Pennsylvania Department of Health
GLEN BROOK REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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GLEN BROOK REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

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GLEN BROOK REHABILITATION AND HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an abbreviated complaint survey and a revisit survey completed on February 6, 2024, it was determined that Glen Brook Rehabilitation and Healthcare Center failed to correct the federal deficiencies cited during the survey of December 8, 2023, and 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:


483.60(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 observation 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 contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and on two of four resident pantries.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

Observation on the East Nursing Unit during the lunch meal on February 6, 2024, at 12:50 PM revealed that Resident meal trays were being passed by nursing staff from an enclosed double door cart. The interior and exterior surface of the cart was visibly soiled and in need of cleaning.

Further observation at this time while completing a test tray for food palatability revealed that the silverware and insulated plastic dome cover (placed over plates of food during transport) had a thick coating of a white substance adhered to the surface.

Observation of the dietary department on February 6, 2024, at approximately 1:15 PM in the presence of the foodservice director revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness:

The floor area behind the ice machine had an accumulation of dirt and debris.

There was an accumulation of debris in the floor drain located outside the walk-in cooler.

There was an accumulation of debris and plastic residue adhered to the surface of two plate lowerators located near the trayline.

There were two racks of 6-ounce plastic beverage glasses with brown stains and a coating of a white substance.

There was a white coating on the surface of the dishwasher.

There were 10 dish racks with a coating of a white substance.

There were insulated plastic mugs, silverware, insulated plastic dome covers, and metal dish pellets (metal base which is heated and place under plates to maintain hot food temperature) all identified as clean revealed a thick coating of a white substance adhered to the outer surfaces of these items.

Interview with the food services director (FSD) at this time confirmed that the kitchen was to be maintained in a sanitary manner. The FSD confirmed that build-up of the white substance on the dishware and service-ware was a concern for a while and that maintenance was aware.

Review of a dishwasher log (no date noted) revealed that a suspected rinse agent malfunction was suspected and was to be replaced (no date for replacement noted).

Observation of the Willow Unit's resident pantry area on February 6, 2024, at 1:50 PM revealed three 4-ounce nutritional shakes on a rack in the refrigerator which were not labeled with a thaw date. Review of the manufacturer's label indicated to use the product within 14 days of thawing.

Observation of the Spruce Unit's resident pantry area on February 6, 2024, at 2:10 PM revealed melted ice cream adhered to the bottom surface of the freezer compartment and a puddle of a yellowish liquid under the clear plastic vegetable crisper in the refrigerator.

There was a 4-ounce pudding which was not dated and a 6-ounce nutritional beverage which was not labeled with a thaw date on the shelf in the refrigerator. Review of the manufacturer's label of the nutritional beverage indicated to use the product within 14 days of thawing.

There was a build-up of a white substance on the top surface of a stainless-steel shelf which being used to hold an ice machine.

Interview with the administrator on February 6, 2024, at 2:30 PM confirmed that during the facility's standard survey which ended on January 27, 2023, a concern was identified with the presence of a white substance on dishware and service-ware, which was attributed to the facility's hard water. The administrator confirmed the recurrent issue with the appearance of the white substance on dishware and service-ware. The administrator confirmed that the dietary department and resident pantries were to be maintained in a sanitary manner to prevent potential contamination of food and storage items.

Refer F867

28 Pa. Code 201.18 (e)(2.1) Management

28 Pa. Code 211.6 (f) Dietary services















 Plan of Correction - To be completed: 03/06/2024

The dirt and debris were cleared from behind the ice machine, floor drain located outside the walk-in cooler. and the plate lowerators located near the trayline. The plastic glasses were cleared of the white substance and brown stains. The surface of the dishwasher, dish rack. ,plastic mugs, dome covers, silverware , metal dish pellets were cleared of the white substance. The interior and exterior surface of the food carts was cleaned. All pantry refrigerators were cleaned and undated food and beverages were discarded.

The Facility Dietary Manager (FDM)/designee will review the storage and service of food in the kitchen to assure that acceptable practices are maintained to prevent contamination and microbial growth of food. NHA/designee will kitchen and pantry cleaning schedules to assure that resident pantry areas will be maintained with acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food.

The FDM/designee will educate the dietary staff on ensuring that nutritional shakes in the pantry refrigerators have a thaw date; The Dietary staff will be educated by the FDM/Designee to ensure that the dish machine has de-limer added bi-weekly to prevent coating on plastic dome covers, mugs and utensils and assure that dirt and debris are cleared to prevent the potential for contamination and microbial growth in food

The FDM/Designee will complete audits to assure food and beverages in the pantry refrigerators have a thaw date; The FDM/Designee will complete random audits of items used in the kitchen- mugs, utensils, dome covers, pellets to assure white coating is not present. Audits will also include kitchen area is free of dirt and debris. Audits will be done weekly for four weeks then monthly for two months or until compliance is achieved. Results of audits will be reviewed by the QAPI committee.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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.
§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on observation and resident and staff interview, it was determined that the facility failed
to provide care in a manner and environment that promotes each resident's quality of life and respect for each resident's dignity and individuality by failing to respond to timely to residents requests for assistance as reported by four residents (Residents 84, 104,176 and 181), timely return a resident's personal clothing for one resident (Resident 182), conduct a dignified dining experience as evidenced by one resident observed (Resident 81), and failed distribute or post menus to afford residents the right to review planned meals to enhance their quality of life as reported by two residents (Resident 172 and 84) out of 27 residents sampled.

Findings include:

Clinical record revealed that Resident 182 was admitted to the facility on December 29, 2023, with diagnoses to include acute and chronic respiratory distress syndrome (lung condition where organs have inadequate oxygen supply due to fluid buildup in the lungs) and severe persistent asthma (chronic respiratory condition caused by inflammation and constriction of the airway, causing shortness of breath, wheezing and cough).

An Admission Minimum Data Set assessment ([MDS]) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated January 4, 2024, revealed that Resident 182 was cognitively intact with a BIMS score (The BIMS test is used to get a quick snapshot of how well you are functioning cognitively, it is a required screening tool used in nursing homes to assess cognition) of 14. The resident required extensive staff assistance with activities of daily living.

Clinical record revealed that Resident 181 was admitted to the facility on January 5, 2024, with diagnosis to include chronic obstructive pulmonary disease ([COPD]a lung disease characterized by persistent respiratory symptoms like progressive breathlessness and cough) and diabetes mellitus type two ([T2DM] chronic condition characterized by high blood sugar levels).

An Admission MDS Assessment dated January 11, 2024, revealed that the resident was cognitively intact with a BIMs score of 12. The resident required a moderate amount of staff assistance with activities of daily living.

Clinical record revealed that Resident 176 was re-admitted to the facility on January 18, 2024, with diagnoses of COPD and acute respiratory failure.

An Admission MDS Assessment dated December 27, 2023, revealed that the resident was cognitively intact with a BIMs score of 12. The resident required an extensive amount of staff assistance with activities of daily living, requiring an assist of two staff and use of a mechanical lift for transfers.

Interview with Resident 176, on February 6, 2024, at approximately 9:09 AM revealed that the resident stated that he waits between 30 to 45 minutes for staff to respond to his requests for assistance via the nurse call bell systems and meet his needs for assistance. He stated, "I know the staff are busy, but I can't do anything for myself, they need to use the lift for me."

Interview with Resident 181 on February 6, 2024, at approximately 9:50 AM, revealed that the resident stated that "quite often" he waits more than 30 minutes and more recently he waited "two hours" for staff to respond to his call bell and provide needed assistance. The resident stated that the waits occurred mostly during the evening shift, on any day of the week, and he felt that the facility "could use more help."

Interview with Resident 182, on February 6, 2024, at approximately 11:37 AM, revealed that the resident stated that she has been living at the facility for approximately five weeks and had a total of 10 clothing outfits on hand in the facility. The resident stated that the facility does her personal laundry, but her clothing does not return from the laundry in a timely manner. The resident stated that to date, the facility has yet to return her clean clothing, and as a result she has been wearing dirty clothing for four days. The resident stated that she does not want to have to wear a hospital gown. She stated that she asked the facility staff where her clothing was on several recent occasions and staff informed her that "it should be back soon." She confirmed that her daughter labeled her clothing with her name so they would not get lost in the facility's laundry. An observation in the resident's room during this interview with Resident 182, revealed 10 empty hangers in her wardrobe closet that were used to hang her clothing, which had yet to be returned to her. Dirty clothing was observed on the resident's chair also awaiting laundering.

Interview with Employee 1, RN, and Employee 2, LPN, confirmed that the facility laundered resident's clothing. These employees confirmed that Resident 82's clean clothing was presently in the laundry room and following surveyor inquiry was returned to the resident her after this interview. Employee 1 RN also took the resident's dirty laundry for laundering and stated that it would be returned to the resident tonight. Employee 2, LPN, stated that the laundry should only take one or two days to be returned to the residents after laundering, and that these nursing employees were unaware that the resident did not have clean clothing available in her room.

A review of Resident 104's clinical record revealed that the resident was cognitively intact and had diagnoses which included cerebral infarction and depression.

During an interview with Resident 104 on February 6, 2024, at 11:30 AM the resident stated that in the past week he has waited up to an hour for the call bell to be answered. Resident 104 stated that he uses a urinal and rings the call bell for staff assistance when he needs the urinal emptied. Resident 104 stated that the staff "do the best they can but there seems to be constant call-offs" at the facility resulting in staff shortages.

A review of Resident 84's clinical record revealed that the resident was cognitively intact and had diagnoses which included Parkinson's disease.

During an interview with Resident 84 on February 6, 2024, at 12:30 PM the resident stated that on Sunday February 4, 2024, on the dayshift she rang the call bell to request staff assistance because she needed to go to the bathroom and requires staff assistance with toileting. Resident 84 stated that she has a clock on the wall of her room, and it took 30 minutes for her call bell to be answered. Resident 84 stated that it is difficult to wait an extended amount of time when she needs to go to the bathroom.

Interview with the nursing home administrator (NHA) on February 6, 2024, at approximately 2:15 PM confirmed that the staff should timely answer call bells and launder and return residents' personal clothing timely.

A review of Resident 81's clinical record revealed the resident was admitted to the facility on with diagnoses which include dysphagia (difficulty swallowing), hypertension, and adjustment disorder.

An observation on February 6, 2024, at approximately 11:50 AM revealed that Resident 81 and Resident 21 were seated together at table in the dining room. Staff served Resident 21 his meal tray at that time. Resident 21 began to eat his meal while Resident 81 sat and watched the resident eat. While Resident 81 was waiting for his meal to be served, the resident appeared visibly annoyed, at times rocking back and forth in his wheelchair and making some grunting noises. Further observations revealed on February 6, 2024, at 12:09 PM Resident 81 was served his lunch meal 19 minutes after his tablemate received his lunch and had eaten his meal.

An interview with the Director of Nursing and Nursing Home Administrator on February 6, 2024, at approximately 2:45 PM confirmed the facility failed to provide a dignified dining experience for Resident 81 by failing to serve residents seated together at the same time.

Observation of four of four nursing units (Willow, Spruce, North, and East) on February 6, 2024, between 9:30 AM and 10:30 AM revealed that current menus were not posted on each of the four nursing units.

Interview with Resident 172 on February 6, 2024, at 11:00 AM confirmed that he did not have a copy of the facility's menu for awareness of the planned meals. Resident 172 confirmed that he would like a copy of the menu so he would know what was being served to help make decisions about what he would like to eat at each meal.

Interview with Resident 84 on February 6, 2024, at 12:30 PM revealed that the resident stated she "never knows what is on the menu." She stated that she would like to know, prior to each meal, what is on the menu and the available alternate choices.

Interview with the administrator on February 6, 2024, at approximately 2:45 PM confirmed that the facility failed to ensure that menus were posted and/or distributed to residents to promote each residents quality of life including for Residents 172 and 84.


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

28 Pa. Code 201.29 (a) Resident Rights

28 Pa Code 211.6 (a) Dietary services
























 Plan of Correction - To be completed: 03/06/2024

Residents 84, 104, 176 and 181 were reviewed to assure that call bells response times were provided based on resident needs. The Director of Laundry reviewed the laundry concerns for resident 182. The Dietary Manager /dietician met with R172 and 84 related to their planned meal request and posted the dietary menus for residents to review the planned meals.

The facility has determined that all residents could be potentially affected.

The staff educator/designee will provide in-service education for licensed and direct care staff on the importance of meeting resident care needs and ensuring timely response to call bells. The NHA/designee will provide education to the Laundry department on the importance of timely return of resident clothing. The NHA/designee will provide education for the Dietary management team on the importance of posting and distributing the proper menus. The staff educator/designee will provide in-service education for direct care staff to assure residents are served at the same time when seated at a table together to enhance resident quality of life.

The NHA/designee will complete audits/interviews to assure timely call bell response time are met, residents laundry are returned timely, audits to assure menus are posted. Call bell response will be audited weekly for 4 weeks, then monthly for 2 months or until substantial compliance is achieved. Audits related to laundry return, menu posting, dining experience will be done weekly for 4 weeks, then monthly for 2 months or until substantial compliance is achieved. Audits will be reviewed through the QAPI Committee.

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.
Observations:

Based on review of the facility's plan of correction from the survey of December 8, 2023, and the findings of the revisit survey ending February 6, 2024, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and implement corrective action plans to prevent continued quality deficiencies related to abuse and acceptable practices for the storage and service of food and to ensure that plans designed to improve the delivery of care and services were consistently implemented to effectively deter future quality deficiencies.

Findings include:

The facility's deficiencies and plan of correction for the survey ending December 8, 2023, revealed that the facility developed a plan of correction that included quality assurance monitoring systems to ensure that solutions were sustained. The results of the current survey ending February 6, 2024, revealed that a thorough investigation of potential abuse had not been completed and continued deficient practice was identified related to this lack of investigation.

In response to the deficiency cited under investigation of abuse during the survey of December 8, 2023, the facility's plan of correction revealed that the plan included that the Administrator/DON/ADON/ Staff educator to assure that incidents are investigated thoroughly to rule out abuse and any allegations of abuse are reported to state survey agency within timeframe. Staff will be educated by Educator on the importance of a thorough investigation when incidents occur so that timely reporting can be done to the state survey agency during daily clinical meeting incidents will be reviewed by Administrator/DON to assure that a thorough investigation was completed, and any allegations of abuse are reported to state survey agency within timeframe.

This corrective active plan was to be in place by January 23, 2024. However, at the time of the revisit survey ending February 6, 2024, review of resident incidents revealed that an allegation of abuse had not been thoroughly investigated and completed investigation, a PB-22, had not been timely submitted to the State Survey Agency within 5 working days of the incident. The facility's quality assurance monitoring plan failed to identify this ongoing deficient practice.

The facility's quality assurance plan failed to identify continued quality deficiency and sustain solutions to the identified quality deficiency in abuse.

In response to the deficiency cited under acceptable practices for the storage and service of food during the survey of December 8, 2023, the facility's plan of correction revealed that the plan included that all debris was disposed of in
the kitchen. A deep clean of the kitchen and pantries has been completed. The facility has determined that all residents have the potential to be affected. All Dietary staff were in-serviced on cleaning assignments and cleaning matrix. The manager will complete a daily checklist of cleaning assignments to insure proper cleaning and oversight. Daily checklists will be reviewed by the Administrator. The audits of the kitchen and pantry will be completed by the Food Service Director/designee weekly for four weeks and then monthly for two weeks or until compliance. Audits will be reported to the monthly QAPI meetings.

This corrective active plan was to be in place by January 23, 2024. However, at the time of the revisit survey ending February 6, 2024, observations of the dietary department and Spruce Unit and Willow Unit pantries revealed continued sanitation and food storage concerns. The facility's quality assurance monitoring plan failed to identify this ongoing deficient practice.

Refer F610, F812

28 Pa. Code 211.12 (c) Nursing services

28 Pa. Code 201.18 (e)(1)(2)(2.1)(4) Management.

28 Pa. Code 211.6 (f) Dietary services
















 Plan of Correction - To be completed: 03/06/2024

The deficient practice related to thorough investigation/reporting related to abuse and sanitation and food storage concerns was corrected.

The QAPI committee will be educated by the governing body/designee on implementing the plan of correction in a consistent and timely manner for areas cited as deficient practice. The NHA/DON/executive DON/Food service director will review current plan of correction for areas cited with the governing body to ensure that measures to problem solve are sustained.

The facility will hold weekly ad hoc QAPI committee meetings to review areas cited as deficient practice and progress. Ad hoc QAPI committee meeting minutes will be submitted to governing body for review.

The QAPI coordinator/designee will review weekly ad hoc QAPI committee meeting minutes to ensure compliance with the plan of correction weekly for four weeks then monthly for two months or until substantial compliance is achieved. The results will be reported to the QAPI committee.

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff: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.
§483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

§483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:

Based on observations, a review of clinical records, and staff interviews it was determined that the facility failed to provide and/or efficiently deploy sufficient nursing staff to consistently provide timely quality of care, services, and supervision necessary to maintain the physical and mental well-being of the residents in the facility.

Findings include:

A review of clinical record revealed Resident 1 was admitted to the facility on November 5, 2019, with diagnoses to include dysphagia (difficulty swallowing) and anxiety disorder.

A review of Resident 81's clinical record revealed that the resident had a diagnoses of dysphagia (difficulty swallowing), hypertension, and adjustment disorder.

A review of clinical record revealed Resident 21 was admitted to the facility on March 25, 2022, with diagnoses of dementia, difficulty walking, and abnormal posture.

Observation on the north nursing unit on February 6, 2024, at approximately 9:00 AM 57 residents were residing on the unit. There was two LPNs (license practical nurses) on the unit and 4 nurse aides assigned to care for the residents. One of these nurse aides, Employee 3, nurse aide, was assigned to sit with Resident 1 for a 1:1 observation for safety, and Employee 7, a nurse aide, was assigned to sit with Resident 21 for a 1:1 observation for safety. leaving two nurse aides to provide direct care to remaining residents.

Observations in the dining room of the north and east nursing units on February 6, 2024, at approximately 11:45 AM revealed approximately 20 residents in the dining room for lunch service. Employee 4 LPN (licensed practical nurse) was the only nursing staff in the dining room and was passing meal trays. Employee 3, a nurse aide, was sitting with Resident 1 performing the 1:1 duties of monitoring the resident. No other staff were observed in the dining room to assist residents with lunch service. Employee 4, a nurse aide, was trying to pass trays to the residents while they were waiting for their meals. Resident 21 was observed to receive his tray at 11:50 AM while his tablemate Resident 81 sat and watched him eat. While Resident 81 was waiting for his tray, the resident appeared visibly irritated, at times rocking back and forth in his wheelchair and making some grunting noises. Resident 81 received his meal at 12:09 PM, 19 minutes after his tablemate.

An interview was conducted with Employee 4, a nurse aide, on February 6, 2024, at approximately 11:50 AM. The employee stated she was sitting with Resident 1 for her 1:1 observation and she was "not going to get a break today." Employee 4 stated that Resident 21 was also on 1:1 observation, but Employee 7, assigned to sit with him, went to lunch and there was no one else to observe him at that time to continue his 1:1. The employee stated there should be at least one nurse and two nurse aides in the dining room to help serve lunch, assist and monitor residents.

Observations in the dining room on February 6, 2024, at approximately 11:55 AM revealed Employee 4 was alone in the dining room passing lunch trays and trying to set the residents up to eat, while assigned to 1:1 observation of Resident 1. Employee 3, left her 1:1 observation and began helping Employee 4 pass lunch trays and set up residents for lunch. At 12:00 PM Employee 5, LPN entered the dining room and began passing trays. The 1:1 observations of both Resident 1 and Resident 21 were not being completed. Resident 21 continued to watch Resident 81 eat his lunch while waiting for his lunch to be served.

Further observations in the dining room on February 6, 2024, at 12:01 PM revealed Resident 1 began choking on her food. The resident was purple, shaking, and was not passing any air. The resident had phlegm coming from her nose. The employees were passing trays and were not aware the resident was choking. The surveyor alerted Employees 3, 4 and 5 that the resident was choking as these nursing employees were distributing meal trays. Employee 5 came over to the resident and began providing black blows to the resident. The resident began to cough and vomited all over her lunch tray. There was no nursing assessment of the resident completed at that time. The nursing employees continued to pass meal trays.

Observations from 12:00 PM through approximately 12:15 PM on February 6, 2024 revealed that the registered nurse was not notified that the resident had choked. The resident was observed to vomit more of a brown substance and was coughing and appeared winded. The resident would pause and try to take a deep breath causing her to cough. The resident was visibly upset and asking staff "please don't leave me."

An interview with Employee 4 on February 6, 2024, at approximately 12:40 PM revealed the employee stated that a nurse from each unit will each observe the dining room for 15 minutes and then rotate out of the dining room. Employee 4 stated there should be at least two nurse aides, a light duty nurse aide, and restorative nurse aide in the dinning room to assist with passing meal trays and assisting residents get set up to eat and fed. The nurse indicated that the light duty aide and restorative aide were off today and there was not enough nursing staff in the dining room at the lunch meal today to supervise and assist residents.

An interview with the Nursing Home Administrator on February 6, 2024, at approximately 2:45 PM confirmed that the facility failed to provide sufficient nursing staff to meet the needs of the residents as observed during this lunch meal.

Refer F550, F684



28 Pa. Code 211.12(c)(d)(1)(3)(4)(5) Nursing services

28 Pa. Code 201.18(b)(1)(e)(1)(2)(3)(6) Management





 Plan of Correction - To be completed: 03/06/2024

The facility cannot retroactively correct this issue. E1 and E7 was educated on duties of supervising residents on 1:1 monitoring.

Dining room staff assignment will be reviewed to assure that sufficient nursing staff is provided to meet the needs of the residents . Random observations of dining rooms will be completed by the DON/designee during meals to ensure proper nurse staffing levels.

The DON/designee will provide in-service education to supervisors, licensed and direct care staff on assuring sufficient staff is assigned and supervision is maintained in dining areas during meals in order to provide timely quality of care, services, and supervision necessary to maintain the physical and mental well-being of the residents in the facility.

The DON/designee will provide random audits in the dining rooms to ensure sufficient staff is present to provide adequate care and supervision of residents. Audits will be done weekly for four weeks, then monthly for two months or until compliance is achieved. Results will be presented in QAPI committee meeting.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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.
§483.10(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 observation and staff interview, it was determined that the facility failed to provide housekeeping services to maintain a clean environment on two of four nursing units (Spruce Unit and Willow Unit).

Findings include:

An observation on February 6, 2024, at approximately 9:00 AM, the hallway connecting Willow and Spruce Wing revealed a visible accumulation of dirt and debris in two ceiling vents.

An observation on February 6, 2024, at approximately 9:09 AM, revealed the floor in resident room 737 on the Willow Unit felt sticky and an accumulation of debris scattered around the resident's bed.

An observation on February 6, 2024, at approximately 10:00 AM, revealed a build-up of white and green stains in the sink in the utility room on Willow Wing.

An observation of the hall outside the facility's main kitchen on February 6, 2024, at 9:15 AM revealed a thick layer of dust in the ceiling ventilation system.

Observation of the resident pantry located on the Spruce Wing on February 6, 2024, at 2:00 PM revealed a thick layer of dust on the fins of the ceiling vent.

Interview with the Nursing Home Administrator (NHA) on February 6, 2024, at 2:15 PM confirmed that the facility and resident environment should be clean.



28 Pa. Code 201.18 (e)(2.1) Management




















 Plan of Correction - To be completed: 03/06/2024

Ceiling vents in the hallway connecting Willow and Spruce wing and Spruce wing pantry have been cleaned. Room 735's floor has been cleaned and uncluttered of debris around resident's bed. The sink in the Willow wing utility room has been cleared of build-up. The ceiling ventilation system outside the main kitchen has been cleaned.

The facility has introduced a Preventive Maintenance policy, a routine cleaning schedule has been established and will be reviewed by NHA.

The NHA/designee will educate the housekeeping and maintenance departments on the importance of proper housekeeping services to maintain a clean homelike environment in the facility.

The Maintenance Supervisor/designee will complete an audit of random vents throughout the facility ventilation system, resident pantry area and floors of resident rooms to assure a safe/clean /sanitary/homelike environment Audits will be completed weekly for 4 weeks, then monthly for two months or until substantial compliance. Audits will be reviewed through the QAPI Committee.

483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination: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(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

§483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

§483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

§483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

§483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:

Based on review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to afford a resident the right to make choices regarding their preferences for daily routines, choice of daily clothing, for one resident out of 27 sampled (Resident 137).

Findings include:

A review of Resident 137's clinical record revealed the resident was admitted to the facility on December 29, 2022, with diagnoses to include cerebral infarction (stroke), left hemiplegia and hemiparesis, osteoarthritis, and gastro-esophageal reflux disease (GERD).

A review of a Annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 6, 2024, section F - preferences for customary routine and activities, indicated that it is very important to the resident for him to choose what clothes to wear.

Resident 137's care plan (a guide used to assist in directing resident care) indicated that the resident had an daily living (ADL) self care performance deficit related to decreased mobility, revision date August 4, 2023. The goal was that he will maintain current level of function in ADLs through the target date April 17, 2024, with planned interventions of that resident required one staff assistance with dressing, revised on January 26, 2023.

Observation on February 6, 2024, at approximately 11:20 AM, revealed that the resident was seated in a wheelchair in his room. The resident was wearing jean shorts at that time, and informed the surveyor that sitting his preference would be to wear long pants, preferably jeans at this time of year. Resident 137 further stated he has no jeans to wear, and that he has told staff several times he has "not seen or worn his long jeans in months."

A second observation on February 6, 2024, at approximately 1:55 PM, revealed that the resident remained sitting in his room, in a wheelchair, wearing jean shorts.

Interview with Employee 6, Nurse Aide, on February 6, 2024, at approximately 2:40 PM, confirmed that she was providing care to Resident 137 today, and that he is wearing shorts. She stated for as long as she can remember, he has worn shorts. Employee 6, (NA) stated that staff on the night shift (11 PM - 7 AM), get him dressed. Employee 6 was unaware of the resident's preference to wear long paints, jeans.

Interview with the Nursing Home Administrator (NHA) on February 6, 2024, at approximately 2:48 PM, confirmed that residents should be afforded the opportunity to choose their preferences for daily routines, including choice of clothing.


28 Pa. Code 201.29 (a) Resident rights

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




 Plan of Correction - To be completed: 03/06/2024

Social services reviewed with resident 137 his preference for choice of daily clothing.

The facility has determined that all residents could be potentially affected.

The staff educator /designee will provide direct care staff in-service education on the importance of affording a resident the right to make choices regarding their preferences for daily routines and clothing.

Social Services will complete random audits of residents to determine facility is meeting their right to make choices regarding their preferences for daily routines and clothing. Residents will be informed during resident council meeting related to policies and procedures related to resident rights. Audits will be completed weekly for four weeks, then monthly for two weeks or until substantial compliance. Audits will be reviewed through the QAPI Committee.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on a review of clinical records, information submitted by the facility, and select investigative reports and resident and staff interviews it was determined that the facility failed to conduct a thorough investigation into an allegation of physical abuse and report the results of the investigation to the State Survey Agency within 5 working days of the incident for one resident out of 25 sampled (Resident 81).

Findings include:

During the survey ending February 6, 2024, the survey team made multiple requests for the facility's current abuse prohibition policy, but the facility did not provide the policy by the conclusion of the survey.

A review of Resident 81's clinical record revealed admission to the facility on December 29, 2022, with diagnoses, of diabetes. A quarterly Minimum Data Set (MDS) assessment dated December 14, 2023, indicated that the resident was cognitively intact with a BIMS (brief interview for mental status - a tool to assess cognitive status) of 14.

A review of Resident 1's clinical record revealed admission on December 14, 2022, with diagnoses, which included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). An annual MDS assessment dated November 2, 2023, indicated that the resident was severely cognitively impaired with a BIMS (brief interview for mental status - a tool to assess cognitive status) of 05.

A review of facility provided investigation entitled "physical" dated January 15, 2024, 10:00 AM revealed that in the facility's lobby, Resident 1 became annoyed with Resident 72 and hit her with her word search book during an activity that was taking place in the lobby. The residents were separated with no injury noted to either resident. Resident 1 was escorted back to her room. Approximately 5 minutes later Resident 1 returned to lobby and became agitated with Resident 81 and hit him in his chest. No injuries were noted according to the facility documentation, and also noted that there were no witness statements for the second incident of physical abuse between Resident 1 and Resident 81.

A review of information submitted by the facility dated January 25, 2024, submitted by the facility solely identified Resident's 1's physical altercations with Resident 72 and Resident 81. The facility did not complete and submit a completed investigation, a PB22 (state format for investigations of allegations of resident abuse) within 5 working days Resident 1's physical abuse of Resident 81.

During an interview with the NHA on February 6, 2023, at approximately 12:50 PM, the administrator confirmed that the facility did not submit a completed investigation into Resident 1's physical abuse of Resident 81 to the State Survey Agency within 5 working days of the incident.

Refer 867

28 Pa. Code 201.29 (a) Resident rights

28 Pa. Code 201.14 (c) Responsibility of Licensee

28 Pa. Code 201.18 (e)(1)(2) Management






 Plan of Correction - To be completed: 03/06/2024

The facility's current abuse prohibition policy was reviewed and revised; The facility submitted a completed investigation with a PB22 for Resident 1's physical abuse of Resident 81.

Current resident incidents in the last 2 weeks related to resident to resident altercations will be reviewed to assure that a thorough investigation was conducted to ensure timely reporting and completion of PB22 within 5 days. Any identified issues will be addressed.

Administrator/DON/Executive DON/ADON/ Staff educator will be educated by RDO/designee to assure that incidents are investigated thoroughly and the results of the investigation/PB22 are submitted to the State Survey Agency within 5 working days of the incident.

Audits of incident reports related to an allegation of abuse will be reviewed by NHA/designee to assure that a thorough investigation is completed by reviewing the checklist and the results of the investigation/PB22 is submitted to the State Survey Agency within 5 working days of the incident. Audits will be done weekly for four weeks, then monthly for two months or until compliance is achieved. Results will be presented in QAPI committee meeting.

483.25 REQUIREMENT Quality of Care: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 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 observations, a review of clinical records, and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure that licensed and professional nurses thoroughly assessed resident status and provided the nursing care required by two residents out of 27 sampled (Resident 181).

Findings include:

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care:
Assessments
Clinical problems
Communications with other health care professionals regarding the patient
Communication with and education of the patient, family, and the patient ' s designated support person and other third parties.

Clinical record revealed that Resident 181 was admitted to the facility on January 5, 2024, with diagnosis to include chronic obstructive pulmonary disease ([COPD]a lung disease characterized by persistent respiratory symptoms like progressive breathlessness and cough) and diabetes mellitus type two ([T2DM] chronic condition characterized by high blood sugar levels).

An Admission Minimum Data Set assessment ([MDS]) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated January 11, 2024, revealed that the resident was cognitively intact with a BIMs score (The BIMS test is used to get a quick snapshot of how well you are functioning cognitively, it is a required screening tool used in nursing homes to assess cognition) of 12. The resident required extensive staff assistance with activities of daily living.

A review of nursing documentation dated January 28, 2024, at 2:54 PM revealed that Resident 181 was being assisted by staff with peri-care (involves cleaning of private areas) Staff reported to nursing that the resident's foreskin (retractable roll of skin covering the end of the penis, when the foreskin of a penis cannot be retracted, this can lead to an emergent situation requiring treatment and in some cases surgery) of penis was unable to be retracted. It was noted that a registered nurse supervisor was made aware and present at the resident's bedside.

There was no further nursing documentation regarding the resident's status, physical condition or findings, regarding this resident's condition, the nursing care provided and its resolution.

During an interview February 6, 2024, at 2:30 PM, the Nursing Home Administrator (NHA) and Nurse Consultant confirmed that there was no documented evidence of a nursing assessment, care provided and resolution related to Resident 181's status.

A review of clinical record revealed Resident 1 was admitted to the facility on November 5, 2019, with diagnosis to include dysphagia (difficulty swallowing) and anxiety disorder.

Observations in the dining room at 12:00 PM revealed Resident 1 was seated alone at a dining table eating her lunch. Employee 3, LPN (license practical nurse), and Employee 4, a nurse aide, were distributing lunch trays to other residents at that time. Employee 5, LPN, entered the dining room to assist with tray pass. Continued observations, revealed that Resident 1 appeared to begin choking on her food. The resident was purple in color and was not observed passing any air. Phlegm was observed coming from her nose. Due to the urgency of the situation, the surveyor alerted the nursing employees passing meal trays to Resident 1's current status. In response, Employee 5, LPN, approached the resident and began providing black blows to the resident. The resident began to cough and vomited all over her lunch tray.
Continued observations, revealed that following the back blows and the resident's response, coughing and vomiting, professional nursing staff was not observed to fully assess the resident at that time, including the resident's vital signs.

Further observations from 12:00 PM through approximately 12:15 PM on February 6, 2024 revealed that the LPN did not notify a registered nurse that the resident had choked. Continued observations revealed that the resident had vomited more brown substance and had been coughing and appeared winded. The resident would pause and try to take a deep breath causing her to cough. The resident was visibly upset and asking staff "please don't leave me." Staff took the resident back to the nursing unit in a wheelchair due to the resident feeling weak and dizzy.

Continued observations on February 6, 2024, from 12:15 PM through approximately 12:35 PM revealed that a registered nurse still did not assess the resident. The resident still appeared visibly shaken and frequent coughing was observed.

An interview with Employee 4, a nurse aide, on February 6, 2024, at approximately 12:45 PM confirmed that no professional nurse had assessed the resident since she choked at lunch today.

An interview with Director of Nursing and Nursing Home Administrator on February 6, 2024, at approximately 2:45 PM confirmed that the facility's licensed and professional nursing staff failed to provide services, consistent with professional standards of practice, by failing to timely and thoroughly assess the resident's status after a choking episode.


28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services

28 Pa. 211.5 (f) Medical records





 Plan of Correction - To be completed: 03/06/2024

Resident 181 is no longer in the facility. Resident 1 was assessed by speech therapy and registered nurse on 2/7/24. Resident remains stable with no new choking episodes.

The facility has determined that all residents could be potentially affected.

DON/designee will provide in-service education for licensed and direct care staff on alerting licensed nursing staff when an acute change in resident condition occurs in order to assure that a registered nurse assesses the resident's change of condition timely.

The DON/designee will review progress notes for residents with acute change of conditions to ensure residents are thoroughly assessed according to the professional standards of practice. Audits will be done weekly for four weeks, then monthly for two months or until compliance is achieved. Results will be presented in QAPI committee meeting.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:


Based on observation and clinical records, resident and staff interview it was determined that the facility failed to follow physician orders for oxygen therapy prescribed for one resident out 27 sampled (Resident 182).

Findings include:

A review of the clinical record revealed that Resident 182 was admitted to the facility on December 29, 2023, with diagnoses to include acute and chronic respiratory distress syndrome (lung condition where organs have inadequate oxygen supply due to fluid buildup in the lungs) and severe persistent asthma (chronic respiratory condition caused by inflammation and constriction of the airway, causing shortness of breath, wheezing and cough).

A review of the resident's care plan for altered respiratory status/difficulty breathing related to respiratory failure dated December 30, 2023, and revised January 10, 2024, revealed that the resident's goal was to have no signs or symptoms or complications related to shortness of breath. Interventions planned were to follow physician order for oxygen. The resident's care plan for respiratory status did not identify non-compliant behavior related to the resident's use of oxygen.

A review of the clinical record revealed that Resident 182 had a current physician order, initially dated January 18, 2024, for oxygen at two liters per minute continuously every shift.

An observation on February 6, 2024, at 11:37 AM and 1:53 PM revealed Resident 182 was seated her wheelchair without her nasal cannula on and no supplemental oxygen running. The oxygen concentrator was turned off in her room on both occasions. The resident stated that she "only wears the nasal cannula when she needs it because she has built up carbon dioxide in her system, from home."

The facility failed to implement the resident's plan of care and provide the resident's oxygen therapy as ordered by the physician and address the resident's non-compliant behavior.

The observations were confirmed during an interview February 6, 2024, the Nurse Consultant, confirmed that resident should be receiving oxygen continuously.



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





 Plan of Correction - To be completed: 03/06/2024

R182 had no negative outcome. Resident oxygen saturation level was monitored to assess her continued need for oxygen and reviewed with physician. Resident was educated on the importance of compliance with physician orders. Orders reviewed with physician to determine appropriateness.

Residents with physician ordered oxygen therapy were reviewed to assure oxygen therapy was provided based on orders. Any non-compliance issues were addressed on the plan of care.

Nursing and therapy staff will be educated by the Staff Educator /designee on the importance of assuring residents with oxygen orders have oxygen in place based on physician orders. Any issues identified with non-compliance will be reported to physician.

DON/designee will conduct random observations of residents with oxygen orders to ensure that oxygen is administered per physician orders. Any issues identified with non-compliance will be reported to physician and addressed on plan of care. Audits will be done weekly for four weeks, then monthly for two months or until compliance is achieved. Results will be presented in QAPI 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 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.
§483.60(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 observation, test tray results, a review of minutes from the facility's food committee meeting, and resident and staff interviews it was determined that the facility failed to serve food and beverages at palatable and appetizing temperatures on one of four nursing units (East Wing).

Findings include:

According to the federal regulation 483.60(i)-(2) Food safety requirements - the definition of "Danger Zone", found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness.

A review of the minutes from the facility's food committee meeting that was conducted by the facility's foodservice director on January 8, 2024, revealed that some food items were not hot enough over the weekend (grilled cheese and soup), spaghetti noodles at times stuck together, and some vegetables were overcooked.

During interview with a resident who wished to remain anonymous on February 6, 2024, at 11:30 AM the resident stated that the kitchen is trying but that at times the food leaves little to be desired and noted that vegetables are often over or undercooked.

A test tray was conducted, on February 6, 2024, on the East Hall at 12:50 PM, at the time the last resident began eating, revealed the following:

The planned menu for the test tray was sweet and sour meatballs, steamed rice, Capri vegetable blend, dinner roll, spiced peaches, and coffee.

Observation of the items on the tray revealed that the peaches were plain and not spiced.

The test tray temperatures that were as follows at the time of service: sweet and sour meatballs were 123.4 degrees Fahrenheit, rice was 129 degrees Fahrenheit, Capri blend vegetables were 112 degrees Fahrenheit, peaches were 62 degrees Fahrenheit, and coffee was 140 degrees Fahrenheit.

The sweet and sour meatballs, rice, Capri blend vegetables, and peaches tasted lukewarm. The food and beverages were not palatable at the temperatures served.

Interview with the foodservice director on February 6, 2024, at 1:15 PM confirmed that the facility failed to consistently serve food items at acceptable and palatable temperatures.







 Plan of Correction - To be completed: 03/06/2024

The facility cannot retroactively correct this issue.

The facility has determined that all residents could be potentially affected.

The Dietary staff will be in-serviced by the Regional Dietary Manager on serving food at palatable and appetizing temperatures and the accuracy of the planned menu for each meal. Food committee minutes will be reviewed by the Regional Dietary Manager and any concerns identified will be addressed with the food service director for resolution.

The Facility Dietary Manager (FDM)/designee will provide test tray audits at point of service for proper temperature and palatability of the meals. An audit of the accuracy of meal menus will also be provided by the FDM/designee. Audits will be done weekly for four weeks, then monthly for two months or until compliance is achieved. Results will be presented in QAPI committee meeting.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Observations:

Based on review of clinical records and select investigative reports and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice for one of 27 sampled residents (Resident 93).

Findings include:

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties.

According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and Subsection 21.18. (a)(5) document and maintain accurate records.

According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.145. (a) The licensed practical nurse (LPN) is prepared to function as a member of a health-care team by exercising sound nursing judgement based on preparation, knowledge, skills, understanding and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place.

A review of Resident 93's clinical record revealed that the resident was admitted to the facility on December 12, 2023, with diagnoses which included dementia (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks).

A review of a facility incident report dated February 2, 2024, at 10:30 PM revealed that the resident had an unwitnessed fall and staff found the resident on the floor, on her buttocks, sitting in front of her wheelchair in her room. The resident was assessed at that time and had bruising to her right forearm and complained of right shoulder pain. The physician was notified, and the resident was sent out to the hospital.

A review of the resident's clinical record revealed a nursing note dated February 2, 2024, at 11:00 PM noting that the nurse was alerted that the resident had a fall. No further information was documented in the resident's clinical record regarding when, where, or how the resident had fallen.

An interview with the Nursing Home Administrator on February 6, 2024, at approximately 2:45 PM confirmed that the facility's nursing staff failed to accurately document the resident's fall in the clinical record.


28 Pa. Code 211.5 (f)(iii) Medical records.

28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.





 Plan of Correction - To be completed: 03/06/2024

The facility cannot retroactively correct this issue.

Current resident incidents of falls in the last seven days will be reviewed to assure that documentation accurately reflects the resident's fall in the medical record by nursing staff.

The DON/designee will provide in-service education to Licensed nursing staff on the documentation standards of the American Nurses Association Principles for Nursing Documentation.

The DON/designee will complete audits of resident records related to incidents of falls to ensure licensed staff are thoroughly and accurately documenting according to professional standards of practice. Audits will be done weekly for four weeks, then monthly for two months or until compliance is achieved. Results will be presented in QAPI committee meeting.

§ 205.25(b) LICENSURE Kitchen.:State only Deficiency.
(b) A service pantry shall be provided for each nursing unit. The pantry shall contain a refrigerator, device for heating food, sink, counter and cabinets. For existing facilities, a service pantry shall be provided for a nursing unit unless the kitchen is sufficiently close for practical needs and has been approved by the Department.
Observations:

Based on observation and staff interview it was determined that the facility failed to provide a device for heating foods in four of four resident pantries.

Findings include:

Observation of the Willow, Spruce, North, and East resident pantries on February 6, 2024, between 1:30 PM and 2:00 PM revealed there was no available heating device to heat/reheat food and/or beverages.

Interview with the administrator on February 6, 2024, at 2:15 PM revealed that the microwaves were removed from the resident pantries for resident safety.

The administrator was unaware of the requirement for a device for heating food in each resident pantry.




 Plan of Correction - To be completed: 03/06/2024

The microwaves were placed in each service pantry area and secured.

The facility has determined that all residents could be potentially affected.

The NHA will review each service pantry area to ensure microwaves are in place to heat/reheat food and beverages and are secured.

The NHA/designee will audit the pantries weekly for 4 weeks, then monthly for 2 months to ensure the microwaves remain in place and are secure. The results will be reported to the QAPI committee.


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