Nursing Investigation Results -

Pennsylvania Department of Health
LAFAYETTE MANOR, INC.
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LAFAYETTE MANOR, INC.
Inspection Results For:

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LAFAYETTE MANOR, INC. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, Civil Rights Compliance, State Licensure Survey and an Abbreviated survey in response to two complaints, completed on August 29, 2019, it was determined that LaFayette Manor, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.









 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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(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 a review of facility policies, observations and staff interviews it was determined that the facility failed to properly perform handwashing, properly store service ware, and verify the sanitizing temperature of the dish machine. in the Main Kitchen (Main Kitchen).

Findings Include:

A review of facility policy "Handwashing" dated 6/25/19, indicated that hand washing is to be performed after touching soiled equipment or utensils.

A review of facility policy " Automatic Ware Washing" dated 6/25/19, indicated that prior to meals the dish machine is checked to make certain proper functioning and appropriate temperatures for cleaning and sanitation.

During an observation of the tray line operations on 8/27/19, at 11:26 a.m. Dietary Aide Employee E3 was observed with gloved hands retrieved two slices of bread from a bread package touching the outside of the package, placed the bread on a piece of parchment paper, retrieved a container of butter, opened the container and then proceeded to spread butter onto the two slices of bread. Dietary Aide Employee E3 then opened the refrigerator and obtained a package of American cheese, obtained cheese from the package and proceeded to assemble the sandwich, then placing it into a skillet to grill without performing handwashing or changing her gloves which created the potential for cross contamination.

During an observation of the tray line operations on 8/27/19, at 11:30 a.m. Cook Employee E4 with gloved hands obtained plates from the plate warmer and proceeded to touch the handles of serving utensils and counter tops. Using the same gloved hand he retrieved a dome plate cover by placing his hand inside the dome touching the portion of the dome that had the potential to touch the resident's food without performing hand washing and changing his gloves.

During an observation of the tray line operations on 8/27/19. at 11:40 a.m. it was revealed that the facility improperly stores thermal soup/cereal bowls in a garbage can that is lined with a garbage can liner. The bowls are randomly placed in the garbage can. The facility failed to store the bowls in an inverted manner to prevent pooling water and the potential for cross contamination.

During an interview on 8/27/19, at 12:20 p.m. the Food Service Director Employee E1 and the Area Support Manager Employee E5 confirmed that the facility failed to preform proper handwashing and properly store equipment which created the potential for cross contamination.

During an observation on 8/29/19, at 10:26 a.m. it was revealed that the facility does not verify the final rinse temperature of the dish machine by running a temperature test strip through the dishmachine to verify the operating condition of the dish machine.

During an interview of 8/29/19, at 10:30 a.m. Food Service Director Employee E1 confirmed that the facility failed to make certain the final rinse temperature of the dish machine was operating properly to sanitize the equipment.

28 Pa. Code: 211.6 (c)(d)(f) Dietary Services.




 Plan of Correction - To be completed: 10/01/2019

0812
Residents who may potentially be affected by the deficient practice will be identified by the Social Service department, DON, and ADON who will review facility resident's clinical records to determine if anyone had signs or symptoms of illness that potentially could be related to the deficient practice. Anyone found will be provided appropriate treatment.
All dietary staff members were in-serviced about proper handwashing and gloving/re-gloving procedures necessary to prevent cross contamination by the dietary manager. Audits will be performed by the dietary manager/dietician to monitor the dietary staff to ensure proper handwashing and gloving/re-gloving to prevent cross-contamination weekly x 4, then monthly x 3. The outcome of the audits with be reported in the monthly QA meetings x3 and the quarterly QAPI meeting x2.
The Dietary Manager changed storage of lids into a drying rack and pods are placed into a cart to prevent pooling of water and cross contamination.
Soup bowls are now placed into racks and a cart that are placed at the end of the line to prevent pooling of water and wet nesting.
The correct final rinse temperature of the dish machine is verified by utilizing a test strip that is inserted in through the tines of a fork 3X a day at each meal time to properly sanitize the equipment. Dietary staff was in-serviced regarding this procedure by the dietary manager.
The Dietary Manager will monitor the documentation of the temperatures on the log ensuring the correct final rinse temperatures weekly x 4, then monthly x 6. The outcomes of the dietary system changes will be reported monthly in the QA meeting and Quarterly in the QAPI meeting X6 months.

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 policies, observation of dining and meal tickets, residents and staff interview, it was determined that the facility failed to provide food preferences for two of eight residents (Residents R18 and R72).

Findings include:

The facility policy, " Food Preferences" last reviewed May 2019, indicated that individual resident food preferences will be obtained in order to ensure resident meal satisfaction. These preferences are obtained upon admission, resident request and any changes in resident health status.

During an observation on 8/27/19, at 12:02 p.m. Resident R18 and Resident R72 told staff that their meals were not what they had ordered.

During observations of their meal ticket on 8/27/19, at 12:02 p.m. both tickets indicated a turkey cutlet and beef kabob. Each tray had a turkey cutlet, but no beef kabob. Resident R18 had indicated at the bottom of the ticket wanting grilled cheese and tomato soup, this was not provided to Resident R18. Resident R72 stated that no one had asked her what her preference was that she wanted a hot dog from the alternate menu.

During an interview on 8/27/19, at 12:18 p.m. Licensed Practical Nurse(LPN) Employee E7 stated that the facility failed to provide food preferences for Residents R18 and R72.

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


 Plan of Correction - To be completed: 10/01/2019

0806
The two residents found to be affected by the deficient practice were served their food preferences immediately.
Residents who may potentially be affected by the deficient practice will be identified by the social service department, DON, and ADON who will interview facility residents to determine if their food preferences were provided.
The Dietary Manager and the Dietitian will visit the residents of the facility and review likes/dislikes, check the tray tickets, making necessary changes, and then notifying staff regarding the changes. The dietary staff will be educated by the dietary manager and the dietician on the importance of honoring residents' food preferences and ensuring that tray tickets match what is being served.
The Dietitian will meet with residents upon admission within the first 48 hours and note on the Food Preference Log the resident's likes/dislikes/preferences. The Dietary Manager will visit within the first week to ensure dietary Likes/Dislikes/Preferences are being followed. Any changes will be made to tray tickets on the same day, dietary staff informed of the changes, and noted on the Meal Round Log. Audits via resident interview and/or matching meal tray tickets of no less than six residents will be performed weekly by the dietary manager/dietician to ensure compliance with food preferences x 4, then monthly ongoing. If required, corrective action will be initiated. Corrective action will be monitored with the monthly Food Committee Meeting.
The Administrator or designee will monitor Meal Round Logs weekly for 1 month, monthly for 3 months, then quarterly thereafter. Results of the monitoring will be reviewed in the monthly QA meetings and in the Quarterly QAPI meetings.


483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12(b) The facility must develop and implement written policies and procedures that:

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

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

483.12(b)(3) Include training as required at paragraph 483.95,
Observations:
Based on review of facility personnel files, policy review and staff interview it was determined that the facility failed to implement policies and procedures related to the screening and training prior to employment for two of six employee files (Dietary Manager Employee E1 and Registered Dietitian Employee E2).

Findings include:

The facility policy " Abuse Prevention Policy and Procedure" last reviewed May 2019, and Dietary policies dated June 25, 2019, indicated "Employment Practices" as Screening of all potential employees and Training of all employees upon hire and annually.

Review of the personnel file for Dietary Manager Employee E1 and Registered Dietitian Employee E2, indicated no documentation of implementation of abuse screening and /or training prior to employment.

During an interview with the Nursing Home Administrator on 8/27/19, at 1:45 p.m. confirmed that the Dietary Manager Employee E1 and Dietician Employee E2 had not had training from their agency nor the facility upon hire.

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

28 Pa. Code: 201.18(b) Management.

28 Pa. Code: 201.19(3) Personnel policies and procedures.


 Plan of Correction - To be completed: 10/01/2019

0607
No residents were found to be affected by the deficient practice.
Residents who may potentially be affected by the deficient practice will be identified by the Social Service Department, the DON, and the ADON who will interview facility residents to determine if anyone was affected by the deficient practice. If residents are found to have been affected by the deficient practice, an investigation will ensue and the required notification(s) issued.
Dietary Manager Employee E1 and Dietitian Employee E2 received training on abuse prevention, awareness, and reporting on 8/28/2019 from Lafayette Manor, Inc. All employees, regardless if employed by the facility or through a contracted service, will receive training regarding abuse and prevention. Copies of records of training received from outside contracted Corporations will be maintained on site to ensure prior abuse education has been received by the contracted employee(s).
The human resource manager will audit all currently contracted employee records to ensure compliance and will process all future contracted employee files to ensure that each employee receives the required training from Lafayette Manor, Inc. and that the education is recorded in the personnel record. Findings will be presented during the monthly QA meeting and to the quarterly QAPI meeting X3 months.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:

Based on review of facility policy, observation and staff interview, it was determined that the facility failed to properly maintain one of two dumpsters. ( Dietary dumpsters)

Findings include:

A review of the facility policy " Trash Disposal" dated 6/25/19, indicated that all garbage and refuse will be disposed of in a proper manner.

During an observation on 8/26/19, at 9:45 a.m. of the dietary dumpster revealed that the dumpster lacked a plug in the drain hole which created the potential for rodent and vermin infestation.

During an interview on 8/26/19, at 9:50 a.m. Food Service Director Employee E1 confirmed the facility to make certain that the dietary dumpster contained plug in the drain hole which created the potential for rodent and vermin infestation.

During an interview on 8/29/19, at 10:00 a.m. Maintenance Director Employee E6 that the unplugged hole created the potential for rodent and vermin infestation.

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




 Plan of Correction - To be completed: 10/01/2019

0814
The hole was immediately plugged with the appropriate device.
Residents who may potentially be affected by the deficient practice will be identified by the Social Service department, DON, and ADON who will review facility resident's clinical records to determine if anyone had signs or symptoms of illness that potentially could be related to the deficient practice. Anyone found will be provided appropriate treatment.
The Dietary Manager or designee will monitor the dietary dumpsters daily x 1 month, then weekly x 4 to ensure the drain hole in each dumpster is plugged with the appropriate device. A log will be created to document the plug is present. The outcomes will be reported to the monthly QA meeting and the quarterly QAPI meeting X3 months.


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