Fox Subacute at South Philadelphia

Inspectors wroteBased on observation, clinical record review and interviews with staff, it was determined the facility failed to ensure Resident R1 was kept safe from accidents related to exposed bedframe parts for one of 10 residents reviewed. This failure resulted in actual harm to Resident R1 who sustained lacerations to the forehead and inside of the mouth as well as bruising to the left eye when the resident's face came into contact with the bed frame during care. Resident R1 required transfer to the hospital. This deficiency is cited as past non-compliance. [...]

Inspectors wroteBased on review of facility policies, clinical record review and interviews with residents and staff, it was determined that the facility failed to ensure that a resident's representative was informed of a resident's change of status to make treatment decisions, for one of 16 residents reviewed (Resident R16).

Inspectors wroteBased on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to ensure that personal privacy was provided during treatment and medication administration for two of 16 residents reviewed (Residents R27 and R28).

Inspectors wroteBased on observation, review of clinical record, review of facility policy and interview with staff, it was determined that the facility failed ensure that a person-centered care plan was developed for one of sixteen residents reviewed. (Resident R27)Review facility policy on plan of care and interdisciplinary care conference revealed that under section policy the facility will develop a meaningful plan of care and compliance with state and federal regulatory requirements that meets the individual needs of the resident in order to provide quality of care and the components that are necessary for the quality of life of the individual. Review of Resident R27's clinical record revealed that Resident was admitted to the facility on [DATE], with diagnoses of Chronic Respiratory Failure. [...]

Inspectors wroteBased on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to ensure that Enhanced Barrier Precautions were followed during treatment and medication administration for three of 16 residents reviewed (Residents R8, R28 and R33).

Inspectors wroteBased on review of clinical documentation and staff interviews, it was determined the facility failed to ensure adequate supervision during care by not ensuring two staff members were present for one of five residents reviewed (Resident R1). This failure constituted neglect and resulted in actual harm to Resident R1, who fell during the provision of incontinence care and sustained a fracture of the right humeral head (upper arm bone at the shoulder). This deficiency was identified as past noncompliance.

Inspectors wroteBased on observation, a review of select facility's policy, clinical records review, and staff interviews, it was determined that the facility failed to ensure the evaluation of resident's need and use of restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom and failed to timely obtain informed consent prior to the use of restraint for one of one sampled residents with restraints. (Residents R5)

Inspectors wroteBased on the observations, review of clinical records, and interview with staff, it was determined that the facility failed to ensure that a resident with limited range of motion, received appropriate services to prevent further decline in range of motion and maintain appropriate positioning for two of 13 resident s reviewed. (Resident R26 and Resident R33). Finding Include: Review of physician order for Resident R26 dated May 9, 2024, revealed an order for hand grip splint to be alternated right to left every 4 hours with a schedule of 12 AM, 4AM, 8AM, 12PM, 4PM and 8PM. Review of physician order for Resident R26 dated July 31, 2024, revealed an order for elbow positioning wedges to be applied bilaterally 4 hours then removed 4 hours with a schedule of 12 AM, 4AM, 8AM, 12PM, 4PM and 8PM. [...]

Inspectors wroteBased on review of clinical record, facility policy, facility documentation, and interviews with staff, it was determined that the facility failed to ensure that adequate assistance was provided to prevent a fall for one of two sampled residents reviewed for falls (Resident R33). This deficiency was identified as past non-compliance.

Inspectors wroteBased on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that adequate catheter care was provided for two of two sampled residents with urinary catheters reviewed (Residents R4, and R39).

Inspectors wroteBased on observations, review of facility policy, and interviews with staff, it was determined that the facility failed to properly date medication vials upon opening and failed to discard expired medication for two of three medication carts (Medication Cart Four and Medication Cart Five) and and two of two medication rooms (Room Two).

Inspectors wroteBased on observations, interviews with staff, and a review of facility policies and documentation, 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.

Inspectors wroteBased on review of clinical records and a staff interview, it was determined that the facility failed to ensure that the resident's representative was notified timely about a hospital transfer for one of three discharge records reviewed (Residents R49).

Inspectors wroteBased on observation, a review of clinical records, facility documentation and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plans regarding the use of hand mitt restraints for one of 13 residents reviewed. (Resident R37).

Inspectors wroteBased on observation, clinical record review and interview with staff, it was determined that the facility did not ensure that medications were discarded according to manufacturer instructions for 1 of 3 medication carts reviewed (Medication Cart Main B).

Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater, in two out of twenty-five medications reviewed.

Inspectors wroteBased on observations, interviews with staff, and a review of facility policies and documentation, 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.

Inspectors wroteBased on review of facility documentation and staff interview, it was determined that the facility failed to ensure nurse aide staff received in-service training to be proficient and competent and that the training be no less than 12 hour annually for two of three nurse aide staff. (Employee 16 and Employee 17). Findings Include: A request for nurse aides annual in-service training record for nurses' aides was requested on April 10, 2024. Review of nurses' aides training records revealed that nurse aides, Employee E16 and Employee E17 did not have the required 12 hours of annual in-service training as required. Interview with Director of Nursing, Employee E2 on April 11, 2024 at 1:02 p.m. confirmed there was no further record on in-service trainings for nurse aides' Employee E16 and Employee E17. 28 Pa. Code 201.14 (a) Responsibility of licensee.