Nursing Investigation Results -

Pennsylvania Department of Health
FOREST CITY NURSING AND REHAB CENTER
Patient Care Inspection Results

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FOREST CITY NURSING AND REHAB CENTER
Inspection Results For:

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FOREST CITY NURSING AND REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance Survey completed on May 24, 2022, it was determined that Forest City Nursing and Rehab Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i) Food safety requirements.
The facility must -

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

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

Based on observation, review of select facility policy and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness.

Findings include:

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

Review of a facility policy entitled "Food Storage" that was reviewed by the facility on May 17, 2022, indicated that food storage areas shall be maintained in a clean, safe, and sanitary manner. All foods or food items shall be stored at least six (6) inches above the floor on shelves, racks, dollies, or other surfaces which facilitate thorough cleaning, in a ventilated room, not subject to sewage or wastewater backflow or contamination by condensation, leakage, rodents, or vermin. Cold foods shall be maintained at temperatures of 41 degrees or below. All foods stored in walk-in refrigerators and freezers shall be stored above the floor on shelves, racks, dollies, or other surfaces that facilitate thorough cleaning. Un-served leftovers shall be labeled, dated, and stored for a period not to exceed three (3) days. House supplements will be dated at the time of receiving and again on thawing. Unserved leftovers shall be labeled, dated, and stored for a period not to exceed 3-days. House supplements will be dated at the time of receiving and again on thawing.

The initial tour of the kitchen was conducted with Employee 1, a cook, on May 21, 2022, at 8:21 AM, and revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, was identified:

Inside the walk-in freezer an 18-ounce bottle of flavored water that was opened was observed in the freezer. Employee 1 reported that it was a staff member's drink. A premade boxed chocolate cake was opened, unsealed, and not dated. There were several cases of frozen food items that were stored in directly on the freezer floor.

Inside the walk-in cooler, the cooler felt warm and the thermometer inside the cooler read 45 degrees. There was an open gallon of whole milk that was not dated.

Observation revealed trays of 4-ounce mighty shakes (high calorie/high protein supplement) and 8-ounce juice supplements that had no thaw dates listed on the trays or cartons. Employee 1 reported that she thought they were pulled from the freezer 3 days ago, but was unable to verify. Once defrosted, shakes should be used within 14-days as per manufacture instructions.

In the dry storage area, there was an opened bag rotini pasta that was not dated.

In the cook's area, the garbage can with trash inside and was not covered.

On a metal shelf underneath a food preparation table, there were bins of clean dishes that were not covered.

Inside the cook's reach-in cooler, the cooler felt warm, and the thermometer read 50 degrees. There was a plastic bag with sliced American cheese, a plastic container of 3-bean salad, and a plastic bag of a half of onion that was dated. Behind the stove, debris and a green scrub pad was observed on the floor.

Employee 1, a cook, was observed wearing gloves to serve the food, but was observed touching non-food kitchen surfaces, including her glasses, and clothing, and then picking up several grilled cheese sandwiches from a pan with hands and placing them in a pan inside the steam table. Employee 1 then grabbed the grilled cheese sandwiches with her gloved hands and put them on the resident's plate.

Employee 1 was then observed placing dinner rolls on the resident's plate with the same gloved hands, instead of using serving utensils. At no time during observation, did the server/cook perform hand hygiene and replace the gloves.

Observation of the trayline on May 21, 2022, at 11:20 AM, revealed employees adding plates, silverware, desserts, and other food items to resident trays were touching their face masks and other non-food kitchen surfaces, and at no time during the observation was hand hygiene performed or gloves changed.

During follow-up visit to the kitchen on May 23, 2022, at 11:10 AM, observation in the walk-in cooler revealed that the temperature reading was 49 degrees F and the cook's reach in refrigerator was 42 degrees F.

The dessert of pineapple tidbits was portioned in dessert cups and not covered.

Interview with the certified dietary manager (CDM), on May 23, 2022, at 11:55 AM verified that the walk-in produce cooler temperature was reading higher due to warmer conditions outside. The CDM confirmed that perishable food items should be stored and handled in a sanitary manner.




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

28 Pa Code 211.6 (c)(f) Dietary services





 Plan of Correction - To be completed: 06/28/2022

The employee's drink was discarded. The unlabeled/undated chocolate cake was discarded. The frozen food was moved to the appropriate shelf. The walk-in cooler and the cooks reach in were checked by maintenance and a repair company was notified. The whole milk was discarded. Undated Mighty shakes and rotini pasta were discarded. Trash can was covered. Clean dishes under the cooks table were covered. The items in the cook's cooler were discarded. The sponge was picked up and discarded and the debris behind the stove was cleaned.
The facility cannot retroactively correct the identified concerns from tray line.
The dietary employees will be educated on handling and storing food in a sanitary manner.
The CDM/designee will complete random audits of the kitchen and tray line and cooler temperatures for compliance 3x per week for 3 months.
The kitchen sanitation audits will be reviewed at monthly QAPI x 3 months.

483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on a review of clinical records and the Resident Assessment Instrument and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two residents out of 18 sampled (Resident 15 and 7).

Findings include:

A review of Resident 15's Quarterly MDS Assessment dated March 9, 2022, revealed in Section I Active Diagnoses revealed that the resident had Pneumonia during the 7 days of the look back period.

Review of Resident 15's clinical record revealed that there was no evidence that the resident was diagnosed with or treated for Pneumonia during the 7 days of the look back period.

According to the RAI User's Manual, Section N0410 for Medications Received, the facility is to record the number of days a medication was received by the resident at any time during the 7-day assessment look back period.

A review of the clinical record of Resident 7 revealed physician's orders for Lovenox (an anticoagulant) 40 milligrams (mg)/ 0.4 milliliters (ml), inject 40 mg subcutaneously one time a day every other day for DVT (deep vein thrombosis) until March 9, 2022..

A review of this Resident's Admission MDS Assessment dated February 13, 2022, Section N0410, indicated that the resident received an anticoagulant "2" days in the seven day look back.

A review of Resident 7's February 2022 Medication Administration Record (MAR) revealed that the resident received Lovenox 40 mg injected subcutaneously "3" times in the seven day look back period.

Interview with the Director of Nursing on May 23, 2022, at 1:41 p.m. confirmed that the MDS was coded in error.




28 Pa. Code 211.5(g)(h) Clinical records

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



 Plan of Correction - To be completed: 06/28/2022

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely because it is by the provisions of federal and state law. The plan of correction represents the facility's credible allegation of compliance.
Resident 15 and resident 7 MDS's were modified.
A 30 day look back audit was completed on N0410 and on Section 1 Active Diagnoses for accuracy. Any discrepancies were modified.
The MDS Coordinator was educated regarding Section N0410 and Section 1 Active Diagnosis from the RAI manual.
The MDS Coordinator/designee will audit 2 random MDS in Section 1 Active Diagnosis and N0401 for accuracy weekly x 3 weeks and then monthly x2. Any discrepancies will be modified as necessary.
The MDS audits will be reviewed at monthly QAPI.

483.21(a)(1)-(3) REQUIREMENT Baseline 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 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:


Based on clinical record review and staff interview it was determined that the baseline care plan of one of the 11 newly admitted residents in the last thirty days (Resident 224) failed to address the residents' immediate individual needs.

Findings:


A review of Resident 224's clinical record revealed that the resident was admitted to the facility on May 18, 2022, with diagnoses that included diabetes mellitus, hypothyroidism, calcaneal spur of right foot, alcoholic cirrhosis of liver with ascites, sleep apnea, chronic obstructive pulmonary disease and morbid (severe) obesity.

Review of Resident 224's baseline care plan failed to identify the goals and objectives and corresponding interventions that addressed the resident's current needs failing to address the resident's initial physician orders, dietary orders, and social services required upon admission and provide instructions for the provision of effective and person-centered care to the resident from the time of admission.

Interview with the Nursing Home Administrator on May 24, 2022 at approximately 2:30 PM confirmed that the facility failed to ensure that the resident's baseline care plan included the minimum healthcare information necessary to properly care for each resident upon their admission and addressed resident-specific health and safety concerns to prevent decline or injury.


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

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






 Plan of Correction - To be completed: 06/28/2022

Resident 224's baseline care plan cannot be retroactively corrected.
New residents will have a baseline care plan completed by the admitting nurse/designee within 48 hours to identify goals, objectives and interventions that address the current needs of the resident. The Baseline care plan will be reviewed with the Resident Representative and or Resident at the Baseline Care plan meeting.
The licensed clinical staff and interdisciplinary team will be educated regarding Baseline Care plans.
An Audit of new admissions will be completed at AM clinical meeting to review the 48-hour care plan.
The Baseline Care Plan Audits will be reviewed at monthly QAPI x 3 months.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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.
483.45(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to clinically justify the use of duplicate drug therapy for bipolar disorder for one resident (Resident 40) out of five sampled residents.

Findings include:

A review of Resident 40's clinical record revealed admission to the facility on November 1, 2019, with diagnoses to include unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) with behavioral disturbance, anxiety disorder, and bipolar disorder (serious mental illness characterized by extreme mood swings, a mood disorder that causes radical emotional changes and mood swings, from manic, restless highs to depressive, listless lows. Most bipolar individuals experience alternating episodes of mania and depression) without psychotic features

Current physician orders dated April 7, 2022, revealed that the resident was receiving Seroquel 100 mg in the morning and 300 mg at bedtime for bipolar disorder and anxiety, Depakote 750 mg twice a day for bipolar disorder, Risperidone 1 mg twice a day and, 1 mg two tablets by mouth at bedtime for unspecified dementia with behavioral disturbance, Bipolar disorder and depression without psychotic features, and Lorazepam 1 mg every six hours as needed for nervousness related to anxiety disorder for anxiety and Zoloft 150 mg at bedtime for depression and Bipolar disorder.

Nursing documentation of May 24, 2022, at 6:40 AM indicated that the resident was awake the entire night, was demanding to get out of bed, resisted care and refused to use call bell. An order was received to increase Risperidone to 1 mg in AM and 2 mg at bedtime.

A pharmacist review dated April 26, 2022, identified a concern with resident receiving duplicate antipsychotic medications Seroquel and Risperidone. The physician responded on April 29, 2022, and stated that the resident requires the present dose of Seroquel and Risperidone for stabilization of mood. The physician stated that "the benefits outweigh the risks."

A review of additional physician progress notes also noted that the resident is on duplicate antidepressant therapy, but again the physician solely noted that the "benefits way outweigh the risks."

A review of the psychiatric evaluation and consultation dated April 18, 2022 written by the nurse practitioner indicated that the resident's symptoms were stable, and no changes were recommended at that time, although the CRNP noted that the resident was receiving some medications in her profile that are not recommended. The CRNP noted to continue non-pharmacological interventions and continue to monitor and document changes in behaviors eating or sleeping patterns period.

There was no physician documentation in the resident's clinical record indicating why the resident's symptoms or condition could not be managed at a lower dose or the specific risks to these residents of attempting a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or a medication can be discontinued.

The Director of Nursing was unable to provide evidence of individualized physician documentation to clinically justify the use of multiple drugs to treat the resident's depression and bipolar disorder.

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

28 Pa. Code 211.5 (f)(g)(h) Clinical records

28 Pa. Code 211.2(a) Physician services






 Plan of Correction - To be completed: 06/28/2022

Resident 40 psychotropic medication will be reviewed by the Consultant pharmacist for possible GDR of medication being provided. Physician will document thoroughly to clinically justify the use of multiple medications.
2. Residents receiving multiple psychotropic medication will reflect GDR attempt with corresponding physician documentation for use.
3. Medical providers will be educated on regulation and facility policy for psychotropic use and necessary documentation to justify safe use.
4. DON/designee will audit resident receiving duplicate therapy and the document by physician for completeness monthly for 3months.
5. Results will be submitted to the QA committee for review x 3 months.

483.60 REQUIREMENT Provided Diet Meets Needs of Each Resident: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 Food and nutrition services.
The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.
Observations:

Based on observations, staff interviews and review of recipes and menu extensions it was determined that the facility failed to ensure that dietary staff used consistent and acceptable serving technique to ensure that each resident consistent receives a nourishing, palatable, and well-balanced diet as planned to meet their daily nutritional needs.

Findings included:

Observation of the tray line on May 21, 2022, at 11:12 PM, revealed that the serving utensil identified for use according to the diet extension (a tool that includes menu items, serving sizes, and serving equipment) for the Shepard's pie indicated that staff should use an 8 oz. ladle. Observation revealed that the cook was observed using a spatula to serve this menu item, which failed to assure adequate and uniform portion size served to residents.

Observation of tray line on May 23, 2022, at 11:20 AM, revealed that Employee 2, a cook, was serving food from the tray line. According to the menu, mechanical soft diets were to receive an open faced turkey sandwiches prepared with crust-less white bread and ground turkey on top. Observation revealed the Employee 2 did not portion the ground turkey uniformly and the amount of ground turkey plated was inconsistently portioned and appeared sparse.

Review of the facility's recipe of the mechanical soft opened faced turkey sandwich revealed that staff were place 2 ounces 1/2-inch diced turkey on one slice of sliced bread and ladle 2 ounces of gravy over the turkey. Observation revealed that no gravy was served on the mechanical soft sandwiches as planned to facilitate ease of chewing and safe swallowing.

Interview with the certified dietary manager (CDM), on May 23, 2022, at 11:55 AM, confirmed that the Shepard's pie was not served properly and should have been served with an 8-ounce ladle instead of a spatula. The CDM also confirmed that the mechanically altered open-faced turkey sandwiches should have been served with gravy on top of the meat and that the sandwiches should not have been served observed resulting in inconsistent portioning.



28 Pa. Code 211.6 (b)(c)(d) Dietary Services





 Plan of Correction - To be completed: 06/28/2022

The facility cannot retroactively correct tray line service on May 21, 2022, and May 23, 2022.
The current dietary cooks will be educated regarding following facility menus and the proper serving utensils to use based on the diet extensions.
New hire dietary cooks will be educated regarding following facility menus and the proper serving utensils to use based on the diet extensions during facility new hire orientation.
The CDM/designee will complete random audits of try line service for proper use of utensils and the following of facility menus.
The audits will be completed weekly x 4 weeks and monthly x 3 months and be presented at monthly QAPI meetings.

211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.
Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

A review of the facility's weekly staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 2.7 hours of general nursing care to each resident:

December 21, 2021 - 2.64 direct care nursing hours per resident
December 23, 2021 - 2.50 direct care nursing hours per resident
December 25, 2021 - 2.47 direct care nursing hours per resident
December 26, 2021 - 2.67 direct care nursing hours per resident
April 16, 2022 - 2.39 direct care nursing hours per resident
April 17, 2022 - 2.53 direct care nursing hours per resident
April 22, 2022 - 2.51 direct care nursing hours per resident
May 17, 2022 - 2.69 direct care nursing hours per resident
May 20, 2022 - 2.60 direct care nursing hours per resident
May 21, 2022 - 2.66 direct care nursing hours per resident

On the above noted dates, the facility failed to provide 2.7 hours of direct nursing care daily.

During a interview on May 24, 2022, at 11 AM the Nursing Home Administrator was unable to provide evidence that the facility had provided at least the minimum of direct care nursing hours per resident on the dates noted above.




 Plan of Correction - To be completed: 06/28/2022

The facility cannot retroactively correct the nursing hours.
Calculation of daily PPD will be completed and reviewed daily for accuracy by the scheduler and back up scheduler.
The NHA/designee and Human Resources/designee will continue recruitment efforts through job postings, sending needs out to agencies, offering sign on bonuses, recruitment bonuses and offering shift pick up bonuses.
Re-education to NHA/DON/ADON/scheduler on calculation of PPD.
Daily PPD will be audited weekly x4, then monthly x2.
The audits will be reviewed x 2 months at monthly QAPI.


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