Pennsylvania Department of Health
ST. MARY'S VILLA NURSING HOME, INC.
Patient Care Inspection Results

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ST. MARY'S VILLA NURSING HOME, INC.
Inspection Results For:

There are  56 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.
ST. MARY'S VILLA NURSING HOME, INC. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a revisit survey completed on January 30, 2024, it was determined that Saint Mary's Villa Nursing Home corrected the federal deficiencies cited during the survey of November 30, 2023, but continued to be out of compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(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 information submitted by the facility, select facility policy and reports and clinical records and staff interviews it was determined that the facility failed to provide necessary supervision and effective safety measures to prevent an elopement by one resident (Resident 1) out of 12 sampled residents.

Findings include:

Review of facility policy entitled "Elopement", last reviewed by the facility April 2023, indicated it is the policy of the facility to promote resident safety through prevention of elopements, while allowing residents as much physical freedom as possible and to initiate a facility-wide search (including the grounds) immediately upon discovery of a missing resident. When residents who are identified as "at risk to leave the facility unattended" cannot be located on the unit, or any resident is identified as missing from the facility, the following procedure will be implemented:
-The charge nurse will notify the nursing supervisor on duty.
-The nursing supervisor will assign specific areas to be searched to specific staff. 1) will be assigned to search all areas within the unit including closets, bathroom, utility rooms, etc. 2) will be assigned to search all other areas in close approximation of where the resident was last seen. 3) will be assigned to search outside perimeters of the facility. 4) will search the ancillary areas.
-The nursing supervisor will notify the Administrator and the Director of Nursing as soon as the search has commenced.

Observation of a posting located at the first-floor nurse's station on January 30, 2024, at approximately 11 AM revealed that the posting indicated that when a [door] alarm sounds, "check panel to see which door is sounding. Silence alarm by pressing 1 2 3 4, call the extension, or check the area of the alarm. If it is clear, reset the alarm. Always remember to reset! The doors are not alarmed if system is not reset."

A review of the clinical record revealed that Resident 1 was admitted to the facility on May 7, 2019, with diagnoses, which included dementia unspecified severity with agitation, depression, and anxiety. According to the resident's MDS assessments, the resident was severely cognitively impaired.

An Elopement Risk Assessment dated October 31, 2023, revealed that the results did not identify Resident 1 to be at risk for elopement.

The resident's annual MDS Assessment dated November 21, 2023, indicated that Resident 1 had not experienced behaviors or wandering but was severely cognitively impaired with a BIMS score of 5.

Review of Resident 1's clinical record revealed that the resident was receiving physical therapy from October 26, 2023, to November 22, 2023, due to a recognized changes in resident's ambulatory status, wheelchair mobility, and transfer status. According to the therapy documentation, Resident 1 made progress exhibiting improved core and bilateral lower extremity (BLE) strength and control, improved transfers and improved transfer ability. The resident had also accepted a wheelchair for mobility on nursing unit to decrease fall risk and propels wheelchair with BLE with supervision with good endurance. The resident was discharged from physical therapy to nursing care and restorative nursing program on November 22, 2023.

Review of information submitted by the facility revealed that on December 4, 2023, at 6:30 PM, nursing staff recognized that Resident 1 was not in her room on the unit. At 6:35 PM a community member passing the facility found Resident 1 on the main road leads to the driveway entrance of the facility, picked up the resident in their car, and then contacted the police. The police contacted then facility,

The facility reviewed video surveillance as part of their investigation, which was also reviewed by the surveyor on January 30, 2024, in the presence of the Nursing Home Administrator. When reviewed at the time of the survey ending January 30, 2024, the video showed Resident 1 had self-propelled herself in her wheelchair off the nursing unit and entered the second-floor elevator at 6:17 PM. The resident took the elevator to the basement level where she propelled herself through the hallway and opened the beauty shop exit door, which "tripped" the facility's alarm. Resident 1 then self-propelled through the opened therapy department door, and is no longer seen on the video. Further observation of the video surveillance revealed that s facility staff member responded to the location of the alarm, opening the beauty shop exit door and looking outside, and searched the immediate area, which included the unoccupied therapy room, but didn't find anyone in the vicinity. The staff member then returned to the nursing unit without looking outside.

Resident 1 was then seen again on video surveillance footage walking outside the facility and down the facility driveway leading away from the building to the main access road where she was then out of video surveillance range.

Observation conducted on January 30, 2024, of the the location where it was believed Resident 1 had exited the facility, revealed a flight of concrete stairs that the resident had to climb to get to the back parking lot of the building. According to interview the Nursing Home Administrator on January 30, 2024, the resident had left her wheelchair in the therapy department and independently walked up the flight of stairs.

Upon return to the facility, Resident 1 was assessed with no injuries identified. The physician ordered the resident to be sent to the emergency room for further evaluation, with no concerns identified.

Facility investigation determined that Resident 1 may have been looking for her old room. The resident's room was recently changed on November 8, 2023, to place her closer to the nurse's station due to frequent falls and attempts to self-rise from her wheelchair. Due to her cognitive impairment, the resident was unable to verbalize why she left the facility or where she was going.

Review of witness statement completed by Employee 1, licensed practical nurse, dated December 4, 2023, revealed that she returned from break as the alarm was being disarmed (silenced) by Employee 2, nurse aide. According to Employee 1, Employee 2 stated that the alarm was tripped by the beauty shop door. Employee 1 then asked Employee 2 to go check the area and when she returned, Employee 2 reported that nobody was downstairs. Then approximately 20 minutes later, the wife of a resident called the unit to inform her that she passed a vehicle who had someone in their car, they assumed it was a resident here [at the facility] so decided to call "Immediately I notified my supervisor and performed a head count on my unit".

Review of witness statement completed by Employee 2, nurse aide, dated December 4, 2023, revealed that just before dinner trays were picked up on [unit] 28, the door alarm was going off. Employee 2 checked the alarm panel and it read "beauty shop." Employee 2 then cancelled the alarm and reset the door. Employee 1 then returned from break and the aides reported the alarm. "I went down to investigate why the beauty shop alarm was going off, it was coming from a chair in the physical therapy room. I turned off the alarm and started to call 'hello, anyone down here?' The chemical room door was open, Employee 2 looked inside, no one was there so she closed the door. Employee 2 then returned to the unit after not finding/seeing anyone in the basement.

There was no indication that any facility employee went outside to look in the immediate vicinity of the exit door, when no one was immediately visible from the vantage point of looking from the doorway.

Interview with the Nursing Home Administrator and the Director of Nursing on January 30, 2024, at approximately 3:00 PM, confirmed that the facility failed to provide necessary supervision and implement effective safety measures for this resident, who left the facility and its grounds unsupervised.


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

28 Pa Code 201.18 (e)(1) Management

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



 Plan of Correction - To be completed: 02/19/2024

The resident was moved back to her old room and nursing unit. The resident is monitored with q 15 minute checks to ensure her whereabouts at all times. Her picture has been placed at our front desk lobby along with other residents identified at risk for exiting facility.

The Elopement Policy was reviewed. All resident's of the facility had a elopement risk assessment completed and no new residents were identified. Assessments will continue on all new admissions, quarterly and with any identified change in condition placing them at risk for exiting.

Staff will be re-educated to ensure a staff member is assigned to search outside parameters of the facility, especially when but limited to when an alarm activated door exiting to the outside is triggered. Education will be conducted by Staff Development/DON/Designee on the policy to ensure they have an understanding of the policy as written.

Elopement Risk Assessments will continue with all new admissions, MDS quarterly assessments and any identified change in condition placing residents at risk for exit seeking. These assessments will be reviewed at QA meetings moving forward. All new staff will be educated on elopement policy and procedure.


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