Pennsylvania Department of Health
GROVE AT LATROBE, THE
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GROVE AT LATROBE, THE
Inspection Results For:

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GROVE AT LATROBE, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit survey completed on March 12, 2024, it was determined that The Grove at Latrobe failed to correct the deficiencies identified during the survey of January 25, 2024, and continued to be out of 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:

483.25 REQUIREMENT Quality of Care:

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.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for two of 15 residents reviewed (Residents 2, 13), and failed to obtain laboratory studies, which resulted in a delay in treatment, for one of 15 residents reviewed (Resident 13).

Findings include:

The facility's policy regarding medication administration, dated January 2, 2024, revealed that medications were to be administered in accordance with written orders of the attending physician.

Physician's orders for Resident 2, dated November 20, 2023, included an order for the resident to receive two 3 milligram (mg) tablets of melatonin (treats sleep problems like insomnia) via the jejunostomy tube (J-tube - a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine) at bedtime. However, there was no documented evidence in the resident's clinical record or Medication Administration Record (MAR) that staff administered the dose of melatonin on March 8, 2024, at 9:00 p.m.

Physician's orders for Resident 2, dated November 21, 2023, included an order for the resident to receive 130 mg of enoxaparin sodium (a blood-thinning medication that helps prevent the formation of blood clots) subcutaneously (SQ - beneath, or under, all the layers of the skin) one time per day. However, there was no documented evidence in the resident's clinical record or MAR that staff administered the dose of enoxaparin sodium on March 7, 2024, at 5:00 a.m.

Physician's orders for Resident 2, dated November 21, 2023, included an order for the resident to receive a 50 milliliters (ml) water flush every four hours. However, there was no documented evidence in the resident's clinical record or MAR that staff administered the 50 ml water flush on March 8, 2024, at 8:00 p.m.

Physician's orders for Resident 2, dated November 29, 2023, included an order for the resident to receive 2 ml of a 250 mg/5 ml oral solution of Gabapentin (a medicine used to treat partial seizures, nerve pain) via the J-tube three times a day. However, there was no documented evidence in the resident's clinical record or MAR that staff administered the dose of Gabapentin on March 8, 2024, at 9:00 p.m.

Physician's orders for Resident 2, dated December 15, 2023, included an order for staff to check the function and placement of the resident's air mattress every shift. However, there was no documented evidence in the resident's clinical record or MAR that staff checked the function and placement of the resident's air mattress on March 8, 2024, during the evening and night shifts.

Physician's orders for Resident 2, dated January 18, 2024, included an order for the resident to receive 0.5 ml of a one mg/ml oral solution of Risperidone (used to treat certain mental/mood disorders) via the J-tube four times a day. However, there was no documented evidence in the resident's clinical record or MAR that staff administered the dose of Risperidone on March 7, 2024, at 5:00 a.m. and March 8, 2024, at 9:00 p.m.

Physician's orders for Resident 2, dated March 7, 2024, included an order for the resident to receive 1 mg of Ativan (medication is used to treat anxiety) via the J-tube two times a day. However, there was no documented evidence in the resident's clinical record or MAR that staff administered the dose of Ativan on March 8, 2024, at 8:00 p.m.

Interview with the Director of Nursing on March 12, 2024, at 2:50 p.m. confirmed that there was no documented evidence in Resident 2's clinical record and/or MARs that the above orders were completed as ordered.

An Admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated February 15, 2024, revealed that the resident was cognitively intact, had an indwelling urinary catheter (tube inserted into the bladder to drain urine), and had diagnoses that included renal (kidney) failure, obstructive uropathy (obstructed urinary flow), and a urinary tract infection (UTI).

A laboratory report, dated March 4, 2024, revealed that Resident 13 had a UTI. Physician's orders for Resident 13, dated March 4, 2024, included an order for the resident to receive 500 mg of Cipro (antibiotic) twice a day for five days for a UTI.

Review of the MAR for Resident 13, dated March 2024, revealed that Cipro was administered to the resident on March 5 through March 9, 2024, for a total of nine doses.

An interview with the Director of Nursing, on March 12, 2024, at 2:52 p.m. confirmed that Resident 13 did not receive 10 doses of Cipro as ordered on March 4, 2024.

The facility's policy regarding laboratory services, dated January 2, 2024, indicated that laboratory studies would be obtained when ordered by the physician.

A quarterly MDS assessment for Resident 13, dated February 15, 2024, indicated that the resident was cognitively intact and had diagnoses that included heart disease, diabetes, and renal (kidney) disease.

A physician's progress note, dated March 1, 2024, at 5:39 p.m. revealed that Resident 13 was seen for altered mental status and it was recommended to obtain bloodwork that included a Complete Blood Count (CBC- analyze red blood cells, white blood cells, and platelets) with differential (count the number of each type of white blood cell in your blood) and a Basal Metabolic Panel (BMP - monitor electrolytes and kidney function).

Physician's orders for Resident 13, dated March 2, 2024, included an order for staff to obtain bloodwork that included a CBC with differential and a BMP.

There was no documented evidence that staff obtained the bloodwork on March 2, 2024, as ordered by the physician.

A nursing note for Resident 13, dated March 4, 2024, at 4:12 p.m. revealed that the Certified Registered Nurse Practitioner (CRNP - a registered nurse with advanced training) reviewed the urinalysis (urine test) and culture and sensitivity (C&S - urine test that identifies specific bacteria and which antibiotics should be used to treat the infection) results and ordered a CBC with differential and BMP in the morning. A physician's order, dated March 4, 2024, included an order for a CBC with differential and BMP.

A laboratory report, dated March 5, 2024, revealed that Resident 13's potassium level was low at 2.9 milliequivalents per liter (mEq/L- normal 3.4-4.5 mEq/L).

A CRNP note, dated March 6, 2024, revealed that the resident had hypokalemia (low potassium) and an order was received to start 40 mEq of potassium daily.

Interview with the Director of Nursing on March 12, 2024, at 2:52 p.m. confirmed that there was no documented evidence that staff obtained the bloodwork for Resident 13 as ordered by the physician on March 2, 2024, which resulted in a delay in new treatment.

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

Plan of Correction - To be completed: 04/17/2024

The facility will provide care and treatment to residents in accordance with professional standards of practice by following physician orders and documenting medication administration on the medication administration record. The facility will ensure laboratory work is completed as ordered by physician.
The concerns identified for residents #2 and #13 cannot be retroactively corrected.
The Assistant Director of Nursing/designee will re-educate licensed nursing, including new hires and agency on the facility policy and procedures of documentation of care and services provided by the nursing staff including licensed nursing staff and nurses' aide staff.
The Director of Nursing (DON)/designee will complete an audit weekly for 2 weeks then monthly for 2 months.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

483.21(b)(1)(3) 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.
§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 on clinical record reviews and staff interviews, it was determined that the facility failed to develop individualized care plans that included the care and services for an ileostomy (a hole/stoma in the abdominal wall which allows waste to leave the body) for one of 15 residents reviewed (Resident 4).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated December 7, 2023, revealed that the resident was cognitively impaired, required assistance from staff with daily care needs, and had an ileostomy.

Resident 4's care plan, dated February 20, 2024, revealed that the resident had an alteration in bowel elimination; however, the care plan did not contain resident-specific interventions related to the resident's ileostomy.

An interview with the Director of Nursing on March 12, 2024, at 4:17 p.m. confirmed that Resident 4's care plan did not include anything regarding the resident's ileostomy.

28 Pa. Code 201.24(e)(4) Admission Policy.

Plan of Correction - To be completed: 04/17/2024

Care Plan for resident 4 to reflect ileostomy.
The Registered Nurse Assessment Coordinator (RNAC) will complete a house audit for all residents with an ileostomy and ensure an individualized care plan for the resident's care needs.
Nursing Home Administrator (NHA)/designee will educate the RNAC and Licensed Practical Nurse Assessment Coordinator (LNAC) on the facility policy and procedures for updating care plans, ensuring that care plans have been devised for residents to meet their needs.
The RNAC/Designee will complete an audit weekly for 2 weeks then monthly for 2 months to validate that care plans have been devised for residents to meet their individual care needs.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that indwelling catheter care was completed as ordered for one of 15 residents reviewed (Resident 2) who had a indwelling suprapubic urinary catheter.

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated June 5, 2023, revealed that the resident usually understood, usually understands, required extensive assistance from staff for his daily care tasks, and had an indwelling suprapubic urinary catheter.

Physician's orders for Resident 2, dated November 21, 2023, included an order for staff to provide indwelling suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder through a cut in the abdomen) care every shift. However, there was no documented evidence in the resident's clinical record, Medication Administration Record (MARs), or Treatment Administration Record (TARs) that staff completed the suprapubic catheter care on March 8, 2024, during the evening and night shifts.

Physician's orders for Resident 2, dated February 25, 2024, included an order for staff to wash the suprapubic catheter site with soap and water, then pat dry, and then apply silver sulfadiazine (used to prevent and treat wound infections) 1 percent cream to the suprapubic catheter site every day and evening shift. However, there was no documented evidence in the resident's clinical record, MARs, or TARs that staff washed the suprapubic catheter site with soap and water, then patted dry, and then applied silver sulfadiazine on March 8, 2024, during the evening shift.

Interview with the Director of Nursing on March 12, 2024, at 2:50 p.m. confirmed that there was no documented evidence in Resident 2's clinical record, MARs, and/or TARs that the above orders were completed as ordered.

28 Pa. Code 211.12(d)(5) Nursing Services.

Plan of Correction - To be completed: 04/17/2024

The facility will provide care and treatment to residents in accordance with professional standards of practice by following physician orders and documenting the care of residents provided in the electronic medical record.
The concerns identified for resident #2 cannot be retroactively corrected.
The Assistant Director of Nursing/designee will re-educate licensed nursing, including new hires and agency on the facility policy and procedures of documentation of care and services provided by the nursing staff including licensed nursing staff and nurses' aide staff.
The Director of Nursing (DON)/designee will complete an audit weekly for 2 weeks then monthly for 2 months.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

483.25(f) REQUIREMENT Colostomy, Urostomy, or Ileostomy Care:

§483.25(f) Colostomy, urostomy,, or ileostomy care.
The facility must ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.

Observations:

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were provided with proper ileostomy (a hole/stoma in the abdominal wall which allows waste to leave the body) care for one of 15 residents reviewed (Resident 4).

Findings include:

The facility's policy regarding ostomy care, dated January 2, 2024, indicated that a patient with an ileostomy must wear an external pouch to collect emerging fecal matter, which will be watery, pasty, or formed, depending on the location of the stoma. Most disposable pouching systems can be used for 3 to 7 days. Any pouching system should be changed immediately if a leak develops and every type of pouch needs to be emptied when it's about one-third full.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated December 7, 2023, revealed that the resident was cognitively impaired, required assistance from staff with daily care needs, and had an ileostomy.

A review of Resident 4's clinical record revealed that there was no documented evidence that physician's orders had been obtained for the care of his ileostomy, including the frequency of emptying and changing the appliance, as well as the necessary size of the appliance.

Review of Resident 4's clinical record as well as the Treatment Administration Records for February and March 2024 revealed no documented evidence that the resident's wafer and collection bag had been changed at all.

Interview with the Director of Nursing on March 12, 2024, at 4:17 p.m. confirmed that there was no physician's order for changing the resident's ileostomy collection bag or wafer and there should have been.

28 Pa. Code 211.12(d)(5) Nursing Services.

Plan of Correction - To be completed: 04/17/2024

The facility will ensure that orders are obtained for the care of colostomy, urostomy, or ileostomy services.
Physician orders have been changed from as needed orders to specifiying the frequency of emptying and changing the appliance as well as the necessary size of the appliance for resident #4's ileostomy.
House audit of residents with an ileostomy, urostomy, and/or colostomy will be completed to ensure that orders include the frequency of emptying and changing the appliance as well as the necessary size of the appliance.
The Assistant Director of Nursing/designee will re-educate licensed nursing, including new hires and agency on the facility policy and procedures of obtaining orders that include frequency of emptying and changing appliances as well as the necessary size of the appliance and documentation of changes.
The Director of Nursing (DON)/designee will complete an audit weekly for 2 weeks then monthly for 2 months.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

483.50(a)(2)(i)(ii) REQUIREMENT Lab Srvcs Physician Order/Notify of Results:

§483.50(a)(2) The facility must-
(i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws.
(ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders.

Observations:

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for one of 15 residents reviewed (Resident 13).

Findings include:

The facility's policy regarding laboratory services, dated January 2, 2024, indicated that laboratory studies would be obtained when ordered by the physician.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated February 15, 2024, indicated that the resident was cognitively intact and had diagnoses that included heart disease, diabetes, and renal (kidney) disease.

A physician's progress note, dated March 1, 2024, at 5:39 p.m. revealed that Resident 13 was seen for altered mental status and it was recommended to obtain bloodwork that included a Complete Blood Count (CBC- analyze red blood cells, white blood cells, and platelets) with differential (count the number of each type of white blood cell in your blood) and a Basal Metabolic Panel (BMP-monitor electrolytes and kidney function).

Physician's orders for Resident 13, dated March 2, 2024, included an order for staff to obtain bloodwork that included a CBC with differential and a BMP.

There was no documented evidence that staff obtained the bloodwork on March 2, 2024, as ordered by the physician.

Interview with the Director of Nursing on March 12, 2024, at 2:52 p.m. confirmed that there was no documented evidence that staff obtained the bloodwork on March 2, 2024, for Resident 13 as ordered by the physician.

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

Plan of Correction - To be completed: 04/17/2024

The facility will obtain laboratory studies as ordered by the physician. The facility cannot retroactively correct the concern identified for resident #13.
The Assistant Director of Nursing/designee will re-educate licensed nursing, including new hires and agency on the facility policy and procedures for obtaining laboratory studies as ordered, and printing list of laboratory work scheduled for the day to ensure that ordered laboratory work is completed as ordered.
The Assistant Director of Nursing (DON)/designee will complete an audit weekly for 2 weeks then monthly for 2 months.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

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