Nursing Investigation Results -

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

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MANORCARE HEALTH SERVICES-DALLASTOWN
Inspection Results For:

There are  101 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-DALLASTOWN - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid, State Licensure and Civil Rights, and an Abbreviated complaint survey in response to two complaints completed on March 21, 2019, it was determined that Manor Care Health Services - Dallastown was not in compliance with the following requirements of 42 CFR Part 483 Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.







 Plan of Correction:


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 observation, individual resident interviews, Resident Group interviews and staff interviews it was determined that the facility failed to serve food that was palatable regarding temperatures and taste for one of one test trays trialed and failed to provide food and drink at an appetizing temperature for three of 35 residents reviewed (Residents 19, 87 and 146).

Findings include:

Review of the clinical record for Resident 19 on March 19, 2019, at 1:00 PM revealed resident has diagnoses that include Peripheral Vascular Disease (poor circulation of the extremities) and Spinal Stenosis (a condition in which the spinal canal narrows and the nerve roots and spinal cord become compressed).

Further review of the clinical record reveals that Resident 19's BIMS (brief interview of mental status) was 15 out of a possible score of 15 indicating he was cognitively intact

During an interview with Resident 19 on March 18, 2019, at 10:30 AM when he was asked about the temperature of the food that is served, he stated "it is cold a lot."

During an interview with Resident 87 on March 18, 2019, he stated that the food was cold.

During an interview with Resident 146 on March 18, 2019, at 11:16 AM the resident revealed concerns that the food is always cold . She also stated that her scrambled eggs were cold the other day and her coffee was so cold it would not melt the creamer. Also revealed that the day that oven baked potatoes wedges were served, they were too hard to eat. She stated that the food is never the appropriate temperature.

During Resident Group interview on March 19, 2019, at 11:00 AM, residents shared concerns that "the temperature of the food is terrible", "french fries are frozen or cold", and that concerns about food keep being made at Resident Council meetings without any changes made.

On March 20, 2019, at 12:53 PM a resident lunch tray was selected for conducting a test tray temperature and taste check. The test tray was transported to 100's nursing unit via an unheated food cart. At 1:01 PM the test tray's food temperatures were taken by facility Registered Dietitian (RD) 1.

The food temperatures were recorded as follows: Lasagna 130 degrees F (fahrenheit) noted to have quite good flavor/ not overcooked; coffee 120 degrees F noted to taste lukewarm and have poor flavor; apple juice 50 degrees and noted minimal apple flavor; diced pears 52 degrees F.

During an interview with facility Dietary General Manager (DGM) 1 on March 20, 2019, at approximately 2:00 PM, DGM 1 revealed that facility dining services had no pre-determined guidelines or benchmarks, etc. in place for establishing any set goals for food temperatures upon service to residents. Facility provided document for Food Temperatures at Point of Service which reflected Regulatory guidelines and contained the statement "Patient acceptance is used as a guide" and "Is food served at preferable temperatures as discerned by the patient and customary practice?"

During an interview with Nursing Home Administrator (NHA) on March 20, 2019, at approximately 2:20 PM, NHA revealed the expectation that foods temperatures should be acceptable to residents.

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

28 Pa. code:201.18(b)(1) Management.
















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 Plan of Correction - To be completed: 04/26/2019

1. Resident 19, 87 and 146 had their dietary tickets reviewed and updated to ensure their choices are being met.

2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the Dietary Preferences and Dislikes QAPI Tool, The Food Service Manager or designee will audit all residents to ensure their dietary tickets (eKardex) are updated with their preferences. The Dietary Manager or designee will conduct food committee meetings with the residents weekly for 4 weeks and then monthly to identify what items the residents enjoy and what needs improved.

3. To ensure that the deficient practice does not reoccur, system changes have been implemented to include reducing the amount of coffee pre-poured so it does not lose temperature and putting cold beverages and sides in the freezer for one hour prior to service. The Food Service Manager or designee will in-service the Food Service staff on Focus on Ftag 804 and kitchen processes to ensure we are providing food that is palatable.

4. Utilizing the Tray Audit Checklist, The Food Service Manager or designee will conduct audits of three test trays weekly for 4 weeks and monthly for 2 months to ensure that food is palatable. The results of the audits will be submitted to the Quality Assurance Committee monthly for review and determination of need for further action as needed.

5. Facility alleges substantial compliance on 4/26/19.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:


Based on observations and staff interviews it was determined that the facility failed to store food in accordance with professional standards for food service safety in the main facility kitchen and in two out three nourishment refrigerators representing two out of three nursing unit pantries.

During entrance tour on March 18, 2019, at 9:33 AM it was observed that in the refrigerator next to the milk cooler for supplements was approximately one case of chocolate healthshakes (perishable nutritionally enriched shake), approximately one fifth case of strawberry healthshakes and approximately one eighth case of vanilla healthshakes that were thawing and that neither the individual cartons or the opened cased boxes they were thawing in contained labeling to indicate when they were pulled from freezer to thaw.

Upon request to facility for policy for supplement labeling, Dietary General Manager (DGM) 1 revealed their company does not have nutritional supplement policy and that they follow manufacture guidelines given to surveyor.

Guidelines provided to survey revealed the form titled "Supplements" which contained the following information: "When full cases are pulled from the freezer, they need thawing/use by sticker put on the box. Example: Product:Supplement Name; received On: Date came in with stock; Opened On/Pulled On : Pulled Date, When Pulled From Freezer; Use by Date: Use By Date is 14 Days After Pulled Date.

On March 20, 2019, at approximately 1:40 PM an observation was made in the nourishment pantry in the 100 nursing unit, while accompanied with facilty Registered Dietitian (RD) 1 of four individually portioned styrofoam containers of applesauce for medication pass which were date with the day before's date (March 19, 2019). RD 1 was unable to comment as to whether the written date represented the prepared date or the use by date.

Observation in the 200 nursing unit's nourishment pantry on March 20, 2019, while accompanied with RD 1 revealed a partial tray of of individually portioned styrofoam containers of applesauce for medication pass which were for March 19, 2019. Interview with Registered Nurse Unit Manager (RN) 1 at this date/time revealed that the dates written on the applesauce containers were use by dates.

During an interview with Nursing Home Administrator (NHA) on March 21, 2019, at approximately 11:40 AM, NHA revealed the expectation that procedure for healthshakes should have been followed and applesauce for medication pass should not have outdated in nursing refrigerators.

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

28 Pa. Code 201.18(b)(3) Management.














 Plan of Correction - To be completed: 04/26/2019

1. No specific resident was identified in the deficiency statement.

2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the Kitchen/Food Services QAPI tool, The Food Service Manager or designee will audit the kitchen to ensure that food storage is sanitary. Items that were not labeled, dated or expired will be discarded. This will be completed before the date of compliance 4/26/19.

3. To ensure that the deficient practice does not reoccur, The Food Service Manager or designee will in-service the Food Service staff on Focus on Ftag 812 to ensure food is stored in accordance with professional standards.

4. Utilizing the Kitchen/Food Services QAPI tool, The Sodexo Manager or designee will conduct audits weekly for 4 weeks and monthly for 2 months to ensure that food is stored safely and according to policy. The results of the audits will be submitted to the Quality Assurance Committee monthly for review and determination of need for further action as needed.

5. Facility alleges substantial compliance on 4/26/19.

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 resident and staff interview, and clinical record review, it was determined that the facility failed to ensure a comprehensive plan of care was developed and implemented for two of 35 resident records reviewed (Residents 77 and 158).

Findings include:

Review of Resident 77's clinical record on March 18, 2019, at approximately 2:00 PM revealed diagnoses that included end stage renal disease (extremely diminished function of the kidneys which results in the need for life sustaining dialysis - process of using a machine to filter toxins from the blood), and diabetes mellitus type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood to the cells for nourishment).

During a resident interview on March 18, 2019, at approximately 1:30 PM Resident 77 revealed that his discharge planning included transfering to a lesser care facility or transferring to a separately licensed facility.

Review of Resident 77's comprehensive plan of care on March 20, 2019, at approximately 1:20 PM revealed that Resident 77 did not have a care plan to address his discharge. Review of Resident 77's resolved and cancelled care plans revealed "[Resident 77] shows potential for discharge and patient, and [representative party] express wish for discharge," was resolved on February 23, 2019.

Review of Resident 77's progress notes on March 21, 2019, at approximately 10:15 AM revealed that Social Services Personnel 1 (SSP) 1 documented on February 25, 2019 that Resident 77 was planning to return to an assisted living facility or remain at the facility. Review of the progress notes revealed that SSP 1 documented Resident 77's discharge plans, and changes to Resident 77's discharge plan on February 26, 28, 2019 and March 4, 6, 13, and 15, 2019.

Review of Resident 77's clinical record revealed that Resident 77 did not have a discharge plan of care between February 23, 2019, to March 21, 2019.

During an interview on March 21, 2019, at approximately 1:45 PM, Director of Nursing revealed it was the facility's understanding that the care plan for Resident 77's discharge was resolved on February 23, 2019. During the staff interview Director of Nursing revealed it was the facility's expectation that residents' plan of care include a care plan to address a residents' discharge plans.

Review of Resident 158's clinical record revealed diagnoses that included difficultly walking, muscle weakness, osteoarthritis (degeneration of the joint cartilage and the underlying bone, causes pain and stiffness especially in the hip, knee, and thumb joints), hemiparesis (weakness of one side of the body) of the left (non-dominant side) following Cerebral Infraction (a blockage or narrowing of the arteries in the brain that supply blood and oxygen), and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning).

Review of Resident 158's March 2019, physician orders revealed an order for House Shake, one time a day, with a start date July 17, 2018.

Review of Resident 158's care plan revealed: a focus area for Nutrition risk related to varied intake, history of significant weight loss; with interventions that included to consume 75-100% nutritional supplement.

During an interview with the Director of Nursing on March 21, 2019, at approximately 11:57 AM it was revealed that the facility only documents that the supplement was accepted.

During an interview with the Nursing Home Administrator on March 21, 2019, at approximately 12:59 PM it was revealed that the care plan should be updated to reflect the house supplement would be offered/accepted and/or consumed.

28 Pa Code 201.25(a) Discharge policy

28 Pa Code 211.11(b)(d) Resident care plan












 Plan of Correction - To be completed: 04/26/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency (s) herein. To remain in compliance with all federal and state regulations, the facility has taken, and will take, the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance. All alleged deficiencies cited have been, or will be corrected by the date or dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. The plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being.

1. A discharge care plan was created for Resident 77. Resident 158 had the care plan updated for house supplement acceptance.

2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the Care Planning QAPI tool a comprehensive audit of residents will be completed by the Interdisciplinary Care Plan Team before the date of compliance 4/26/19.

3. To ensure that the deficient practice does not reoccur, The Administrator or designee will in-service the Social Service staff and the Dietitian on the Focus on the Ftag 656 regulation to ensure a comprehensive plan of care is developed and implemented.

4. Utilizing the Care Planning QAPI tool, the Social Service Coordinator or designee will audit 5% of resident care plans weekly for 4 weeks and monthly for 2 months to ensure a comprehensive plan of care is developed and implemented for discharge planning and supplements. The results of the audits will be submitted to the Quality Assurance Committee monthly for review and determination of need for further action as needed.

5. Facility alleges substantial compliance on 4/26/19.

483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities: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) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

483.24(b)(2) Mobility-transfer and ambulation, including walking,

483.24(b)(3) Elimination-toileting,

483.24(b)(4) Dining-eating, including meals and snacks,

483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
Observations:


Based of observations, review of clinical records, and interviews with facility staff it was revealed that the facility failed to provide necessary individualized services to maintain Activities of Daily Living (ADL- wash face, brush teeth, eating, brush hair) in regards to independence with eating and drinking for one of 35 residents reviewed (Resident 158).

Findings include:

Review of Resident 158's clinical record revealed diagnoses that included difficultly walking, muscle weakness, osteoarthritis (degeneration of the joint cartilage and the underlying bone, causes pain and stiffness especially in the hip, knee, and thumb joints), hemiparesis (weakness of one side of the body) of the left (non-dominant side) following Cerebral Infraction (a blockage or narrowing of the arteries in the brain that supply blood and oxygen), and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning).

Observation in Resident 158's room on March 18, 2019, at approximately 10:32 AM revealed an unopened carton of house supplement, dated March 17th, on the windowsill.

Review of Resident 158's March 2019, physician orders revealed an order for House Shake, one time a day, with a start date July 17, 2018.

Review of Resident 158's quarterly Minimum Data Set (MDS- a comprehensive assessment of a resident's functional capabilities and helps nursing home staff identify health problems) dated March 1, 2019, revealed that Resident 158 requires supervision and set up help with eating/drinking.

Review of Resident 158's care plan revealed: a focus area for Nutrition risk related to varied intake, history of significant weight loss; with interventions that included to consume 75-100% nutritional supplement; and another focus area for Activity of Daily Living (ADL- wash face, brush teeth, eating, brush hair) self- care deficit relate to physical limitations due to a CVA, with a goal that Resident 158 will receive assistance as necessary to meet ADL needs, and interventions that included: assist with eating as needed, and to attempt to put soda in cup to give to resident, do not give bottles or cans.

Review of the Nursing Assistant daily documentation for care provided revealed: house supplement was documented as accepted for the past 30 days; fluids were offered and accepted for the past 14 days and Resident 158 was independent with drinking and was provided assistance with set up for 17 out of 20 instances.

During an interview with the Director of Nursing on March 21, 2019, at approximately 11:57 AM it was revealed that the facility only documents that the supplement was accepted. Surveyor noted that Resident 158 requires assistance with set up for meals and snacks and would then be independent with eating and drinking. The expectation was revealed that the supplement should have been opened by staff.

During an interview with the Nursing Home Administrator on March 21, 2019, at approximately 12:48 PM it was revealed the explanation to the care plan intervention "attempt to put soda in cup to give to patient, do not give patient bottles or cans, initiated May 25, 2018;" revealed that Resident 158 would may have difficulty opening a soda can or bottle.

Pa. Code 211.12(d)(1)(3)(5) - Nursing Services





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 Plan of Correction - To be completed: 04/26/2019

1. Resident 158 had his task list updated to include assisting in opening his nutritional supplement upon accepting it.

2. New admissions and current residents have the potential to be affected by the deficient practice. The Unit Manager or designee will complete a Nutrition Critical Element Pathway Observation audit on each unit before the date of compliance 4/26/19.

3. The Director of Nursing or designee will in-service nursing staff on the Nutrition Critical Element Pathway Observation and The Focus On the FTag 676 Activities of Daily Living.

4. Utilizing the Nutrition Critical Element Pathway Observation the Unit Managers or designee will audit 10% of residents weekly for 4 weeks and monthly for 2 months to ensure that appropriate assistance is provided with supplements and meals. The results of the audits will be submitted to the Quality Assurance Committee monthly for review and determination of need for further action as needed.

5. Facility alleges substantial compliance on 4/26/19.



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 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(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 observations, review of select facility documents and staff interviews it was determined that the facility failed to follow the scheduled menu as per the advance prepared menu for one out of one served meals reviewed (Resident 177) and also to assure that menus are developed and prepared to meet the resident choices for one of 35 residents reviewed (Resident 162).

Findings include:

Review of the clinical record on March 19, 2019, at 1:00 PM for Resident 162 revealed clinical diagnoses that included Moderate Protein Calorie Malnutrition (malabsorption of protein in the intestinal tract) and Peripheral Vascular Disease (poor circulation of the extremities).

Observation on March 18, 2019, at 12:30 PM revealed Resident 162 receiving her lunch. Review of Resident 162's menu slip revealed that she is to receive extra gravy, chicken noodle soup, and mashed potatoes every day with lunch and dinner. The meal presented was penne pasta and chicken sauce, there was no chicken noodle soup, mashed potatoes or extra gravy. Resident 162 stated that she did not receive her preference per the menu slip. Nursing Assistant 4 (NA) 4 notified the kitchen to obtain the missing food items.

Observation on March 19, 2019, at 1:08 PM revealed the following on the resident's lunch tray, ham, brussel sprouts, boiled potatoes instead of mashed and no gravy. The resident refused the meal and NA 5 notified the kitchen to obtain mashed potatoes and other preferences.

Review of Resident 162's clinical record revealed the following progress note, "11/5/2018 12:47 Nutrition/Weight Note, The only decided upon food additions was a banana QD (every day) at breakfast and mashed potatoes and gravy QD at lunch and dinner."

During an interview on March 19, 2019, at 1:28 PM with the Dietary General Manager (DGM) 2 she stated that special instructions all printed on all meal tickets. She also stated that she would think that extra items would be provided in addition to the meal being served.

During an interview on March 19, 2019 at 2:05 PM, DGM 2 confirmed that chicken noodle soup and mashed potatoes are always available.

During an interview on March 19, 2019, at 2:21 PM with NA 4 and NA 5, they stated that Resident 162, hasn't been receiving her food preferences and that it was an ongoing issue. The staff stated they are aware that Resident 162 likes her extra items, and do always call the kitchen to obtain the items, if they are not provided.

During an interview with the Registered Dietitian (RD) 1 on March 21, 2019, at 11:01AM she confirmed that Resident 162 should receive extra gravy, chicken noodle soup and mashed potatoes at both lunch and dinner every day.

During an interview with the Nursing Home Administrator and Director of Nursing on March 21, 2019, at 11:33 AM they confirmed that meal preferences should be followed.

Review of Resident 177's clinical record revealed diagnoses that included Diabetes Mellitus Type 2 (long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin with common symptoms that include increased thirst, frequent urination, and unexplained weight loss) and mild protein-calorie malnutrition (form of malnutrition that is defined as a range of conditions arising from coincident lack of dietary protein and/or energy (calories) in varying proportions.

Review of Resident 177's current active physician orders revealed order "CHO (carb)[carbohydrate] controlled diet Regular texture" with a start date of January 15, 2019.

Review of facility Week 4 menu for CHO Carb Control Menu planned to be served to residents ordered a CHO Carb controlled diet (unless food preferences dictated otherwise) revealed that the planned lunch meal for Wednesday March 20, 2019, was to be Lasagna, Caesar Salad, Cauliflower and Pears.

Observation of Resident 177's prepared lunch tray upon service to her nursing unit on March 20, 2019, at 1:01 PM revealed that her meal contained Lasagna, Pears, and salad consisting of iceberg lettuce served with french dressing. The tray did not have cauliflower nor Caesar dressing. Further review of Resident's meal slip failed to reveal any food dislikes.

During an interview with (DGM) 1 on March 20, 2019, at approximately 2:00 PM, GM 1 revealed that cauliflower was not available for the lunch meal on this date and that broccoli had been substituted. GM 1 provided no further information regarding the absence of broccoli on resident 177's lunch tray.

During an interview with Nursing Home Administrator (NHA) on March 20, 2019, at approximately 2:20 PM, NHA revealed expectation that resident's lunch meal should have been served as planned (with substituted vegetable).

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




















 Plan of Correction - To be completed: 04/26/2019

1. Resident 177 and 162 had their dietary tickets (eKardex) reviewed and updated to ensure their choices are being met.

2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the Dietary Preferences/Dislikes QAPI Tool, The Food Service Manager or designee will audit all residents to ensure their dietary tickets are updated with their preferences. This will be completed before the date of compliance 4/26/19.

3. To ensure that the deficient practice does not reoccur, The Food Service Manager or designee will in-service the Food Service staff on Focus on Ftag 803 to ensure the tickets and scheduled menus are followed.

4. Utilizing the Tray Audit Checklist, The Food Service Manager or designee will conduct audits of three test trays weekly for 4 weeks and monthly for 2 months to ensure that food is on the tray according to the ticket and the menu. The results of the audits will be submitted to the Quality Assurance Committee monthly for review and determination of need for further action as needed.

5. Facility alleges substantial compliance on 4/26/19


483.60(i)(3) REQUIREMENT Personal Food Policy: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(i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.
Observations:


Based on policy review, observations, and interviews it was determined that the facility failed to implement a policy for the use and storage of foods brought to residents by family/ visitors to ensure safe and sanitary storage, and consumption in one of two nursing unit refrigerators observed (nursing unit 100).

Findings include:

Review of facility policy, "Foods From Outside Sources," revealed in Procedure 5. Food must be labeled with resident name and date it was bought to the facility and stored in nursing pantry." Review of line 7 revealed "Unconsumed food will be disposed of consistent with manufacturer guideline, food labels or upon evidence of spoilage. Disposal shall be consistent with center polices related to food safety." review of line 8 revealed "Nursing department is assigned responsibility for monitoring the designated refrigerator and discarding outdates (five days inserted-handwritten)."

Review of facility policy (note outside food policy line 7 references disposal shall be consistent with center policies related to food safety) "Labeling Food and Date Marking" reveal;ed in line 2 "the following are labeling guidelines for refrigerated, ready -to-eat, TCS food-time/temperature control for safety. while the 2013 food Code states that foods held for more than 24 hours are marked, it is recommend that all items placed in refrigeration units be labeled with the name of the item, the date the item is placed in the refrigerator and /or the date is is to be used...foods from processing plants are marked at the time the original container is opened and if the food is held for more than 24 hours, the date or day by which the food is to be consumer or discard is indicated. ?The day the original container is opened is counted as day 1 and the day or date marked for consumption or discarding ma not exceed a manufacturer's (use by) date." Review of line 6 revealed "Refrigerators and storage areas are routinely check for temperatures, labeling and dating of food items with food being discarded when bend the (use by) date " and line 7 revealed "Foods that are not potentially hazardous such as ketchup and mustard in gallons or smaller bulk quantities are marked with the opening date."

Observations in the 100 unit nourishment refrigerator while accompanied with Registered Dietitian 1 (RD) 1 revealed the presence of one bottle of hot sauce marked with a room number and no resident name or date opened; an opened container of mustard with room number and no name; small container of fruit cocktail with a room number dated for July 30 with no name, a large can of fruit cocktail with room number and dated 7/30 with no name; an almost empty 84 ounce bottle of prune juice with a room number and no opened date or resident name-manufacturer note on bottle states "use within 7-10 days of opening; a half full bottle of applecranberry juice with a a resident name and room number but no opened date; a opened bottle of ranch dressing labeled with room number and open date; a half bottle of ketchup labeled with room number only and no open date; a half bottle of splash smoothies labeled with resident name no label with open date and manufacturer use by date of May 1, 2019; a large bottle of diet cranberry juice labeled only with room number.

Based on standard practices for food service safety, facility outside food policy indicating foods should be labeled with resident names and dates and reference to facility policy regarding disposal and food safety, the facility failed to implement policy to ensure safety of foods brought in from outside.

During an interview with Nursing Home Administrator (NHA) on March 21, 2019, at 12:58 PM, NHA agreed that resident names should be on food items.

Pa Code 211.6(c) Dietary Services

























 Plan of Correction - To be completed: 04/26/2019

1. No specific resident was identified in the deficiency statement.

2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the Nourishment Pantries QAPI tool, the Unit Managers or designee will audit all the nursing unit refrigerators. Items that were not labeled, dated or expired were discarded. This will be completed before the date of compliance 4/26/19.

3. To ensure that the deficient practice does not reoccur, The Administrator or designee will in-service nursing staff on Focus on Ftag 813 to ensure that foods are labeled according to The Foods From Outside Sources policy.

4. Utilizing the Nourishment Pantries QAPI tool, The Unit Manager or designee will conduct audits weekly for 4 weeks and monthly for 2 months of the nursing unit refrigerators to ensure that food is labeled, dated and not expired. The results of the audits will be submitted to the Quality Assurance Committee monthly for review and determination of need for further action as needed.

5. Facility alleges substantial compliance on 4/26/19.




483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
Observations:


Based on observations, interview with staff and residents and review of facility policies, it was determined that the facility failed to provide a sanitary environment for one resident out of all facility residents' rooms reviewed (Resident 146) and for all residents utilizing hallway in location adjacent to resident 146's room.

Findings include:

Review of facility's Housekeeping job description reflects staff performs housekeeping and cleaning activities within well established guidelines and assigned areas and shift to ensure that quality standards, safety guidelines and customer service expectations are met.

During an interview with Resident 146 in her room on March 19, 2019, at approximately 10:35 AM, Resident pointed to a yellowish stain in front of heater about 6 inch diameter. Resident 146 said 2 days ago staff was getting her ready for bathroom and put her wheelchair in front of heater while they were getting the lift and she had an accident on floor. The stain is still on floor and this incident happened March 16, 2019.

Nurse Aide 3 (NA) 3 observed the spot also and said she would get housekeeping to mop the spot on March 18, 2019 at 1:30 PM it was noted that Housekeeping mopped the spot during the morning. An additional observation of the room revealed a brown dried ring was still on floor.

On March 19, 2019, at 10:00 AM with the Environmental Services staff Member 1 (ES) 1 we went back to the room and spot was gone. It was conveyed that the dried ring was there yesterday after mopping and that Resident 146 had stated that the spot was there for 2 days.

ES 1 revealed the expectation that if the spot still remained there after one mopping then he would expect housekeeping to go over again until throughly cleaned.

During an interview on March 20, 2019, at 2:30 PM with the Nursing Home Administrator it was revealed that spot should have been mopped up totally.

It was observed during course of four day survey of numerous observations of excessive urine odor outside of Resident 146's door. Interviews with nursing staff revealed the resident has something particular with her health that makes the urine smell so strong. Nursing staff did not reveal that anything other than the usual housekeeping efforts had been implemented to address this.

28 Pa. Code: 207.2(a) Administrative responsibility.









 Plan of Correction - To be completed: 04/26/2019

1. The room of Resident 146 was detailed cleaned. Ecolab educated the Housekeeping Manager on procedures to eliminate urine odors.

2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the Environmental QAPI tool, the Housekeeping Manager or designee will audit current resident rooms to ensure that rooms are sanitary and odor free. This will be completed before the date of compliance 4/26/19.

3. To ensure the deficient practice does not reoccur, The Housekeeping Manager or designee will in-service the housekeeping staff on Focus on F Tag 921 regulation to ensure we are providing a sanitary environment for the residents.

4. Utilizing the Environmental QAPI tool, the Housekeeping Manager or designee will audit 5% of resident rooms weekly for 4 weeks and monthly for 2 months to ensure that they are providing a sanitary environment. The results of the audits will be submitted to the Quality Assurance Committee monthly for review and determination of need for further action as needed.

5. Facility alleges substantial compliance on 4/26/19.


35 P. S. 448.809b LICENSURE Photo Id Reg:State only Deficiency.
(1) The photo identification tag shall include a recent photograph of the employee, the employee's name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.


Observations:


Based on observation and staff interview it was determined the facility failed to ensure employees wear facility issued identification for two of four resident areas observed (Stations 1 and 2).

Findings Include:

An observation on March 18, 2019, at 10:46 AM revealed the medical records professional (MR)1 walking on Station 1 without a facility issued identification badge. An immediate interview with MR 1 revealed she "left it in my office."

An observation on March 18, 2019, at 10:50 AM revealed Nursing Assistant 1 (NA) 1 on Station 1 without her facility issued identification badge. An immediate interview with NA 1 revealed she "forgot my ID."

An observation on March 19, 2019, at 2:35 AM revealed Nursing Assistant 2 (NA) 2 on Station 2 not wearing a facility issued identification badge.

An observation on March 20, 2019, at 11:06 AM revealed the registered dietician (RD) 1 not wearing an identification badge. An immediate interview with RD 1 revealed she left her ID in her car.

Review of the facility's Professional Appearance and Dress Code Guidelines for Employees, most recently revised June 2016, reads, in part, "While on duty, all employees must wear name badges so they are clearly visible."

An interview with the Nursing Home Administrator on March 21, 2019, at approximately 11:35 AM revealed an expectation staff would wear their identification badges.









 Plan of Correction - To be completed: 04/26/2019

1. No specific resident was identified in the deficiency statement.

2. No specific resident was identified in the deficiency statement.

3. To ensure that the deficient practice does not reoccur, The Administrator or designee will in-service Department Heads and Nursing staff on State Chapter 53 Photo Identification Badges.

4. Utilizing a Uniform Audit, The Human Resource Director or designee will conduct audits weekly for 4 weeks and monthly for 2 months of 10 staff members to ensure that they are wearing their photo identification badge. The results of the audits will be submitted to the Quality Assurance Committee monthly for review and determination of need for further action as needed.

5. Facility alleges substantial compliance on 4/26/19.


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