Pennsylvania Department of Health
WILLOW TERRACE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WILLOW TERRACE
Inspection Results For:

There are  160 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.
WILLOW TERRACE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, and State Licensure Survey, an Abbreviated Survey in response to 3 complaints and a reportable event completed on April 1, 2024, it was determined that Willow Terrace was not in compliance with the 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 related to the health portion of the survey process.


 Plan of Correction:


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 observation, and review of resident clinical records, it was determined that the facility failed to ensure proper accommodation of needs for one of 32 residents reviewed regarding appropriate bed size and mattress (Resident R17).

Findings include:

Review of Resident R17 annual MDS (an assessment of resident needs) dated January 22, 2024, indicated the resident was cognitively intact, diagnosed with a history of a cerebrovascular accident (stroke), arthritis, and quadriplegia. The MDS indicated the resident was impaired on one side of his upper body, both sides of his lower body, and was completely dependent on staff for bed mobility and all activities of daily living (ADL). The MDS indicated the resident was on a scheduled pain management regimen and reported the pain would frequently affect his sleep, and frequently interfere with his day-to-day activities, including therapy. The resident rated the intensity of his pain, an 8 out of 10 (ten being the worst level of pain).

Further review of Resident R17's clinical record revealed a plan of care for chronic pain related from his limited range of motion, and contractures in his upper and bilateral lower extremities. Interventions included staff facilitating passive and active movements to enhance the flexibility of the resident's joints, and the use of bilateral side rails for the resident's bed mobility, and repositioning. Interventions included assessing the bed for loose rails and contacting maintenance for repairs.

On March 27, 2024, at approximately 12:00 p.m. the surveyor observed Licensed Practical Nurse (LPN) Employee E7 asked Resident R17 to turn to his left side. The resident was tall, and thin and had limited space in his bed for repositioning. Both legs were bent at the knees, and his feet were pressed against the bottom of the bed frame. The resident was unable to independently turn himself using the bed rails because of his awkward positioning and needed the LPN to turn him onto his side. The mattress was observed with an area bulging and not smooth. The resident stated the bed was uncomfortable and explained, "Some man came this weekend to look at his bed and said, 'Well, this is what you get' and left." Immediately the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were called to the room. An attempt was made to reposition the resident by moving his body towards the top of the bed. Once repositioned, the feet no longer touched the bed frame, but the resident's head was approximately six inches past the head of the bed's mattress.

28 Pa. Code 210.29(4) Resident rights.











 Plan of Correction - To be completed: 05/10/2024

This provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

R17 Bed was extended to accommodate his needs and the mattress was replaced.

The DON/designee conducted an audit of residents 70 inches or taller to ensure that the length of their bed and mattress accommodates the needs of the resident.

The DON/designee educated licensed staff on accommodation of residents needs which includes ensuring that a residents bed and mattress are appropriate for the resident.

The DON/designee will conduct audits of new admissions to ensure their bed and mattress are the appropriate size. Audits will be done weekly x 4 weeks then monthly x 2 months.

Results of the audits will be submitted to the quality assurance committee to determine if further action is needed.



483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities: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.
483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

483.24(b)(2) Mobility-transfer and ambulation, including walking,

483.24(b)(3) Elimination-toileting,

483.24(b)(4) Dining-eating, including meals and snacks,

483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
Observations:

Based on observations, clinical record reviews, review of facility policy and interviews with residents and staff, it was determined that the facility failed to provide assistance with showers for three of five residents reviewed (Residents R96).

Findings include:

Review of facility policy, Refusal of Care, revised March 2024, indicated that "the nurse will monitor for recurring refusals of medication, treatments, care and services." Further review revealed that "the IDT team will meet with the resident/resident representative to ascertain the reasons why they are refusing care and services" and will "review and offer alternative interventions as appropriate."

Interview with Resident R96's power of attorney on March 27, 2024, at approximately 2:00 p.m. revealed that Resident R96 was not provided assistance with showers.

Review of physician orders for Resident R96 revealed that the resident was to receive showers on Mondays and Thursdays on the 7-3 shift.

Review of Resident R96's current care plan, date-initiated September 7, 2023, revealed that the "resident requires assist of 1 for showering or bathing." Further review failed to reveal a care plan regarding shower refusals and interventions for Resident R96.

Further review of resident R96's clinical records revealed that the resident had not received a shower on the following dates marked as "-97 (N/A), 31 (no), -98 (refused): January 4, 8, 11, 15, 18, 22, 25, 2024; February 1, 5, 8, 12, 15, 19, 22, 2024; and March 4, 14, 18, 2024.

Interview with the Administrator, Employee E1, on April 1, 2024, at 1:11 p.m. confirmed that there was no documentation in the clinical records of the reason as to why Resident R96 was not provided assistance with showers on the days noted above. Further interview confirmed there was no evidence of meetings with the interdisciplinary team and resident representative to ascertain the reasons why the resident was refusing care; no alternative interventions were offered.

28 Pa Code 211.12(d)(5) Nursing services






 Plan of Correction - To be completed: 05/10/2024

R96 received a shower.

The DON/designee conducted a 1 week look back of residents that refused showers to ensure documentation indicated a reason for the refusal and alternative interventions were offered.

The DON/designee educated Nursing staff on the Policy "Refusal of Care" which states the nurse will monitor for refusals and that the IDT will offer alternate interventions as appropriate.

The DON/designee will monitor shower refusals to ensure appropriate documentation is in place.

Audits will be done weekly x 4 weeks then monthly x 2 months.
Results of the audits will be submitted to the quality assurance committee for 2 months to determine if further action is needed.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on review of clinical records, interviews with staff and review of facility policy, it was determined that the facility failed to ensure a resident who required respiratory care received the necessary care and services in accordance with professional standards of practice, and resident's plan of care for one of 32 resident records reviewed (Resident R96)

Findings included:

Review of the facility's policy titled, "BIPAP CPAP" revised May 2021 states, " BIPAP and CPAP is administered by Licensed Nurses with a Physician's order ... prescribed for some residents to augment resident breathing when they have difficulty maintaining adequate ventilation due to obstructive sleep apnea, central sleep apnea and complex sleep apnea."

Review of Resident R96's clincial record revealed that the resident was admitted to the facility on May 30, 2023, diagnosed with Obstructive Sleep Apnea (intermittent airflow blockage during sleep). Review of physician orders dated June 1, 2023, instructed to use the C-pap machine at bedtime and remove in the morning to aide with breathing related to the resident's shortness of breath. Further review of the resident's record revealed on March 6, 2024, the resident was transferred to the hospital and returned on March 8, 2024. There was no documented evidence of an order to continue the use of a C-pap machine or that the physcian was contacted related to the use of a C-pap machine.

Interview with Resident R96's Power of Attorney on March 27, 2024, at approximately 2:00 p.m. revealed that Resident R96 was escorted to the ophthalmologist appointment on March 6, 2024, without an oxygen tank, which resulted in Resident R96's admission to the hospital for shortness of breath.

Review of physician orders for Resident R96 revealed an order dated August 17, 2023, which stated, "Oxygen at 2 L/min for Pulse Ox <90%, shortness of breath, or dyspnea; as needed."

Review of Resident R96's clinical record, Oxygen Saturation Summary, dated February 5, 2024, through March 5, 2024, revealed that Resident R96 was utilizing Oxygen via Nasal cannula 28 times during the 30-day lookback period, leading up to her appointment on March 6, 2024. Further review revealed that on March 4, 2024, through March 5, 2024, Resident R96 was on oxygen via nasal cannula continuously, two days prior to the appointment.

Review of Resident R96's care plan, date-initiated August 17, 2024, failed to reveal a care plan for oxygen use and respiratory care.

Interview with nurse aide, Employee E8, who escorted Resident R96 to the ophthalmologist appointment on March 6, 2024, confirmed that the resident did not have an oxygen tank present at the appointment. Further interview revealed that the resident began to experience shortness of breath at the appointment and was admitted to the hospital.

Review of hospital documentation dates March 6, 2024, confirmed that Resident R96 was admitted to the Hospital on March 6, 2024, for "shortness of breath."

Interview with the Director of Nursing, Employee E2, on April 1, 2024, at approximately 1:00 p.m. confirmed the above-mentioned findings. Further interview confirmed that Resident R96 was not assessed for oxygen saturation levels prior to leaving to the appointment and that there was no documented evidence of Resident R96 being cleared by the physician to proceed to the appointment without a portable oxygen tank. Employee E2 confirmed that Resident R96's oxygen levels needed to be assessed prior to being escorted to the Ophthalmology appointment on March 6, 2024.

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




 Plan of Correction - To be completed: 05/10/2024

R96 currently has an order for the use of a C-pap machine.

The DON/designee conducted a 1 week look back of new/re-admissions to ensure if a C-pap was in use and/or the C-pap is continued as previously ordered.

The DON/designee conducted a 1 week look back of residents that are on oxygen that went out for appointments, to ensure that residents had an oxygen tank taken with them to the appointment.

Licensed staff were educated on the BIPAP/CPAP policy as well as ensuring that residents that have oxygen orders have an oxygen tank sent with them when going on appointments.

The DON/designee will audit new/readmissions to ensure if previously on a CPAP that the CPAP was ordered. Audits will be done weekly x 4 weeks then monthly x 2 months.

The DON/designee will audit residents scheduled for appointments that have oxygen orders to ensure that an oxygen tank is taken with them to the appointment. Audits will be done weekly x 4 weeks then monthly x 2 months.

Results of these audits will be submitted to Quality assurance committee for 2 months to determine if further action is needed.

483.40 REQUIREMENT Behavioral Health Services: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 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations:

Based on the review of clinical records and interviews with staff, it was determined that the facility failed to ensure each resident received the necessary behavioral health services in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for two of 32 resident records reviewed (Resident 18 and R61).

Findings include:

Review of Resident R18 clinical record revealed the resident was initially admitted to the facility on June 10, 2020 diagnosis included Traumatic Brain Injury, Major Depressive Disorder, recurrent, severe with psychotic symptoms, Unspecified Dementia, unspecified severity, with other behavioral disturbances, Vascular Dementia, unspecified severity, with other behavioral disturbance, Schizoaffective disorder, unspecified, Mood Disorder due to unknown physiological condition with depressive features, and unspecified Symbolic Dysfunctions,

Review of Resident R18 psychiatric consultation dated August 9, 2023, indicated the physician recommendations were to monitor behaviors for agitation and/or psychoses, adverse effects of his medication and to follow-up with an appointment in three months. Further review of the clinical record revealed the facility failed to reschedule the appointment in the recommended time frame. The following psychiatric consultation was not until February 21, 2024, when the resident complained of increased anxiety with rapid breathing, pounding in his chest, and difficulty sleeping.

The delay in rescheduling Resident R18's psychiatric consultation was confirmed with the Nursing Home Administrator on March 27, 2024, at 5:54 p.m. when no other documentation for review was found.

Review of Resident R61's clinical record revealed the resident was initially admitted to the facility September 17, 2020, diagnosis included, Unspecified Dementia, Anxiety disorder, Major Depressive disorder, and insomnia.

Review of Resident R61's psychiatric consultation dated November 29, 2023, revealed the reason for the follow up visit was due to reports of nightmares, with yelling in his sleep. Resident reported dreams of people chasing him that occurs once a month. The nurses indicated it happens about twice a week. Otherwise, he is feeling "pretty good" considering the circumstances. Expresses hopelessness about not being able to leave here. The consult recommended following up in three months.

Further review of Resident R61's clinical record revealed the facility failed to reschedule the appointment in the recommended time frame and no further appointments had been scheduled.

The delay in rescheduling Resident R61's psychiatric consultation was confirmed with the Nursing Home Administrator on March 27, 2024, at 5:54 p.m. when no other documentation for review was found.


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







 Plan of Correction - To be completed: 05/10/2024

R18 The facility is unable to retroactively correct this.

R61 was seen for a follow up psychiatric appointment on 4/10/24.

The DON/designee conducted an audit of the last 14 days of psychiatric consultations to ensure that if follow up is recommended, a follow up appointment is scheduled.

Nursing staff will be educated on ensuring psychiatric consult follow up.

The DON/designee will conduct audits of psychiatric appointments to ensure that follow up appointments are scheduled as recommended. Audits will be done weekly x 4 weeks then monthly x 2 months.

Results of these audits will be submitted to Quality assurance committee for 2 months to determine if further action is needed.

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 interview with staff and review of facility policy, it was determined that the facility failed to provide services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of a resident by failing to assist in community placement options until completion for one of 32 resident records reviewed (Resident R61).

Findings include:

Review of facility policy titled, "Discharge Planning Process" dated March 2021, last reviewed April 2023 stated, "The policy is to ensure that the resident has a planned program of post-discharge continuing care that takes his/her needs into account for a safe discharge. Discharge planning is interdisciplinary and is initiated preadmission, admission and continues through continum of care.

Review of Resident R61's clinical record revealed the resident was initially admitted to the facility September 17, 2020, diagnosis included, Unspecified Dementia, Anxiety disorder, Major Depressive disorder, and insomnia.

Review of Resident R61's Social Service note dated June 29, 2023, revealed Social Services met with Resident R61 to introduce him to housing opportunities. The person offering these services took the resident's background information and informed him of housing options he was able to offer. The resident stated he was interested in learning more about the housing options and was told the person would return to the facility with additional information.

Review of Resident R61's Social Services note dated July 14, 2023, revealed the resident attended a housing meeting to gather more information and the Social Worker indicated more housing options would be provided.

Social Services note dated August 14, 2023, revealed Resident R61 wanted to move in with his son and the son was able to give 24-hour supervision.

Social Services note dated August 23, 2023, informed the resident a care conference discharge meeting would be scheduled.

Social Services note dated September 6, 2023, attempted to contact son and left message.

Review of Resident R61's September 6, 2023, psychiatric consultation noted the resident's frustration over still being here and is requesting assistance to find a place to go. The psychiatric stated, "the resident's capacity for discharge to another place is generally intact, but due to some mild short term memory impairment, he will need a place where his medications are dispensed. Ask social worker to work with patient to attempt to find a discharge plan."
.
Continue review of Resident R61's Social Service notes indicated the resident's son was contacted in October, November, and December 2023 to schedule the care conference discharge meeting and each time the son had to cancel due to car troubles.

The last documented Social Service note was dated December 12, 2023, indicated the resident's son was still experiencing transportation issues and needed to reschedule the meeting for January 12, 2024. No other correspondence was found regarding Resident R61's discharge.

On March 29, 2024, at 11:24 a.m. during an interview with the Director of Social Services stated that was how it was left, the son had car problems and confirmed that there was no documented evidence that further attempts were made finding outside housing for Resident R61.


28 Pa. Code 201.14 (a) Responsibility of licensee







 Plan of Correction - To be completed: 05/10/2024

R61 discharge plan was updated.

The social service director/designee conducted an audit of residents planning to discharge to ensure documentation reflects ongoing communication in regards to discharge planning.

The NHA educated the social service department on the policy Discharge Planning Process.

The Social service Director/designee will Audit residents planning to discharge to ensure documentation reflects ongoing communication in regards to discharge planning.

Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee for 2 months to determine if further action is needed.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:

Based on review of facility policy, review of clinical records, and interview with staff, it was determined that the facility failed to provide pharmaceutical services to meet resident's needs including acquiring, receiving, and administering medications for two of 32 residents reviewed (Resident R17 and R96).

Findings include:

Review of the facility policy titled, "Medication Storage/Unavailable Medications" not dated, states when medications are not available the nurse will urgently initiate action. If delivery of the medication will be late or missed, take the medication from the emergency stock supply. If the medication is unavailable the nurse will call the physician for further orders. The policy further instructs to document missed doses on the EMAR (electronic medical record), document explanation for missed , "See nurses notes for explanation." Document explanation of missed dose in the nurses note, describing the circumstance of medication shortage, notification of pharmacy and response and action(s) taken.

Review of Resident R17 annual MDS (an assessment of resident needs) dated January 22, 2024, indicated the resident was cognitively intact, diagnosed with a history of a cerebrovascular accident (stroke), arthritis, and quadriplegia. The MDS indicated the resident had an impairment on one side of his upper body, both sides of his lower body, and was completely dependent on staff for bed mobility and all activities of daily living (ADL). The MDS indicated the resident was on a scheduled pain management regimen and reported the pain would frequently affect his sleep, and frequently interfere with his day-to-day activities, including therapy. The resident rated the intensity of his pain an 8 out of 10 (ten being the highest level of pain).

Further review of Resident R17's clinical record revealed a plan of care for chronic pain related from his limited range of motion, and contractures in his upper and bilateral lower extremities. Interventions included administer analgesia as per orders, facilitating passive and active movement to enhance flexibility of his joints, and the resident's use of bilateral side rails for bed mobility.

Review of Resident R17's medical record revealed an order for Tramadol HCl Oral Tablet 50 mg. for pain management active from December 22, 2023, to January 12, 2024, instructing to give 50 milligrams (mg) by mouth every 6 hours scheduled at 12:00 a.m., 6:00 a.m., 12:00 pm. and 6:00 p.m. The order was discontinued on January 12, 2024, and a new order, instructing to give 50 mg of Tramadol every eight hours, at 6:00a.m., 2:00 p.m., and 10 p.m. The order was discontinued on January 29, 2024, and a new order, instructing to administer 50 mg of Tramadol, four times a day, to be administered at 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m. and is currently active.

Review of Resident R17's electronic medical administration record (EMAR) and review of the nursing progress notes revealed the medication Tramadol was documented as not given, not available. pending delivery and/or back ordered for the following dates:

On January 1, 2024, three dosages were not administered
On January 2, 2024, two dosages were not administered
On January 21, 2024, one dose was not administered
On January 22, 2024, two dosages were not administered
On January 26, 2024, two dosages were not administered
On January 27, 2024, two dosages were not administered
On February 9, 2024, two dosages were not administered
On February 16, 2024, three dosages were not administered
On February 26, 2024, one dose was not administered
On March 11, 2024, one dose was not administered

Continued review of Resident R17's clinical record revealed no documented evidence that the physician was made aware of the missed doses or that an alternate treatment was requested. Further review of the clinical record revealed no documented evidence the licensed nurse activated backup pharmacy process and procedures to obtain and administer the medication.

Interview with Licensed Registered Nurse, Employee E7 on March 27, 2024, at 10:30 a.m. was not aware the emergency supply of medication included pain medication Tramadol.

Review of Resident R96 clinical record revealed the resident was admitted with Chronic Systolic Congestive Heart Failure (the heart does not pump efficiently) Atrial Fibrillation (irregular heartbeat) and Obstructive Sleep Apnea on May 30, 2023.

Resident R96 was ordered Carvedilol Oral Tablet 25 mg, instructed to give one tablet by mouth two times a day for hypertensive chronic kidney disease /end stage renal disease . On January 20, 2024, nursing progress note indicated the medication was not given due to the medication "ordered."


On March 5, 2024, Resident R96 was ordered Nitrofurantoin Macrocrystal oral capsule 100 mg, instructed to give one capsule by mouth two times a day for an urinary tract infection. Further review revealed the medication was not administered due to medication "not available."

Continued review of Resident R96's clinical record revealed no documented evidence that the physician was made aware of the missed doses or that an alternate treatment was requested. Further review of the clinical record revealed no documented evidence the licensed nurse activated backup pharmacy process and procedures to obtain and administer the medication.

28 Pa. Code 211.9 (a)(1) Pharmacy Services.






 Plan of Correction - To be completed: 05/10/2024

R17 is currently receiving Tramadol as ordered.
R96 is currently receiving Carvedilol as ordered.

The DON/designee conducted a 1 week look back of medications documented as not available to ensure appropriate procedures were followed to obtain the medication, or the physician was notified.

The DON/designee educated licensed staff on the medication storage/unavailable medications policy as well as use of the emergency stock supply.

The DON/designee will audit Medication documentation to ensure if a medication is not available appropriate procedures are followed. Audits will be done weekly x 4 weeks then monthly x 2 months.

Results of these audits will be submitted to the Quality assurance committee for 2 months to determine if further action is needed.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:

Based on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food that was palatable, attractive, and served at the proper temperature for one of five nursing units observed (third floor nursing unit)

Findings include:

Review of undated facility policy titled, "Meal Tray Accuracy Audit Report Policy," indicated that "for satisfactory result, all got items must be 135 degrees or higher" and "all cold items must be 45 degrees or below at point of service.

Interview with Resident R119 on March 26, 2024, at 12:04 p.m. revealed that "food is always cold" and "coffee is never hot."

Observations during a test tray conducted with The Food Service Director, Employee E3, on March 27, 2024, at 12:58 p.m. revealed that the hot coffee registered at 133.7 degrees Fahrenheit (F); macaroni and cheese at 135.7 degrees F; green beans at 138.4 degrees F; mashed potato at 124.9 degrees F; milk at 56 degrees F; rice pudding at 62.8 degrees F; and cranberry juice at 61 degrees F.

An interview with the FSD, on March 27, 2024, at 1:03 p.m. confirmed that the above-mentioned food items were below and above the acceptable temperatures and therefore not palatable.

Observations during the lunch meal, in the third-floor dining room, on March 26, 2024, at 12:39 p.m. revealed Resident R39 received his lunch meal which, according to the meal slip consisted of puree peas, pureed rice, and pureed potatoes. Observations revealed the consistency of the foods appeared as liquid which spread throughout the whole plate. Interview with the FSD confirmed that Resident R39's meal was not the appropriate pureed consistency. Further interview revealed that the pureed foods needed "one and a half packets of thickening powder added" to make the pureed foods attractive, palatable, and the appropriate pureed consistency.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.6(f) Dietary services




 Plan of Correction - To be completed: 05/10/2024

The facility cannot retroactively go back and correct this deficiency.

The FSD/designee educated dietary staff on Meal tray accuracy which includes appropriate meal temperatures.
The FSD/designee educated dietary staff on the appropriate consistency of pureed food to make pureed foods attractive, and palatable.

The FSD/designee will conduct tray temperature audits daily at random meals x 1 week, then weekly x 4 weeks then monthly x 2 months.

The FSD/designee will audit the consistency of pureed food daily at random meals x 1 week, then weekly x 4 weeks then monthly x 2 months.

Results of these audits will be submitted to the quality assurance committee for 2 months to determine if further action is needed.

483.60(e)(1)(2) REQUIREMENT Therapeutic Diet Prescribed by Physician: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(e) Therapeutic Diets
483.60(e)(1) Therapeutic diets must be prescribed by the attending physician.

483.60(e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law.
Observations:

Based on review of facility policy, review of clinical record, observations, and staff and resident interviews, it was determined that the facility failed provide food items consistent with the prescribed diet order for one of four residents reviewed for nutrition (Resident R149).

Findings Include:

Review of facility diet guide sheet revealed Tuesday lunch offerings on March 25, 2024, was Herb Rubbed Pork, Parley New Potatoes, Braised Cabbage, and Chilled Peas. Per the diet guide sheet, a resident on a mechanically soft diet (consisting of food that have been bended, mashed, pureed, or chopped, making them soft and easy to eat without biting or chewing), should receive ground herb rubbed pork, mashed potatoes, and pureed braised cabbage.

Review of Resident R149's physician orders revealed the resident was ordered a Mechanically Soft Textured diet dated January 25, 2024.

Dining observation conducted on March 26, 2024, at 1:16 p.m. revealed Resident R149's meal ticket confirmed that the resident was ordered a Mechanical Soft Diet. Further review of the meal ticket indicated the resident was to receive ground herb rubbed pork with gravy, mashed potatoes, and pureed braised cabbage. Further observations of Resident R149's lunch time meal tray revealed the resident was served a regular consistency diet which included whole slices of rubbed pork, cubed potatoes, and braised cabbage; Licensed Practical Nurse, Employee E6, confirmed this finding.

Further observations with the Speech Therapist, Employee E5, revealed that the resident had pocketed the cabbage due to the inability to swallow. The resident proceeded to taking the cabbage out of his mouth for over a ten-minute span. Interview with Employee E5 confirmed that the meal that was served to Resident R149 during lunch was not appropriate and had placed the resident at risk for chocking and aspiration hazard.

28 Pa. Code 211.6 (a) Dietary Services










 Plan of Correction - To be completed: 05/10/2024

R149 is currently receiving the correct diet

The FSD/designee conducted an initial audit during meal service on each unit to ensure that residents received diets as ordered.

The FSD/designee educated dietary staff on meal tickets match the diet that is being served.
The DON/designee educated nursing staff on ensuring that meal tickets match the diet that is being served.

The FSD/designee will conduct meal observations to ensure meal tickets match the diet that is being served.

Audits will be done daily x 1 week then weekly x 4 weeks then monthly x 2 months.
Results of the audits will be submitted to the quality assurance committee for 2 months to determine if further action is needed.


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 observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Findings include:

Review of facility policy titled, "Uniform Policy," revised May 27, 2023, indicated that facial hair coverings will be worn to cover any and all facial hair."

Review policy titled, "Dating and Labeling Policy" revised January 24, 2023, indicated that the "kitchen will assure food safety by maintaining proper dated and labels to all goods and ready to eat food products ..."

An initial tour of the main kitchen was conducted on March 25, 2024, at approximately 10:19 a.m. with the Food Service Director (FSD), Employee E3.

Observations revealed that two kitchen staff were not wearing a facial hair covering.

Observations in the reach in refrigerator in the main cooking area revealed that gravy and macaroni and cheese was unlabeled and undated; hashbrowns and peas were inappropriately dated with the month and year, "3/24."

Observations in the main refrigerator revealed four uncooked poultry products (turkey) were stored on the highest rack in the refrigerator and were leaking pink liquid. Further observations revealed that breadcrumbs and egg wash (mix of beaten whole egg) were stored on the rack below the raw poultry.

Interview with the FSD on March 25, 2024, at approximately 10:40 a.m. confirmed that safe refrigerator storage requires raw poultry to be stored on the lowest rack possible; and that eggs are to be stored below ready-to-eat/fully cooked foods and produce, above raw poultry. FSD confirmed that the raw turkey was leaking pink liquid.

Interview with the FSD at 10:41 a.m. on March 25, 2024, confirmed the above findings.

28 PA Code: 201.14(a) Responsibility of licensee.

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







 Plan of Correction - To be completed: 05/10/2024

Staff donned facial hair coverings. Identified foods were appropriately labelled and dated, and arranged in cold storage per professional standards for safe refrigerator storage.

The FSD/designee educated dietary staff on uniform policy, dating and labelling policy, and safe refrigerator storage.


The FSD/designee will conduct kitchen observation audits to ensure uniform policy, dating and labelling policy and safe refrigerator storage procedures are being followed. Audits will be done daily x 1 week then weekly x 4 weeks then monthly x 2 months.

Results of the audits will be submitted to the quality assurance committee for 2 months to determine if further action is needed.



483.70(g)(1)(2) REQUIREMENT Use of Outside Resources: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.
483.70(g) Use of outside resources.
483.70(g)(1) If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility must have that service furnished to residents by a person or agency outside the facility under an arrangement described in section 1861(w) of the Act or an agreement described in paragraph (g)(2) of this section.

483.70(g)(2) Arrangements as described in section 1861(w) of the Act or agreements pertaining to services furnished by outside resources must specify in writing that the facility assumes responsibility for-
(i) Obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility; and
(ii) The timeliness of the services.
Observations:

Based on interviews with residents and staff and review of clinical records, it was determined that the facility failed to ensure timely provision of professional services furnished by outside providers, for one of 32 residents reviewed (Residents R17).

Findings include:

Review of Resident R17 annual MDS (an assessment of resident needs) dated January 22, 2024, indicated the resident was cognitively intact, diagnosed with a history of a cerebrovascular accident (stroke), arthritis, and quadriplegia. The MDS indicated the resident had an impairment on one side of his upper body, both sides of his lower body, and was completely dependent on staff for bed mobility and all activities of daily living (ADL).

During an interview on March 27, 2024, Resident R17 stated he had a cardiologist appointment in July but couldn't get a ride to his appointment, so the facility cancelled it but did not reschedule another visit.

Review of the nursing progress notes dated July 17, 2023, stated, "Cardiology appointment cancelled."

This was confirmed on March 27, 2024, at 4:00 p.m. with the Nursing Home Administrator when no evidence of a rescheduled cardiologist appointment was found.

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



 Plan of Correction - To be completed: 05/10/2024

R17 cardiology appointment was scheduled.

The DON/designee did a 30 day look back of residents with cardiology appointments to ensure if a follow up is indicated a follow up appointment was scheduled.

Licensed staff were educated on the importance of scheduling follow up appointments when a resident returns from cardiology.

The DON/designee will audit residents returning from cardiology appointments to ensure that if a follow up is indicated a follow up appointment is scheduled. Audits will be done weekly x 4 weeks then monthly x 2 months.

Results of these audits will be submitted to the quality assurance committee for 2 months to determine if further action is needed.

483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition: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.
483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.
Observations:

Based on observations of the food and nutrition department, review of facility policy and interviews with staff, it was determined that the facility failed to maintain essential food service equipment in safe operating condition.

Findings Include:

Review of facility policy titled, "Dish Machine Usage Policy," revised November 15, 2023, revealed that "dishwasher staff will monitor and record dish machine temperatures to assure compliance for wash and rinse cycles ... FSD (food service director) or Designee will monitor temperature log and PPM readings prior to each usage for compliance."

An initial tour of the main kitchen was conducted on March 25, 2024, at approximately 10:19 a.m. with the Food Service Director (FSD), Employee E3.

Observations of the dish room revealed Dietary Aide, Employee E4, was utilizing the dish machine. Further observations revealed that the dish machine thermometers were not operating; FSD confirmed that the dish machine was not functioning properly.

Review of the dish machine temperature log titled, "Dish Machine Ware Washing- Low Temperature," revealed missing wash temperatures, final rinse temperatures, and chlorine sanitizer PPM for breakfast, lunch, and dinner meals from March 22, 2024, through March 25, 2024.

Interview with the foodservice director, Employee E3 at 10:21 a.m. revealed that staff are not trained to "look at the thermometers, they just run the machine" and that they do not fill out the temperature log.

Review of documentation titled, "Cleanslate Kitchen Service Report" dated March 25, 2024, confirmed that the dish machine "wash temperature and rinse temperature" were out of compliance.

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

28 Pa. Code 211.6(d) Dietary services








 Plan of Correction - To be completed: 05/10/2024

The Dish Machine is working appropriately. Vendor addressed repair on 3/25/24.

The FSD/designee educated dietary staff on the dish machine usage policy.

The FSD/designee will conduct audits to ensure temperatures are being taken and recorded and PPM readings are being done prior to each usage for compliance. Audits will be done daily x 1 week then weekly x 4 weeks then monthly x 2 months.

Results of the audits will be submitted to the quality assurance committee for 2 months to determine if further action is needed.



Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port