Pennsylvania Department of Health
 HERITAGE CARE CENTER
Patient Care Inspection Results

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HERITAGE CARE CENTER
Inspection Results For:

There are  178 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.
HERITAGE CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to nine complaints, completed on May 22, 2024, it was determined that Heritage Care Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.60(a)(3)(b) REQUIREMENT Sufficient Dietary Support Personnel:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.60(a)(3) Support staff.
The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

§483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § 483.21(b)(2)(ii).
Observations:

Based on review of facility documents, and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential kitchen duties in the Main Kitchen.

Findings include:

Review of Facility Assessment dated 2/28/24, indicated that individual preferences are met related to diet in conjunction with the medical needs of the resident, Appropriate consistencies are offered in line with physician orders and speech therapy recommendations. The facility employs a dietitian as well as staff that interacts with the residents daily to obtain preferences, Meal preparations are made with an attempt to meet food preferences of the individual.

Review of the facility's "Cart Delivery Schedule: indicated the following:
2 East is to receive lunch at 11:56 a.m.
3 South is to receive lunch at 12:10 p.m.
3 West is to receive breakfast at 7:57 a.m., lunch at 12:17 p.m., and dinner at dinner at 5:32 p.m.
And that all times are within +/- 5 minutes.

Review of a resident representative concern dated 5/8/24, indicated that " They have been sending the meals up on Styrofoam plates and plastic utensils", and "many patients have swallowing issues and are not given the appropriate diets which is increasing aspiration (when food or liquids enter a person's airway and eventually the lungs by accident) risks", and "They used to get a weekly menu where they would circle what they wanted. They have not gotten a menu in a week. Residents are served food they did not want".

Review of a resident representative concern dated 5/13/24, indicated that "Breakfast is coming after 9:00 a.m., lunch after 2:00 p.m., and dinner at 6:00 p.m.".

Review of a resident representative concern dated 5/15/24, indicated that a resident "Has tried to talk to nutrition, asking for a more nutrient dense diet. We can't speak to anyone in nutrition, there is no one available".

Review of a resident representative concern dated 5/20/24, indicated that a resident "Gets moist meals because of his dysphagia (difficulty swallowing). Sometimes he doesn't get the right meals so he can ' t eat it".

During an interview on 5/22/24, at 9:45 a.m., Food Service Director (FSD) Employee E1 stated that she had 22 staff members working in the kitchen, however once the facility was bought by a different company, she lost a lot of staff and is now down to eight staff members. FSD Employee E1 stated that food has been served late, and they are using a lot of Styrofoam as "There is no one to do dishes". FSD Employee E1 confirmed that food has been served cold as it has been served in Styrofoam. FSD Employee E1 also stated that she used to "pass out menus to residents for them to select what they desired to eat on Wednesdays and then enter the data for Saturday, but now there is no one to pass or enter the preferences". FSD Employee E1 stated that she has been trying to fill in some of the duties in the kitchen herself and that "I'm overwhelmed".

During an interview on 5/22/24, at 9:50 a.m. Dietary Employee E2 stated "We don't have enough staff to get my job done. It's the worst it's ever been in 20 years".

During an interview on 5/22/24, at 10:40 a.m. Diet Technician Employee E3 stated that the Dietary Department has been short since the new owners took over and that her normal duties are to complete clinical nutrition assignments which involve assessments and visiting residents, however she has had to work the past eight out of eleven days in the kitchen as a dietary aide, and can't complete her own work.

During an interview on 5/22/24, at 10:45 a.m. Resident R10 confirmed that she has been receiving food in Styrofoam and added "I hate Styrofoam".

During an interview on 5/22/24, at 10:49 a.m. Resident R11 stated that "The food is late. It's in Styrofoam and its cold. We used to get menus but now we don't. I've been getting food I wouldn't order".

During an interview on 5/22/24, at 10:52 a.m. Resident R12 stated that "You don't get a menu anymore. You get what you get and if you don't like it too bad", and "Meals are late. We get breakfast at 9:00 a.m., Lunch 1:00 p.m. or later, and dinner 7:00 p.m. or after". Resident R12 also stated that she does receive food in Styrofoam and "I hate it because it comes cold".

Review of "Cart Delivery Schedule", indicated that Resident R12 should have her breakfast delivered at 7:57 a.m., lunch at 12:17 p.m., and dinner at 5:32 p.m.

During an observation on 5/22/24, at 11:30 p.m. the Nursing Home Administrator (NHA) was delivering dirty breakfast dishes to the Main Kitchen.

During an interview on 5/22/4, at 11:30 p.m. FSD Employee E1 stated that the NHA has washed dishes several times due to the dietary staffing shortage.

During an observation on 5/2/24, at 12: 18 p.m. the meal cart was delivered to 2 East.

Review of "Cart delivery schedule" indicated that 2 East was to have meals delivered at 11:56 a.m.

During an interview on 5/22/24, at 12:22 p.m. Resident R13 stated that "meals have been late at least one hour".

During an observation on 5/22/24, at 12:32 p.m. the meal cart was delivered to 3 south.

Review of "Cart Delivery Schedule" indicated that 3 South was to have meals delivered at 12:10 p.m.

During an interview on 5/22/23, at 12:40 p.m. Registered Nurse (RN) Employee E4 stated that the dietary department has been short and that employees who work in laundry have been working in dietary to help out.

During an interview on 5/22/24, at 5:55 p.m. NHA confirmed that the facility failed to have sufficient dietary staff to perform essential kitchen duties in the Main Kitchen.


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



 Plan of Correction - To be completed: 07/09/2024

The dietary is currently sufficiently staffed. The facility currently has 1 full time Registered Dietician, 1 full time Dietary manager, 1 full time Diet Tech, 2 full time cooks, and 6 full time dietary aides, 1 prn. Meal cart delivery will be completed as per delivery schedule. No Styrofoam/paper products will be utilized unless authorized by the Dietary Manager and/or Nursing Home Administrator. Dietary staff will be re-educated by the Dietary Director/designee on the timely meal delivery, meal tickets, prescribed meal delivered, food temperatures, resident preferences. The dietary manager will review staffing to ensure adequate staffing. In the event of call offs, all attempts to be made to procure staff. The Dietary manager/designee will audit cart schedules and paper product use 3 times per week x 2 weeks then monthly x 2 months. Any discrepancies will be addressed as appropriate and re-education provided. The results of the findings will be submitted to the facility QAPI meeting.
483.25 REQUIREMENT Quality of Care: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.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of facility policy, clinical record review, and resident and staff interview, it was determined that the facility failed to follow physician orders for medication and treatment administration for four of four residents reviewed (Resident R1, R2, R4, and R5).

Findings include:

Review of facility policy "Medication Administration and Charting Guidelines" last reviewed October 2023, indicated to chart after administering medication. There are only three acceptable reasons for not administering a medication or treatment: resident is out on pass, medication is held due to medical reason, and refusal by the resident. The resident's MAR (medication administration record) is initialed by the person administering a medication; or, if utilizing an eMAR (electronic) the medication is clicked as administered.

Review of facility policy "Wound Dressing Change" last reviewed October 2023, indicated to document procedure including any significant findings in the resident's record after performing a wound dressing change.

Review of the clinical record indicated Resident R1 was admitted to the facility on 4/18/24.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/2/24, indicated diagnoses of high blood pressure, diabetes (too much sugar in the blood), and non-pressure chronic ulcer of unspecified part of right lower leg.

Review of a physician order dated 4/25/24, indicated to wash right lower extremity with soap and water, apply Santyl (an ointment for wound healing) and non-adherent Allevyn (an absorbent dressing) to wick drainage. Cover with Kerlix (gauze wrap) and ACE bandage (an elastic bandage) daily. Only replace Allevyn and Kerlix twice daily.

Review of Resident R1's April 2024 Treatment Administration Record (TAR) documentation indicated the ordered wound dressing change was not completed during the day shift on 4/26/24.

During an interview on 5/22/24, at 3:52 p.m. the Assistant Director of Nursing (ADON) confirmed Resident R1's wound dressing change was not documented as completed during the day shift on 4/26/24.

Review of the clinical record indicated Resident R2 was admitted to the facility on 6/6/19.

Review of Resident R2's MDS dated 5/10/24, indicated diagnoses of high blood pressure, diabetes, and hypertrophy of tongue papillae (a condition where the bumps on the tongue become swollen and inflamed).

Review of a physician order dated 4/29/24, indicated to cleanse mouth with toothette (swab) soaked in Peroxide Sore Mouth Cleanser 1.5% solution. Pay special attention to black area on her tongue. Cleanse mouth 5 times per day, in morning upon arising, after meals and at bedtime.

Review of Resident R2's May 2024 MAR documentation indicated Resident R2 did not receive ordered mouth care after lunch on 5/5/24, and during the morning medication pass on 5/12/24, and 5/15/24.

During an interview on 5/22/24, at 3:52 p.m. the ADON confirmed documentation indicated Resident R2 did not receive ordered mouth care on 5/5/24, 5/12/24, and 5/15/24.

Review of the clinical record indicated Resident R4 was admitted to the facility on 9/5/23.

Review of Resident R4's MDS dated 5/15/24, indicated diagnoses of high blood pressure, diabetes, and muscle wasting.

Review of a physician order dated 10/27/23, indicated to apply Nystatin (used to treat fungal infections) one application topically four times daily under breasts and abdominal folds for rash.

Review of Resident R4's May 2024 MAR documentation indicated Resident R4 did not receive ordered Nystatin on 5/5/24, 5/12/24, and 5/16/24 during the lunch medication pass.

Review of a physician order dated 11/18/23, indicated to apply Calmoseptine ointment (a skin barrier protectant) to groin and thigh twice a day for rash/excoriation.

Review of Resident R4's May 2024 MAR documentation indicated Resident R4 did not receive ordered Calmoseptine on 5/12/24 during the day shift.

Review of a physician order dated 3/6/24, indicated to administer Artificial Tears one drop to both eyes four times a day for dry eyes.

Review of Resident R4's May 2024 MAR documentation indicated Resident R4 did not receive ordered Artificial Tears on 5/5/24 during the lunch medication pass, on 5/12/24 during the morning medication pass, and 5/6/24 during the lunch medication pass.

Review of a physician order dated 3/8/24, indicated to administer PreserVision (an eye vitamin) one chewable tablet two times a day for eye health.

Review of Resident R4's May 2024 MAR documentation indicated Resident R4 did not receive ordered PreserVision on 5/8/24 during the bedtime medication pass, on 5/12/24 and 516/24 during the morning medication pass.

Review of a physician order dated 3/25/24, indicated to check capillary blood glucose level and administer Humalog (a rapid acting insulin injected under the skin to lower blood sugar levels) subcutaneously before meals and at bedtime as per sliding scale:
70 - 140 = 0 units
141 - 180 = 1 unit
181 - 220 = 2 units
221 - 260 = 3 units
261 - 300 = 4 units
301 - 340 = 5 units
>340 = 6 units and call physician

Review of Resident R4's May 2024 MAR documentation indicated the resident did not receive required insulin coverage for a CBG reading of 331 on 5/12/24, during the morning medication pass.

During an interview on 5/22/24, at 3:52 p.m. the ADON confirmed documentation indicated Resident R4 did not receive ordered Nystatin, Calmoseptine, Artificial Tears, PreserVision, and Humalog on the dates listed above.

Review of the clinical record indicated Resident R5 was admitted to the facility on 5/15/23.

Review of Resident R5's MDS dated 5/14/24, indicated diagnoses of high blood pressure, hyperlipidemia (too much fat in the blood) and depression (a constant feeling of sadness and loss of interest).

Review of a physician order dated 5/15/23, indicated to administer Latanoprost 0.005% eye drops one drop to left eye one a day at bedtime for glaucoma (a group of eye conditions that can cause blindness).

Review of Resident R5's May 2024 MAR documentation indicated the resident did not receive ordered Latanoprost on 5/8/24 during the bedtime medication pass.

Review of a physician order dated 7/15/23, indicated to administer Timolol 0.5% eye drops one drop to left eye twice a day for glaucoma.

Review of Resident R4's May 2024 MAR documentation indicated the resident did not receive ordered Timolol on 5/8/24 during the bedtime medication pass.

During an interview on 5/22/24, at 3:52 p.m. the ADON confirmed documentation indicated Resident R5 did not receive ordered Latanoprost and Timolol on 5/8/24 during the bedtime medication pass.

During an interview on 5/22/24, at 3:52 p.m. the ADON confirmed that the facility failed to follow physician orders for medication and treatment administration for four of four residents reviewed (Resident R1, R2, R4, and R5).

28 Pa. Code 201.18 (b)(1) Management.
28 Pa. Code 201.29(d) Resident Rights.
28 Pa. Code 211.10 (c)(d) Resident Care policies.
28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 07/09/2024

Resident R1 has been discharged. Resident R2, R4, and R5 continues to receive medications as ordered.
Active residents will continue to receive medications as per MD order. The Director of Nursing/designee will monitor medication and treatment administration via PCC dashboard for any missed medications/treatments at the facilities AM clinical meeting.
Licensed nurses will be re-educated on medication/treatment administration to include glucose monitoring by the Director of Nursing/designee. Any discrepancies will be addressed as appropriate. The DON/designee will complete audits to ensure medications passed as per physician's order. Audits will be completed weekly x 2, monthly x 2. Findings will be submitted to the monthly QAPI committee meeting.
483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime: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(f) Frequency of Meals
§483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

§483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

§483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.
Observations:

Based on review of facility documents, meal delivery observations, resident interviews, and staff interviews it was determined that the facility failed to ensure that meals were served at regularly scheduled times for three weeks.

Findings include:

Review of the facility's "Cart Delivery Schedule: indicated the following:
2 East is to receive lunch at 11:56 a.m.
3 South is to receive lunch at 12:10 p.m.
3 West is to receive breakfast at 7:57 a.m., lunch at 12:17 p.m., and dinner at dinner at 5:32 p.m.
And that all times are within +/- 5 minutes.

Review of a resident representative concern dated 5/13/24, indicated that "Breakfast is coming after 9:00 a.m., lunch after 2:00 p.m., and dinner at 6:00 p.m.".

During an interview on 5/22/24, at 9:45 a.m., Food Service Director (FSD) Employee E1 stated that she had 22 staff members working in the kitchen, however once the facility was bought by a different company on 5/1/24, she lost a lot of staff and is now down to eight staff members. FSD Employee E1 stated that food has been served consistently late.

During an interview on 5/22/24, at 10:52 a.m. Resident R12 stated that "Meals are late. We get breakfast at 9:00 a.m., Lunch 1:00 p.m. or later, and dinner 7:00 p.m. or after".

Review of "Cart Delivery Schedule", indicated that Resident R12 should have her breakfast delivered at 7:57 a.m., lunch at 12:17 p.m., and dinner at 5:32 p.m.

During an observation on 5/2/24, at 12: 18 p.m. the meal cart was delivered to 2 East.

Review of "Cart delivery schedule" indicated that 2 East was to have meals delivered at 11:56 a.m.

During an interview on 5/22/24, at 12:22 p.m. Resident R13 stated that "meals have been late at least one hour".

During an observation on 5/22/24, at 12:32 p.m. the meal cart was delivered to 3 south.

Review of "Cart Delivery Schedule" indicated that 3 South was to have meals delivered at 12:10 p.m.

During an interview on 5/22/24, at 5:55 p.m. NHA confirmed that the facility failed to ensure that meals were served at regularly scheduled times for approximately three weeks.


28 Pa code 211.6(a) - Dietary Services


 Plan of Correction - To be completed: 07/09/2024

Meal cart delivery will be completed as per cart schedule. The cart schedules have been reviewed to ensure cart schedule times are accurate and appropriate. The dietary staff will be re-educated by the Dietary Manager/designee on the cart delivery times and notification to the Dietary Manger/designee if a discrepancy is noted. The Dietary manager/designee will audit cart delivery times to ensure meal carts are delivered on unit as scheduled and to include resident satisfaction interviews 3 times per week x 2 weeks then monthly x 2 months. Audit findings will be reported to the facility QAPI meeting.
483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes: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(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

§483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;
Observations:

Based on review of facility documents, resident interviews, and staff interviews, it was determined that the facility failed to provide menu selections according to the resident's preference for three weeks.

Findings include:

Review of Facility Assessment dated 2/28/24, indicated that individual preferences are met related to diet in conjunction with the medical needs of the resident. Meal preparations are made with an attempt to meet food preferences of the individual.

Review of a resident representative concern dated 5/8/24, indicated that "They used to get a weekly menu where they would circle what they wanted. They have not gotten a menu in a week. Residents are served food they did not want".

During an interview on 5/22/24, at 9:45 a.m., Food Service Director (FSD) Employee E1 stated that she had 22 staff members working in the kitchen, however once the facility was bought by a different company, she lost a lot of staff and is now down to eight staff members. FSD Employee E1 also stated that she used to "pass out menus to residents for them to select what they desired to eat on Wednesdays and then enter the data for Saturday, but now there is no one to pass or enter the preferences".

During an interview on 5/22/24, at 10:49 a.m. Resident R11 stated "We used to get menus but now we don ' t. I've been getting food I wouldn't order".

During an interview on 5/22/24, at 10:52 a.m. Resident R12 stated that "You don't get a menu anymore. You get what you get and if you don't like it too bad".

During an interview on 5/22/24, at 5:55 p.m. NHA confirmed that the facility failed to provide menu selections in accordance with resident's preferences.


28 Pa Code: 211.6(a)(c ) Dietary service.



 Plan of Correction - To be completed: 07/09/2024

Meal preferences will be reviewed with current residents and updated in the system. The Dietary Manager met with the resident council. Menus to be provided and posted per policy and an "always available" menu provided in the event a resident does not wish to have the menu item. Re-education will be provided to the dietary staff on the menu and "always available" menu items by the Dietary Manager/designee. The Dietary Manger/designee will interview/audit 5 residents/floor weekly x 2 weeks then monthly x 2 to ensure menu selections are being followed. Any discrepancies will be addressed and re-education provided as appropriate. Results of the interviews/audit will be reported to the facility QAPI meeting.

483.60(d)(3) REQUIREMENT Food in Form to Meet Individual Needs: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(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(3) Food prepared in a form designed to meet individual needs.
Observations:

Based on facility documents, and staff interviews, it was determined that the facility failed to provide food in a form to meet individuals' needs in one of four residents ordered nectar thickened liquids (liquids that are thickened to ease with swallowing difficulties), and one in 20 residents ordered easy to chew diet textures.

Findings include:

Review of Facility Assessment dated 2/28/24, indicated that individual preferences are met related to diet in conjunction with the medical needs of the resident, Appropriate consistencies are offered in line with physician orders and speech therapy recommendations.

Review of a resident representative concern dated 5/8/24, indicated that "Many patients have swallowing issues and are not given the appropriate diets which is increasing aspiration (when food or liquids enter a person's airway and eventually the lungs by accident) risks".

Review of a resident representative concern dated 5/20/24, indicated that a resident "Gets moist meals because of his dysphagia (difficulty swallowing). Sometimes he doesn't get the right meals so he can't eat it".

During an interview on 5/22/24, at 1:18 p.m., Speech Therapist (ST) Employee E5 confirmed that she has observed on at least two occasion that residents were not provided the correct liquid or diet texture to address their chewing and or swallowing needs. ST Employee E5 stated that one day last week she observed one resident's lunch tray that was to have nectar thickened liquids, and he received thin liquids instead, and another resident that was to receive easy to chew meats and received regular meats instead.

During an interview on 5/22/24, at 5:55 p.m. NHA confirmed that the facility failed to provide food in a form to meet individuals' needs in one of four residents ordered nectar thickened liquids, and one in 20 residents ordered easy to chew diet textures.

28 Pa. Code: 211.6(d) Dietary services.



 Plan of Correction - To be completed: 07/09/2024

Residents will be served food that meets individual needs to include consistencies and in line with physician orders and speech therapy recommendations. The dietary staff will be re-educated on diet orders and meal tickets by the Dietary Director/designee to ensure residents receive their diets per physician orders. The Dietary Director/designee will audit the tray line and trays to ensure the correct diets are provided and to include resident satisfaction interviews 3 times a week x 2 weeks then monthly x 2 months. Any discrepancies will be addressed as appropriate. The audit findings will be reported to the facility QAPI meeting.
483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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(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 resident interviews, and staff interviews, it was determined that the facility failed to serve food products at palatable temperatures for three weeks.

Findings include:

Review of a resident representative concern dated 5/8/24, indicated that " They have been sending the meals up on Styrofoam plates and plastic utensils".

During an interview on 5/22/24, at 9:45 a.m., Food Service Director (FSD) Employee E1 stated that she had 22 staff members working in the kitchen, however once the facility was bought by a different company, she lost a lot of staff and is now down to eight staff members since 5/1/24. FSD Employee E1 stated that they are using a lot of Styrofoam as "There is no one to do dishes". FSD Employee E1 confirmed that food has been served cold as it has been served in Styrofoam.

During an interview on 5/22/24, at 10:45 a.m. Resident R10 confirmed that she has been receiving food in Styrofoam and added "I hate Styrofoam".

During an interview on 5/22/24, at 10:49 a.m. Resident R11 stated that food is served in Styrofoam and its cold.

During an interview on 5/22/24, at 10:52 a.m. Resident R12 stated that she does receive food in Styrofoam and "I hate it because it comes cold"

During an interview on 5/22/24, at 5:55 p.m. Nursing Home Administrator confirmed that the facility failed to serve food products at palatable temperatures.

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



 Plan of Correction - To be completed: 07/09/2024

Residents will be served food at palatable temperatures. No paper products will be utilized unless authorized by the Dietary Supervisor and/or Nursing Home Administrator.
The dietary staff will be provided re-education by the Dietary manger/designee on food temperature requirements and paper product usage. The dietary manager/designee will perform tray temperature audits, resident satisfaction interviews and no paper product usage 3 times a week x 2 weeks and then monthly x 2 months to ensure compliance. Any discrepancies will be addressed as appropriate. Results of the auditing will be submitted to the facility QAPI meeting.
483.35(a)(1)(2) REQUIREMENT Sufficient 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(a) Sufficient Staff.
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)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

§483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:

Based on resident interviews, staff interviews, clinical record review, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of ten of 17 residents reviewed (Resident R1, R2, R3, R4, R6, R7, R8, R9, R11, and R12).

Findings include:

Review of facility policy "Activities of Daily Living (ADL)" last reviewed October 2023, indicated showers and/or baths are offered and provided as indicated.

Review of facility policy "Bath: Tub" last reviewed October 2023, indicated baths are given according to a pre-determined schedule and as needed. Document bath and personal care on ADL flow sheet.

Review of facility policy "Call Lights" last reviewed October 2023, indicated staff are to respond to call lights and communication devices promptly and in person whenever possible.

Review of a greivance dated 5/19/24, Resident R1 stated that she pressed her call button at 7:15 a.m. on 5/19/24, and that at 7:45 a.m. she was still waiting for assistance.

During an interview on 5/22/24, at 10:49 a.m. Resident R11 stated, "Staff is always short and stretched" and, "I have to wait 20 - 25 minutes for them to answer my light."

During an interview on 5/22/24, at 10:52 a.m. Resident R12 stated that there has been less staff since new ownership and that, "I get medicine about an hour later now." Resident R12 also stated, "We are human beings. We are elderly, we shouldn't have to live like this. I feel bad for residents who can't do thing for themselves."

During an interview on 5/22/24, at 11:00 a.m. Resident R8, when asked if call lights took a long time to be answered, stated, "Sometimes it takes a little while to answer, no more than 30 minutes."

During an interview on 5/22/24, at 11:20 a.m. Resident R9, when asked if call lights took a long time to be answered, stated, "Usually 15 to 20 minutes. This place ain't no good. There used to be enough staff until it got sold and people left, now there aren't enough staff."

During an interview on 5/22/24, at 11:22 a.m. Resident R6 stated, "I have to wait a long time for my call light to be answered, about 15 minutes."

During an interview on 5/22/24, at 11:27 a.m., Resident R7, when asked if call lights took a long time to be answered, stated, "I have to wait 30 minutes."

During an interview on 5/22/24, at 11:28 a.m. Nurse Aide Employee E6 stated "We have less help now. I can't get to showers. It takes me at least 20 minutes or more to answer call bells. I'm not doing my best work. I like to pamper my residents and I can't do extra things for them now like put lotion on them."

During an interview on 5/22/24, at 12:40 p.m. Registered Nurse Employee E4 stated, "It's been hard to get things done."

During an interview on 5/22/24, at 1:10 p.m. Resident R1 stated, "I've had two showers since I got here in April. When I first got here, my wound dressing was ordered to be changed twice a day, I was lucky if it was being changed once a day. For the first three weekends I was here, I was told I couldn't get out of bed because there wasn't enough staff. An aide came in yesterday to change me at 2:30 p.m. and told me if I got back into bed now I couldn't get back out because there wasn't enough staff."

Review of a resident representative concern dated 5/15/24, stated, "Mom has been showered once in three weeks."

Review of Resident R1's Kardex indicated the resident was scheduled to receive showers every Wednesday and Saturday during the evening shift.

Review of Resident R1's "Bathing Monitor" documentation indicated Resident R1 was last showered on 4/27/24. Documentation revealed six missed bathing opportunities (5/1/24, 5/4/24, 5/8/24, 5/11/24, 5/15/24, and 5/18/24).

Review of a resident representative concern dated 5/20/24, stated "They (residents) are not bathed."

Review of Resident R2's Kardex indicated the resident was scheduled to receive showers every Monday and Thursday during the day shift.

Review of Resident R2's "Bathing Monitoring" documentation indicated Resident R2 was last bathed on 4/29/24. Documentation revealed six missed bathing opportunities (5/2/24, 5/6/24, 5/9/24, 5/13/24, 5/16/24, and 5/20/24).

Review of a resident representative concern dated 5/8/24, stated, "Resident R3 has not received a shower in over two weeks because she was told there was not enough staff to shower her. She is very upset and is worried that she smells."

Review of Resident R3's Kardex indicated the resident was scheduled to receive showers on Wednesday and Saturday during the day shift.

Review of Resident R3's "Bathing Monitoring" documentation indicated Resident R3 was last showered on 4/24/24. Documentation revealed eight missed bathing opportunities (4/27/24, 5/1/24, 5/4/24, 5/8/24, 5/11/24, 5/15/24, 5/18/24, and 5/22/24)

Review of a resident representative concern dated 4/30/24, stated, "My mother has not received a shower in over five weeks due to the absence of essential supplies."

Review of Resident R4's Kardex indicated the resident was scheduled to receive showers on Tuesday and Friday evenings.

Review of Resident R4's "Bathing Monitoring" documentation indicated Resident R4 was last bathed on 5/2/24. Documentation revealed six missed bathing opportunities (5/3/24, 5/7/24, 5/9/24, 5/14/24, 5/17/24, and 5/21/24)

During an interview on 5/22/24, at 3:46 p.m. the Director of Nursing (DON) confirmed documentation indicated that Residents R1, R2, R3, and R4 have not received showers as scheduled.During an interview on 5/22/24, at 5:55 p.m. the Nursing Home Administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of ten of 17 residents reviewed (Resident R1, R2, R3, R4, R6, R7, R8, R9, R11, and R12).


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

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

28 Pa. Code: 201.20(a) Staff development.

28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.


 Plan of Correction - To be completed: 07/09/2024

Resident R1 discharged. Residents R2, R3, R4, R6, R7, R8, R9, and R12 have received ADL care to include bathing per care plan. Active residents shower schedules have been reviewed to ensure accuracy and completion per schedule. Call bells will be prioritized and answered per policy.
Staffing will be reviewed daily to ensure adequate staffing numbers. If additional staff are needed calls will be made to agency and facility staff to replace call offs.
Nursing staff will be re-educated by the Director of Nursing/designee on shower schedule, medication pass to include times, supplies available, preferences and answering call bells per facility policy.
Audits will be completed weekly times 2 then monthly times two, 6 resident per unit, by the Director of Nursing/designee on shower schedule, medication pass to include times, supplies available, preferences and answering call bells per policy on all 3 shifts. Auditing to also include resident satisfaction interviews. Findings will be reported to the monthly QA meeting.
483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.
Observations:

Based on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that a resident was free of a significant medication error for one of four residents (Resident R4).

Findings include:

Review of facility policy "Medication Administration and Charting Guidelines" last reviewed October 2023, indicated to chart after administering medication. There are only three acceptable reasons for not administering a medication or treatment: resident is out on pass, medication is held due to medical reason, and refusal by the resident. The resident's MAR (medication administration record) is initialed by the person administering a medication; or, if utilizing an eMAR (electronic) the medication is clicked as administered.

Review of the clinical record indicated Resident R4 was admitted to the facility on 9/5/23.

Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/15/24, indicated diagnoses of high blood pressure, diabetes (too much sugar in the blood), and muscle wasting.

Review of a physician order dated 3/25/24, indicated to check capillary blood glucose level and administer Humalog (a rapid acting insulin injected under the skin to lower blood sugar levels) subcutaneously before meals and at bedtime as per sliding scale:
70 - 140 = 0 units
141 - 180 = 1 unit
181 - 220 = 2 units
221 - 260 = 3 units
261 - 300 = 4 units
301 - 340 = 5 units
>340 = 6 units and call physician

Review of Resident R4's May 2024 MAR indicated insulin was not administered for a CBG reading of 331 during the morning medication pass on 5/12/24.

During an interview on 5/22/24, at 3:52 p.m. the Assistant Director of Nursing confirmed that the facility failed to ensure that a resident was free of a significant medication error for one of four residents (Resident R4).

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

28 Pa. Code: 201.29(b)(d)(j) Resident rights.

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

28 Pa. Code 211.9 (k)(l)(1)(2) Pharmacy services.


 Plan of Correction - To be completed: 07/09/2024

Resident R4 is currently in stable condition and will continue to receive medications as ordered.
Active residents will continue to receive medications as per MD order. The Director of Nursing/designee will monitor medication administration via PCC dashboard for any missed medications at the AM clinical meeting.
Licensed nurses will be re-educated on medication administration to include glucose monitoring by the Director of Nursing/designee. Any discrepancies will be addressed as appropriate.
The DON/designee will complete audits to ensure medications are administered as per MD order. The director of Nursing/designee will review medication passes in AM clinical meeting 5 times per week times 2 weeks. Then monthly x 2 months. Findings will be submitted to the monthly QAPI committee meeting.

§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:
Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide a minimum of one nurse aide per 12 residents during the day and evening shift for nine of 21 days during the day shift (4/28/24, 5/4/24, 5/5/24, 5/8/24, 5/9/24, 5/10/24, 5/12/24, 5/13/24, and 5/18/24, and 19 of 21 evening shifts (4/28/24, 5/1/24, 5/2/24, 5/3/24, 5/4/24, 5/5/24, 5/6/24, 5/7/24, 5/8/24, 5/9/24, 5/10/24, 5/11/24, 5/12/24, 5/13/24, 5/14/24, 5/15/24, 5/16/24, 5/17/24, and 5/18/24) and one nurse aide per 20 residents during the night shift on 15 of 21 days (4/28/24, 4/30/24, 5/1/24, 5/3/24, 5/7/24, 5/8/24, /5/9/24. 5/10/24, 5/11/24, 5/12/24, 5/13/24, 5/14/24, 5/15/24, 5/16/24, and 5/17/24).

Findings include:

Review of facility census data, nursing time schedules from 4/18/24 through 5/18/24 revealed the following nurse aide staffing shortages.

Day shift:
Date Census Full time equivalents (FTE) present FTE required

4/28/24 116 6.0 9.67
5/4/24 113 7.0 9.42
5/5/24 112 7.0 9.33
5/8/24 107 8.0 8.92
5/9/24 108 5.5 9.0
5/10/24 107 7.0 8.92
5/12/24 105 4.0 8.75
5/13/24 104 6.0 8.67
5/18/24 101 7.96 8.42

Evening shift:

Date Census FTE present FTE required

4/28/24 116 6.0 9.67
5/1/24 114 7.0 9.5
5/2/24 115 6.5 9.58
5/3/24 115 4.0 9.58
5/4/24 113 7.0 9.42
5/5/24 112 5.5 9.33
5/6/24 110 5.5 9.17
5/7/24 107 4.5 8.92
5/8/24 107 6.0 8.92
5/9/24 108 8.0 9.0
5/10/24 107 5.0 8.92
5/11/24 107 5.0 8.92
5/12/24 105 4.0 8.75
5/13/24 104 6.6 8.67
5/14/24 103 6.57 8.58
5/15/24 103 7.17 8.58
5/16/24 102 5.58 8.5
5/17/24 102 4.02 8.5
5/18/24 101 5.8 8.42

Night shift:
Date Census FTE present FTE required

4/28/24 116 4.0 5.8
4/30/24 117 4.0 5.85
5/1/24 114 5.0 5.7
5/3/24 115 5.0 5.75
5/7/24 107 4.0 5.35
5/8/24 107 4.0 5.35
5/9/24 108 5.0 5.4
5/10/24 107 4.0 5.35
5/11/24 107 5.0 5.35
5/12/24 105 3.0 5.25
5/13/24 104 5.0 5.2
5/14/24 103 5.0 5.15
5/15/24 103 4.09 5.15
5/16/24 102 4.59 5.10
5/17/24 102 2.08 5.10


During an interview on 5/22/24, at 2:20 p.m. the Nursing Home Administrator confirmed the facility failed to provide a minimum of one nurse aide per 12 residents during the day and the evening, and one nurse aide per 20 residents during the night shift, with no additional excess higher-level staff to compensate this deficiency.


 Plan of Correction - To be completed: 07/09/2024

The Director of Nursing and scheduling coordinator were provided re-education regarding the minimum certified nurse aide's (CNA) hour requirement by the Nursing Home Administrator.
The facility has previously increased hourly wages, offer sign on bonuses and extra shift pick up bonuses to qualified staff, flexible schedules and have placed advertisements on media settings for recruitment.
The facility has an ongoing weekly staffing meeting which consists of the Director of Nursing or designee and the Staffing Coordinator, in which a review and "look ahead" for the week occurs.
The Director of Nursing or designee will monitor the nursing hours/nurse aide ratios daily and report any noted under hour days to the Nursing Home Administrator as appropriate.
Results of the monitoring will be reported through the facility Quality Assurance Meetings.
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:
Based on review of nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift on seven of 21 days (4/28/24, 5/1/24, 5/3/24, 5/4/24, 5/5/24, 5/11/24, and 5/12/24), and one LPN per 30 residents during the evening shift on five of 21 days (5/8/24, 5/9/24, 5/10/24, 5/11/24, and 5/16/24).

Findings include:

Review of facility census data, nursing time schedules from 4/18/24 through 5/18/24 revealed the following nurse aide staffing shortages.

Day shift:
Date Census Full time equivalents (FTE) present FTE required

4/28/24 116 3.0 4.64
5/1/24 114 3.0 4.56
5/3/24 115 2.0 4.6
5/4/24 113 4.0 4.52
5/5/24 112 4.0 4.48
5/11/24 107 3.0 4.28
5/12/24 105 3.0 4.2


Evening shift:

Date Census FTE present FTE required

5/8/24 107 3.0 3.57
5/9/24 108 3.0 3.6
5/10/24 107 3.0 3.57
5/11/24 107 2.0 3.57
5/16/24 102 2.74 3.4


During an interview on 5/22/24, at 2:20 p.m.. the Nursing Home Administrator confirmed the staffing shortages and that the facility failed to provide one LPN per 25 residents during the day shift, and one LPN per 30 residents during the evening shift as required with no additional excess higher-level staff to compensate this deficiency.


 Plan of Correction - To be completed: 07/09/2024

The Director of Nursing and scheduling coordinator were provided re-education regarding the minimum Licensed Practical Nurse (LPN) hour requirement by the Nursing Home Administrator.
The facility has previously increased hourly wages, offer sign on bonuses and extra shift pick up bonuses to qualified staff, flexible schedules and have placed advertisements on media settings for recruitment.
The facility has an ongoing weekly staffing meeting which consists of the Director of Nursing or designee and the Staffing Coordinator, in which a review and "look ahead" for the week occurs.
The Director of Nursing or designee will monitor the minimum Licensed Practical Nurse (LPN) daily and report any noted under hour days to the Nursing Home Administrator as appropriate.
Results of the monitoring will be reported through the facility Quality Assurance Meetings.
§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:
Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on 15 of 21 days (4/28/24, 5/1/24, 5/3/24, 5/4/24, 5/5/24, 5/7/24, 5/8/24, 5/9/24, 5/10/24, 5/11/24, 5/12/24, 5/13/24, 5/16/24, 5/17/24, and 5/18/24).

Findings include:

Nursing time schedules for the time frame of 4/28/24 through 5/18/24, revealed that the facility failed to maintain 2.87 hours of general nursing care to each resident in a 24-hour period on the following dates:

4/28/24 - 2.26
5/1/24 - 2.57
5/3/24 - 2.29
5/4/24 - 2.32
5/5/25 - 2.31
5/7/24 - 2.45
5/8/24 - 2.31
5/9/24 - 2.64
5/10/24 - 2.31
5/11/24 - 2.24
5/12/24 - 1.82
5/13/24 - 2.48
5/16/24 - 2.79
5/17/24 - 2.65
5/18/24 - 2.61

During an interview on 5/22/24, at 2:20 p.m. the Nursing Home Administrator confirmed the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on five of 21 days.


 Plan of Correction - To be completed: 07/09/2024

The Director of Nursing and scheduling coordinator were provided re-education regarding the minimum number of general nursing hour requirement by the Nursing Home Administrator.
The facility has previously increased hourly wages, offer sign on bonuses and extra shift pick up bonuses to qualified staff, flexible schedules and have placed advertisements on media settings for recruitment.
The facility has an ongoing weekly staffing meeting which consists of the Director of Nursing or designee and the Staffing Coordinator, in which a review and "look ahead" for the week occurs.
The Director of Nursing or designee will monitor the general nursing hours daily and report any noted under hour days to the Nursing Home Administrator as appropriate.
Results of the monitoring will be reported through the facility Quality Assurance Meetings.

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