Pennsylvania Department of Health
GROVE AT WASHINGTON, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GROVE AT WASHINGTON, THE
Inspection Results For:

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GROVE AT WASHINGTON, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated survey in response to three complaints completed on June 4, 2024, it was determined that The Grove of Washington was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:

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.

§483.10(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 review of facility policy, observations, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information in one area (storage shed).

Findings include:

Review of the facility policy "Confidentiality" dated 1/31/24, indicated that residents have the right to personal privacy and confidentiality of his or her personal and clinical records.

Review of the facility policy "Medical Records Storage" dated 1/31/24, indicated that all medical records will be stored in a secure, fire-protected, waterproof area.

During an observation of a unsecured storage shed behind the facility on 6/4/24, at 8:15 a.m., approximately 75 boxes of loose paper, with resident information observed throughout the shed.

During an interview on 6/4/24, at 8:17 a.m., Maintenance Director Employee E1 confirmed that the paperwork was stored in the storage shed due to lack of space, and the shed is left unsecured "all the time."

During an interview on 6/4/24, at 9:20 a.m., the Nursing Home Administrator confirmed that the facility failed to maintain the confidentiality of residents' medical information and failed to make certain the information was secured in one area(storage shed).

28 Pa. Code 201.29(j) Resident rights.

28 Pa. Code 211.5(b) Clinical records.

Plan of Correction - To be completed: 07/03/2024

The facility will maintain confidentiality of resident medical records. As soon as the deficient practice was identified, all resident medical information was removed from the maintenance shed and stored in the facility in a secure area. The regional clinical consultant will reeducate NHA, DON, and medical records director on Federal regulation F0583 the privacy/confidentiality of medical records detailing keeping resident medical information in one secure area. The Nursing home Administrator will complete a weekly audit x 4 weeks and then monthly x 3 months to validate that the facility is maintaining the confidentiality of resident medical information in one secure area. These audits will be forwarded to the monthly Quality Assurance Performance Improvement Committee for review and frequency of audits.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

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.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:
Based on observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, homelike environment on one of two nursing units(North Wing), and in the main dining room.

Findings include:

During observations on 6/4/24, from 8:45 a.m., through 9:45 a.m., the following was identified:

Residents R1 and R2 had hole in he floor near baseboard by the bathroom.
Residents R3 and R4 had areas of chipped paint under the window surrounding the heater.
Residents R5 and R6 had a cracked ceiling above bed 2, Resident R6 stated "the ceiling may leak through the hole, but I haven't seen any water".
Resident room 131 currently empty had a broken wall plug plate in the bathroom.
Residents R7 had unfinished drywall with spackling behind beds.
The main dining room floor has multiple spots of brown substance and appears soiled with food debris.

During an interview on 6/4/24, at 10:00 a.m., the Nursing Home Administrator and the Maintenance Director Employee E1 confirmed that the facility failed to maintain a clean, homelike environment on one of two nursing units (North Wing Nursing Unit) and in the main dining room.

28 Pa. Code: 201.29(j)(k) Resident rights.

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

Plan of Correction - To be completed: 07/03/2024

The facility will provide a clean, sanitary and homelike environment for residents. The concerns identified during survey for the North Wing and dining room will be addressed and corrected. The Facility will complete a house audit of resident rooms, shower rooms, dining rooms and resident bathrooms to identify any concerns and will generate a work list to be completed by the maintenance and housekeeping departments.

The Nursing Home administrator or Designee will re-educate the maintenance and housekeeping departments on federal tag 0584, which includes providing the residents with a safe, clean and comfortable homelike environment. The Nursing Home Administrator or Designee will complete an audit 3 times a week for four weeks then weekly for four weeks then monthly for three months to ensure resident rooms, shower rooms, dining rooms and resident bathrooms are safe, clean and comfortable. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

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 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

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

Observations:
Based on review of facility policy, facility documentation, and staff interviews, it was determined that the facility failed to protect residents from neglect for one of two residents (Resident R8), by failing to follow physicians orders during incontinence pad change and linen change. This was identified as past non-compliance.

Findings include:

Review of the United States Code of Federal Regulations (CFR), 42 CFR Freedom from Abuse, Neglect, and Exploitation defined neglect as "the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress."

Review of the facility policy "Abuse Protection" dated 1/31/24, with a previous review date of 1/26/23, indicated that all resident have a right to be free from abuse, neglect, etc. and the facility is committed to protecting the residents from abuse by anyone providing services to the residents.

Review of the clinical record indicated that Resident R8 was admitted to the facility on 3/11/24, with diagnoses which included diabetes, history of pulmonary blood clots, bacteremia and wound of her right leg. A Minimum Data Set(MDS- periodic review of resident care needs) dated 3/18/24, indicated the diagnoses remained current and Section G0110 (ADL's) indicated Resident R8 requires assistance of two staff for bed mobility. Resident R8 had an enabler bar on the left side of her bed.

Review of a facility provided information in a report dated 5/16/24, indicated that Resident R8 had been receiving incontinence care and linen change when Nurse Aide (NA) Employee E2 rolled Resident R8 onto her right side where there was no enabler bar and onto the floor.

Review of the incident report dated 5/16/24, indicated Resident R8's being rolled out of bed with enabler bar on left but not right side and one staff assisting her.

Review of a statement dated 5/16/24, indicated NA Employee E2 had rolled Resident R8 to her right side toward the Nurse Aide and enabler bar then she rolled Resident R8 towards the left, Resident R8 rolled off edge of bed onto the floor. The Nurse Aide ran and got assistance from other staff.

During an interview on 6/4/24, at 10:25 a.m., Resident R8 stated that she had told NA Employee E2 she did not feel comfortable rolling without a second person since there was not an enabler bar on the right side, but NA Employee E2 stated "I got you".

During an interview and observation on 6/4/24, at 1:30 p.m. NA Employee E3 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E3 stated she looks on the kiosk and demonstrated on the kiosk how the information is found.

During an interview on 6/4/24, at 1:32 p.m., Licensed Practical Nurse (LPN-Agency) Employee E4 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. LPN Employee E4 stated that she looks at the clinical record as she does not document in the kiosk tasks.

During an interview on 6/4/24, at 1:44 p.m. NA Employees E5, E6, E7 and E8 stated that they have access to the kiosk and that the information is found in there and they also share the information between shifts.

During an interview on 6/4/24, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to protect a resident from neglect.

On 5/16/24, the facility initiated education for all direct care nursing staff including Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Nurse Aides (NAs) to ensure that ordered transfer guidelines were understood and followed appropriately.

This plan included the following:

-Immediate re-education of NA Employee E2.
-Facility completed a full house audit to ensure correct transfer statuses were documented for each resident.
-Education was provided on 5/16/24 and 5/20/24, to all facility staff on abuse and neglect.
-Audits and education were reviewed with the Quality Assurance and Performance Improvement Committee for trends and outcomes.

The facility has demonstrated compliance with the regulation since 5/31/24.

During an interview on 6/4/24, at 2:45 p. m., with the Nursing Home Administrator and Director of Nursing, and review of the facility's immediate actions, education, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring the prevention of resident neglect.

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

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

28 Pa. Code 201.20(b)(1) Staff Development.

28 Pa. Code 201.29(a) Resident rights.

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.11(d) Resident care plan.

28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Plan of Correction - To be completed: 06/25/2024

Past noncompliance: no plan of correction required.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:
Based on review of facility policy, clinical records, facility documentation, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision and implement effective bed mobility interventions as per physician order to promote resident safety, for one of two residents (Resident R8). This deficiency is cited as past non-compliance.

Findings include:

Review of facility policy entitled "Accidents and Incidents- Investigating and Recording", dated 1/31/24, indicated that all incidents and accidents occuring on the premises must be investigated and reported to the administrator. Regardless of the incident/accident, staff are to render immediate assistance, conduct an initial assessment and provide emergency interventions and if necessary, call 911. An employee witnessing an accident or incident involving a resident must report such occurrence to his or her supervisor immediately. Do not leave the victim unattended unless necessary to summon assistance. A witness statement is to be obtained and the Supervisor must be informed so that medical attention can be provided.

Review of the clinical record indicated that Resident R8 was admitted to the facility on 3/11/24, with diagnoses which included diabetes, history of pulmonary blood clots, bacteremia and wound of her right leg. A Minimum Data Set(MDS- periodic review of resident care needs) dated 3/18/24, indicated the diagnoses remained current and Section G0110 (ADL's) indicated Resident R8 requires assistance of two staff for bed mobility. Resident R8 had an enabler bar on the left side of her bed.

Review of a facility provided information in a report dated 5/16/24, indicated that Resident R8 had been receiving incontinence care and linen change when Nurse Aide (NA) Employee E2 rolled Resident R8 onto her right side where there was no enabler bar and onto the floor.

Review of the incident report dated 5/16/24, indicated Resident R8's being rolled out of bed with enabler bar on left but not right side and one staff assisting her.

Review of a statement dated 5/16/24, indicated NA Employee E2 had rolled Resident R8 to her right side toward Nurse Aide Employee E2 and enabler bar then she rolled Resident R8 towards the left, Resident R8 rolled off edge of bed onto the floor.

During an interview on 6/4/24, at 10:25 a.m., Resident R8 stated that she had told NA Employee E2 she did not feel comfortable rolling without a second person since there was not an enabler bar on the right side, but NA Employee E2 stated "I got you."

During an interview and observation on 6/4/24, at 1:30 p.m. NA Employee E3 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E3 stated she looks on the kiosk and demonstrated on the kiosk how the information is found.

During an interview on 6/4/24, at 1:32 p.m., Licensed Practical Nurse (LPN-Agency) Employee E4 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. LPN Employee E4 stated that she looks at the clinical record as she does not document in the kiosk tasks.

During an interview on 6/4/24, at 1:44 p.m. NA Employee E5, E6, E7 and E8 stated that they have access to the kiosk and that the information is found in there and they also share the information between shifts.

During an interview on 6/4/24, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide adequate supervision for one of two residents (Resident R8).

On 5/16/24, the facility initiated education for all direct care nursing staff including Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Nurse Aides (NAs) to ensure that ordered transfer guidelines were understood and followed appropriately.

This plan included the following:

-Immediate re-education of NA Employee E2.
-Facility completed a full house audit to ensure correct transfer statuses were documented for each resident.
-Education was provided on 5/16/24 and 5/20/24, to all facility staff on abuse and neglect.
-education was provided to all nursing staff and will be provided to all new and agency staff on following physician orders for care, detailing providing assistance of two staff if ordered, and when providing care to residents in bed to ensure resident safety.
-Audits and education were reviewed and are still being completed with the Quality Assurance and Performance Improvement Committee for trends and outcomes.

The facility has demonstrated compliance with the regulation since 5/31/24.

During an interview on 6/4/24, at 2:45 p. m., with the Nursing Home Administrator and Director of Nursing, and review of the facility's immediate actions, education, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are free from accidents/incidents regarding bed mobility /transfer status of residents and had achieved substantial compliance as of 5/31/24.

28 Pa. Code 201.14(a) Responsibility of licensee

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

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

Plan of Correction - To be completed: 06/25/2024

Past noncompliance: no plan of correction required.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(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.

Plan of Correction - To be completed: 07/03/2024

1. The facility cannot correct that nurse aide staffing ratios were not met during the day shift for 16 of 21 days (5/14/24, 5/16/24, 5/17/24, 5/18/24, 5/19/24, 5/20/24, 5/21/24, 5/22/24, 5/23/24, 5/24/24, 5/25/24, 5/26/24, 5/28/24, 5/29/24, 5/30/24 and 5/31/24).

2. The facility will ensure that nurse aide staffing ratios are met every shift.

3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5510 and ensuring nurse aide staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at daily staffing meeting. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist.

4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure nurse aide staffing ratios are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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.

Plan of Correction - To be completed: 07/03/2024

1. The facility cannot correct that LPN staffing ratios were not met during the daylight and night shifts on four of 21 days (5/12/24, 5/22/24, 5/25/24 and 5/26/24

2. The facility will ensure that LPN staffing ratios are met every shift.

3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5530 and ensuring LPN staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at daily staffing meeting. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist.

4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure LPN staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.

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