear an immobilizer (for healing of fracture) I got a wound on the inside of my left ankle and was seeing a wound doctor at the hospital."

Review of Resident R62's physician's wound notes dated June 11, 2024 revealed the physician ordered ankle-brachial pressure indices (ABIs) a diagnostics for lower extremity arterial disease), left arterial duplex ultrasound (examines the arteries that carries blood to the leg) and left venous reflux ultrasound (evaluate for venous insufficiency).

When Resident R62 returned from the appointment, nursing progress note, dated June 11, 2024, noted the three tests prescribed by the physician and that the doctor was "Made aware of the recommendations and approved".

Review of the following wound appointment dated June 25, 2025, indicated on the last visit (June 11, 2024) prescription for ABI's, left arterial duplex ultrasound, and left venous reflux ultrasound sent with patient to take to facility in order for the facility to schedule. The studies need to be done prior to follow-up in two weeks.

Further review of Resident R62's clinical records revealed no evidence the ABI test was conducted.

Interview with Unit Manager Employee E11 on August 8, 2024, at 1:00 p.m. stated "we don't do ABI at the facility, and I do not see the test completed."

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

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

Plan of Correction - To be completed: 09/20/2024

A. Physician change ABI order to doppler study and study was completed.
B. All orders for ABI were reviewed to assure completion.
C. Nurses were provided education on proper f/u and completion of ABI or doppler orders
D. DON or designee will review all orders for ABI x 2 months with results reported through CVQI process

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 §483.70(e) 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 interviews with staff, it was determined that the facility failed to maintain proper infection control practices to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of 22 residents reviewed (Resident R8 and R42 )

Findings include:

Infection control policy for all nursing care procedures when caring for residents, revised on August 2012 states to perform hand hygiene after removing gloves, before handling clean or soiled dressings, and before moving from a contaminated body site to a clean body site during resident care and to perform hand hygiene before preparing or handling medications.

Review of the facility policy "Enhanced Barrier Precautions Policy and Procedure" updated August 2024, states the purpose of this policy is to mitigate the risk of transmission of Multidrug-Resistant Organisms (MDRO) by implementing Enhanced Barrier Precautions (EBP) by expanding the use of personal protective equipment (PPE) during high-contact resident care activities for certain residents. High contact examples include, providing hygiene, changing briefs, or assisting with toileting, device care or use of feeding tube and wound care. The same policy further states that indwelling medical device, is a device that provides a direct pathway for pathogens in the environment to enter the body and cause infection. Examples of indwelling medical devices for which EBP should be used include, but are not limited to indwelling urinary catheters and Feeding tube.

Review of Resident R42 quarterly MDS (Minimum Data Set, an assessment of residents' needs) dated May 14, 2024, assessed the resident with severe cognitive impairment, physical impairments to one side of the resident's upper and lower body, dependent on staff for wheelchair mobility, toileting, personal hygiene and bathing. The MDS included diagnosis of high blood pressure, Peripheral vascular disease (restricted blood flow to the lower extremities) Diabetes Mellitus (lack of insulin needed to send glucose to cells, leading to high blood sugar) Cerebrovascular Accident (stroke) and clinically depressed.

Review of Resident R42 physician orders effective since March 9, 2024, revealed the resident required a G-Tube (a surgically inserted feeding tube into the stomach for nourishment), instructed to wash the site daily with soap and water, to apply a foam dressing pad daily to the sacrum for preventative care.

On August 5, 2024 at 12:15 p.m with Licensed Practical Nurse (LPN) Employee E13 and Nursing Assistants (NA) Employee E16 and E17, Resident R42's incontinence and wound care was observed and staff did not ensure the enhanced barrier protection was being followed. During wound care the LPN removed Resident R42's sacral dressing and failed to clean hands prior to donning new gloves.

August 7, 2024 at approximately 9:00 a.m. during medication administration LPN E13 held Resident R8's cup with hand on top of cup and palm rested on the rim as the drink was delivered to the resident.

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

Plan of Correction - To be completed: 09/20/2024

A. Proper care for effected Resident was completed.
B. Proper procedure while performing enhanced barrier dressing changes was provided to all Nurses.
C. DON or designee will observe dressing changes three times per week for four weeks and then once per week x 2 months.
D. Results of observations will be reported through CQI process

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Plan of Correction - To be completed: 09/20/2024

A. Community is unable to retroactively correct deficiencies
B. DON or designee will conduct daily review of staffing to ensure required ratios for C.NA.'s and Nurses are met each shift

C. The staffing coordinator will in-service to the staffing requirements.

DON or designee will conduct audits to assure compliance weekly x 4 weeks, monthly x 2 months with results reported through CQI process.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Plan of Correction - To be completed: 09/20/2024

A. Community is unable to retroactively correct deficiencies
B. DON or designee will conduct daily review of staffing to ensure required ratios for C.NA.'s and Nurses are met each shift
C. The staffing coordinator will in-service to the staffing requirements.
DON or designee will conduct audits to assure compliance weekly x 4 weeks, monthly x 2 months with results reported through CQI process.

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