Pennsylvania Department of Health
 LONGWOOD AT OAKMONT
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LONGWOOD AT OAKMONT
Inspection Results For:

There are  63 surveys for this facility. Please select a date to view the survey results.

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LONGWOOD AT OAKMONT - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey, completed on February 22, 2024, it was determined that Longwood at Oakmont 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 as they relate to the Health portion of the survey process.


 Plan of Correction:


483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
§483.21(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.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:
Based review of facility policy, clinical records, facility documents and staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans for four out of six sampled resident records (Resident R5, R8, R16, and R22).

Findings include:

The facility "Comprehensive care plans" policy dated 11/9/23, indicated that the facility's interdisciplinary team, in coordination with the resident, family or representative, develops and maintains a comprehensive care plan for each resident. Each resident's comprehensive person-centered care plan is designed to incorporate identified problems, reflect treatment goals, and aid in preventing and reducing declines in resident functional status. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.

Review of the clinical record indicated Resident R5 was admitted to the facility on 12/14/23.

Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/20/23, indicated diagnoses of dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory), glaucoma (a group of eye conditions that can cause blindness), and unsteadiness on feet.

Review of a progress note dated 1/29/24, at 6:23 a.m. stated, "Shortly before 6 am this writer was made aware by Dietary chef that resident made it outside of secondary entrance outside of sliding doors. Resident stated to this writer she was trying to go to church. She had pushed the inner sliding doors of track and made it outside of the sliding door entrance. Just prior to this resident was taken to bathroom and sitting in her recliner chair in her room. Resident was safely returned to her room. Physician and family to be made aware."

Review of a physician's order dated 1/29/24, indicated to apply a watch mate (a safety device used to protect residents at risk of wandering) and check function every shift.

Review of Resident R5's care plan did not include goals and interventions related to wandering behaviors.

Review of the clinical record indicated Resident R8 was admitted to the facility on 5/12/23.

Review of Resident R5's MDS dated 2/2/24, indicated diagnoses of high blood pressure, dementia, and muscle weakness.

Review of a physician's order dated 6/5/23, indicated to apply a watchmate and check function every shift.

Review of Resident R8's care plan did not include goals and interventions related to wandering behaviors.

Review of Resident R16's admission record indicated she was admitted on 9/8/23, with diagnoses that included repeated falls, adult failure to thrive (a condition characterizing the impact of multiple medical conditions resulting in a downward spiral of poor nutrition, weight loss, inactivity, and decrease in functional ability), and spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness).

Review of Resident R16's MDS assessment (Minimum Data Set assessment: MDS - a periodic assessment of resident care needs) dated 2/1/24, indicated that the diagnoses were current upon review. Section M-Skin conditions F-eschar (dry, dead tissue within a wound) indicated a "1", meaning one wound was present. Section M-Skin conditions G-Unstageable Deep tissue injury indicated a "1", meaning another wound was present.

Review of Resident R16's clinical nurse note dated 11/1/23, indicated that staff notified by nurse aide for nurse to come to Resident R16 room due to a blackened areas to her right foot. Nurse noted a blackened area with a trace of concave appearance of measuring 1.0 cm x 1.2 cm x 0.0 cm and a area on the left inner foot measuring 1.0 cm x 1.0 cm x 0.0 cm. Charge Nurse was notified."

Review of Resident R16's clinical record dated 2/20/24, indicated that she had wounds on her Left Medial Heel with measurements (2.5cm length x 2.2cm width x 0.1 cm), a Right Lateral Heel an Unstageable Pressure Injury with measurements (0.6cm length x 0.5cm width x 0.4 cm depth) and a Right Lateral Foot Deep Tissue Pressure Injury with measurements (0.6cm length x 0.5cm width and no measurable depth).

Review of Resident R16's care plans dated 11/10/23 did not include any concerns with skin integrity, pressure areas, or skin break down.

Review of the clinical record indicated Resident R22 was admitted to the facility on 8/20/21.

Review of Resident R22's MDS dated 11/20/23, indicated diagnoses of high blood pressure, diabetes (too much sugar in the blood), and reduced mobility.

Review of a progress note dated 10/21/23, indicated a watchmate was applied after Resident R22 was found on the elevator stating he was, "going to find his guys at the farm to go hunting for deer." The progress note stated, "Shortly after 1:00 p.m., stairwell alarm sounded and Resident R22 was observed trying to open the door and head down the stairs."

Review of Resident R22's care plan did not include goals and interventions related to wandering behaviors.
During an interview on 2/22/24, at 1:04 p.m. the Director of Nursing (DON) confirmed that the facility failed to develop and implement comprehensive care plans for Residents R5, R8, R16, and R22 as required.

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


 Plan of Correction - To be completed: 04/10/2024

Residents 5, 8, 22 and all like residents require an elopement care plan. The facility completed an audit on all residents who were assessed to be at risk for elopement on February 27, 2024. All residents with elopement risk have a care plan for elopement. A second audit of all residents with pressure injuries was completed on February 27, 2024. A care plan was entered for Resident #22 to address pressure injuries. All other residents with identified pressure injuries have a pressure injury care plan in place.

Upon admission of a new resident or identification of a new risk for elopement or pressure injury, the nursing team will review the elopement risk assessment and pressure injury risk to prepare care plans as indicated. By March 29, 2024, the MDS coordinator and project nurse will be re-educated on the care plan policy as it relates to elopement and wounds. Care plan audits for residents at risk for elopement or pressure injury will be conducted weekly for six weeks by the Director of Nursing or designee. Any identified missing care plans will be addressed upon discovery.
Elopement and pressure injury care plan audits will be presented and reviewed at the facility QAPI meeting at least quarterly to evaluate trends and develop further action for any negative trends found with missing care plans.
 

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

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

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:
Based on review of facility policy, clinical record review, investigation documentation, and staff interview, it was determined that the facility failed to conduct a thorough investigation of an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) to rule out neglect for one of two residents (Resident R5).

Findings include:

Review of facility policy "Elopement" last reviewed 11/9/23, indicated staff shall investigate and report all cases of missing residents. When a departing individual returns to the facility, the Director of Nursing or Charge Nurse shall examine the resident for injuries, obtain vital signs, notify the attending physician, notify the resident's legal representative of the incident, and complete and file the report of the incident/accident, note length of time gone and outside temperature.

Review of facility policy "Abuse" last reviewed 11/9/23, indicated neglect is defined as the failure of the community, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Reports of abuse (mistreatment, neglect, or abuse) are promptly and thoroughly investigated.

Review of the clinical record indicated Resident R5 was admitted to the facility on 12/14/23.

Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/20/23, indicated diagnoses of dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory), glaucoma (a group of eye conditions that can cause blindness), and unsteadiness on feet.

Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status ("BIMS", a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment

Review of Resident 5's MDS assessment dated 12/20/23, Section C0500-BIMS screening indicated a score of "13" revealing that Resident R5 was alert and oriented to person, place and situation.

Review of Resident R5's "Behavior Monitoring" documentation indicated that Resident R5 displayed behaviors of agitation, restlessness, and pacing on 1/25/24, 1/26/24, 1/27/24, and 1/28/24.

Review of a progress note dated 1/29/24, at 6:23 a.m. stated, "Shortly before 6 am this writer was made aware by Dietary chef that resident made it outside of secondary entrance outside of sliding doors. Resident stated to this writer she was trying to go to church. She had pushed the inner sliding doors of track and made it outside of the sliding door entrance. Just prior to this resident was taken to bathroom and sitting in her recliner chair in her room. Resident was safely returned to her room. Physician and family to be made aware."

Review of the clinical record failed to indicate a physical assessment and vital signs were obtained after Resident R5 was returned to her room.

Review of an Incident Report failed to include at which time Resident R5 was last seen in the facility, who last saw her, and length of time gone.

Review of incidents submitted to the State indicated that during the elopement Resident R5 was wearing a brief, socks, and a t-shirt. The outdoor temperature was 32 degrees Fahrenheit.

During an interview on 2/22/24, at 11:54 a.m. the Director of Nursing (DON) stated, "We didn't do much of an investigation because it was pretty cut and dry from the nurse's note."

During an interview on 2/22/24, at 1:11 p.m. the DON confirmed that the facility did not obtain witness statements from the staff on duty at the time of Resident R5's elopement. The DON also confirmed the facility was unable to locate documentation to indicate that a physical assessment and vital signs were performed after Resident R5 was returned to her room.

During an interview on 2/22/24, at 1:11 p.m. the DON confirmed that the facility failed to conduct a thorough investigation of an elopement to rule out neglect for one of two residents (Resident R5).

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

28 Pa Code: 201.29 (a )(c)(d) Resident Rights

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


 Plan of Correction - To be completed: 04/10/2024

On February 26, 2024 the administrator and Director of Nursing reviewed the incident that occurred with resident #5 on January 29, 2024. Director of Nursing/designee gathered statements from witnesses that were present at the time of the event. The elopement event had previously been reported on the 01/29/2024 of the event and corrective actions were in place on the date of the event. The review acknowledged that the nurse did not complete vital signs when the resident returned to her room. The resident has not had any negative outcomes from the elopement event that occurred on January 29, 2024.
Residents at risk for elopement had the potential to be affected by the alleged deficient practice. The project nurse completed and audit of all residents elopement assessment to ensure we have identified all residents at risk. There were no identified adverse outcomes based on the review of the elopement assessments.
Team members will be re-educated by the date of compliance on the elopement and abuse and neglect policies to review the need for appropriate investigation and resident assessment following an elopement. The interdisciplinary team will review Investigations, risk management documentation, root cause analysis completion with any potential or actual elopement events. The nurse educator/designee will continue to educate any new team members on the policies related to elopement and abuse.
The interdisciplinary team will audit all investigations five days per week for six weeks, The audits will ensure that all of the required follow up activities related to elopements have been completed and follow up actions have occurred.
Results of the audits will be reviewed by members of the Quality Assurance Performance Improvement Committee at quarterly meetings for review to determine if the identified issue has improved or if there will be follow up actions to address any potential issues non-compliance.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:
Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of two residents (Resident R5).

Findings include:

Review of facility policy "Elopement" last reviewed 11/9/23, indicated staff shall investigate and report all cases of missing residents. When a departing individual returns to the facility, the Director of Nursing or Charge Nurse shall examine the resident for injuries, obtain vital signs, notify the attending physician, notify the resident's legal representative of the incident, and complete and file the report of the incident/accident, note length of time gone and outside temperature.

Review of the clinical record indicated Resident R5 was admitted to the facility on 12/14/23.

Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/20/23, indicated diagnoses of dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory), glaucoma (a group of eye conditions that can cause blindness), and unsteadiness on feet.

Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status ("BIMS", a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment

Review of Resident 5's MDS assessment dated 12/20/23, Section C0500-BIMS screening indicated a score of "13" revealing that Resident R5 was alert and oriented to person, place and situation.

Review of Resident R5's "Behavior Monitoring" documentation indicated that Resident R5 displayed behaviors of agitation, restlessness, and pacing on 1/25/24, 1/26/24, 1/27/24, and 1/28/24.

Review of a progress note dated 1/29/24, at 6:23 a.m. stated, "Shortly before 6 am this writer was made aware by Dietary chef that resident made it outside of secondary entrance outside of sliding doors. Resident stated to this writer she was trying to go to church. She had pushed the inner sliding doors of track and made it outside of the sliding door entrance. Just prior to this resident was taken to bathroom and sitting in her recliner chair in her room. Resident was safely returned to her room. Physician and family to be made aware."

Review of the clinical record failed to indicate a physical assessment and vital signs were obtained after Resident R5 was returned to her room.

Review of incidents submitted to the State indicated that during the elopement Resident R5 was wearing a brief, socks, and a t-shirt. The outdoor temperature was 32 degrees Fahrenheit.

During an interview on 2/22/24, at 11:54 a.m. the Director of Nursing (DON) stated, "We didn't do much of an investigation because it was pretty cut and dry from the nurse's note."

During an interview on 2/22/24, at 1:11 p.m. the DON confirmed that the facility did not obtain witness statements from the staff on duty at the time of Resident R5's elopement. The DON also confirmed the facility was unable to locate documentation to indicate that a physical assessment and vital signs were performed after Resident R5 was returned to her room.

During an interview on 2/22/24, at 1:11 p.m. the DON confirmed that the facility failed to make certain each resident received adequate supervision that resulted in an elopement for one of two residents (Resident R5).

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

28 Pa. Code 201.18(b)(1)(3) Management.

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


 Plan of Correction - To be completed: 04/10/2024

On February 27, 2024 the project nurse completed a full house audit of residents at risk for elopement. The team will be re-educated on the definition of elopement to mean "a resident who is in a location for which we were not aware." The team will be educated of potential signs of elopement that will initiate an immediate intervention to mitigate the risk of elopement for the resident.

Residents at risk for elopement had the potential to be affected by the alleged deficient practice. The project nurse completed a whole house audit of all resident elopement assessments to ensure we have identified all residents at risk. There were no identified adverse outcomes from the elopement assessments reviewed.
A root cause analysis was completed and the team determined resident #5 had no prior episodes of exit seeking. The nurse had seen the resident while assisting her with toileting just prior to her going outside. The team recognizes that the resident was able to push open the emergency doors that were locked. The facility will add a manual door alarm to alert staff if those emergency locked doors are pushed.

~All residents who are at risk for wandering/elopement were audited, reassessed as required, and care plans were updated for appropriate interventions. Staff will be re-educated on all of the tasks in the elopement policy including full body assessment and obtaining vital signs upon the resident's return.

Team members will be re-educated by the compliance date on signs of potential elopement and document and respond to any instance of known exit seeking by instituting interventions to prevent an elopement. If an elopement should occur, team members will complete the checklist of all tasks per policy. The interdisciplinary team will audit all actions taken at the time of an elopement event to ensure the resident is safe and any assessments identifying healthcare intervention has taken place.

§ 201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:
Based on state regulations, staff interview, and review of the facility's Infection Control Committee Meeting attendance records, it was determined that the facility failed to ensure that Infection Control meetings occurred and that all of the required nine multidisciplinary members were present at the Infection Prevention Subcommittee meetings (administration, laboratory personnel, pharmacy staff, a physical plant personnel, and a member from the community) for four of four quarters of 2023 and that residents and/or resident representatives were notified of acquired healthcare-associated infections for 11 of 11 months (March 2023, April 2023, May 2023, June 2023, July 2023, August 2023, September 2023, October 2023, November 2023, December 2023, and January 2024).

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L. 154, No. 13), known as the Medical Care Availability and Reduction of Error (MCARE) Act, Chapter 4, Section 403(1) Infection Control plan states, "A health care facility... shall develop and implement an internal infection control plan that shall include... a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility." A review of the applicable members at infection control meetings include medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plan personnel, patient safety officer, a community member, and a member of the infection control team.

Patient Safety Authority Jurisdiction states: (a)The occurrence of a healthcare-associated infection is deemed a serious event. Written notification to the resident of the serious event should be documented.

A review of the facility's Infection Control Meeting attendance record for the 2023 Quarter 1 meeting failed to revealed that the administrator and a member from the community were in attendance.

A review of the facility's Infection Control Meeting attendance record for the 2023 Quarter 3 meeting failed to reveal that pharmacy staff, laboratory personnel, and physical plant personnel were in attendance.

A review of the facility's Infection Control Meeting attendance record for the 2023 Quarter 4 meeting failed to reveal a member from the nursing staff were in attendance.

A review of the facility's Infection Control surveillance failed to reveal that an Infection Control meeting occurred for Quarter 2 of 2023.

A review of the facility's Infection Control surveillance from March 2023 to January 2024, failed to reveal that notification to affected residents and/or resident representatives was completed in regards to acquired healthcare-associated infections while at the facility.

During an interview on 2/22/24, at 9:45 a.m. the Director of Nursing (DON) confirmed that the facility was unable to locate the Infection Control meeting attendance record for Quarter 2 of 2023 and that the facility did not provide notification to affected residents and/or resident representatives in regards to acquired healthcare-associated infections.

During an interview on 2/22/24, at 9:45 a.m. the DON confirmed that the facility failed to ensure that Infection Control meetings occurred, all nine multidisciplinary members were present at the Infection Control meetings, and that notification of acquired healthcare-associated infections was provided to affected residents and/or resident representatives.


 Plan of Correction - To be completed: 04/10/2024

On February 27, 2024 the Director of Nursing determined that infection control meetings were held in each quarter of 2023 and quarter 4 was completed in January of 2024 however the sign in sheets could not be located. The Infection Control meetings always proceed the Quality Assurance Performance Improvement committee. The meetings are offered via zoom for committee members who are not able to attend in person and will be documented as having attended if they are not here to sign the sign in sheets.

The sign in sheets for future meetings will be re-designed to include all of the required members who attend the infection control meeting. Members not attending in person will be noted on the sign in sheet.

After scheduled infection control meetings, the director of nursing/infection preventionist will review the sign in sheets to ensure all team members are documented as having attended. The completed sign in sheets will be scanned into an electronic folder to ensure the sign in sheets are not lost.

The sign in sheets from the prior meeting will be reviewed at the beginning of the next meeting to ensure that the attendance sheets are up to date. Any identified trends with attendance or sign in sheets will be addressed at the time of the review.

The Director of Nursing acknowledged that we did not send written notifications to residents/resident representatives regarding identified acquired healthcare-associated infections while at the facility. Starting immediately, residents with current healthcare associated infections currently will receive written notification of their infection, their treatment and the timeframe for the treatment. All residents going forward will be sent the appropriate notification concerning an acquired healthcare-associated infection while residing at Longwood. The notification will be mailed or sent via email.

The Infection Preventionist / designee will maintain copies of the notifications sent to residents and/or resident representatives related to healthcare associated infections. The infection preventionist/designee will audit each week for six weeks the letters that are issued to residents/responsible parties related to healthcare acquired infections. The notifications will be matched to the list of reportable infections each week for six to ensure a letter with proof of receipt is provided. The report of the matched lists will be presented at the quarterly infection control meeting. Any negative trends related to missed notifications will be addressed upon discovery at the quarterly infection control meeting and /QAPI committee meeting for further follow up action, if needed.
 

§ 205.6(a) LICENSURE Function of building.:State only Deficiency.
(a) No part of a building may be used for a purpose which interferes with or jeopardizes the health and safety of residents. Special authorization shall be given by the Department ' s Division of Nursing Care Facilities if a part of the building is to be used for a purpose other than health care.

Observations:
Based on observation and staff interview, it was determined that the facility failed to maintain kitchen area services designated for facility residents in four out of four nursing units (Countryside, Riverside, Gardenside, and Woodside), by failing to obtain permission from the State Licensing Agency to utilize the kitchen for Assisted Living Facility and to also utilize the Independent Living Facility kitchen for the nursing care facility.

Findings Include:

Review of Waivers/Exceptions dated 10/20/99, indicated that the State Licensing Agency approved an exception to this State licensure regulation to allow the facility to have an Assisted Living Facility (ALF) dining room to be located on the north end of the first floor nursing care facility. Documentation submitted indicates that the proposed ALF will be connected to the north side of the nursing care facility and that the ALF dining room will be directly inside the nursing care facility, thus avoiding intrusion into any resident care areas. A restroom will be located adjacent to the dining area. The nursing care facility and ALF will have separate entrances.

Review of this exception dated 10/20/99, did not include approval for shared services between the Long Term Care (LTC) facility and the ALF or the Independent Living Facility (ILF).

During an interview on 2/20/24, at 9:35 a.m. Dining Manager Employee E1 stated that there was no walk-in refrigerator or walk- in freezer in the department and that additional foods were stored in the adjacent building that housed the ILF on the Continues Care Retirement Community Campus.

During an interview on 2/21/24, at 10:05 a.m., Cook Employee E2 stated that the kitchen for the LTC Facility was not designed to be a fully functioning kitchen, and that he must go over to the ILF "every morning" to obtain the foods required for meal preparation in the ILF walk-in fridge and walk-in freezer. Cook Employee E2 also stated that most of the food for LTC residents is made in the LTC kitchen but that they obtain soups, salads, and desserts that are prepared in the ILF kitchen, as it contains different equipment not housed in the LTC kitchen.

During an interview on 2/21/24, at 10:30 a.m. Dining Manager Employee E1 confirmed that ILF kitchen prepares some foods for the LTC and that the LTC kitchen also prepares foods for the ALF that is attached to the LTC building.

During an interview on 2/22/24, at 9:50 a.m., the Nursing Home Administrator confirmed that the facility failed to maintain kitchen services designated for the facility residents, and failed to file the appropriate waivers/exceptions to allow the LTC kitchen to prepare foods for the attached ALF, and to also utilize the ILF kitchen for LTC residents as required.


 Plan of Correction - To be completed: 04/10/2024

Longwood at Oakmont utilizes two kitchens to serve meals to the residents in the skilled nursing facility. Prior to 2017, all meals were prepared in the main building of our Continuing Care Retirement Community (CCRC) and delivered to the skilled nursing facility to be served from individual neighborhood unit kitchens. In 2017, Longwood at Oakmont added a gas stove to the serving kitchen, which is housed in the same building as the skilled nursing facility, in order to cook meals and distribute meals to our four neighborhood kitchens and our 20 apartment personal care home. The space in the kitchen housed in the skilled nursing facility does not accommodate a walk-in dry food storage area nor a walk-in refrigerator/freezer to store the amount of food needed to prepare three daily meals for the residents living in the skilled nursing building.

The main kitchen on the CCRC campus provides full meal service for the residents in our other personal care home located in the same building of the main kitchen. The team working in that kitchen is required to comply with the same federal and state regulations that apply to the kitchen in the skilled nursing facility kitchen. There have not been any identified negative outcomes from the food service plan that is currently being managed from two separate kitchens.

The Dining Services Director/designee, will provide re-education to team members in the main kitchen concerning government regulations related to food safety, food storage, food handling, hygiene, and sanitation to ensure that all employees understand the importance of compliance and the potential consequences of non-compliance.

A letter requesting a waiver to serve from both kitchens was emailed on February 28, 2024 to the Pennsylvania Department of Health.

The Dining Services Director Designee will conduct weekly audits for six weeks or until the appropriate waiver is obtained utilizing the surveyor tool to ensure that the kitchens are maintaining regulatory compliance. Inspections and audits will assess compliance with government regulations in both kitchens. These inspections will cover all aspects of food handling, storage, cleanliness, and employee hygiene. Issues of non-compliance will address any deficiencies identified through corrective actions.

Results of the audits will be present to the Quality Assurance Performance Improvement Committee to address any trends that may require further follow up action.


§ 205.25(a) LICENSURE Kitchen.:State only Deficiency.
(a) There shall be at least one kitchen large enough to meet the needs of the facility.

Observations:
Based on observation and staff interview, it was determined that the facility failed to provide a kitchen large enough to meet the needs of the facility for residents in four out of four nursing units (Countryside, Riverside, Gardenside, and Woodside).

Findings Include:

During an interview on 2/20/24, at 9:35 a.m. Dining Manager Employee E1 stated that there was no walk-in refrigerator or walk-in freezer in the department and that additional foods were stored in the adjacent building that housed the ILF on the Continues Care Retirement Community Campus.

During an interview on 2/21/24, at 10:05 a.m., Cook Employee E2 stated that the kitchen for the LTC Facility was not designed to be a fully functioning kitchen, and that he must go over to the ILF "every morning" to obtain the foods required for meal preparation in the ILF walk-in fridge and walk-in freezer. Cook Employee E2 also stated that most of the food for LTC residents is made in the LTC kitchen but that they obtain soups, salads, and desserts that are prepared in the ILF kitchen as it contains different equipment not housed in the LTC kitchen.

During an interview on 2/21/24, at 10:30 a.m. Dining Manager Employee E1 confirmed that the ILF kitchen stores, and prepares some foods for the LTC as the LTC kitchen cannot accommodate all of the necessary equipment.


 Plan of Correction - To be completed: 04/10/2024

Longwood at Oakmont utilizes two kitchens to serve meals to the residents in the skilled nursing facility. Prior to 2017, all meals were prepared in the main building of our Continuuing Care Retirement Community (CCRC) and delivered to the skilled nursing facility to be served from individual neighborhood unit kitchens. In 2017, Longwood at Oakmont added a gas stove to the serving kitchen, which is housed in the same building as the skilled nursing facility, in order to cook meals and distribute meals to our four neighborhood kitchens and our 20 apartment personal care home. The space in the kitchen housed in the skilled nursing facility does not accommodate a walk-in dry food storage area nor a walk-in refrigerator/freezer to store the amount of food needed to prepare three daily meals for the residents living in the skilled nursing building.

The main kitchen on the CCRC campus provides full meal service for the residents in our other personal care home located in the same building of the main kitchen. The team working in that kitchen is required to comply with the same federal and state regulations that apply to the kitchen in the skilled nursing facility kitchen. There have not been any identified negative outcomes from the food service plan that is currently being managed from two separate kitchens.

The Dining Services Director/designee, will provide re-education to team members in the main kitchen concerning government regulations related to food safety, food storage, food handling, hygiene, and sanitation to ensure that all employees understand the importance of compliance and the potential consequences of non-compliance.

A letter requesting a waiver to serve from both kitchens was emailed on February 28, 2024 to the Pennsylvania Department of Health.

The Dining Services Director Designee will conduct weekly audits for six weeks or until the appropriate waiver is obtained utilizing the surveyor tool to ensure that the kitchens are maintaining regulatory compliance. Inspections and audits will assess compliance with government regulations in both kitchens. These inspections eill cover all aspects of food handling, storage, cleanliness, and employee hygiene. Issues of non-compliance will address any deficiencies identified through corrective actions.

Results of the audits will be present to the Quality Assurance Performance Improvement Committee to address any trends that may require further follow up action.



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