Pennsylvania Department of Health
GREEN HOME INC
Patient Care Inspection Results

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GREEN HOME INC
Inspection Results For:

There are  84 surveys for this facility. Please select a date to view the survey results.

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GREEN HOME INC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, Civil Rights Compliance Survey, and Complaint Investigation, completed on January 12, 2024, it was determined that The Green Home, Inc. was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain linens in a sanitary manner in the facility's main linen supply storage area.

Findings include:

In an interview with Employee 6, Assistant Director of Nursing, on January 12, 2024, at 11:30 AM, Employee 6 indicated the facility does not complete any laundering of linens or resident items in the facility and items were sent out of the facility to be laundered.

In a concurrent observation of the area, clean linens and laundry are returned to the facility that Employee 6 revealed to be an area through a door in the back service hallway of the facility. Upon entering the door, a storage area behind a metal cage was observed on the left, which contained mattresses and multiple other items. Just past the cage area on the left was a man observed working at a table, multiple tools and equipment were observed in the area, which Employee 6 confirmed was the "maintenance shop area." On the left side of the other room after the "maintenance shop area," not separated by any walls or rooms, only shelving of maintenance tools and supplies, were several large bins on wheels containing various linens such as towels, wash cloths, blankets, and sheets. Four of the bins containing blankets and towels, were observed stacked 12-18 inches above the top of the bin. A black cover was observed lying over the very top portion of the items completely exposing the linens on all sides until reaching the level that was inside the bin.

The bins of linens noted above were also located within 10-20 feet of a set of double doors, which opened to the exterior of the building. During the observation with Employee 6, an employee of the facility was observed entering through the doors and walking past the exposed bins of linens.

In a concurrent interview and observation with Employee 7, environmental services, Employee 7 indicated the clean linens are all delivered through the observed double doors and that extra linens were ordered due to a long holiday weekend. Employee 7 indicated that the linens should have all been covered. During the interview with Employee 7, an additional employee was observed entering through the double doors noted above. Employee 7 indicated staff of the facility do enter and exit through the doors located in front of the exposed linen.

The above findings regarding the storage of linens were reviewed with Employee 1, Assistant Nursing Home Administrator, and Employee 2, corporate consultant, on January 12, 2024, at 12:05 PM.

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

28 Pa. Code 205.26 (d) Linen Storage


 Plan of Correction - To be completed: 02/20/2024

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.
1. No resident harm identified.
2. The stock clean linens were moved to a location away from high traffic areas with walls and a door.
3. The housekeeping manager or designee will educate housekeeping staff on keeping all stock clean linens covered.
4. Weekly audits of covering stock clean linens will be completed weekly x4 then monthly x2 with results reported in QAPI.
5. Compliance by February 20, 2024

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide bathing and dressing assistance for a resident dependent on staff assistance for one of two residents sampled for activities of daily living (Resident 31).

Findings include:

Observation and interview with Resident 31 on January 9, 2024, at 1:17 PM revealed Resident 31 was out of bed in her personal chair, still in her nightgown. Her hair appeared disheveled. Interview with Resident 31 at this time stated she needs staff assistance to get dressed. Resident 31 stated she prefers to get dressed in comfortable clothes. She stated she does not have a specific shower day, she indicated she lets the staff know when she wants a shower if staff are available.

Observation of Resident 31 on January 10, 2024, at 11:40 AM revealed Resident 31 was out of bed, but she was still in her nightgown.

Clinical record review revealed the facility admitted Resident 31 on May 23, 2023. A review of Resident 31's most recent MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated November 7, 2023, indicated nursing staff assessed Resident 31 as requiring moderate assistance for upper body dressing and dependent on staff for lower body dressing. Staff also assessed Resident 31 as dependent on staff for bathing.

A review of Resident 31's task documentation (ADL, activities of daily living charting) revealed the following shower documentation since October 1, 2023:

From October 1 to 28, 2023, no documentation of a shower
From October 30 to November 17, 2023, no documentation of a shower
From December 14 to 31 2023, no documentation of a shower

Further review revealed that Resident 31's bathing preference was identified as preferring a shower.

A review of Resident 31's current care plan revealed she will be odor-free, dressed, and out of bed daily.

Findings were reviewed with Employee 1 (assistant nursing home administrator) and Employee 2 (corporate consultant) during a meeting on January 10, 2024, at 2:00 PM.

The facility failed to provide bathing and dressing assistance for a resident dependent on staff assistance.

28 Pa Code 211.11(d)(1)(5) Nursing services


 Plan of Correction - To be completed: 02/20/2024

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.
1. Resident 31's shower preferences were reviewed with resident and updated on the care plan. Resident 31 was provided alternate clothing of her choosing but still states she prefers to wear the hospital gowns. Preferences updated on care plan.
2. A whole house audit was completed regarding clothing preference and shower documentation with care plans updated as needed.
3. DON or designee will educate staff on shower documentation and resident clothing preferences.
4. Random audits will be completed for shower documentation and honoring clothing preference weekly x4 then monthly x2 with results reported to QAPI.
5. Compliance by February 20, 2024

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 store food service equipment in a sanitary manner in the facility's main kitchen.

Findings include:

An observation of the main kitchen on January 9, 2024, at 12:36 PM revealed a large open utensil storage rack was located at the end of a production table in the food preparation area. The tall rack, which extended higher than the production table contained multiple spoons, whisks, spatulas, and ladles, hanging from the rack. The food contact surfaces of the utensils were exposed to dust/debris as well as splatter/splash from items being prepared on the food preparation table. Concurrent interview with Employee 5, dietary supervisor, indicated the utensils were considered clean and available for dietary employees to use in food service and production and it was not expected of the staff to wash/sanitize the utensils before use.

An observation in the main kitchen on January 11, 2024, at 11:00 AM revealed dietary staff obtaining utensils from the above utensil rack and placing them in front of pans of food on the steam table where an employee was observed taking the temperatures of the food for lunch service.

An observation on January 12, 2024, in the main kitchen at 10:47 AM revealed staff preparing food in the kitchen and setting up the steam table for lunch. Dietary staff was observed obtaining utensils from the open utensil rack carrying it to a preparation table and began using the utensil to place food in bowls without cleaning/sanitizing the utensil first.

The above information was reviewed with Employee 1, Assistant Nursing Home Administrator and Employee 2, corporate consultant on January 12, 2024, at 12:10 PM.

28 Pa. Code 201.14(a) Responsibility of licensee


 Plan of Correction - To be completed: 02/20/2024

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.
1. No resident harm identified.
2. A covered utensil rack has been purchased.
3. The dietary manager or designee will educate dietary staff on maintaining hanging utensils in the enclosed rack.
4. Random audits will be completed of the enclosed utensil rack weekly x4 then monthly x2 with results reported in QAPI.
5. Compliance by February 20, 2024

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff: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.
§483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:

Based on the review of facility documentation and staff interviews, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of resident tracheostomy and catheter care.

Findings include:

A review of the facility documentation revealed that the facility had nine residents with indwelling urinary catheters (insertion of a tube into the bladder to remove urine) and one resident with a tracheostomy (a surgical airway management procedure that consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea).

A request for nursing staff competencies for tracheostomy and catheter care revealed the facility was unable to provide any.

An interview with Employee 6 (acting director of nursing) on January 12, 2024, at 12:27 PM confirmed the facility could provide no documentation that ensured nurses have specific competencies and skill sets to care for the residents' needs listed above.

28 Pa Code 201.20(a) Staff development

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


 Plan of Correction - To be completed: 02/20/2024

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.
1. No residents were harmed, and all residents received appropriate tracheostomy and catheter care.
2. Competencies were completed with nursing staff for tracheostomy and catheter care.
3. The NHA or designee will educate IP/SDC, ADON, and DON on completing competencies in addition to educations.
4. A review of completed competencies will be submitted to QAPI monthly x3.
5. Compliance by February 20, 2024

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of 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.
§483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to respect a resident's right to privacy for two of 19 residents reviewed (Residents 8 and 65).

Findings include:

Clinical record review for Resident 8 revealed nursing documentation dated January 1, 2024, noting Resident 8 was found on the floor and the nurse noted the baby monitor was in use.

Clinical record review for Resident 65 revealed nursing documentation dated December 22, 2023, noting Resident 65 was found on the floor and staff heard the chair alarm going off through the baby monitor at the nurses' station. A review of the facility investigation into Resident 65's fall revealed she is to have a voice monitor when in closed-door isolation.

Interview with Employee 1 (assistant nursing home administrator) on January 12, 2024, at 1:30 PM confirmed the facility was utilizing baby monitors (audio amplifiers) in resident rooms. She stated the facility used the baby monitors to amplify the sound of resident alarms. There was no evidence in Resident 8 or 65's clinical records that the facility obtained permission for the baby monitors.

The facility failed to protect Residents 8 and 65 right to privacy.

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


 Plan of Correction - To be completed: 02/20/2024

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.

1. Monitors used during an isolation situation have been removed from Resident 8 and 65's rooms and no other residents within the facility have a monitor in use.
2. All monitors are secured in NHA office and not accessible to staff.
3. All relevant staff will be educated on Resident privacy and obtaining consent prior to implementing a device to amplify sounds within isolation rooms.
4. All requests for additional monitoring will be reviewed in IDT to ensure appropriateness and approval/consent from resident/family prior to placing monitor in a resident room.
5. Compliance by February 20, 2024


483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§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 clinical record review, review of select facility policies and procedures, and resident and staff interview, it was determined that the facility failed to thoroughly investigate and report misappropriation of resident property for one of 19 residents reviewed (Residents 36).

Findings include:

The facility policy entitled, "Abuse, Neglect, Exploitation General Policy, effective June 2022, and last revised in January 2024, revealed that the facility goal is to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves but is not limited to identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and /or misappropriation of resident property is more likely to occur.

The facility is responsible to investigate and report cases of possible abuse, neglect including involuntary seclusion, exploitation, and misappropriation of property to external agencies in accordance with the regulation. All facility employees, family members, and volunteers are educated that all alleged or suspected violations involving mistreatment, neglect or abuse including injuries of unknown origin, involuntary seclusion, and misappropriation of resident property are reported immediately to the nurse on duty and/or as well as the Director of Nursing (DON) and/or the Nursing Home Administrator (NHA) to ensure a timely investigation is initiated.

The facility will report all alleged violations to the NHA, state agency, adult protective services, and all other required agencies within the specified time frame.

Interview with Resident 36 on January 9, 2024, at 12:40 PM revealed that he had 41.00 dollars that he put in a tin on his tray table, and it went missing. He did not remember the exact date or time that this occurred but knew that it was summertime. He said that it was approximately a week from the time he put the money in the tin until he noticed it missing. He said that it was reported to staff, but that he was told that there was nothing they could do about it. He indicated that he talked with the social worker but could not remember her name at the time of the interview.

Clinical record review revealed a clinical progress note completed by Employee 4, social services, on August 28, 2023, at 3:43 PM that indicated that Resident 36 reported to social services that he had lost $40.00 in cash. The note indicated that Resident 36 said the last time he saw the money was last week when he had put his bingo money in the tin on his tray table. Employee 4 asked Resident 36 if his sister may have taken the money for his phone bill and he said, 'no because she was the one that gave him the money.' Employee 4 left a voicemail for his sister regarding the money.

A clinical progress note dated August 29, 2023, at 11:29 AM by Employee 4 indicated that another voice mail was left for Resident 36's sister asking about the $40.00 in cash that he may or may not have had in his room.

There were no other progress notes in the clinical record related to Resident 36's allegation of missing money.

Interview with Employee 1, Acting NHA, and Employee 2, corporate consultant, on January 12, 2024, at 9:21 AM revealed that the facility did not further investigate Resident 36's allegation of missing money, and it was not reported to external agencies in accordance with the regulation.

The facility failed to investigate and report the allegation of misappropriation of property for Resident 36.

28 Pa. Code 201.14(a) Responsibility of licensee

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

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

28 Pa. Code 211.10(d) Resident care policies

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


 Plan of Correction - To be completed: 02/20/2024

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.
1. Resident 36 was reimbursed the total of his missing money.
2. NHA or designee will review all allegations of missing money from previous 3 months to ensure investigation complete and resolved.
3. NHA or designee will educate social services, ANHA, ADON, and DON on investigating and reporting any allegations of missing money.
4. All investigations regarding allegations of missing money will be reviewed for completeness and reporting needs weekly x4 then monthly x2 with results reported to QAPI.
5. Compliance by February 20, 2024

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

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

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to medically justify and evaluate the clinical necessity for a urinary catheter for one of three residents reviewed for catheter use (Resident 65) and implement appropriate services for one of three residents reviewed for catheter use (Resident 26).

Findings included:

Clinical record review revealed the facility admitted Resident 65 on August 21, 2023, without an indwelling urinary catheter (insertion of a tube into the bladder to remove urine) . Resident 65 was admitted to the hospital from November 13 to 15, 2023, and a Foley catheter was placed in Resident 65 due to "terminal illness."

An observation of Resident 65 on January 9, 2024, at 10:55 AM revealed a catheter remained in place.

A review of Resident 65's clinical record revealed a "Physician Notification/Order Request Form," dated November 22, 2023, indicating the nurse requested the physician add a diagnosis of obstructive uropathy. Further review of Resident 65's clinical record revealed no documentation of the clinical necessity for Resident 65's catheter.

The facility did not receive a verbal physician's order for Resident 65's catheter until December 16, 2023.

An interview with Employee 6 (acting director of nursing) confirmed these findings. She revealed the facility had no further documentation supporting the clinical necessity for Resident 65's urinary catheter.

An observation of Resident 26 on January 9, 2024, at 1:30 PM revealed the resident was lying in bed. A catheter bag with tubing attached was observed hanging from a piece of metal at the bottom of the resident's bed frame, with most of the catheter bag unhygienically lying directly on the floor of the resident's room.

The above finding regarding Resident 26 was reviewed with Employee 1, Assistant Nursing Home Administrator, and Employee 2, corporate consultant on January 10, 2024, at 2:00 PM.

A follow-up observation of Resident 26 on January 12, 2024, at 10:23 AM revealed the resident was in bed with a catheter bag hanging from a metal piece on the lower foot portion of the bed frame with the side of the bag lying directly on the floor.

The January 12, 2024, findings for Resident 26 were concurrently reviewed with Employee 1, and Employee 2.

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


 Plan of Correction - To be completed: 02/20/2024

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.

1. Resident 65's urinary catheter has been discontinued. Resident 26's bed is in the lowest position for safety. A basin was placed as a barrier between the floor and the catheter bag.
2. All residents with a foley catheter have an appropriate diagnosis. All residents who have a bed in the low position for safety and a urinary catheter have had a basin placed as a barrier between the floor and the catheter bag.
3. DON or designee will educate medical director, facility APP, and Palliative APP on diagnosis for foley catheter. DON or designee will educate nursing staff regarding placing basin under catheter bags for residents with beds in low position for safety.
4. Random audits of appropriate diagnosis for a foley catheter and basins under catheter bags of those residents with bed in low position will be completed weekly x4 then monthly x2 with results reported to QAPI.
5. Compliance by February 20, 2024

483.25(m) REQUIREMENT Trauma Informed Care: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(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.
Observations:

Based on clinical record review and staff and resident interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care and eliminate or mitigate re-traumatization for one of five residents reviewed for mood/behavior (Resident 42).

Findings include:

Clinical record review for Resident 42 revealed a current diagnosis of Chronic Post Traumatic Stress disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event).

During an interview with Resident 42 on January 12, 2024, at 9:13 AM upon discussion of her PTSD diagnosis, the resident stated being asked the same questions over and over and having staff she doesn't know triggers her stress. Resident 42 did not elaborate on any other details of her trauma.

Clinical record review for Resident 42 revealed an active plan of care for the resident for PTSD, which included interventions of psychiatry/psychology as ordered, encourage to maintain relationships with family and friends, and monitor for signs of and symptoms of depression and anxiety. There was no evidence in Resident 42's plan of care to indicate what individualized specific events may retraumatize the resident, how facility staff can prevent/minimize triggers from occurring, or how to help the resident cope with any trauma related responses to events.

There was no evidence facility staff identified what Resident 42's specific triggers were that may retraumatize the resident or implemented measures into the resident's plan of care as to how facility staff can prevent/minimize triggers from occurring for the resident.

The above information was reviewed with Employee 1, Assistant Nursing Home Administrator, and Employee 2, corporate consultant, on January 12, 2024, at 12:05 PM. They indicated no additional information was available for Resident 42 regarding her PTSD.

28 Pa Code 201.24 (e)(4) Resident care plan

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

28 Pa. Code 211.16(a) Social services


 Plan of Correction - To be completed: 02/20/2024

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.
1. Resident 42's care plan has been updated to reflect specific triggers and measures to prevent/minimize triggers from occurring.
2. All residents with trauma informed care plans were reviewed and updated with specific triggers and measures to prevent/minimize triggers from occurring.
3. Social services staff were educated on trauma informed care plans to include specific triggers and measures to prevent/minimize triggers from occurring.
4.Trauma informed care plans will be audited weekly x4 then monthly times 2 with results reported in QAPI.
5. Compliance by February 20, 2024

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by two of two residents reviewed (Residents 30 and 63).

Findings include:

Clinical record review for Resident 30 revealed the facility admitted her on July 17, 2023, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 30's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated July 18, 2023, indicated that the facility assessed Resident 30 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 30's care plan revealed a problem for impaired cognitive/communication skills for daily decision making due to a diagnosis of dementia. The interventions included to break tasks into short segments, provide verbal reminders while she is performing self-care, engage in activities that do not require frequent decisions, limit choices to two simple options, assist her to select clothing that is clean and in good repair, fits and is appropriate for the season, and shoes will have non-skid soles and fit well, and to establish a daily routine and post it in her room.

Observation of Resident 30"s room on January 11, 2024, at 10:10 AM revealed that there was no daily routine posted in her room.

Clinical record review for Resident 63 revealed the facility admitted him on April 5, 2023, with diagnosis including Dementia. A review of Resident 63's most recent comprehensive MDS dated April 10, 2023, indicated that the facility assessed Resident 63 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 63's care plan revealed a problem for impaired cognitive skills for daily decision making due to a diagnosis of dementia. The interventions included to break tasks into short segments; provide verbal reminders while he is performing self-care, engage in activities that do not require frequent decisions, limit choices to two simple options, and to establish a daily routine and post it in his room.

Observations of Resident 63's room on January 11, 2024, at 10:14 AM revealed that there was no daily routine posted in his room.

An interview with Employee 4, social services, on January 12, 2024, at 12:50 PM confirmed that a daily routine was not established and posted in the rooms for Resident 30 or Resident 63, as indicated by their care plan and that the care plans were not person-centered care plans to address their specific needs related to their diagnosis of dementia.

The findings were reviewed with Employee 1 (Acting Nursing Home Administrator) and Employee 4 (social services) during a meeting on January 12, 2024, at 12:55 PM.

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

28 Pa Code 211.11(d) Resident care plan


 Plan of Correction - To be completed: 02/20/2024

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.
1. Resident 30 and resident 63's care plans were updated to address their specific needs related to their diagnosis of dementia.
2. All residents with a diagnosis of dementia were audited for care planning of specific needs related to their dementia diagnosis.
3. Social services staff were educated on individualized care plans for dementia diagnosis.
4. Audits will be completed for new residents with a dementia diagnosis weekly x4 then monthly times 3 with results reported to QAPI.
5. Compliance by February 20, 2024

§ 201.14(c) LICENSURE Responsibility of licensee.:State only Deficiency.
(c) The licensee through the administrator shall report as soon as possible, or, at the latest, within 24 hours to the appropriate Division of Nursing Care Facilities field office serious incidents involving residents as set forth in § 51.3 (relating to notification). For purposes of this subpart, references to patients in § 51.3 include references to residents.

Observations:

Based on observation and staff interview, it was determined that the facility failed to report confirmed cases of COVID-19 within 24 hours to the State Licensing Agency, Department of Health, Division of Regulatory Oversight and Nursing Care Facilities.

Findings include:

Review of the Division of Regulatory Oversight and Nursing Care Facilities Message Board revealed a posted message dated June 7, 2023, and reposted again on September 17, 2023, regarding COVID reporting requirements which noted the following:

In response to the PA Department of Health's release, on June 6, 2023, of PAHAN(Pennsylvania Health Alert Network)-2023 - 700-06-06-ADV Updated Reporting Requirements for COVID-19 Following the End of the COVID-19 Public Health Emergency and PENNSYLVANIA DEPARTMENT OF HEALTH 2023 - PAHAN - 701-06-06-ADV COVID-19 Outbreak Identification and Reporting for Healthcare Settings, the Division of Nursing Care Facilities is providing this reminder to long term care skilled nursing facilities that outbreaks of COVID-19 among residents and staff should continue to be reported to the Division of Nursing Care Facilities via the Event Reporting System.

An outbreak is defined as one or more residents with a probable or confirmed case of COVID-19 acquired in the facility.

A staff outbreak is defined as one or more health care personnel with a probable or confirmed case of COVID-19 who was working in the facility while infectious.

In an entrance interview with Employee 1, assistant nursing home administrator, and Employee 2, corporate consultant, on January 9, 2024, at 10:35 AM, Employee 1 and Employee 2 indicated there were no active cases of COVID-19 in the facility.

A review of the Division of Nursing Care Facilities Event Reporting System revealed the facility had not reported any cases of COVID-19 among employees or residents since September 2023.

A review of the facility's tracking of COVID-19 among employees and residents revealed the facility had an employee test positive for COVID-19 on September 11, 2023, and was not reported. There was an outbreak of COVID-19 starting on October 24, 2023, with another facility employee and an additional 16 employees tested positive for COVID-19 and 10 residents tested positive for COVID-19 since that date, with the latest resident testing positive on December 30, 2023, and an employee testing positive on January 1, 2024.

Interview with Employee 2, on January 10, 2024, at 10:30 AM confirmed the facility failed to report confirmed cases of COVID-19 as required to the State Licensing Agency, PA Department of Health, Division of Regulatory Oversight and Nursing Care Facilities.


 Plan of Correction - To be completed: 02/20/2024

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.
1. All required COVID-19 reporting has been completed to the appropriate agencies.
2. A review of COVID-19 positive cases within the facility in the last 3 months was completed with all missed reporting completed.
3. The NHA or designee will educate The Infection Preventionist, ADON, and DON on the requirements of reporting COVID-19 to appropriate agencies.
4. Random audits for COVID-19 reporting will be completed weekly x4 then monthly x2 with results reported to QAPI.
5. Compliance by February 20, 2024

§ 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 clinical record review and staff interview, it was determined that there was no evidence that identified the disposition of a resident's personal belongings following discharge from the facility for two of three closed records reviewed (Residents 71 and 72).

Findings include:

A closed clinical record review for Resident 71 revealed that he was transferred to the hospital on November 10, 2023.

Interview with Employee 1 (Assistant Nursing Home Administrator, ANHA) on January 11, 2024, at 2:23 PM revealed that Resident 71 did not return to the facility after his discharge to the hospital on November 10, 2023.

A review of Resident 71's personal belongings inventory form revealed that it was not signed by the resident/responsible party upon discharge from the facility. Further review of the resident's closed clinical record revealed no documentation to indicate the disposition of Resident 71's personal belongings.

Clinical record review for Resident 72 revealed that she expired on November 8, 2023. Review of Resident 72's "Personal Belonging Inventory- Admission" noted the items Resident 72 was admitted with on August 10, 2023. Further review of Resident 72's closed clinical record revealed there was no documentation of the disposition of Resident 72's belongings.

Interview with Employee 2, Corporate Consultant, on January 12, 2024, at 9:45 AM confirmed the above noted findings related to the disposition of Resident 71 and Resident 72's personal belongings.


 Plan of Correction - To be completed: 02/20/2024

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.
1. Resident 71 and resident 72's families were contacted to confirm disposition of all belongings.
2. A whole house audit will be completed on all discharges in previous 3 months to ensure belongings dispositioned.
3. NHA or designee will educate RN supervisors, social services, and medical records on disposition of belongings.
4. A random audit of disposition of belongings will be completed weekly x4 then monthly x2 with results reported to QAPI.
5. Compliance by February 20, 2024


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