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  63 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, and Civil Rights Compliance Survey completed on March 28, 2024, it was determined that Green Valley Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:

Based on a review of the facility's abuse prohibition policy, select incident reports and clinical records, and interviews with staff and a resident's family, it was determined that the facility neglected to provide the care and services necessary to avoid physical harm and maintain the physical health of one resident out of 14 residents sampled (Resident 33), resulting in an sprained ankle, which caused the resident pain and a decline in abilities to perform activities of daily living.

Findings include:

A review of the facility policy titled "Abuse Policy and Procedure," indicated as last reviewed by the facility on November 1, 2023, revealed that it is the facility's policy to protect residents from neglect and all incidents of suspected neglect will be thoroughly investigated and reported to the Pennsylvania Department of Health and other agencies as directed by law. The policy defines neglect as the failure of the facility, its employees, or service providers to provide services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

A clinical record review revealed that Resident 33 was admitted to the facility on August 13, 2023, with diagnoses that included cerebral ischemia (a condition characterized by impaired blood flow to the brain) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities).

A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 16, 2024 revealed that Resident 33 has severe cognitive impairment with a BIMS score of 05 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00-07 indicates severe cognitive impairment).

The resident's care plan identified that Resident 33 had ADL self-care performance deficit related to dementia and impaired balance, initiated August 14, 2023, with planned interventions that the resident requires the assistance of two staff for toileting.

A physician's order was noted on January 3, 2024, indicating that Resident 33 requires two staff for all transfers with a gait belt and rollator walker (a mobility assistance device with wheels).

A physician's order was initiated on January 19, 2024, for physical therapy, therapeutic exercise, therapeutic activity, wheelchair training, and gait training.

An employee witness statement dated February 29, 2024, provided by Employee A1, nurse aide, revealed that on February 29, 2024, at 9:45 AM, he was transferring Resident 33 from the toilet when the resident's left knee gave out. Employee A1's statement indicated that he then lowered Resident 33 to the floor. The employee's statement indicated that Employee A1 transferred the resident by himself without the assistance of another staff member as the resident required.

A progress note dated February 29, 2024, at 9:58 AM revealed that Resident 33's left leg gave out while being transferred from toilet to wheelchair. The note indicated that no injuries were identified and that the resident had no complaints of pain.

A progress note dated February 29, 2024, at 3:03 PM revealed that Resident 33 was reporting left ankle tenderness, edema, and pain. The resident's left ankle was swollen. The resident's representative was present and indicated that Resident 33 was not able to bear weight on her ankle. The physician ordered that Resident 33 was to receive an X-ray of her left ankle.

A progress note dated February 29, 2024, at 5:08 PM revealed that X-ray results were received and no fractures were noted.

A review of a facility incident report dated March 1, 2024, revealed that Employee A1, nurse aide, was aware that Resident 33 required the assistance of two staff members for transfers, but Employee A1 felt he was strong enough The report indicated that Employee A1 received a written disciplinary warning and was educated on following physician orders and care plans. The report also indicated that Resident 33's ankle was sprained with edema and slight redness.

A progress note dated March 1, 2024, at 12:30 PM revealed that the resident continued to have left ankle pain. Resident 33's left ankle was wrapped for support, ice was applied, and the leg was elevated. The resident had complaints of pain when bearing weight.


A review of the resident's Medication Administration Records for February 2024 and March 2024 revealed that Resident 33 received:

Tylenol 325 mg on February 29, 2024, at 2:53 PM with a pain level of 6 out of 10
Tylenol 325 mg on February 29, 2024, at 11:57 PM with a pain level of 4 out of 10
Tylenol 325 mg on March 1, 2024, at 10:30 AM with a pain level of 6 out of 10
Tylenol 325 mg on March 1, 2024, at 3:42 PM with a pain level of 6 out of 10

A physician order was initiated on March 2, 2024, for Resident 33 to be transferred with a Hoyer lift until her ankle swelling decreased. The order was discontinued on March 13, 2024.

A review of physical therapy treatment encounters revealed that on February 26, 2024, prior to the injury to the resident's ankle, on February 29, 2024, Resident 33 performed gait training for 10 feet, 40 feet, and 30 feet with a front wheeled walker (mobility device) with the assistance of one staff and performed sit-to-stand transfer training with the assistance of one staff. The summary of service indicated that the resident did not experience pain during the session. On February 26, 2024, the resident's progress was discussed with Resident 33's family member. The resident was able to ambulate 15 to 20 feet. The family member indicated that he is hopeful that with continued treatment he will be able to take Resident 33 home. The note indicated that there would be a greater focus on transfer training. The summary of service indicated that the resident did not experience pain during the session.

Therapy documentation indicated that on February 28, 2024, Resident 33 performed sit-to-stand transfer training with minimal staff assistance. The summary of service indicated that the resident did not experience pain during the session.

Following the injury to the resident's ankle on February 29, 2024, therapy noted on March 4, 2024, that Resident 33 performed transfer training from sit to stand with moderate assistance from one staff member. During the physical therapy session, the resident complained of a constant stabbing left foot/ankle pain level of 5 out of 10. The summary of service indicated that the resident's left foot pain impacted the therapy session.

Therapy noted on March 6, 2024, that Resident 33 performed transfer training from sit to stand with moderate and maximum assistance from one staff member. During the physical therapy session, the resident reported moderate pain in the left ankle/foot. The summary of service indicated that pain limited the resident's ability to transfer and ambulate.

Therapy noted on March 8, 2024, that Resident 33 performed transfer training from sit to stand with moderate assistance from one staff member. The resident was able to stand for a maximum of 30 seconds with caregiver assistance. The summary of service indicated that the resident was reporting pain in the left foot that limited transferring and ambulation.

A documentation survey report for February 2024 of the activities of daily life tasks "walking in the corridor" (how the resident walks in the corridor) and "walking in the room" (how the resident walks in her room) revealed that Resident 33 was able to walk in the facility corridors on 12 occasions with staff assistance and 16 times in her room with staff assistance from February 1, 2024, through February 29, 2024.

However, following the resident's ankle injury on February 29, 2024, the documentation survey report for March 2024 for the activities of daily life tasks "walking in the corridor" and "walking in her room" revealed that these tasks were not applicable or that the resident was dependent on staff for the activities occurring from March 1, 2024, through March 25, 2024.

During an interview on March 26, 2024, at 11:10 AM, Resident 33's family member stated that Resident 33 fell and twisted her ankle a few weeks ago while one staff member was trying to transfer her instead of two people that she requires. He explained that since the resident's fall, Resident 33 "has had a setback" in her physical rehabilitation. He stated that the resident is now unable to walk as well as she did before the incident. He explained that the goal is for Resident 33 to be discharged home after rehab, but now he's unsure when the resident will have recovered enough to return home.

During an interview on March 28, 2024, at approximately 9:30 AM, the Nursing Home Administrator (NHA) confirmed that the facility staff failed to ensure that Resident 33 received the services necessary to avoid physical harm. The NHA confirmed that Employee A1, Nurse Aide, was aware that Resident 33's transfer was to be performed with two people but neglected to assure the presence of a second person and performed the transfer by himself, resulting in Resident 33's sprained ankle and subsequent decline in activities of daily life (i.e. walking in her room and corridor.




28 Pa. Code 201.18 (e)(1) Management

28 Pa. Code 201.29 (a) Resident Rights

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




 Plan of Correction - To be completed: 05/02/2024

The facility has completed the appropriate investigation into the incident and required reporting has been completed. Employee A1 is no longer employed by the facility.

A review of incident reports for the last 7 days will be completed to ensure that any event that may have been the result of abuse or neglect has been properly investigated and reported.

Staff will be re-educated to take the proper steps for preventing and reporting allegations of abuse. Neglect will be highlighted with nursing staff. Facility will also educate leadership on the proper reporting requirements when an abuse or neglect allegation is received.

The ADON or designee will audit any concerns of Abuse or Neglect monthly for three months to ensure that proper actions and reporting have been completed. The audit findings will be communicated with the QAPI team for review and input.

483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff: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(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e)

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.
Observations:

Based on staff interview and a review of employee time sheets and qualifications, it was determined that the facility failed to employ a full-time qualified director of food and nutrition services manager in the absence of a full-time qualified dietitian.

Findings include:

An interview with the food service director (FSD) on March 26, 2024, at 9:30 AM revealed that she was currently enrolled in an online course to become a certified dietary manager and she was presently not qualified for the position according to regulatory criteria.

Further interview with the FSD revealed that the facility employed a part-time consultant dietitian who works approximately four hours per week.

Review of monthly time sheets for the consultant dietitian dated December 4 through March 22, 2024, confirmed that the consultant dietitian did work four hours per week and was not full-time.

Interview with the nursing home administrator (NHA) on March 26, 2024, at approximately 11:30 AM, confirmed that the previous full-time qualified foodservice director's last day of employment was on October 20, 2023. The administrator confirmed that the facility did not currently employ a full-time qualified food service director in the absence of a full-time qualified dietitian.

Refer F812

28 Pa Code 201.18 (e)(1)(6) Management.



 Plan of Correction - To be completed: 05/02/2024

No individual resident has been identified for this deficiency.

No additional residents have been affected by this deficiency.

The facility currently has a full-time dietary employee that has 2 or more years of experience in the dietary department with supervisory experience in food and nutrition services. This employee is currently enrolled in an approved course of study in food safety management and will finish the program in two months. The facility will hire a Registered Dietician or equivalent to supervise the department and meet the needs of the facility until the employee has successfully finished the course and becomes certified.

The NHA will monitor this issue on a weekly basis to ensure that the dietary employee continues on the timeline for course completion and certification as well as on-going dietitian support. Findings will be communicated with the QAPI team and adjusted as needed.


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

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

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

Based on observation 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 in the food and nutrition services department and resident pantry.

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).

According to CMS guidance, dated May 20, 2014 (S & C 14-34-NH) Skilled nursing and nursing facilities should use pasteurized shell eggs or liquid pasteurized eggs to eliminate the risk of residents contracting Salmonella Enteritis (SE). The use of pasteurized eggs allows for resident preference for soft-cooked, undercooked or sunny-side up eggs while maintaining food safety. In accordance with the Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA) standards, skilled nursing and nursing facilities should not prepare nor serve soft-cooked, undercooked or sunny-side up eggs from unpasteurized eggs.

Observation during the initial tour of the food and nutrition services department on March 26, 2024, at 9:15 AM revealed two cases of fresh shell eggs, which were not pasteurized (salmonella infections may be prevented by using pasteurized eggs in place of unpasteurized eggs in the preparation of foods where the egg will not be thoroughly cooked) were present on a shelf in the walk-in refrigerator.

Interview with the food service director (FSD) at this time confirmed that the fresh shell eggs were being used to serve "dippy" eggs. The FSD confirmed that the fresh shell eggs were not pasteurized. The FSD confirmed that the fresh shell eggs were ordered by mistake instead of pasteurized shell eggs from the food supplier.

Observation of the resident pantry refrigerator on March 26, 2024, at 11:30 AM revealed the following food storage/sanitation concerns:

There was a thawed 4-ounce nutritional shake and a 10-gallon plastic bag which contained 4-ounce nutritional shakes in the refrigerator which were not dated with a thaw or discard date. The manufacturer label noted the shakes should be used within 14 days after thawed.

There were two plastic storage containers of applesauce on the shelf, which were not dated.

There were two 46-ounce bottles of thickened juice, which were opened but not dated. The manufacturer label noted that the juice should be used within 10 days of opening.

There was a 60-ounce bottle of apple juice, which was opened but not dated.

There was a spill observed under the plastic pull-out crisper drawer of the refrigerator.

Interview with the foods service director (FSD) on March 27, 2024, at 9:30 AM confirmed that food and beverages were to be stored and thawed according to acceptable practices. The FSD confirmed that the food and nutrition services department and resident pantry were to be maintained in a sanitary manner to prevent potential contamination of food and storage items.

Refer F801

28 Pa. Code 201.18 (e)(2.1) Management

28 Pa. Code 211.6 (f) Dietary services




 Plan of Correction - To be completed: 05/02/2024

The identified items in the café refrigerator have been discarded. Pasteurized eggs were obtained immediately and were used for any undercooked eggs. The refrigerator was cleaned the same date.

Resident food storage areas will be reviewed to ensure that food is properly labeled and dated.

The dietary department will place a use by date on any product that do not have a best buy date printed on the product or products that have a limited shelf life once thawed or opened. Only pasteurized eggs will be purchased. Dietary staff will be educated on the updated dating process.

The food service director will audit the main walk-in cooler and the café refrigerator twice weekly for four weeks and then monthly for three months to ensure that items are dated properly, and the refrigerator is kept clean. The audit findings will be communicated with the QAPI team for review and input.
.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on observations, a review of clinical records, and resident and staff interviews, it was determined that the facility failed to provide reasonable accommodations to facilitate a resident's participation in activities for one of the 14 residents sampled (Resident 41).

Findings include:

A clinical record review revealed that Resident 41 was admitted to the facility on February 15, 2024, with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe).

A review of an initial comprehensive Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 17, 2024 revealed that Resident 41 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

The resident's care plan, initated February 15, 2023, identified that Resident 41 has a need for socialization and engagement with interventions planned to invite the resident to scheduled activities. Resident 41's activity preferences were identified as bingo, arts and crafts, exercise, singing in church choir, and church or faith based activities.

During an interview on March 26, 2024, at 12:00 PM, Resident 41 stated that she doesn't attend many activities because her wheelchair will not pass through the Activity Room door. She explained that once, she sat in the hallway outside the Activity Room during spiritual services and listened the best she could because her wheelchair won't fit through the door.

A review of the facility's March 2024 Activity Calendar revealed that approximately 50 activities are scheduled to occur in the facility's Activity Room, including bingo, hymnal singing, and pastoral activities.

A review of Resident 41's wheelchair dimensions and specifications revealed that the resident has a bariatric wheelchair with a 30-inch seat. The wheels of the chair extend an additional four inches from the seat on both sides of the chair with an approximate width of the chair at 40 inches.

During an observation on March 28, 2024, at approximately 10:15 AM, the Director of Maintenance measured the Activity Room door as 36-inches. During an interview at the same time as the observation, the Director of Maintenance confirmed that Resident 41 was unable to enter the facility's Activity Room because her wheelchair would not fit through the door. He also explained that he was aware of the issue and provided a work order dated March 15, 2024, to address the resident's access to the room, which had yet to be completed as of the time of the survey ending March 28, 2024.

During an interview on March 28, 2024, at approximately 9:30 AM, the Nursing Home Administrator (NHA) confirmed that the facility failed to make reasonable accommodations to afford Resident 41 the opportunity to participate in activities of choice.





28 Pa. Code 201.29 (a) Resident rights



 Plan of Correction - To be completed: 05/02/2024

The facility has reviewed with resident 41 which activities she is most interested in. Those activities have been moved to a location which allows the resident to attend.

The facility will review other residents to ensure there are no factors which cause a resident to not be able to attend activities.

Staff will be re-educated to the fact that reasonable accommodation must be made for a resident with specific needs. The facility will adjust and modify the location and time of activities to allow residents with specific needs to attend.

The NHA or designee will interview 10 residents on a monthly basis to ensure that they have had the opportunity to attend activities of their choice. The audit will be completed monthly for three months. The audit findings will be communicated with the QAPI team for review and input.


483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.
Observations:

Based on a review of the facility's abuse policy and employee personnel files and staff interview, it was determined that the facility failed to implement their established abuse prohibition procedures for fully screening and training one employee out of five reviewed to ensure that they were eligible for employment in a long-term care nursing facility (Employee 1).


Findings include:

A review of the facility's policy titled "Abuse Policy and Protection" last reviewed by the facility November 1, 2023, revealed procedures for screening potential employees for history of abuse, neglect, and misappropriation of property that included protocols for conducting background checks for Federal criminal (if applicable) and State criminal, reference checks to focus on obtaining information from current and previous employers, and verification that all employees with certification or licensure are checked to verify licensure or certification is in good standing. It also indicated in the training procedures that the facility trains employees and volunteers through orientation and annually on issues related to abuse, which includes the facility's abuse prevention policies and procedures.

Review of the personnel files of newly hired employees in the last 4 months, provided by the facility during the survey ending March 28, 2024, revealed that Employee 1 (nurse aide) was rehired on December 23, 2023. Employee 1 was initially hired August 16, 2022, and terminated August 18, 2023. There was no documented evidence that the facility obtained an employment application for the December 23, 2023, re-hire of Employee 1. There was no indication that a PA State Police criminal background check was conducted. There was no indication that the facility contacted previous employers to screen for history of abuse or mistreatment. There was no indication that the employee's nurse aide certification was verified. There also was no documentation that Employee 1 had received orientation training to include abuse training, according to facility policy.

Interview with Employee 2 (Business Office Manager) on March 27, 2024, at 11:25 AM verified that the facility did not have an application packet for Employee 1's re-hire on December 23, 2023. She indicated that Employee 1 was beyond the 30-day return to work timeframe and that the facility should have obtained a new application. Employee 2 was unable to provide evidence that a PA criminal background check was completed, that previous employers were contacted, and that Employee 1's nurse aide certification was verified. There was also no evidence that Employee 1 received orientation training to include abuse training for the December 23, 2023, employment.


28 Pa Code 201.18 (e)(1) Management

28 Pa. Code 201.29(a)(c) Resident rights

28 Pa. Code 201.20(b)(d) Staff Development

28 Pa. Code 201.19 (6)(7)(9)(10) Personnel





 Plan of Correction - To be completed: 05/02/2024

Employee 1 is no longer an employee of the facility.

A review of the employees who worked during the last payroll will be completed to ensure that those staff have appropriate abuse and neglect training completed. The audit will be expanded if necessary.

A new checklist tool has been created to ensure that new hire employees have completed the necessary NA or license verification if applicable, background checks, reference checks and training prior to providing care for the residents. Leadership will be educated to the new form which must be approved by the NHA prior to the first day of work.

A review of 10 employees per month will be completed by the business office manager to ensure that the necessary documentation has been completed for each employee as it relates to abuse and neglect prevention. The audit findings will be communicated with the QAPI team for review and input.

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on the review of the facility's abuse prohibition policy, clinical records, select facility investigations, and staff interviews, it was determined that the facility failed to timely report an instance of resident neglect to the State Survey Agency for one out of the 14 residents reviewed (Resident 33).

Findings include:

A review of the facility policy titled "Abuse Policy and Procedure," indicated as last reviewed by the facility on November 1, 2023, revealed that it is the facility's policy to protect residents from neglect, and all incidents of suspected neglect will be thoroughly investigated and reported to the Pennsylvania Department of Health and other agencies as directed by law. The policy indicates that the nature of the allegations and the names of the resident(s) and individual(s) implicated will be reported to the Department of Health within five calendar days of the incident.

A witness statement dated February 29, 2024, provided by Employee A1, nurse aide, revealed that on February 29, 2024, at 9:45 AM, he was transferring Resident 33 from the toilet when her left knee gave out. Employee A1 indicated that he then lowered Resident 33 to the floor.

A progress note dated February 29, 2024, at 9:58 AM revealed that Resident 33's left leg gave out while being transferred from toilet to wheelchair. The note indicated that no injuries were identified and that the resident had no complaints of pain.

A progress note dated February 29, 2024, at 3:03 PM revealed that Resident 33 was reporting left ankle tenderness, edema, and pain. The note indicated that the resident's left ankle was swollen. The resident's representative was present and indicated that Resident 33 was not able to bear weight on her ankle.

A review of a facility incident report dated March 1, 2024, revealed that Employee A1, Nurse Aide, was aware that Resident 33 required the assistance of two staff members for transfers, but Employee A1 felt he was strong enough The report indicated that Employee A1 received a written disciplinary warning and was educated on following physician orders and care plans. The report also indicated that Resident 33's ankle was sprained with edema and slight redness.

A Fall Committee Meeting Progress note dated March 7, 2024, at 10:33 AM indicated that Resident 33 fell during a transfer and sustained an ankle injury. The progress note indicated that a nurse aide transferred the resident with only one staff member when the resident had physician orders for the use of two staff members. Education was provided to the nurse aide.

During an interview on March 28, 2024, at approximately 9:30 AM, the Nursing Home Administrator (NHA) confirmed that the facility staff failed to ensure that Resident 33 received the services necessary to avoid physical harm. The NHA confirmed that Employee A1, Nurse Aide, was aware that Resident 33's transfer was to be performed with two people but neglected to assure the presence of a second person and performed the transfer by himself, resulting in Resident 33's sprained ankle. The NHA confirmed that the neglect of Resident 33 that occurred on February 29, 2024, was not reported to the State Survey Agency within the required time frames.

Refer to F600


28 Pa Code 201.1 (a) Responsibility of licensee

28 Pa Code 201.18 (e)(1) Management




 Plan of Correction - To be completed: 05/02/2024

The incident involving resident 33 and employee A1 has been reported.

A review of incident reports for the last 7 days will be completed to ensure that any event that may have been the result of abuse or neglect has been properly investigated and reported.

Staff will be re-educated to the requirement that allegations of resident neglect need to be reported timely per the regulation. Leadership staff will be re-educated to the reporting timeline requirements and to the agencies that the issue needs to be reported.

The ADON or designee will audit any concerns of Neglect monthly for three months to ensure that proper actions and reporting have been completed. The audit findings will be communicated with the QAPI team for review and input.

483.40(d) REQUIREMENT Provision of Medically Related Social Service: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.
§483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.
Observations:


Based on review of clinical records and staff interviews, it was revealed that the facility failed to provide therapeutic social services to promote the mental and psychosocial well-being of one resident out of 14 sampled (Resident 8)

Findings include:

According to regulatory guidance at

Situations in which the facility should provide social services or obtain needed services from outside entities include, but are not limited to the following:

Meeting the needs of residents who are grieving from losses and coping with stressful events.
Lack of an effective family or community support system or legal representative;
Expressions or indications of distress that affect the resident's mental and psychosocial well-being, resulting from depression, chronic diseases (e.g., Alzheimer's disease and other dementia related diseases, schizophrenia, multiple sclerosis), difficulty with personal interaction and socialization skills, and resident to resident altercations;
Abuse of any kind (e.g., alcohol or other drugs, physical, psychological, sexual, neglect, exploitation);
Difficulty coping with change or loss (e.g., change in living arrangement, change in condition or functional ability, loss of meaningful employment or activities, loss of a loved one); and
Need for emotional support.

A review of the clinical record revealed that Resident 8 was admitted to the facility on May 31, 2023, with diagnoses to include malignant neoplasm of the colon, chronic obstructive pulmonary disease (COPD), depression and dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning).

A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 22, 2023, revealed that the resident was moderately cognitively impaired with a BIMS score of 10 (Brief Interview for Mental, which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information).

The resident's care plan indicated that she has a behavior problem related to verbal and other behaviors, date-initiated June 6, 2023.

A review of a behavior note dated December 1, 2023, 5:03 PM indicated that the resident asked aides for scissors or a razor. When asked why she stated "I want to slit my wrists."

There was no documentation in Resident 8's clinical record that therapeutic Social Services were provided to the resident in response to the statement of distress made on December 1, 2023.

Interview with Director of Social Services, on March 27, 2024, at approximately 2:20 PM revealed she was not aware of the statement made by the resident and verified that she had not followed up, or talked with Resident 8 in response to statement of wanting to slit her wrists.

Interview with the Nursing Home Administrator (NHA) on March 28, 2024, at approximately 9:00 AM, confirmed that there was no documented evidence of the provision of therapeutic social services provided to Resident 8 following her statement of desire to harm herself.


28 Pa. Code 201.29 (a) Resident rights.



 Plan of Correction - To be completed: 05/02/2024

Resident 8 is no longer a resident of the facility.

The DON/Designee will review the 24-hour progress note report for the last 10 days to ensure that any identified behavior problems related to verbal and other behaviors are followed up on by social services and any additional needs are addressed.

The DON/designee will educate the IDT team and the nurse supervisors on the review of the 24-hour progress note report and the process for handling any identified behavior problems related to verbal and other behaviors. Nurses' notes for the past 24 hours will be reviewed in the interdisciplinary team (IDT) meeting daily. The NHA/designee will educate the social services department on following up and addressing identified behavior problems related to verbal and other behaviors.

An audit will be completed daily x 5 days, weekly for three weeks and monthly for two months to ensure that identified behavior problems related to verbal and other behaviors are followed up timely and any additional needs are addressed. Findings will be communicated with the QAPI team for review and input.


483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Observations:

Based on a review of clinical records and resident and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records consistent with professional standards of practice by failing to timely and accurately document the facility's response to a change in a resident's condition for one resident out of 14 sampled.


Findings include:

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care:
Assessments
Clinical problems
Communications with other health care professionals regarding
the patient
Communication with and education of the patient, family, and the patient ' s designated support person and other third parties.

A review of the clinical record revealed that Resident 40 was most recently admitted to the facility on February 26, 2024, with diagnoses that included congestive heart failure (CHF), diabetes, chronic kidney disease, and gastro-esophageal reflux disease (GERD).

A quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated March 3, 2024, indicated that the resident was cognitively intact with a BIMS (brief interview to assess cognitive status) score of 15 (13 - 15 represents cognitively intact), had impairment on both sides with her functional range of motion (ROM) in her lower extremity, and that she required substantial/maximal assistance with her lower body dressing.

A nursing note dated March 23, 2024, at 12:53 PM, indicated that the resident's vital signs were stable, continued on a fluid restriction as ordered, laid down after each meal, with feet elevated, left lower leg weeping and monitored. Weight within normal limits. Continues on pain management as ordered. No new areas noted. Nursing noted "Will continue to monitor."

A review of a nursing note dated March 24, 2024, at 8:15 PM, indicated that the resident had some weeping of the left lower extremity and an dressing (ABD) was applied, loose wrap of cling to contain the drainage.

During an interview Resident 40 on March 26, 2024, at approximately 11:20 AM, in her room, the resident was seated in a wheelchair. The resident stated that her legs are "weeping." and showed the surveyor her left lower extremity, which presented clear fluid running down her leg. She stated she was recently hospitalized for congestive heart failure (CHF), had a recent weight gain, and is taking a diuretic (medication to help the body reduce extra fluid from the body). The resident was unsure if the physician was aware of the condition of her legs and the weeping.

A nursing note dated March 26, 2024, at 12:12 PM, noted that the resident's bilateral lower legs were edematous and weeping. The resident complained of shortness of breath (SOB). Pulse ox 94 % on room air. Nebulizer treatment was provided as ordered and effective. Nursing noted that the resident had no signs/symptoms distress. The physician was made aware.

A nursing note dated March 27, 2024, at 9:41 AM, indicated that the resident's physician was in facility this morning, visited with the resident, and reviewed all lab results. A new order was noted to increase the resident's Trazadone (a medication used to treat depression) to 25 milligram (mg) at bedtime (HS). Nursing noted that the resident was aware of all information.

There was no corresponding physician progress note reflecting the contents of this physician visit with the resident and if the physician had discussed the condition of the resident's weeping lower leg with the resident.

During a follow-up interview with Resident 40 on March 27, 2024, at approximately 1:35 PM, the resident was seated in a wheelchair in her room, with bilateral cling dressings loosely wrapped down at her ankles. Resident 40 stated last evening some nurse was speaking with her and had applied the dressings and had changed her bedding because of the sheets being wet. The resident further stated she had no recollection of the physician being in to visit her this morning as noted in the nursing progress note or examining her legs earlier this morning. She continued to state, "I'm worried about this", pointing to her legs.

Interview conducted on March 27, 2024, at approximately 1:45 PM with the Director of Nursing (DON), revealed that the DON stated that she spoke with Resident 40 last evening (March 26, 2024), had applied the dressings, and had changed the resident's bedding because of they were wet. The DON further stated that she had spoken to the physician last evening, and that the physician had been in the facility early this morning. She further acknowledged that there was no documentation of this physician visit however. The DON also noted that there were no current orders for the bilateral legs to be wrapped noted in the resident's clinical record.

A review of a late entry nurses note, entered in the resident's clinical record, following surveyor interview with the DON on March 27, 2024, and dated March 26, 2024, at 6:00 PM, revealed " spoke to physician regarding weeping legs for 3 days, and resident is uncomfortable with the bed linen now getting wet and she feels it is increasing from her legs. Unable to see exact area where weeping is coming from legs, +2 edema, not warm to touch or reddened, pulse present able to where slippers that were tight dressing was applied to lower legs with abd pad and cling was utilized. Physician is aware to see resident in am, resident was educated on edema present and decrease in fluids and physician to see in AM."

A nursing note also dated March 27, 2024, at 1:58 PM, indicated that the resident's physician was aware of legs weeping, orders noted to continue fluid restrictions.

Nursing noted on March 27, 2024, at 2:00 PM, that a new order was received to wrap legs with dry dressing at bedtime and that the resident was aware of information.

An interview with the Nursing Home Administrator (NHA) on March 28, 2024, at approximately 9:00 AM confirmed that the facility failed to demonstrate that the nursing documentation in the resident's clinical record surrounding the resident's change in condition was not timely, accurate and complete.


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

28 Pa. Code 211.5 (f) Medical records





 Plan of Correction - To be completed: 05/02/2024

A physician order was obtained for resident 40 to wrap her legs.

The 24-hour report will be reviewed for the last 10 days to ensure that any identified current needs have been addressed.

Education will be provided to the professional nursing staff to ensure that required treatments are communicated with the physician and an order is obtained timely. Education will be provided on timely and detailed charting.

5 resident charts will be audited weekly for four weeks and monthly for three months to ensure that residents who need a new or revised treatment have been identified and the physician has been notified, order received, and documentation is complete. The audit findings will be communicated with the QAPI team for review and input.

§ 201.18(b)(2) LICENSURE Management.:State only Deficiency.
(2) Protection of personal and property rights of the residents, while in the facility, and upon discharge or after death, including the return of any personal property remaining at the facility within 30 days after discharge or death.
Observations:

Based on the review of clinical records and staff interview it was determined that the facility failed to maintain a complete and accurate record of a residents' personal possessions upon admission for one resident out of three sampled (Resident 248)

Findings included:

A review of the clinical record of Resident 248 revealed that the resident was admitted to the facility on January 22, 2024, and was discharged home on February 6, 2024.

The inventory list on admission for Resident 248 revealed that fifteen (15) personal items were noted on the form. Resident 248's inventory list on admission was not signed by the resident or responsible party or a staff member's.

Interview with the Nursing Home Administrator (NHA) on March 28, 2024, at approximately 9:00 AM, confirmed that the inventory sheet did not have the resident, responsible parties, and or staff member signatures on admission to verify the accuracy of inventory.




 Plan of Correction - To be completed: 05/02/2024

The documentation for the belongings for resident 248 cannot be corrected retroactively.

Current resident charts will be reviewed to ensure a belongings sheet is current on the chart and has been signed.

The facility will re-educate nursing staff as to the need for the belongings sheet and the requirement to have it signed upon admission and discharge.

The facility will audit the charts of residents discharged for the month to ensure that the belonging sheets have been signed on admission and discharge. The audit will occur for three months. The audit findings will be communicated with the QAPI team for review and input.



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