Nursing Investigation Results -

Pennsylvania Department of Health
MANORCARE HEALTH SERVICES-GREEN TREE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MANORCARE HEALTH SERVICES-GREEN TREE
Inspection Results For:

There are  113 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.
MANORCARE HEALTH SERVICES-GREEN TREE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and an Abbreviated Survey in response to two complaints completed on April 11, 2019, it was determined that ManorCare Health Services-Greentree 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(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 a review of facility policies, sanitizer solution logs, observations and staff interviews it was determined that the facility failed to properly label and date food products, maintain equipment in a clean and sanitary condition, properly perform hand washing, and test, monitor and document the sanitizing chemical for the dish machine in the Main Kitchen (Main Kitchen).
Findings include:
A review of facility policy "Labeling Food and Date Marking" dated 1/31/19, indicated that the foods are label and dated upon delivery, preparation or opening the item.
A review of facility policy "Storage of Food" dated 1/31/19, indicated that food items were to be labeled upon delivery. Bulk food items such as flour and sugar are to be stored with scoops out of the food product and food is to be labeled when opened.
A review of facility policy "Sanitation Rounds" dated 1/31/19, indicated that sanitation rounds are conducted on a periodic basis and of any area of concern were corrected.
A review of facility policy "Glove Usage" dated 1/31/1, indicated that gloves are used when staff is handling food or touching eating surfaces. Gloves are to be changed when they become soiled such as touching counter tops and refrigerator doors handles.
A review of the facility policy "Dishwasher Operation - Low Temperature Machine" dated 1/31/19, indicated that a chlorine sanitizing rinse is use in low temperature dishwasher. Staff is to complete the dishwasher set up and then complete a wash cycle and test the chemical solution for proper concentration.
During an observation of the Main Kitchen on 4/8/19, at 9:15 a.m. the following was observed;
-the storeroom contained an opened, undated and unsealed bag of bread croutons.
-the walk in refrigerator contained two trays of undated pre-portioned containers of fruit cocktail,
-the freezer contained an opened and undated bag of flour tortilla shells, five pans of undated vegetable lasagna, and two undated containers of vegetable soup.
-there were two unlabeled and undated bulk food containers that contained white substances
-one of the bulk food containers that contained a white substance contained a disposable cup, along with food debris on top of the white substance. The bulk food container's lid was cracked and the outside of the container contained a spilled red substance.
-the cook's reach in refrigerator contained 12 undated grilled cheese sandwiches, an opened and undated container of chicken base and an opened, undated carton of liquid eggs.
-stored under the serving line was an opened, undated gallon container of vegetable oil and an opened and undated container of peanut butter.
During an interview on 4/8/19, at 9:30 a.m. Food Service Director Employee E10 confirmed that the facility failed to properly label and date and store food products in a sanitary manner to prevent the potential for cross contamination.
During an observation of the tray line on 4/9/19, at 11:30 a.m. it was revealed that the facility did not invert flatware stored in flatware cylinders. Dietary Aide Employee E11 was observed with gloved hands touching counter tops and then touching the eating surface of the spoon, knife, and fork while wrapping the utensils in the napkin without performing hand washing or changing his gloves when they became contaminated.
During an interview on 4/9/19, at 11:46 .a.m. Food Service Director Employee E10 confirmed that Dietary Aide Employee E11 failed to perform hand washing and change his gloves and touched the eating surface of the flatware which created the potential for cross contamination.
During observation of the dish room operations on 4/10/19, at 10:01 a.m. Dietary Supervisor Employee E12 conducted a test of the chemical sanitizer solution for the dishwasher that revealed a chemical strength of zero parts per million (ppm). Further investigation by the Food Service Director Employee E10 revealed that the sanitizer solution bottle was empty and not dispensing chemical into the final rinse of the dishwasher.
A review of the facility "Sanitizer Solution Log" date 4/9/19, and 4/10/19, revealed that the facility failed to test, monitor and document the testing of the sanitizer chemical strength for the final rinse prior to the start of the washing procedures.
During an interview on 4/10/19, at 10:15 a.m the Food Service Director Employee E10 confirmed that the facility failed to make certain that the chemical strength of the sanitizer chemical was at 200 - 400 ppm. prior to the start of the washing procedures which created the potential for cross contamination.
28 Pa Code: 211.6 (c)(d)(f) Dietary services.


 Plan of Correction - To be completed: 05/29/2019

Upon initial discover, bulk food containers were removed and/or cleaned as appropriate. All undated food items were discarded by the Food Service Director/designee upon discovery.
Upon discovery, Food Service Director immediately placed a new sanitizer solution bottle for the dishwasher and all previous items were re-washed.
Dietary employees will be educated by the Food Services Director/designee on food safety practices to include handwashing, sanitization of small wares, rotating stock and discarding outdated items, and dishwasher operation-low-temperature machine policy on or before the date of compliance. New hires will be educated during their new hire orientation.
Audits will be completed 3 x per week for 4 weeks, then weekly x3 months using the Kitchen/Food Services QAPI audit tool to determine compliance of food safety standards by the Food Service Director/designee. Results will be tracked and trended and reported to QAA for review and recommendations.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:
Based on review of facility policies and clinical records and staff interview, it was determined that the facilty failed to make certain that the physician order that specified the resident's wishes regarding life sustaining treatments were formulated and accurate for three of 32 residents (Resident R99, R303, and R401).

Findings include:

The facility policy "Emergency Management" dated 1/31/19, indicated that it is the policy to provide a process for identification of a patient's advanced directives. The Physician's Orders for Life Sustaining Treatment (POLST) form is used by the physician to document physician's order and patient's or patient's decision makers awareness and agreement with those orders regarding life-sustaining treatment.

The clinical record indicated that Resident R401 was admitted to the facility 3/25/19, with diagnoses that included repeated falls, difficulty walking and atrial fibrillation (irregular and often rapid heart rate).

The POLST indicated that in the event that she had no pulse and was not breathing, Resident R401 requested DNR/Do Not Attempt Resuscitation (Allow Natural Death) and requested limited additional interventions.

Review of the physician order dated 3/26/19, indicated that Resident R401 was a Full Code indicating that full resuscitation and life sustaining measures were to be implemented.

During an interview on 4/8/19, at 12:12 p.m. Registered Nurse (RN) Unit Manager Employee E2 confirmed that the Code Status for Resident R401 was not consistent between the POLST and the physician order.

The Admission Record Report indicated Resident R99 was admitted to the facility on 1/18/19, with diagnoses that included gastrointestinal hemorrhage (GI bleed), pneumothorax (an abnormal collection of air in the space between the lung and the chest wall), and muscle weakness.

A review of Resident R99's electronic clinical record revealed a code status of Full Code indicating full resuscitation and life sustaining measures were to be implemented.

A review of Resident R99's POLST revealed that the POLST was not complete. A copy of the incomplete POLST was requested from Unit Clerk Employee E6. The POLST copy provided by Unit Clerk Employee E6 revealed that the POLST had been completed by Certified Registered Nurse Practioner (CRNP) Employee E7 with a completion date of 2/26/19.

During an interview on 4/10/19, at 12:07 p.m. Unit Clerk Employee E6 and CRNP Employee E7 confirmed that Resident R99's POLST was incomplete prior to a copy being requested by the surveyor and that CRNP Employee E7 completed the POLST and backdated the completion date to 2/26/19.

The Admission Record Report indicated that Resident R303 was admitted to the facility on 2/27/19, with diagnoses that included muscle weakness, atrial fibrillation, and high blood pressure.

A review of Resident R303's electronic clinical record revealed a code status of Full Code indicating full resuscitation and life sustaining measures were to be implemented.

A review of Resident R303's POLST revealed that the POLST was not complete.

During an interview on 4/10/19, at 11:45 a.m. RN Unit Manager Employee E8 confirmed that Resident R303's POLST was incomplete.

28 Pa. Code 201.14 (a) Responsibility of licensee.

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

28 Pa. Code: 201.29(d) Resident rights.


 Plan of Correction - To be completed: 05/29/2019

R401's order was corrected to reflect POLST/wishes. Initially completed on 2/26/19 with CRNP advanced care planning and note reflected of decision/wishes. R99 wishes were reviewed on 4/25/19 of POLST, completed and verified. R303 no longer resides at facility.
A comprehensive audit using the Advanced Directives QAPI tool will be completed by the DNS/designee to ensure MD orders and POLST are accurate and complete on or before the date of compliance.
Licensed staff and CRNPs will be educated on Use of PA orders for Life sustaining Treatment (POLST) form procedure by the ADNS/ designee on or before the date of compliance. New hires will be educated during their new hire orientation. Residents will be offered the opportunity to complete a POLST form if they do not have one and choose to do so.
Audits of 50% of new admissions will be completed by the ADNS/ designee for completion of POLST and orders 1x a week x4 weeks, then monthly x3 using the Advanced directives QAPI tool. Results will be tracked and trended and reported to QAA committee for review and recommendations.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:
Based on a review of pest control service reports, observations and staff interviews it was determined that the facility failed to properly dispose of refuse to prevent the potential for pest and rodent infestation in the outside garbage compactor area (Outside compactor area).

Findings include:

During an observation of the outside garbage compactor area on 4/8/19, at 8:54 a.m. it was revealed that the compactor bin was full of garbage. The dietary staff attempted to add and compact garbage which resulted in garbage and liquid spilling out of the front and back of the compactor bin. The compactor bin was not enclosed in the back of the compactor. There were dry dead tree leaves, disposable beverage cups and lids, and disposable gloves on the ground behind the storage shed and compactor.

During an interview on 4/8/19, at 9:13 a.m. Food Service Director Employee E10 revealed that the dietary staff was unable to dispose of garbage over the weekend due to the compactor being inoperable and confirmed that the facility failed to maintain the compactor, bin and area surrounding the outside garbage compactor area in manner to prevent the potential for pest and rodent infestation.

During an observation of the outside garbage compactor area on 4/9/19, at 11:38 a.m. revealed the the compactor bin remained not enclosed. The ground area in the front of the compactor contained spilled liquids and a build up of an orange colored substance.

During an interview on 4/9/19, at 11:40 a.m. Food Service Director Employee E10 confirmed that the facility failed maintain the area around the outside garbage compactor area which created the potential for pest and rodent infestation.

A review of the facilty "Summary of Service" reports from the contracted pest control vendor indicated the following for the dumpster area:
- On 6/11/18, an accumulation of trash behind shed noted. Please remove trash to prevent attraction of pests.
- On 7/9/18, an accumulation of trash behind shed noted. Please remove trash to prevent attraction of pests.
- On 8/6/18, an accumulation of trash behind shed noted. Please remove trash to prevent attraction of pests.
- On 9/10/18, an accumulation of trash behind shed noted. Please remove trash to prevent attraction of pests.
- On 10/1/18, an accumulation of trash behind shed noted. Please remove trash to prevent attraction of pests.
- On 11/5/18, an accumulation of trash behind shed noted. Please remove trash to prevent attraction of pests.
- On 12/3/18, an accumulation of trash behind shed noted. Please remove trash to prevent attraction of pests.
- On 1/3/19, an accumulation of trash behind shed noted. Please remove trash to prevent attraction of pests.
- On 2/11/19, an accumulation of trash behind shed noted. Please remove trash to prevent attraction of pests.
- On 3/14/19, an accumulation of trash behind shed noted. Please remove trash to prevent attraction of pests.
- On 4/3/19, Rodent feeding, all bait eaten in bait station, Stations rebaited to combat and monitor rodent activity.

During an interview on 4/11/19, at 12:10 p.m. the Nursing Home Adminsitrator confirmed that the facility failed to follow up on the pest control vendor's recommendation for the dumpster area which created the potential for pest and rodent infestation.

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


 Plan of Correction - To be completed: 05/29/2019

Dumpster and shed were immediately cleaned of debris. Waste Management was contacted to assess dumpster for maintenance and repairs.
An audit of dumpster/shed area will be completed by the Food Service Director/designee to ensure garbage is disposed properly using the on or before the date of compliance using the Kitchen/Food Services QAPI audit tool.
Education of disposal of garbage and refuse properly will be conducted to environmental service staff, dietary staff, and maintenance/ancillary staff by NHA/designee on or before the date of compliance. New hires will be educated during their new hire orientation.
Audit of dumpster and shed area will be conducted 3 x week for 4 weeks, then 1 x month for 3 months to ensure garbage and refuse is disposed of properly using the Kitchen Sanitation QAPI tool by the Maintenance Director/ designee. Results will be tracked and trended and reported to QAA for review and recommendations.

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime: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(f) Frequency of Meals
483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.
Observations:
Based on review of facility policy, facility records, observations and resident, family and resident group and staff interviews, it was determined that the facility failed to serve meals at regular times to meet the needs and preferences of residents on one of four nursing units (Third floor nursing unit).

Findings include:

The facility policy "2019 Cart Delivery Schedule" last reviewed 1/31/19, indicated that lunch trays are delivered to the Third Floor nursing unit from 12:50 p.m. to 12:55 p.m. and dinner trays from 6:25 p.m. until 6:30 p.m.

During an interview on 4/08/19, at 11:09 a.m. Resident R55 indicated dinner has been coming late at 7:00 p.m., I don't like that, it is too late.

During an interview on 4/9/19, at 9:36 a.m. Resident R56's family member indicated that meal times are unpredictable and sometimes that interferes with therapy.

During the Resident Group interview on 4/9/19, at 2:00 p.m. Residents 500 through 515 indicated
that meal trays are late and they are never served at the same time. The staff are assisting residents in the dining room while the trays sit on the delivery cart and the food gets cold. The Resident Group indicated that the evening meal sometimes does not arrive until 6:45 or 7:00 p.m. and Bingo had to be moved from 7:00 p.m. to 7:30 p.m. because residents were still eating.

A review of the Resident Council Minutes for 2/7/19 and 3/7/19, revealed that residents had a concern of late dietary trays.

A review of the Activity Schedule revealed that Bingo was scheduled on the third Thursday of the month at 7:00 p.m. in February and March 2019, however Bingo was moved to 7:30 p.m. for April 2019.

During an observation on 4/8/19, at 1:17 p.m. it was revealed that the dietary cart with the lunch trays arrived on the third floor nursing unit, the scheduled arrival was 12:50 to 12:55 p.m..

During an observation on 4/10/19, at 1:11 p.m. it was revealed that the dietary cart with lunch trays had arrived on the second floor nursing unit. The nurse aids finished passing the trays at 1:23 p.m.

During an interview on 4/10/19, at 1:23 p.m. The Registered Dietician Employee E5 confirmed the third cart on the Third Floor Nursing Unit was delivered at 1:11 and trays were passed until 1:23 p.m.

28 Pa. Code: 211.6(b)(c) Dietary services.


 Plan of Correction - To be completed: 05/29/2019

R56 no longer resides in facility. Facility will review R55 meal delivery preference time frame on or before the date of compliance.
Dietary employees will be educated by the Food Services Director/designee on meal delivery schedule and frequency of meals on or before the date of compliance. New hires will be educated during their new hire orientation.
Audits will be completed 3 x per week for 4 weeks, then weekly x3 months using the Tray Audit checklist to ensure cart delivery time is based on schedule by the Food Service Director/designee. Results will be tracked and trended and reported to QAA for review and recommendations.

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 review of facility policies, observations and resident group and staff interviews, it was determined that the facility failed to serve meals at a palatable temperature on two of four nursing units (Second floor and Third floor nursing units).

Findings include:

The facility policy "Assessing Meal Satisfaction" last reviewed 1/31/19, indicated that food is served at preferable temperature (hot foods are served hot and cold foods are served cold) as discerned by the resident.

The facility policy "Food Temperatures at Point of Service" dated 1/31/19, indicated that food is served to the resident at preferable temperatures.

During the Resident Group interview on 4/9/19, at 2:00 p.m. Residents R500 through R515 indicated
that while the staff are assisting residents in the dining room their trays sit on the delivery cart and the food gets cold.

During an observation on 4/10/19, at 1:11 p.m. it was revealed that the dietary cart with lunch trays had arrived. The nurse aides finished passing the trays. At 1:23 p.m. a test tray was conducted the following food temperatures were recorded: ham 117 Degrees Fahrenheit ( ), sweet potatoes 127 , broccoli 117 , hamburger 111 , hot tea water 111 and milk 48 A taste test revealed food was lukewarm and not at a palatable temperature.

During an interview on 4/10/19, at 1:23 p.m. The Registered Dietician Employee E5 confirmed the test tray on the Third Floor Nursing Unit was not at a preferred temperature for palatability and the facility had failed to maintain hot food temperatures.

During an observation on 4/10/19, at 1:26 p.m. it was revealed that the dietary cart with lunch trays had arrived. The nurse aides finished passing the trays. At 1:37 p.m. a test tray was conducted the following food temperatures were recorded: ham 123 pureed sweet potatoes 133 , Capri mixed vegetables 131 , hamburger 113.6 and milk 54 Based on this surveyor testing these food items it was determined that hot food was served cold and cold food served warm which was determined to be non palatable.

28 Pa. Code: 211.6(b)(c)(d) Dietary services.


 Plan of Correction - To be completed: 05/29/2019

Upon discovery, food items on the serving line were checked for proper temperatures and corrective actions by the Food Service Director/designee were taken as needed.
Dietary staff will be educated by Food Services Director/designee on hot and cold temperature holding and delivery expectations to ensure palatability on or before the date of compliance. New hires will be educated during their new hire orientation.
Audits will be completed 3 x per week for 4 weeks, then weekly x3 months using the Tray Line Audit checklist to ensure accurate tray temperature is met by the Food Service Director/designee. Meal satisfaction will also be discussed monthly at resident food committee and/or Resident Council and re-evaluated to make improvements. Results will be tracked and trended and reported to QAA for review and recommendations.

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 review of facility policies, observations and resident group and staff interviews, it was determined that the facility failed to follow the displayed menu and maintain documentation of menu substitutions for one of one meal service (Lunch meal 4/10/19).

Findings include:

A review of facility policy "Menu Posting" dated 1/31/19, indicated that menus are posted in public areas to provide residents access to meal items being served throughout the day.

A review of facility policy "Menu Substitutions" dated 1/31/19, indicated that menu substitutions are used when a planned menu item needs to be replaced. The menu substitution is recorded on a substitution log.

During the Resident Group interview on 4/9/19, at 2:00 p.m. Residents R500 through R515 indicated that they do not always receive correct menu items on their meal trays.

During a tray line observation on 4/10/19, at 12:30 p.m. it was revealed the displayed menu indicated that the facility was serving Molasses Pepper Glazed Ham, Roasted Sweet Potatoes, and Cauliflower. The observation revealed facility served to residents the following substitutions: pureed sweet potatoes, broccoli and then Capri mixed vegetables when the facility was out of stock of the broccoli. The facility did not inform the residents of these menu substitutions prior to the meal.

During an interview on 4/11/19, at 12:04 p.m. Food Service Director Employee E10 confirmed that the facility failed to follow the displayed, planned menu for the lunch meal on 4/1/19, failed to notify the residents of the menu change, and maintain a substitution log of approved menu substations.

28 Pa. Code: 211.6(a)(b) Dietary services.


 Plan of Correction - To be completed: 05/29/2019

Daily menus will be posted outside dining areas. Menu item substitutions will be identified, documented on menu substitution log and approved by the RD. Moving forward the Food Services Director will ensure that menu changes will be communicated to the residents via the menu postings in a timely manner.
Dietary staff will be re-educated by the Food Services Director/designee on following; the planned menu, notification to residents when menu needs to be changed, and the use of the substitution log which is reflected in the Menu Substitution Policy on or before the date of compliance. In addition, upon hire the Food Service Director/designee will educate the dietary staff on the Menu Substitution policy.
Audits will be completed 3 x per week for 4 weeks, then weekly x3 months using the Tray Audit checklist to ensure tray accuracy is met by the Food Service Director/designee. Results will be tracked and trended and reported to QAA for review and recommendations.

483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:

Based on a review of facility policy, observations, and Resident Group and staff interviews, it was determined that the facility failed to display information on how to file a grievance in the Main Lobby and on two of four nursing units (Second and Third Floor nursing units).

Findings include:

The facility policy "Know Your Rights Reporting a Grievance" last reviewed 1/31/19, indicated residents have the right to information on how to file a grievance or complaint.

During the Resident Group interview on 4/9/19, at 2:00 p.m. Residents R500 through R514 (15 of 16 Residents), did not know how to obtain a concern/grievance form or where to submit a concern form to file a grievance.

During an observation on 4/10/19, from 12:15 p.m. until 12:30 p.m. it was revealed that in the Main Lobby concern/grievance forms were available to residents however, there was no information indicating how or where to submit the concern forms. On the Third Floor nursing unit, the concern form box used to house concern/grievance forms had no forms available and no information on how to submit a concern was displayed. On the Second Floor nursing unit there was no box to house concern/grievance forms and no information on how to submit a concern was displayed.

During an interview on 4/10/19, at 12:30 p.m. the Nursing Home Administrator confirmed that information on how to file a grievance and concern/grievance forms were not available to residents throughout the facility.

28 Pa Code: 201.18(e)(4) Management.



 Plan of Correction - To be completed: 05/29/2019

Facilities posting of Grievance information will be placed in lobby area and on second floor and third floor nursing units.
Comprehensive review of nursing units and lobby area will be completed to ensure posting of grievance is displayed using the Administrative QAPI tool by the NHA/designee on or before the date of compliance.
Education of how a resident may file a grievance to include how to file a grievance anonymously will be completed to members of resident council by NHA/designee on or before the date of compliance. New admissions will receive information on how to file a grievance including how to file anonymously in the admission packet.
Audits of grievance postings will be completed weeklyx4, then monthly x3 by NHA/ designee using the Administrative QAPI tool. Results will be tracked and trended and reported to QAA committee for review and recommendations.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:
Based on facility policy and clinical record review, resident and staff interviews, it was determined that the facility failed to implement a person centered care plan for one of two residents (Resident R111).

Findings include:

The facility policy "Interdisciplinary Care Planning" last reviewed 1/31/19, indicated that the resident's care plan is a tool that guides the interdisciplinary healthcare team in how to meet the individual resident's needs and identifies the types and methods of care the resident should receive.

A review of the Minimum Data Set (MDS-a comprehensive assessment of care needs) dated 3/5/19, indicated Resident R111 was admitted to the facility on 8/14/18, and had current diagnoses that included aphasia (loss of ability to understand or express speech) and stroke.

During an interview on 4/8/19, at 12:26 p.m. Resident R111 expressed responses to questions from this surveyor by voicing yes or no and pointing to numbers on a board. She sometimes was frustrated with not being able to say more words. She was able to point to numbers when asked her age but could not express self with the alphabet board found in the room. When asked if she liked word searches said can't; and if she liked music, she started to sing words.

A review of the speech encounter notes for Resident R111 indicated the following: On 10/20/19, she demonstrated ability to read sentences aloud; 10/22/19, instructed on applications using the ipad (computer); 10/23/19, resident attempted to explain using visual model (showing one or two fingers for one or two); 10/24/19, resident instructed not to respond quickly to yes or no questions, responds quickly then often changes response, information regarding ipad, given two days ago, still in drawer; 10/27/19, Resident has difficulty verbalizing complex thoughts; 10/29/19 required initial sound cues to produce sounds while reading.

A review of the care plan revealed documentation did not include strategies for how staff could communicate with Resident R111. The care plan for refusal to take medications or wear a hand splint indicated the goal for her was to verbalize understanding of consequences of refusal, however speech therapy had indicated on 10/27/19 that verbalizing complex thoughts was difficult for her. The care plan for pain/discomfort indicated Resident R111 will express that pain level is acceptable however the plan did not indicate how she could communicate pain level.

During an interview on 4/11/19, at 9:15 a.m. Registered Nurse Employee E4 confirmed the care plan failed to indicate Resident R111's communication goals and the interventions necessary to attain those goals.

During an interview on 4/11/19, at 11:000 a.m. the Activities Director confirmed that Resident R111 had refused many activities by saying "no" but was unaware that Speech Therapy had provided an approach to have Resident R111 not rush to answer and respond slowly because sometimes no actually meant yes.

During an interview on 4/11/19, 11:05 a.m. the Director of Rehabilitation confirmed the facility failed to incorporate the approaches developed by speech therapy to assist Resident R111 with communication into the interdisciplinary plan of care.

28 Pa. Code: 211.11(a)(b)(c)(d)(e) Resident care plan.


 Plan of Correction - To be completed: 05/29/2019

R111 was re-evaluated by SLP on 4/16/19 and care plan interventions will be updated by ADNS/designee to reflect current recommendations of speech. Speech therapist began education on 4/18/19 to R111's direct care staff of licensed staff and nursing assistances.
A comprehensive review of residents with aphasia will be completed by ADNS/designee to ensure person-centered care plans using the Care Planning QAPI tool on or before the date of compliance.
The IDT team will be educated on interdisciplinary care plan procedures by ADNS/ designee on or before the date of compliance. New hires will be educated during their new hire orientation. Current resident and new admissions with aphasia will have comprehensive care plans developed that are person centered.
Care plan audits for current residents and new admissions with a diagnosis of aphasia will be completed weekly x4, then monthly x3 by ADNS/designee. Results will be tracked and trended and reported to QAA for review and recommendations.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:
Based on a review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to provide activities of daily living (ADL) assistance for two of four residents (Resident R139 and R303).

Findings include:

A review of facility policy "Shaving" dated 1/31/19, indicated that shaving was provided for personal hygiene and grooming needs and remove unwanted facial hair.

A review of a care plan initiated 3/29/19, indicated that Resident R303 required assistance with daily hygiene and grooming.

During an observation on 4/9/19, at 1:32 p.m. Resident R303 appeared to be unshaven with several days beard growth.

During an interview on 4/9/19, at 1:32 p.m. Resident R303 confirmed that he didn't like being unshaven but felt that he should not have to ask for assistance.

During an interview on 4//9/19, at 1:35 p.m. Registered Nurse (RN) Employee E9 confirmed that Resident R303 was unshaven and the facility failed to meet the needs of the resident and provide ADL assistance with care

A review of a care plan initiated 3/11/19, indicated that Resident R139 required assistance with daily hygiene and grooming.

During an observation on 4/10/19, at 11:00 a.m. Resident R139 appeared to be unshaven with several days beard growth.

During an interview on 4/10/19, at 11:00 a.m. Resident R139 confirmed that he did not like being unshaven, but did not know that the staff would assist him.

During an interview on 4/10/19, at 11:05 a.m. RN Unit Manager Employee E8 confirmed that Resident R139 was unshaven and that the facility failed to meet the needs of the resident and provide grooming assistance.

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

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 05/29/2019

R139 and R303 no longer reside at the facility.
A comprehensive review of those residents who require assistance with ADL's will be completed by ADNS/designee to ensure shaving needs are met using the Activities of Daily Living CMS pathway on or before the date of compliance.
Nursing staff will be educated on nursing guidelines of AM/PM care and shaving by ADNS/designee on or before the date of compliance. New hires will be education during their new hire orientation. Current residents and new admissions who require assistance with shaving will be shaved per their preference.
Audits of 10 resident's who require assistance with adl's will be completed 3 x per week for 4 weeks, then weekly x3 months using the Activities of Daily Living CMS pathway to ensure shaving needs are met by the ADNS/ designee. Results will be tracked and trended and reported to QAA for review and recommendations.

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes: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)(4) Food that accommodates resident allergies, intolerances, and preferences;

483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;
Observations:
Based on review of facility policies and meal tickets, observations and resident and staff interviews, it was determined that the facility failed to provide food preferences for three of 32 residents (Residents R77, R118, R126).

Findings include:

The facility policy "Tray Line Audit Checks" last reviewed on 1/31/19, indicated that checks of tray line set-up and serving process may be helpful to validate quality of foods and meal service, to check food temperatures and menu requirements for food items and portion control equipment to identify problematic trends to refer to QAPI (Quality Assurance and Performance Improvement) Committee.

During the Resident Group interview on 4/9/19, at 2:00 p.m. Residents 500 through 515 indicated
that meal trays are do not match what is ordered or are missing items and gave the following examples: a tray had a juice box but no glass provided, a tray had 4 empty glasses but no beverage, a tray had 7 jellies-five too many, one tray had no ketchup for the hamburger, and another had no fruit or vegetable only a meat.

During lunch meal observation on 4/10/19, at 12:55 p.m. Resident R77's meal service ticket indicated that he is to receive one honey thickened milk, two honey thickened apple juice and yogurt twice a day with meals. On his tray he received two honey thickened milk, one honey thickened apple juice and no yogurt.

During an interview on 4/10/19, at 12:55 p.m. Registered Nurse (RN) Employee E4 confirmed that Resident R77 did not receive the items as listed on his meal service ticket and that the facility failed to provide these preferences.

During initial interview on 4/8/19, Resident R118 indicated dissatisfaction with his breakfast meal. He stated that they ask you what you want for breakfast and then they never give it to you. He had requested ham, scrambled eggs, tea and toast. During breakfast meal observations from 4/8/19 through 4/10/19, Resident R118 only received tea from the items he requested.

During an interview on 4/10/19, at 1:10 p.m. RN Employee E4 confirmed that Resident R118 has an order for the dietary preferences listed above and that the facility has failed to provide these preferences.

During lunch meal observation on 4/10/19, at 12:55 p.m. Resident R126's meal service ticket indicated that she is to receive a no-sugar added shake with her meal. Her meal tray did not include a no-sugar added shake.

During an interview on 4/10/19, at 12:55 p.m. RN Employee E4 confirmed that Resident R126 did not receive her no-sugar added shake and that the facility failed to provide her preference.

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


 Plan of Correction - To be completed: 05/29/2019

Facility reviewed R77, R118, and R126 meal service ticket for accuracy and preferences. Tickets are updated as indicated.
Dietary employees will be educated by the Food Services Director/designee on the Tray Line Audit check policy to ensure accuracy of tray on or before the date of compliance. New hires will be educated during their new hire orientation.
Audits will be completed 3 x per week for 4 weeks, then weekly x3 months using the Tray Line Audit checklist to ensure tray accuracy is met by the Food Service Director/designee. Results will be tracked and trended and reported to QAA for review and recommendations.


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