Nursing Investigation Results -

Pennsylvania Department of Health
FOREST CITY NURSING AND REHAB 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
FOREST CITY NURSING AND REHAB CENTER
Inspection Results For:

There are  47 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.
FOREST CITY NURSING AND REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Abbreviated Complaint and Civil Rights Compliance Survey completed on February 1, 2019, it was determined that Forest City Nursing and Rehab Center was not in 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:


483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:This is a less serious (but not lowest level) 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 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(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e)

This includes:
483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who-
(i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is:
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.
Observations:

Based on staff interviews and a review of employee credentials it was determined that the facility failed to employ a full time qualified dietary services supervisor in the absence of a full time qualified dietitian.

Findings include:

During the initial tour of the food and nutrition services department on January 29, 2019, at 9:30 a.m., the dietary manager (DM) stated that her responsibilities included oversight of food preparation, service, and the storage of food. The DM stated that her job also included filling in as the cook on an as needed basis. The DM stated that the facility utilized a part-time registered dietitian who was responsible for the clinical oversight of residents.

During an interview January 31, 2019, at approximately 11 AM the assistant Nursing Home Administrator (ANHA) stated that the facility's dietitian hours decreased from full time to consultant status on December 6, 2018. The DON stated that from December 7, 2018, continuing to the time of the survey the facility did not have the services of a full time qualified dietitian. The DON relayed that the consultant dietitian would come to the facility approximately two times a week to complete resident assessments and address any resident care issues related to nutrition.

A review of the dietary manager's personnel file and interview with the DON further confirmed that the facility's full time dietary manager did not possess the regulatory required qualifications for the position.

The DON was unable to provide evidence that the food service director was receiving frequently scheduled consultation from a qualified dietitian to ensure that adequate guidance was provided to the food service director and staff of the dietary department.

Refer F803, F804, F812


28 Pa. Code 211.6 (c)(d) Dietary services
previously cited 3/30/18

28 Pa Code 201.18(e)(6) Management























 Plan of Correction - To be completed: 03/26/2019

The facility cannot retroactively correct their failure to employ a full time qualified dietary services supervisor.
The facility hired a qualified certified dietary manager, credentialed by the Certifying Board for Dietary Managers.
The qualifications for the management of other departments were reviewed and found to be in regulatory compliance for those requiring certification and or licensure.
The consultant dietitian will have weekly scheduled consultations with the qualified CDM to ensure that adequate guidance is provided to the food service director and staff of the dietary department.
Weekly evidence of documented consultation between the RD and CDM will be provided to the Administrator/ Designee to assure the dietitian is providing guidance to the CDM and dietary staff.

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program:This is a less serious (but not lowest level) 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 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 facility's infection control policies and procedures and staff interview, it was determined the facility failed to develop an antibiotic stewardship program.

Findings include:

Review of the facility policy entitled "Antibiotic Stewardship Program" last reviewed by the facility on May 2018, revealed the facility will incorporate seven elements of antibiotic stewardship to include: leadership committee, accountability, drug expertise, action, tracking, reporting and education. The policy failed to include evidence that an antibiotic stewardship program was in place to improve antibiotic use for the safety of residents.

There were no protocols developed to review clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made and identify what infection assessment tools or management algorithms are used for one or more infections.

There was no process for periodic review of antibiotic use by prescribing practitioners. No protocols were developed to optimize the treatment of infections by ensuring residents receiving antibiotics are prescribed the appropriate antibiotic.

In an interview on February 1, 2019, at 11:15 AM, the Assistant Nursing Home Administrator and Infection Control Registered Nurse stated that the facility had not yet developed specific protocols relating to antibiotic use and was unable to provide evidence of a functioning antibiotic stewardship program in the facility at the time of the survey.

Refer F757


28 Pa. Code 211.12 (c) Nursing services
Previously cited 3/30/18

28 Pa. Code 211.10(a)(d) Resident care policies
Previously cited 3/30/18





 Plan of Correction - To be completed: 03/26/2019

We cannot retroactively correct our failure to develop an antibiotic stewardship program to improve antibiotic use for the safety of residents.
The facility policy entitled "Antibiotic Stewardship Program" has been revised to include evidence that the program is in place to improve antibiotic stewardship through the use of the facilities newly developed suspected infection observation form. This tool will enable staff to review clinical signs and symptoms to determine if criteria is met for the justification of antibiotic use. In addition a protocol was developed to review any other pertinent diagnostic testing as well as the need to determine if the antibiotic is appropriate or if adjustments to therapy is indicated.
The Director of Nursing and Infection Control nurse will educate the licensed staff on the Antibiotic Stewardship Program including the uses of the newly developed suspected infection observation form which will determine if criteria is met before initiation of antibiotic therapy.
Attending Physicians were made aware of the changes to our Antibiotic Stewardship Program.
The infection control nurse will audit residents upon initiation of antibiotic therapy to determine that antibiotics are only ordered when necessary and are appropriate to the infection being treated. The infection control nurse will submit an audit of her findings weekly to the Director of Nursing. Findings will be reviewed at the scheduled quality assurance meetings.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) 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 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) 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 during a tour of the dietary department and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for microbial growth in food, which increased the risk of food-borne illness.

Findings include:

During the initial tour of the dietary department on January 30, 2019, at approximately, 9:30 a.m., with the Dietary Manager, the following sanitation issues, with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified:

The floor of the dry storage room was dirty; food debris and dirt was observed beneath the metal tiered storage units. The filter of the air conditioner, located above the door, was observed coated with cobwebs and dirt.

There was an opened plastic bag of shredded cheese on the shelf with no open date observed in the walk-in refrigerator.

The floor of the walk in freezer was soiled with dirt and food debris. There were two opened plastic bags with breaded chicken and pork chops, no open date and not secured closed.

The metal rack (located outside the refrigerator, storage for clean plates (desert) and bowls, revealed that multiple plates and bowls dirty with dried food. Silver trays were observed stacked on top of each other, while still wet with water observed inside.

The blade on the manual can opener was observed to be coated with sticky debris.

Two frying pans stored on a suspended ceiling rack, were observed with grease adhering to the inside surface.

The pallet holder was dirty inside with food debris and dried liquid stains.

Observation of the cooks refrigerator revealed that food stored on the floor of the unit and the walls were sticky and debris accumulated around the perimeter of the refrigerator.

Multiple lip plates were observed to be stained.

Dirt and food debris was observed behind the stove Dirt and food debris was observed accumulated around the perimeter of the kitchen area.

During an observation of the lunch meal service on January 31, 2019 at approximately 11:50 AM Employee 5 (dietary aide) with gloved hands, was observed to place dirty dishes into the dishwasher and with the same gloved hands removed the clean dishes from the clean side. She then went back to the dirty side of the dishwasher and started to rinse a pot and placed it into the rack and into the wash cycle. Employee 5 with the same gloved hands removed the clean pot from the dishwasher. These failures to maintain a separate flow of work for clean and dirty dishware was confirmed by the Dietary Manager at the time of the observation.

At approximately 12 PM Employee 3(cook) was observed plating the residents' lunch meal. Employee 3 relayed to the dietary aide that he only had 3 plates left to utilize for this meal service and Employee 3 needed an additional three plates to complete the residents' meal service. When Employee 3 had used the last available plate, he then, wearing the same gloves used during plating residents' meals, went to the dishwasher area, rinsed off three dirty plates with the sprayer and placed them into the dishwasher. He started the dish machine in the wash cycle, waited several seconds, opened the dishwasher door prior to the completion of the wash cycle and removed the three plates. Employee 3 then obtained a used towel from the cart in the clean dish area and wiped off the plates. Employee 3 wore the same pair of gloves throughout.

This observation was confirmed at the time by the Dietary Manager. The Dietary Manager was unable to state why the staff had run about of plates. The regular plates were white and fit into the plate warmers in order to maintain the temperature of the food delivered to the residents. The 10 blue plates used at the end of lunch service were larger than the white plates and did not fit properly into the pallet warmer.

During an additional interview January 31, 2019, at approximately 9:30 AM the dietary manager stated that the current par level of plates in the kitchen was 103. The census at the time of the survey was 95. The maximum resident capacity in the facility is 132. The dietary manager confirmed there were not enough plates in the facility.

Interview with the Dietary Manager at this time, confirmed that these observations were food safety, sanitation and management concerns.

Refer F801


28 Pa. Code 211.6 (c)(f) Dietary services.

28 Pa Code 201.18(e)(6) Management





 Plan of Correction - To be completed: 03/26/2019

The floor of the dry storage room and the floor of the walk in freezer were cleaned. Food debris and dirt beneath the metal tiered storage units was removed. The filter in the air conditioner above the door was changed. The open bag of shredded cheese in the walk in refrigerator and the open undated bags of breaded chicken and pork chops in the walk in freezer were discarded. Bowl and plates from the metal storage rack and wet silver trays were washed in the dishwasher, dried and returned. Sticky debris was removed from the blade of the can opener. Two identified frying pans were replaced. Cooks refrigerator was cleaned and affected food was discarded. Lip plates have been replaced. Sufficient dinner plates that fit properly into the pellet warmers were ordered to ensure a sufficient amount of plates for resident dining. Dirt and debris behind the stove and perimeter of the kitchen area were cleaned. The inside of the pallet holder was cleaned.
Employee #5 and employee # 3 were in-serviced by the infection control nurse on changing gloves between clean and dirty tasks in order to promote food service safety and decrease the potential for microbial growth in food which could increase the risk of food borne illness. Employee #3 was also reeducated on the importance of running the dishwasher through a full cycle to ensure sanitation of dishes and use of clean towels in an effort to prevent the potential for microbial growth and food borne illness.
A revised weekly cleaning schedule for the entire kitchen is in the process of being developed and implemented.
Dietary staff were reinserviced by the infection control nurse on the dietary department policies and procedures for safe storage of food and dietary sanitation to prevent the potential for microbial growth in food, which can increase the risk of food-borne illness. .
The assistant NHA/designee will conduct weekly audits of the dietary areas for cleanliness and safe food storage. Any identified unacceptable findings will be corrected immediately. Results of the audits will be reviewed at the quality assurance committee meeting where a need for continuance or resolution will be determined.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a written notice of transfer to the hospital was provided to the resident and the residents' representative for six of six residents reviewed for transfer to the hospital. (Residents 81, 47, 6, 25, 67, and Resident 23 )

Findings include:

A review of the clinical record revealed that Resident 81 was transferred and admitted to the hospital on December 12, 2018, and returned to the facility on December 17, 2018.

A review of Resident 47's clinical record revealed that the resident was transferred and admitted to the hospital on November 12, 2018, and returned to the facility on November 16, 2018.

Resident 6 was transferred to the hospital on January 8, 2019, and admitted he returned to the facility on January 10, 2019.

Resident 25 was transferred to the hospital on November 6, 2018, and admitted, he returned to the facility on November 8, 2018.

Resident 67 was transferred to the hospital on November 16, 2019, and was admitted, he returned to the facility on November 19, 2018.

Resident 23 was transferred and admitted to the hospital on October 13, 2018 and returned to the facility on October 19, 2018.

Further clinical record reviews revealed no evidence that a written notice was provided to the above residents and their representatives regarding the transfer that included the required contents: reason for the transfer, contact and address information for the Office of the State Long-Term Care Ombudsman, and if applicable, information for the agency responsible for the protection and advocacy of individuals with developmental disabilities.

Interview with the Director of Nursing on January 31, 2019, at approximately 11:00 AM verified that the facility did not send written notices to the resident and their residents' representatives of the facility initiated transfers of the above residents, but does send a monthly report to the State Ombudsman of facility initiated transfers.



28 Pa. Code 201.14(a) Responsibility of Licensee

28 Pa. Code 201.29(i) Resident rights













 Plan of Correction - To be completed: 03/26/2019

The facility cannot retroactively issue written notices of transfer to the hospital for residents # 81, 47, 6, 25, 67, and 23.
Our current bed hold transfer /therapeutic notification form was amended to include the reason for the facility initiated transfer to the hospital in a language that the resident and representative could understand and the hospital to which the resident was transferred.
The facility will ensure that a written notice of transfer to the hospital is provided to the resident and the resident representative which will include the reason for hospitalization in a language both the resident/representative can understand.
The Director of Nursing is in the process of inservicing all licensed staff on the changes to the Bed Hold Transfer/therapeutic Leave Notification form with focus of providing the reason for transfer to the hospital in a language the resident/representative can understand.
The quality assurance committee designee will do a weekly audit of bed hold/transfer /therapeutic leave notification forms to ensure that a written notice of transfer to the hospital was provided to the resident and representative in a language they could understand. The audit will be reviewed at the next quarterly QA committee meeting to evaluate our compliance with determination to discontinue the audit or alter the need for future audits.


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 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 observation, staff interview and review of select facility policy revealed that the facility failed to implement procedures to effectively clean and disinfect glucose meters (a medical device for determining the approximate concentration of glucose \ in the blood) to prevent the potential spread of infection for two out of two residents observed (Resident 72 and Resident 1)

Findings include:

A review of the facility policy entitled Blood Glucose Testing dated as reviewed May 2018 revealed that the procedure indicated the area to be punctured was to be cleaned with an alcohol prep pad and the area is to dry completely. Non-sterile gloves are to be worn then prick the finger with a lancet, squeeze finger until a drop of blood appears and then touch the blood to the glucose strip. Remove the strip remove gloves and wash hands. The meter is to be cleaned and disinfected between each resident.

During observation of Employee 1 the LPN (licensed practical nurse) on January 30, 2019, at 11:00 AM obtaining blood glucose levels by using a glucometer, Employee 1 took the glucometer from the drawer of the medication cart, did not clean the glucometer or apply gloves. She took a dry cotton swab into Resident 72's room, placed the glucometer on the resident's over-bed table. Employee 1 did not clean the over the bed table, on which multiple personal items of the resident were present. Employee 1 wiped the resident's finger with a dry cotton ball and and pricked his finger with the lancet. Employee 1 placed the glucometer back on the medication cart and did not clean the glucometer. She then placed the glucometer back on medication cart, donned gloves and took the glucometer into Resident's 1 room. She rolled back the sheet to uncover the resident's hand and placed the dry cotton ball and glucometer on the bedsheet, which was covering the resident. She then swabbed the resident's finger with a dry cotton swab and pricked her finger with a lancet and applied the blood to the strip in the glucometer. She returned the glucometer to the medication cart by placing back into its nylon case without cleaning it after using it on Resident 1.

Interview with the DON (director of nursing) on January 30, 2019, at 2:30 PM confirmed that Employee 1 did not obtain a blood sample according to facility procedures and did not clean and disinfect the glucometer as per facility procedure and manufacturer specifications, to prevent potential spread of infection.



28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services.
Previously cited 3/30/18


28 Pa. Code 211.10 (a)(d) Resident care policies
Previously cited 3/30/18








 Plan of Correction - To be completed: 03/26/2019

Employee #1 was counseled by the Director of Nursing regarding her failure to follow established procedures for obtaining a blood sample for a glucose reading, providing a clean field for equipment and failure to clean and disinfect the glucometer as per facility procedure and manufacturer specifications, to prevent potential spread of infection.
Licensed nursing staff including employee #1 are being reeducated on the policy and procedure for obtaining blood glucose samples and the cleaning and disinfecting of glucometers and importance of providing a clean field for equipment used for testing. Education will also include a focus on preventing potential spread of infection of blood borne pathogens.
A competency was developed and implemented for obtaining residents blood glucose testing. Following in-service education all licensed staff will be observed for technique by an RN who has adequately completed the competency to ensure that all licensed staff use proper technique to prevent the potential spread of infection.
A random recheck of 4 nurse's technique for performing blood glucose monitoring will be done weekly using the competency. Times will be varied to assure all shifts are included. Reeducation will be provided should practice be found to be below competency standard. The blood glucose competency will be reviewed by the DON/designee weekly and reviewed at the quarterly quality assurance committee meeting.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:
Based on resident and staff interviews, observations and temperature assessments it was determined that the facility failed to serve food at palatable temperatures.

Findings include:

During a group interview with cognitively intact residents conducted on January 30, 2019, at 11:00 a.m., multiple residents complained that the food served to residents on the first floor is often served cold.

Observation of the first floor lunch meal service on January 30, 2019, revealed that food cart left the kitchen at 12:20 PM arriving on the first floor nursing area at 12:22. At 12:25 PM, one nurse aide passed the trays to the residents on all three wings of the first floor. When there were two trays left to pass, a second nurse aide arrived and passed the last tray at 12:40 PM.
A test tray assessment was completed at the time the last resident was served and began eating revealing the following:

soup - 127 degrees farenheit; lasagna 131.5 degrees farenheit, garlic bread-121 degrees farenheit; the pudding was 58.6 degrees farenheit, coffee - 129.6 degrees farenheit, cranberry juice - 56.4 degrees farenheit and milk - 56.2 degrees farenheit.

The food and beverage items were not palatable at the temperatures served.

A review of service line food temperature record (a log of temperatures that are taken of the food before plating (pre-meal service) revealed that for the supper meals on January 28th and 29th,2019 and prior to the lunch meal January 30, 2019, food temperatures were not recorded prior to the meal service.

Interview with the dietary manager on January 30, 2019, at approximately 1 p.m., confirmed that the above temperatures were out of range for acceptable temperature and palatability. She further confirmed that pre-service trayline temperatures documented on the above dates.



28 Pa. Code 201.29(j) Resident rights.
previously cited 3/30/18

28 Pa. Code 211.6(c) Dietary services.
previously cited 3/30/18














 Plan of Correction - To be completed: 03/26/2019

Service line food temperatures are taken prior to each meal and recorded on the service line food temperature record to ensure that meals are at accurate and palatable temperatures when leaving the service line.
The assignment of lunch time duties has been revised to assure sufficient amount of staff are present to pass trays.
Food temperature and palatability satisfaction surveys will be done with capable residents and reviewed by the dietary manager/designee.
The dietary staff are being inserviced regarding acceptable temperature ranges for hot and cold food leaving the service line and the necessity of completing the log for each meal prior to meal service.
Nurses and Nursing Assistants were inserviced regarding the necessity to pass food trays in a timely manner therefore ensuring that food is served at acceptable palatable temperatures.
The dietary manager/designee will complete ten test trays weekly at various times and floors and document the temperatures.
Dietary manager/designee will audit test tray logs for completion daily.
Findings of the test tray and temperature logs will be submitted to the next quarterly quality assurance meeting for continuation or revision.



483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed: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(c) Menus and nutritional adequacy.
Menus must-

483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

483.60(c)(2) Be prepared in advance;

483.60(c)(3) Be followed;

483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

483.60(c)(5) Be updated periodically;

483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.
Observations:

Based on observation, review of the facility planned menus and menu extensions for regular, therapeutic, mechanically altered and renal diets and staff interview it was determined that the facility failed to follow planned menus to meet the nutritional needs of the residents including three of four residents sampled prescribed a renal diet (Residents 81, 73, and 86).

Findings include:

Review of the facility's Week Three Menu Extension revealed that the renal/regular diet for lunch included lasagna with Alfredo sauce, tossed lettuce salad, Texas toast /half slice and a cupcake with a choice of beverage; the puree renal diet included puree lasagna with Alfredo sauce and puree bread

A review of the clinical record revealed that Resident 81 was prescribed a renal, no added salt diet, (2 gm a day low sodium, 1200 mg phosphorus restriction, 80 mg of protein and 60 meq of potassium).

A review of the clinical records revealed that Resident 86 was prescribed a renal, no added salt diet. A review of the clinical record revealed that Resident 73 was prescribed a pureed renal diet.

Observation of the tray line during the lunch meal on January 30 , 2019, at 11 a.m., revealed that Residents 81 and 86 received two pieces of breaded chicken on whole wheat bread on their lunch trays. There was no indication at the time of the observation that these residents did not want the Lasagna that was planned on the menu. Breaded chicken was noted as the alternate entree for the regular diet. The menu also did not differentiate the beverages that were acceptable for renal diet.

Observation revealed that Resident 73 received regular puree lasagna ( made with tomato sauce, not the Alfredo sauce planned for renal diet) noted on the menu as well as the puree bread and vegetable. Resident 73 was not served the planned menu items on renal diet menu.

Continued observation revealed that Employee 3 (Cook) utilized a blue handled scoop to serve the puree bread and lasagna and a green handled scoop for the vegetable (different colored handles differentiate the portion size of the scoop, i.e., half a cup, cup, quarter cup)

During an interview at that time January 30, 2019, at approximately 12 PM Employee 4 (dietary manager) stated that she was unable to state if Employee 3 (cook) was using the proper size scoop to serve the portions of the items planned for the puree diets. She stated that she utilized a green scoop to serve all the puree food. The Dietary Manager did not know the portion sizes of the different colored handled scoops.

Interview with Employee 4 (dietary manager) January 30, 2019, at approximately 12:25 PM was unable to explain why the residents on the regular renal diets received breaded chicken on whole wheat bread, instead of the planned entree (Lasagna with Alfredo sauce) and the resident on the puree renal diet received the regular puree lunch entree instead of the renal alternative made with the Alfredo sauce. Employee 4 confirmed that it could not be determined if residents receiving puree consistency meals were receiving the full nutritional and caloric value of the planned menus based on dietary's staff lack of knowledge of portions and correct utensils to plate the food.



28 Pa Code 211.6 (a)(b)(c)(d) Dietary services.
previously cited 3/30/18










 Plan of Correction - To be completed: 03/26/2019

Residents #81, 86, and 73 are receiving the planned menu items on the renal diet including appropriate beverages.
Two additional residents identified with an ordered renal diet are also receiving the planned menu items on the renal diet including appropriate beverages.
Beverages acceptable for renal diets are now included on the planned menus.
A portion guide for serving amounts of regular items and puree items is visibly posted near the tray line to ensure residents receive the correct portions of food.
An inservice will be presented on the importance of following planned regular menus and menu extensions to meet the nutritional needs of the residents. The Menu Matrix recommended regular and extended diets, including renal diets, were reviewed with the dietary staff. The Menu Matrix defines the appropriate portion size for each item served to meet the nutritional needs of the residents. Dietary staff were inserviced on the proper size scoop to use when serving portions of planned menu items including puree diets.
Audits will be conducted on renal trays to identify if correct planned renal menu was followed including the beverage that is acceptable for the renal diet. One tray will be audited daily at random meals.
Audits will be conducted on puree trays to identify if correct portions are served according to the suggestion amount listed on the menu matrix. One tray will be audited daily at random meals.
Findings of these audits will be discussed at the quarterly quality assurance committee meetings.


483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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.
483.45(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on a review of clinical records and staff interview, it was determined that the facility failed to attempt dose reductions of psychotropic medications for two of five residents sampled (Resident 58 and 82).

Findings include:

A review of the clinical record revealed that Resident 58 was admitted to the facility on January 23, 2017 and had diagnoses that included dementia, depression and anxiety. The resident had a physician's order dated May 18, 2018, for Risperdal (an antipsychotic medication) .25 mg q HS (at bedtime) for dementia with behavioral disturbance.

A review of pharmacy recommendations dated October 30, 2018, revealed that the pharmacist requested that the physician evaluate the resident's current dose of Risperdal .25 mg and consider a gradual dose reduction. The physician response was "patient symptoms are not stable, dose decrease will cause a decline."

The physician's response did not include resident specific details of the instability of the resident's symptoms and a risk vs. benefit analysis of antipsychotic drug use. The physician failed to note how the medication, and its current dose, improved the resident's quality of life. In addition, the physician's response was not individualized to the resident's symptoms and potential decline, and failed to include resident specific information related to the benefit of the current dose of the medication and why a dose reduction was clinically contraindicated.

A review of the clinical record revealed that Resident 82 was admitted to the facility on March 24, 2018, with diagnoses that included dementia with psychosis. The resident's admission order from March 24, 2018, included Zyprexa (an antipsychotic medication) 5 mg daily for dementia with psychosis.

A review of pharmacy recommendations dated October 30, 2018, revealed that the pharmacist requested that the physician evaluate the current dose of Zyprexa 5 mg and to consider a gradual dose reduction to 2.5 mg daily. The physician response was "any reduction dose of Zyprexa would cause an exacerbation of psychotic symptoms."

A review of pharmacy recommendations dated January 24, 2019, revealed that the pharmacist requested that the physician evaluate the current dose of Zyprexa 5 mg and to consider a gradual dose reduction to 2.5 mg daily. The physician response was "no dose reduction warrant, patients condition is stable."

During an interview with the Director of Nursing (DON) on January 31, 2019, at 9:00 AM the DON confirmed that there was no gradual dose reductions attempts of the above psychoactive medications for Residents 58 and 82.


28 Pa. Code 211.2(a) Physician services

28 Pa. Code 211.5(f)(g)(h) Clinical records
Previously cited 3/30/18

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

28 Pa. Code 211.12(c)(d)(3)(5) Nursing Services
Previously cited 3/30/18








 Plan of Correction - To be completed: 03/26/2019

Resident 58 and Resident 82 has had a dose reduction in their Antipsychotic medication.
All other residents with antipsychotic medications will be reviewed and all who have not had a reduction in the last year will have a reduction attempted.
All Physicians and Licensed Nurses will be educated on the need for a gradual dose reduction at least annually by the Director of Nursing.
A random audit of residents on antipsychotic medication will be done monthly by the Director of Nursing to assure that gradual dose reduction occur at least yearly. This audit will be reviewed by the quality improvement committee, who will make recommendations for changes to the study as appropriate.

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 a review of clinical records, select incident/accident reports and abuse investigations and staff interview it was determined that the facility failed to provide sufficient staff assistance with activities of daily living to prevent an accident and minor injury to one resident out of 21 sampled (Resident 52).

Findings included:

A review of the clinical record revealed that Resident 52 was admitted to the facility on March 13, 2017, with diagnoses to include diabetes and right sided hemiplegia (weakness).

A review of the resident's plan of care dated July 13, 2018, revealed that Resident 52 required maximum assistance of two persons for transfers with a rollator walker and gait belt. A review of a Brief Interview for Mental Status (BIMS) dated as completed October 10, 2018, revealed that the resident was cognitively intact with a score of 14.

A review of a facility investigation report and information dated December 4, 2018, at 6 AM submitted by the facility revealed that Employee 2 (a nurse aide) was providing care to Resident 52, while the resident remained in bed. Employee 2 transferred the resident from her bed to the wheelchair when the resident's foot slipped and the resident fell to the floor. The resident landed on her right side and was witnessed to hit her head on the bedside table. There was no loss of consciousness. The resident was assessed and had a 2 cm x 1.5 cm laceration to the right side of her head and a 8 cm x 5 cm superficial abrasion to her right shoulder area. The physician was contacted and treatment and observation were ordered.


A review of an employee witness statement from Employee 2 revealed that the employee provided the resident's care, including bed mobility, without the assistance of another staff member or the use of the resident's walker and a gait belt on December 4, 2018, as planned for the resident's activities of daily living.

During an interview January 31, 2018 at approximately 11 AM the director of nursing confirmed that Employee 2 was aware that Resident 52 required the assistance of two staff members and the rollator walker and a gait belt for transfers and that the resident was not provided with sufficient staff assistance and assistance devices during this transfer to prevent this accident and injury.



28 Pa. Code 211.12 (a)(c)(d)(5) Nursing services.
Previously cited 3/30/18















 Plan of Correction - To be completed: 03/26/2019

Employee #2 was counseled and received education on the importance of following the resident individualized plan of care with regard to following directives on using sufficient staff assistance and appropriate assistive devices to transfer residents in order to provide for the safety and welfare of the resident. In addition employee #2 received education on abuse and neglect and the need to obtain and provide sufficient staff assistance and assistive devices during transfer to prevent accident and injuries
The nurse educator provided education to direct care staff on abuse, neglect and the need to follow the resident's individualized plan of care to prevent accidents and injury.
The facility developed and implemented a competency for direct care givers to ensure residents are transferred safely according to their individualized plan of care.
To assure competency is maintained random competencies recheck will be done on five aides per week at varied times to assure all three shifts are included. Reeducation will be provided should practice be found to be below competency standard. These audits will be reviewed weekly by the Director of Nursing and reported on at the quarterly QA meeting where recommendation to adjust the study will be made as appropriate.


483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs: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(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

483.45(d)(1) In excessive dose (including duplicate drug therapy); or

483.45(d)(2) For excessive duration; or

483.45(d)(3) Without adequate monitoring; or

483.45(d)(4) Without adequate indications for its use; or

483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
Observations:

Based on a review of clinical records and staff interviews it was determined that the facility failed to ensure that one resident's drug regimen was free of unnecessary antibiotic drugs out of 21 residents sampled (Resident 13).

Findings included:

A review of Resident 13's clinical record revealed an order dated January 15, 2019, to obtain urine culture and sensitivity.

A physician's order, dated January 16, 2019, was noted for Levaquin (Levofloxacin) 500 mg daily.

A review of the resident's medication administration record for the month of January 2019, revealed that the resident received two doses of Levaquin.

A review of laboratory test results, dated January 18, 2019, revealed the identified organism was resistant to treatment with Levaquin.

A new order physician order, dated January 18, 2019, was noted to discontinue Levaquin, and to start Macrobid 100 mg two times a day for 14 days for a UTI (urinary tract infection).

During an interview with the DON and Assistant Nursing Home Administrator on February 1, 2019, at 12:45 PM, these staff members confirmed that the administration of Levaquin was not clinically justified.


Refer F881





 Plan of Correction - To be completed: 03/26/2019

Resident #13 has no ill effect from the unnecessary antibiotic administered.
The Antibiotic Stewardship Program has been revised to include a suspected infection observation form. This tool will enable staff to review clinical signs and symptoms to determine if criteria is met for the justification of antibiotic use.
The Director of Nursing and Infection Control nurse will educate the licensed staff on the newly developed suspected infection observation form which will help determine if criteria is met for the justification of use of antibiotic therapy.
Physicians were notified by the facility of the criteria needed to warrant the use of antibiotics. If a physician orders an antibiotic when criteria is not met they will be made aware by the nurse. If they continue to order the antibiotic, the medical director will be notified to intervene to assure no unnecessary medication are ordered.
An audit will be done weekly to monitor that no antibiotics are ordered that do not have criteria met. Findings will be reviewed at the scheduled quality assurance meetings with recommendations made as appropriate to modify the study.


483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition: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.
483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.
Observations:

Based on a facility incident investigation report, observation and staff interview, it was determined that the facility failed to ensure safe operating equipment in the kitchen.

Findings include:

A review of a facility investigation revealed that on December 29, 2018, at 5:10 am, the day shift cook entered the walk-in freezer and became locked inside. Approximately 25 minutes later, a night shift nurse aide entered the kitchen and heard the cook yelling from within the freezer.

A review of a dietary department shift meeting dated December 29, 2018, indicated to the employees on duty that the freezer door was "sticking" when entering the freezer and to use the "buddy" system; letting someone know that you are in the freezer.

A maintenance request was made after the incident on December 31, 2018. The handle was noted to be broken, the parts ordered and the handle repaired January 9, 2019.

During an interview January 29, 2019, the dietary manager confirmed that the freezer had not been functioning safely.


28 Pa. Code 207.2(a) Administrator's responsibility

28 Pa. Code 211.6(c) Dietary services.
previously cited 3/30/18

28 Pa Code 201.18(e)(6) Management






 Plan of Correction - To be completed: 03/26/2019

The newly installed freezer door handle is operational. In addition a telephone with instructions and phone numbers was installed inside the freezer as an additional safety measure for dietary staff who enter the freezer.
All other equipment operated by door handles in the dietary department were inspected by the maintenance department and found to be operational.
An additional door handle for the freezer is ordered in the event of any possible malfunction. A shift meeting with dietary employees related to the new door handle and installation of a communication system within the freezer was presented.
Weekly inspection of the freezer door function will be completed by the safety committee member. Findings of the safety committee inspections will be discussed at the monthly safety committee meetings for the next three months at which time a decision will be made to continue or discontinue the weekly inspection.


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