Nursing Investigation Results -

Pennsylvania Department of Health
GREEN VALLEY SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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GREEN VALLEY SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  55 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
GREEN VALLEY SKILLED NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and Abbreviated Complaint Survey completed on April 7, 2022, it was determined that Green Valley Skilled Nursing and Rehabilitation 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:


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:

Based on a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to timely notify the resident's interested representative, of a change in condition, a significant weight loss for one resident and scheduled diagnostic testing with the potential need to alter treatment, for one resident out of 12 sampled residents (Resident 24, and 26).

Findings include:


The facility policy "Monitoring Resident's Weight" and "Notification of change", last reviewed by the facility in January 2022, indicated any resident with weight changes of 5 (five) pounds weight gain or loss, the resident will be reweighed at the time of the noted change in weight. The facility will immediately inform the resident, consult the physician and if known, notify the resident's legal representative or an interested family member per federal and state regulations and residents right to privacy. Nursing services shall be responsible for notifying the resident, the attending physician and interested family or responsible party when: any change in the resident's physical, mental or psychological status, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications, and any scheduled appointments.

A review of the clinical record revealed that Resident 24 was admitted to the facility on August 23, 2021, with diagnoses to include dementia (thinking and social symptoms that interfere with daily function), chronic obstructive pulmonary disease (COPD), and gastro-esophageal reflux disease (GERD), chronic kidney disease, fracture of first lumbar vertebra (a bone in your lower back) and left femur (long bone of your leg), cerebral infarction (stroke), protein calorie malnutrition, and peripheral vascular disease (slow and progressive circulation disorder).

A quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated November 24, 2021, indicated that the resident was cognitively intact with a BIMS (brief interview to assess cognitive status) score of 15 (13-15 represents cognitively intact) and required staff assistance with bed mobility, transfer, toilet use, personal hygiene, and dressing.

Resident 24's clinical record reflected a primary representative (responsible party and emergency contact #1) as a family friend.

A continued review of the resident's clinical record weight record revealed the following recorded weights:

October 6, 2021 (10:03 AM) - 191.8 Lbs.
November 8, 2021 (9:23 AM) - 178.2 Lbs. weight loss (7.09 %) in 33 days.
January 13, 2022 (11:50 AM) - 170.6 Lbs. weight loss (11.05%) in 99 days.
February 28, 2022 (11:48 AM) - 164.2 Lbs. weight loss (14.39 %) in 145 days.
March 7, 2022 (10:46 AM) - 154.6 Lbs. weight loss (19.40 %) in 152 days.
April 5, 2022 (4:31 PM) - 145.0 Lbs. weight loss (24.40 %) in 181 days.

There was no documented evidence that the facility had notified the resident's interested representative of the significant unplanned weight loss identified on November 8, 2021, until January 18, 2022, after the additional significant weight loss was noted on January 13, 2022.

A review of the clinical record revealed that Resident 26 was admitted to the facility on March 15, 2004, with diagnoses including Alcohol Induced Dementia (caused by long-term, excessive consumption of alcoholic beverages, resulting in neurological damage and impaired cognitive function).

Resident 26 was hospitalized on December 15, 2021, and returned to the faciltiy December 28, 2021, returning to the facility with a new diagnosis of congestive heart failure (A progressive heart disease that affects pumping action of the heart muscles).

A quarterly Minimum Data Set assessment dated March 3, 2022, indicated that the resident was moderately cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 9 (13-15 represents cognitively intact).

Resident 26's clinical record revealed that the resident had a stress test scheduled for January 21, 2022. There was no documentation present in resident's clinical record conducted during the survey of April 7, 2022, to indicate that the resident's responsible party was notified of the resident's scheduled appointment for a stress test.

Interview with the Director of Nursing (DON) on April 7, 2022, at approximately 9:50 AM, confirmed the facility failed to notify Resident 24's interested representative of the resident's he significant unplanned weight loss and failed to notify Resident 26's responsible party of a scheduled appointment for diagnostic testing.



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

28 Pa Code 201.29(a)(l)(2) Resident rights






 Plan of Correction - To be completed: 05/10/2022

Resident 24 no longer resides in the facility. Resident 26's interested representative was made aware of the unplanned weight loss. His cardiac appointment for diagnostic testing was cancelled. Residents in the facility with demonstrated weight loss within the past 30 days will be reviewed by the interdisciplinary care team to ensure notification of responsible parties/interested representatives. Residents in the facility scheduled for upcoming outside appointments for diagnostic testing will be reviewed by the interdisciplinary team to ensure timely notification of the resident's responsible party/representative. Licensed nurses will receive in service training from the director of nursing or designee regarding notification of changes to include significant weight loss and scheduled appointments for outside diagnostic tests. Weekly audits of resident records to ensure compliance will be completed by nursing supervisors as assigned for 1 quarter. Results will be reported by the director of nursing during the monthly quality assurance committee meeting for 1 quarter.
Date of Compliance: May 10, 2022
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 12 sampled (Resident 3 and 33).

Findings include:

A review of Resident 3's clinical record revealed admission to the facility on October 14, 2021. A physician order dated October 19, 2021, was noted for the resident to receive Hospice care.

An admission MDS Assessment dated October 21, 2021, and quarterly MDS Assessment dated January 21, 2022, in Section O0100 K Hospice Care both indicated that Resident 3 did not receive hospice care while a resident at the facility.

However, the resident had been receiving Hospice care since October 19, 2021, and the admission MDS Assessment of October 21, 2021, and quarterly MDS dated January 21, 2022 were both inaccurate.

A quarterly MDS Assessment dated January 21, 2022 indicated that in Section K0300 Weight Loss that the resident did not have a loss of 5% or more in the last month or loss of 10% or more in 6 months.

Review of the resident's weights indicated that on admission on October 14, 2021, the resident weighed 183 pounds.

Resident 3's weight on January 17, 2022, was 163.8 pounds, a 19.2 pound or 10.49% significant weight loss. The resident's quarterly MDS dated January 21, 2022, was inaccurate.

Interview with Director of Nursing on April 6, 2022, at 1:10 p.m. confirmed that Resident 3's admission MDS Assessment of October 21, 2021, and quarterly MDS Assessment dated January 21, 2022 were both inaccurate with respect to the resident's weights.

A review of Resident 33's clinical record revealed that he was admitted to the facility on September 19, 2018, with diagnoses of dementia (thinking and social symptoms that interfere with daily function), chronic kidney disease, diabetes, and Crohn's disease (a chronic inflammatory bowel disease that affects the lining of the digestive tract).

A review of the quarterly MDS Assessment dated March 16, 2022, revealed that in Section H Bladder and Bowel, 0100, Appliances, was coded to reflect that Resident 33 had an indwelling catheter (a thin tube) during the 14 day look back period.

Physician orders dated March 2022 and April, 2022, Treatment Administration Record (TAR) failed to reveal documented evidence of the usage and or care of an indwelling urinary catheter.

Interview with Director of Nursing (DON) on April 5, 2022, at 1:40 PM, confirmed the aforementioned MDS Assessment was inaccurate with respect to the resident having an indwelling urinary catheter.

Interview with the Nursing Home Administrator (NHA) on April 5, 2022, at 1:45 PM, 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: 05/10/2022

Resident 3 no longer resides in the facility. Resident 33 continues to void without the use of an indwelling catheter. His MDS coding was corrected. MDS' of residents currently receiving hospice services will be reviewed by the facility RNAC to ensure accurate coding. MDS' of residents exhibiting significant weight loss within the past 30 days will be reviewed by the consultant dietitian to ensure accurate coding. MDS' of residents documented for use of an indwelling catheter will be reviewed by the RNAC to ensure accurate coding. The RNAC and dietitian will receiving in service training by the NHA regarding accurate MDS coding of section K, H and O. Audits will be completed by the director of nursing or designee to ensure compliance as follows: 2 times weekly for 1 month, then 1 weekly for 2 months. Results will be reported by the director of nursing during the monthly quality assurance committee meeting for 1 quarter.
Date of compliance: May 10, 2022
483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:


Based on a review of clinical records, observation, and staff interviews it was determined that the facility failed to consistently provide care and services, consistent with professional standards of practice, to prevent and/or promote healing of pressure sore development for one resident identified at risk for pressure sores out of 12 sampled residents (Resident 24).

Findings:

According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk.

The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair.

A review of the clinical record revealed that Resident 24 was admitted to the facility on August 23, 2021, with diagnoses of dementia (thinking and social symptoms that interfere with daily function), chronic obstructive pulmonary disease (COPD), and gastro-esophageal reflux disease (GERD), chronic kidney disease, fracture of first lumbar vertebra (a bone in your lower back) and left femur (long bone of your leg), cerebral infarction (stroke), protein - calorie malnutrition, and peripheral vascular disease (slow and progressive circulation disorder).

An admission Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated August 24, 2021, indicated that the resident was moderately cognitively impaired and required staff assistance with bed mobility, transfer, toilet use, personal hygiene, and dressing.

A review of Resident 24's care plan initiated August 24, 2021, revealed planned interventions of keeping the resident's skin clean and dry, use of lotion on dry skin, a pressure relieving cushion to protect the skin while up in chair, pressure relieving mattress to protect the skin while in bed, a low air loss mattress. There were no specific measures planned regarding pressure reduction or skin care for the resident's feet and lower extremities at this time or for the frequency of repositioning the resident in bed as the resident required staff assistance with bed mobility.

Review of Resident 24's Braden Scale Assessment (a standardized, evidence -based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries) dated September 13, 2021, revealed that the resident scored an 18 (total score of 15-18 indicates the resident was AT RISK) for developing a pressure sore

A progress note dated September 14, 2021, indicated that the resident had a complaint of heel pain. In response to the resident's complaints of heel pain, staff put a pillow under the resident's ankles and elevated heels. No further complaints of pain were noted. There was no documented evidence that professional nursing staff had assessed the skin integrity of the resident's lower extremeties, including both heels at this time.

However, two days later a nursing note dated September 16, 2021, indicated that an unstageable pressure ulcer was found on the left heel measuring 2.5 cm x 2.2 cm. The wound had both, eschar and necrotic (tissue that is dead, cannot be saved, black, brown, leather, scab-like) tissue. Skin prep (a treatment - liquid film that protects an area by reducing friction) applied, heel floats and bilateral lower extremities elevated on pillows while in bed. It was noted that the physician and resident representative were aware.

A review of a facility provided incident report (IR) dated September 16, 2021, at 11:00 AM revealed that the resident had a necrotic area on the left heel reported by therapy, measuring 2.5 cm x 2.2 cm necrotic/slough (yellow - white material in the wound bed, usually wet, and soft). Skin prep (a treatment - liquid film that protects an area by reducing friction) applied, heel floats and bilateral lower extremities elevated on pillows while in bed. The resident was interviewed and stated both heels are sore. Physician and resident representative aware.

Following the resident's noted complaint of heel pain on September 14, 2021, and development of an unstageable pressure ulcer on the left heel on September 16, 2021, skin protectant - prep (SP) to bilateral heels every shift, heels up on cushion when in bed and heel protectors when in bed were added to the resident's care plan on September 17, 2021.

A progress note dated September 17, 2021, indicated that blisters were now present on both of the resident's heels, fluid filled blister with dark fluid. The right heel measured 5.0 cm x 4.2 cm and the left heel blister measured 5.2 cm x 5.0 cm. It was noted to continue with previous orders for both lower extremities to consult the outside-community wound consultant.

A review of a facility provided incident report (IR) dated September 17, 2021, at 11:23 AM revealed that while treating the resident's left heel wound, the resident complained of right heel pain. A fluid filled, dark, blister was observed on right heel. Skin prep applied, heel floats and bilateral lower extremities elevated on pillows while in bed. The resident was questioned, interviewed, and stated "both heels have been hurting for a while."

There was no documented evidence that the facility had fully assessed both the resident's heels when the resident complained of heel pain on September 14, 2021.

A wound consultant report dated September 23, 2021, indicated an initial visit for wound evaluation and management for intact, deep tissue injury (DTI) of the right and left heels. This initial assessment revealed a purple/maroon localized area of discolored intact skin with blood-filled blister roof of the right heel measuring 4.0 centimeter (cm) x 4.0 cm without drainage. Periwound (tissue surrounding a wound) is without erythema (redness). The left heel appears purple/maroon localized area of discolored intact skin with blood-filled blister roof of the left heel measuring 3.0 centimeter (cm) x 2.0 cm without drainage. Periwound (tissue surrounding a wound) is without erythema (redness). This is an unstageable pressure ulcer/injury of the right and left heel due to a DTI. Recommendation is for cleanse the affected area with normal saline solution (NSS) or wound cleanser. Apply skin prep to the affected area every (q) shift and as needed (prn).

Wound consultant documentation dated October 7, 2021, indicated a deep tissue injury (DTI) of the right and left heels. The assessment revealed a purple/maroon localized area of discolored intact skin with blood-filled blister roof of the right heel measuring 2.0 cm x 4.0 cm without drainage. The periwound is without erythema. The left heel appears purple/maroon localized area of discolored intact skin with blood-filled blister roof of the left heel measuring 2.0 cm x 2.0 cm without drainage. The periwound is without erythema. Recommendation is for cleanse the affected area with normal saline solution (NSS) or wound cleanser. Discontinue the skin prep, and start betadine to the heels twice (BID) daily.

Wound consultant documentation dated October 21, 2021, noted a DTI of the right heel. The assessment revealed a purple/maroon localized area of discolored intact skin with blood-filled blister roof of the right heel measuring 4.0 cm x 4.5 cm without drainage. The periwound was without erythema. The left heel appears full-thickness wound of the left heel measuring 3.0 cm x 2.5 cm x 0.1 cm, (site of previous DTI-eschar removed during visit to reveal wound underneath). Wound base is 10% slough, 10% eschar, and 80% granular, small amount non-odorous serosanguinous drainage. The periwound was without erythema. The left heel was reclassified, after the eschar removal from a DTI, to a Stage III pressure ulcer. Recommendation was for the right and left heel affected areas to be cleansed with normal saline solution (NSS) or wound cleanser. Betadine to the right heel BID. The left heel treatment was to discontinue the betadine, apply Ca (calcium) Alginate to wound bed daily and prn, cover with bordered dressing.

Wound consultant documentation dated October 27, 2021, indicated a DTI of the right heel. The assessment revealed a purple/maroon localized area of discolored intact skin with blood-filled blister roof of the right heel measuring 3.0 cm X 3.0 cm X 0.0, without drainage. The periwound is without erythema. The left heel appears full-thickness, stage III wound measuring 1.5 cm X 0.5 cm X 0.1, Wound base is 100% intact stable eschar, without drainage. The periwound is without erythema. Recommendation is for the right and left heel is to cleanse the affected area with normal saline solution (NSS) or wound cleanser. Betadine to the right heel BID. The left heel treatment is to discontinue the Ca (calcium) Alginate, and apply betadine to the left heel BID.

Wound consultant documentation dated November 25, 2021, indicated a DTI of the right heel was reclassified, but failed to identify its current wound classification. However, it was described as a full-thickness wound of the right heel measuring 1.0 x 3.0 x 0.0 cm, wound base 100% lifting eschar without drainage. The periwound was without erythema. The left heel appeared as a full-thickness, Stage III wound measuring 1.0 cm x 0.5 cm x 0.1 cm, wound base was 100% lifting eschar, without drainage. The periwound was without erythema. Recommendation for the right and left heel were to cleanse the affected area with normal saline solution (NSS) or wound cleanser. Betadine to the right and left heel BID, leave open to air (OTA).

The results of a diagnostic test Venous Doppler - left and right lower extremities) dated December 15, 2021, revealed a positive study with occlusive (stopping the flow of) deep vein thrombosis (DVT) of the left lower extremity and a nonocclusive multilevel thrombus (blood clot) of the left leg. No DVT right leg, however a right popliteal fossa (behind the knee) Baker's cyst was noted.

The results of a diagnostic test (Arterial Doppler - left and right lower extremities) dated December 16, 2021, revealed a high grade (greater than 90%) stenosis of the right Dorsalis Pedis Artery (DPA), with moderate ischemia (inadequate blood supply) in the right leg. Occlusion of the left percutaneous transluminal angioplasty (PTA) of the left leg artery.

Wound consultant documentation dated January 6, 2022, indicated a full thickness wound of the resident's right heel measuring 1.0 cm x 2.0 cm. The wound base was 100% lifting eschar with peeling. No drainage, the periwound was without erythema. Left heel full thickness wound was fully epithelialized, without induration, was closed. Recommendation at this time were for a vascular consult do to a greater than 90% stenosis (narrowing), in the right Dorsalis Pedis Artery (DPA) (a blood vessel - artery in the lower leg - foot) and also for the Right heel to cleanse the affected area with normal saline solution (NSS) or wound cleanser. Betadine to the right heel BID, leave open to air (OTA), left heel treatment is discontinued.

Wound consultant documentation dated January 27, 2022, noted a full thickness wound of the right heel measuring 3.3 cm x 3.0 cm wound base 100% lifting eschar around the entire wound bed. No drainage, the periwound was without erythema. Recommendation for the right heel was to cleanse the affected area with normal saline solution (NSS) or wound cleanser. Betadine to the right heel BID, leave open to air (OTA).

On February 22, 2022, Peripheral Vascular Disease (PVD) was added to Resident 24's diagnosis list, after the development and progression, from September 2021 - February 2022, of both the right and or left heel pressure areas.

Wound consultant documentation dated April 7, 2022, noted a full thickness wound of the resident's right heel measuring 1.0 cm x 2.0 cm x 0.1 cm. The wound base was 100% slough. Scant amount of nonodorous serosanguinous drainage, the periwound was without erythema. The recommendation for the right heel was to cleanse the affected area with normal saline solution (NSS) or wound cleanser. Discontinue the betadine, start Santyl to wound daily and cover with foam dressing.

Observation on April 7, 2022, at approximately 9:30 AM, of Resident 24's right and left heels in the presence of Employee 1 (CRNP) wound consultant, revealed a clean, oval shaped open area on the right heel, measuring approximately 1.0 cm x 2.0 cm x 0.1 cm. The wound bed appeared white and soft, with minimal drainage without odor. The left heel was dry and intact.

Interview with the Director of Nursing (DON) on April 7, 2022, at approximately 10:00 AM, confirmed that the facility was unable to provide documented evidence that adequate interventions were in place prior to the development of Resident 24's identified pressure wounds on both his heels.

Interview with the Nursing Home Administrator (NHA) on April 7, 2022, at approximately 10:30 AM, confirmed that the facility was unable to provide evidence of the timely implementation of effective measures to prevent avoidable pressure sores on both heels of the resident identified at risk for pressure sore development.



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

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

28 Pa. Code 211.5(f) Clinical records.





 Plan of Correction - To be completed: 05/10/2022

Resident 24 no longer resides in the facility. Residents currently in the facility will have their Braden scale assessments reviewed by the nursing administrative team to ensure that any resident determined to be at risk for pressure sores and those with pressure sores will receive care and services consistent with professional standards of practice to prevent and/or promote healing. Licensed nurses, C N As and therapists will receive in service training by the director of nursing regarding consistent provision of care and services per professional standards of practice to prevent and/or promote healing of pressure sores. Audits will be completed by the director of nursing or designee to ensure compliance as follows: 2 audits per week for 2 months, then 1 audit per week for 1 month. Results will be reported by the director of nursing during the monthly quality assurance committee meeting for 1 quarter.
Date of Compliance: May 10, 2022
483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to accurately and consistently monitor fluid consumption to ensure adequate hydration status of a resident on a physician prescribed fluid restriction for one resident out of three residents sampled (Resident 9).

Findings include:

A review of the clinical record revealed that Resident 9 was admitted to the facility on January 31, 2022 with diagnoses that included congestive heart failure (a weakness of the heart that leads to a build-up of fluid in the lungs and surrounding body tissues).

A physician order dated February 14, 2022, was noted for a 1800 ml( cc)/day fluid restriction. Dietary will provide the resident 480 cc breakfast, 480 cc lunch and 480 cc dinner and nursing would provide 160 cc per shift (in total would equal 1920 cc per day despite physician order for 1800 cc of fluid per day).

A review of Resident 9's meal tray tickets for meals served on April 7, 2022 revealed that only 360 cc of fluid were provided at the resident's dinner meal instead of the 480 ccs. Dietary provided the resident with only 1320 ccs on that date instead of the planned 1440 ccs.

Interview with the director of nursing on April 7, 2022 at 11:00 AM confirmed that Resident 9 was only to be provided 360 cc of fluid for dinner and not 480 cc as noted in the current physician order breakdown for the allotment of the resident's fluid restriction.

Review of the clinical record revealed that Resident 9's daily fluid intake was recorded on the resident's April 2022 Medication Administration Record for fluids administered each shift with medications and on the resident's Tasks Record for fluids provided with meals.

Further review of the clinical record revealed no documented evidence that Resident 9's total daily fluid intake was calculated at the end of the day to ensure adherence to the physician ordered 1800 cc fluid restriction and to ensure the resident's hydration needs were met based on the physician ordered fluid restriction. The facility failed to demonstrate consistent and accurate monitoring of the resident's fluid intake to timely identify if the resident repeatedly exceeded the physician ordered fluid restriction or if the resident's fluid intake was consisently adequate to meet the resident's needs for adequate hydration status.

Review of the resident's April 2022 Medication Administration Record from April 1 though April 5, 2022, revealed that the resident's fluid intake with medications each day varied from 280 to 880 cc (allowance 480 cc based on 160 cc each shift for nursing to provide to resident).

Review of the resident's April 2022 Tasks Record from April 1 through April 5, 2022, revealed the resident's total daily intake with meals varied from 700 to 1440 cc with meals (allowance of 1320 cc total based on 480 cc breakfast, 480 cc lunch, and 360 cc supper).

The resident's total daily fluid intake from April 1, 2022, through April 5, 2022 varied from 1480 to 1900 cc daily.

A phone interview with the consultant registered dietitian (RD) on April 7, 2022 at 12:15 PM confirmed that when a fluid restriction is ordered by the physician, a fluid allowance is provided for nursing (to provide with medications) and dietary (to be provided with meals). The RD confirmed that a resident's actual fluid intake may vary from what is allowed.

Interview with the director of nursing (DON) on April 7, 2022 at 12:30 PM failed to provide documented evidence that Resident 9's total actual daily fluid intake was being monitored to ensure the physician prescribed fluid restriction was being followed and the resident's hydration needs were being met.




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

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





 Plan of Correction - To be completed: 05/10/2022

Resident 9's fluid restriction has been discontinued per his physician. He is tolerating fluids without difficulty and his hydration status appears adequate. Residents in the facility with physicians' orders for fluid restriction will be assessed by the interdisciplinary care team to ensure accurate accounts and documentation of consumed fluids. The assistant director of nursing will provide in service training to nursing staff regarding accurate and consistent monitoring of fluid consumption to ensure adequate hydration status. Weekly audits of residents with orders for fluid restriction will be completed by the assistant director of nursing or designee for 1 quarter. Results will be reported by the assistant director of nursing during the monthly quality assurance committee meeting for 1 quarter.
Date of Compliance: May 10, 2022
483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i) 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 and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage 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).

Observation of the food and nutrition services department on April 5, 2022 at 9:30 AM revealed 2 cases of bottled water and one case of napkins stored directly on the floor in the dry storage room.

Observation of the snack cart located on the nursing unit on April 5, 2022, at 11:20 AM revealed four 4-ounce thawed Mighty Shakes (nutritional beverage), which were not labeled with a thaw date. The manufacturer label noted to consume the product within 14 days of thawing.

Observation of the food and nutrition services department on April 7, 2022 at 12:00 PM revealed a thick layer of dust on two ceiling vents located in the food preparation area.

Interview with the food and nutrition services director on April 7, 2022 at 11:40 AM confirmed the food and nutrition services department was to be maintained in a sanitary manner.




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

28 Pa Code 211.6(c) Dietary services






 Plan of Correction - To be completed: 05/10/2022

No residents were identified in this F tag. The 2 cases of bottled water and 1 case of napkins were removed from the floor in the dry storage room. The mighty shakes missing thaw dates were discarded. The ceiling vents in the food preparation area have been cleaned and are free of dust. The NHA will provide in service training to the food service director and dietary staff regarding maintaining the food and nutrition services department in a sanitary manner. Weekly audits will be completed by the NHA or designee to ensure compliance for 3 months. Results will be reported by the NHA during the monthly quality assurance committee for 1 quarter.
Date of compliance: May 10, 2022
201.21(c) LICENSURE Use of outside resources.:State only Deficiency.
(c) The responsibilities, functions and objectives and the terms of agreement, including financial arrangements and charges of the outside resource shall be delineated in writing and signed and dated by an authorized representative of the facility and the person or agency providing the service.
Observations:

Based on observation, a review of the facility's contract with a outside consultant and staff interview it was determined that the facility failed to ensure that on-site visits by the consultant dietitian were of sufficient duration and frequency as delineated in writing in the signed facility contract for a consultant dietitian.

Findings include:

Observation on April 5, 2002, at 9:30 AM revealed that the facility employed a full-time qualified food and nutrition services director (FSD). Interview with the FSD at this time revealed that the facility employed a consultant dietitian on a part-time basis. The FSD stated that the majority of interaction with the consultant dietitian was via remote computer access and telephone.

At the time of the survey ending April 7, 2022, deficient facility practice was identified under the requirements for nutrition/hydration status maintenance and food sanitation.

According to the Title 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations Subsection 211.6 (d) Dietary Services - If consultant dietary services are used, the consultant's visits shall be at appropriate times and duration and frequency to provide continuing liason with medical and nursing staff, advice to the administrator, resident counseling, guidance to the dietetic services supervisor and staff of the dietary department, approval of menus, and participation in the development or revision of dietary policies and procedures and in planning and conducting inservice education and programs.

Review of the consultant dietitian's signed contract with the facility dated March 3, 2021, revealed that responsibilities of the consultant dietitian included providing hours of onsite consulting and that monthly visits should be at least sixteen hours on the premises of the facility.

Interview with the administrator on April 8, 2022 at 10:00 AM confirmed that presently the facility's contracted registered dietitian was not providing at least 16 hours of onsite consulting monthly as delineated in the written contractual agreement between the facility and facility's consultant dietitian. At the time of the survey ending April 7, 2022, the administrator was unable to provide documented evidence of actual time the consultant registered dietitian spent onsite at the facility.





 Plan of Correction - To be completed: 05/10/2022

No residents were identified in this P tag. The facility will ensure on site visits completed by the consultant dietitian are of sufficient duration and frequency per the signed facility contract. This will include documentation of dates and duration of visits. The NHA will review the contracted requirements with the consultant dietitian. The NHA will monitor the documentation of the dietitian visits monthly and will address any issues of noncompliance if determined necessary at the time of the occurrence.
Date of compliance: May 10, 2022

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