Pennsylvania Department of Health
GREENERY CENTER FOR REHAB AND NURSING
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GREENERY CENTER FOR REHAB AND NURSING
Inspection Results For:

There are 248 surveys for this facility. Please select a date to view the survey results.

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GREENERY CENTER FOR REHAB AND NURSING - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated Survey in response to a complaint completed on February 26, 2024, it was determined that Greenery Center for Rehab and Nursing 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 as they relate to the Health portion of the survey process.

Plan of Correction:

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in �483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in �483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in �483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

�483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in �483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under �483.15(c)(9).

Observations:
Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify physicians of increased capillary blood glucose (CBG) levels for three of seven residents (Resident R1, R4, and R18).

Findings include:

Review of the facility policy "Physician Communication/Change in Condition" dated 6/1/23, indicated to notify a physician for glucose levels to:
1. Follow specific physician orders if present; or
2. Greater than 300 mg/dl (milligrams per deciliter) in a diabetic patient not using sliding-scale insulin; or
3. Greater than 450 mg/dl (or machine registers hi) in a diabetic patient using sliding scale insulin.

Review of the clinical record indicated Resident R1 was admitted to the facility on 1/26/24.

Review of Resident R1's Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 1/22/24, included diagnoses of end stage renal disease (ESRD, an inability of the kidneys to filter the blood) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).

Review of a physician's orders dated 1/17/24, 1/19/24, 1/22/24, 1/23/24, and 2/9/24, all indicated to inject Humalog insulin (fast-acting medication to lower blood sugar levels) per sliding scale; if blood glucose is greater than 400 give 12 units and call the doctor.

Review of the clinical record electronic January and February 2024 Medication Administration Record (MAR) failed to reveal physician notification of the following blood sugar levels:

1/17/24, at 6:48 a.m. the CBG was 486 mg/dl.
1/18/24, at 5:14 a.m. the CBG was 401 mg/dl.
1/20/24, at 3:05 p.m. the CBG was 498 mg/dl.
1/22/24, at 6:19 a.m. the CBG was 492 mg/dl.
1/27/24, at 11:59 p.m. the CBG was 581 mg/dl.
1/28/24, at 9:55 p.m. the CBG was 472 mg/dl.
1/29/24, at 5:42 a.m. the CBG was 424 mg/dl.
1/31/24, at 8:20 p.m. the CBG was 409 mg/dl.
2/01/24, at 6:42 a.m. the CBG was 500 mg/dl.
2/02/24, at 12:18 p.m. the CBG was 409 mg/dl.
2/02/24, at 8:13 p.m. the CBG was 413 mg/dl.
2/03/24, at 2:51 p.m. the CBG was 500 mg/dl.
2/03/24, at 6:08 p.m. the CBG was 475 mg/dl.
2/06/24, at 5:50 p.m. the CBG was 478 mg/dl.
2/06/24, at 8:51 p.m. the CBG was 488 mg/dl.
2/11/24, at 4:51 p.m. the CBG was 456 mg/dl.

Review of a clinical record indicated Resident R4 was admitted to the facility on 12/4/23.

Review of the MDS dated 1/29/24, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and diabetes.

Review of physician's orders dated 12/5/23, indicated to inject Novolog insulin (fast-acting medication to lower blood sugar levels) per sliding scale with an additional 10 units; if blood glucose is greater than 400 to call the doctor.

Review of Resident R4's February 2024 MAR failed to reveal physician notification of the following blood sugar levels:

2/02/24, at 1:41 p.m. the CBG was 485 mg/dl.
2/02/24, at 8:13 p.m. the CBG was 413 mg/dl.
2/23/24, at 12:47 p.m. the CBG was 430 mg/dl.
2/03/24, at 6:08 p.m. the CBG was 475 mg/dl.
2/06/24, at 5:50 p.m. the CBG was 478 mg/dl.

Review of a clinical record indicated Resident R18 was admitted to the facility on 2/20/24.

Review of the facility diagnoses list included diagnoses of metabolic encephalopathy (alteration in consciousness caused by a chemical imbalance affecting the brain) and diabetes.

Review of Resident R18's physician's orders no orders for sliding-insulin. A physician order dated 2/21/24, indicated to assess Resident R18's CBG before meals and at bedtime.

Review of Resident R18's February 2024 MAR failed to reveal physician notification of the following blood sugar levels:

2/21/24, at 5:41 p.m. the CBG was 354 mg/dl.
2/21/24, at 8:47 p/m. the CBG was 366 mg/dl.
2/22/24, at 6:44 p.m. the CBG was 346 mg/dl.
2/23/24, at 5:18 a.m. the CBG was 424 mg/dl.
2/23/24, at 1:11 p.m. the CBG was 323 mg/dl.
2/23/24, at 6:17 p.m. the CBG was 388 mg/dl.
2/23/24, at 8:48 p.m. the CBG was 307 mg/dl.
2/24/24, at 5:23 a.m. the CBG was 433 mg/dl.
2/24/24, at 11:58 a.m. the CBG was 510 mg/dl.
2/24/24, at 4:36 p.m. the CBG was 529 mg/dl.
2/24/24, at 9:49 p.m. the CBG was 490 mg/dl.

During an interview on 2/26/24, at approximately 2:00 p.m. the Director of Nursing confirmed that the facility failed to notify physicians of increased capillary blood glucose levels for three of seven residents.

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: 04/10/2024

Resident R1, R4, R18 were assessed by the DON and the Physicians were notified of the elevated blood sugar results. No negative outcomes were found for failure to notify physician of blood sugar greater than 400 on a sliding scale and 300 for resident without a sliding scale.
Whole house audit of Diabetic residents was conducted by the DON to identify resident with blood sugar greater than 300 if resident is not using a sliding scale insulin or Greater than 450 in a resident using a sliding insulin scale. Physician Notifications were correctly completed.
Licensed Staff will be educated by the DON or Designee on the Physician Notification policy for Blood Sugar greater than 400 on a sliding scale and 300 without a sliding scale.
DON or Designee will audit Blood Sugar results greater than 400 for residents on a sliding scale and 300 for residents without a sliding scale to ensure Physician Notification occurred. Audit will be completed weekly times 4, Findings will be reported to Quality Assurance Performance Improvement Committee (QAPI) who will determine the need for continuing audits.

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff:

�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 observations and interviews, 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 13 of 15 residents (Resident R1, R2, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17).

Findings include:

During an observation on 2/23/24, at 4:25 p.m., Resident R2 stated, when asked about facility staffing and care, "There's not enough care. They are slow coming." When asked if he had ever soiled himself while waiting for care, Resident R2 stated, "Instead of coming, you crap in your diaper, and live with it."

During an interview on 2/23/24, at 4:28 p.m., when asked about facility staffing and care, Resident R5 stated, "The staff has to bust their balls."

During an interview on 2/23/24, at 4:32 p.m., when asked about facility staffing and care, Resident R6 stated, "Usually ok, but you have to wait if they are busy."

During an interview on 2/23/24, at 4:34 p.m., when asked about facility staffing and care, Resident R7 stated, "They could definitely use a few more."

During an interview with Residents R8 and R9 on 2/23/24, at 4:34 p.m., when asked about facility staffing and care, Resident R8 confirmed that call light response time can be long. Resident R9 stated, "No, there's not enough" and confirmed that she has waited over an hour for call light response. When asked if either resident had soiled themselves waiting for staff assistance, both Resident R8 and R9 confirmed that they both have.

During an observation on 2/23/24, at 4:40 p.m., Resident R10 was observed with a large amount of facial hair. When asked about facility staffing and care, she stated that she did not want to say anything bad about staff.

During an interview on 2/23/24, at 7:30 p.m., when asked if there were enough nursing staff to care for the residents Resident R10 stated (emphatically), "No, no-way." "They are short of everything, we have to wait and wait because they are so backed up, 17 patients to one aide." "The aides are beat to death." "Way too short-staffed. I've waited an hour to go to the bathroom."

During a group interview of Resident R12, Resident R13, and a family member for Resident R12 on 2/23/24, at 7:37 p.m., when asked if there were enough nursing staff to care for the residents, the family member for Resident R12 stated, "There are never enough. The evening shift sucks." "My father doesn't get his showers." "He's supposed to have assistance to go to the bathroom, but he tells me he gets up on his own because he cannot wait the aides to come and help him." "I was here on Sunday, and (Resident R13) wanted to get into bed. He waited from 6:30 p.m. until I left at 8:00 p.m. and still hadn't gotten into bed. His sister told me he didn't get into bed until after 9:00 p.m." The family member for Resident R12 stated she and the family member for R13 each watch out for the other resident because they are so worried about the care their family members receive. Resident R13 stated "I'm paralyzed on one side; I can't do anything on my own. They tell me they will be right back, and they never come."

During an interview on 2/23/24, at 8:01 p.m., when asked if there were enough nursing staff to care for the residents the family member for Resident R14 stated, "Sometimes they are short-handed, that's why I come in and try to fill-in." When asked about call light response, Resident R14 stated "it depends on how many are here, they work really hard." When asked if there was a particular time of day where they had more concerns, the family member for Resident R14 confirmed that it is worse on the evening shift.

A review of facility provided grievance forms from December 2023, through February 2024, revealed the following:

12/26/23: Resident R15 entered a concern that he wasn't bathed since admission. Review of grievance resolution on 1/3/24, indicated that care was given, referencing the bathing record attached to the investigation. This document provided bathing information for the "Previous 14 days from when the record was opened. The final date showing on the record was 1/7/24, revealing that the previous 14 days of the report would be 12/25/23, through 1/7/24. No bathing was revealed from 12/25/23, through 1/1/24, confirmed Resident R17's concern. Bathing was revealed from 1/2/24, through 1/7/24, which was after the grievance was filed.

2/1/24: Family member for Resident R1 stated "There was not enough staff and that the nurse left the building at 5:00 a.m." Review of facility documents reveal this concern was substantiated.

2/13/24: Family member for Resident R16 had concerns about Resident R16's showers. Review of grievance resolution revealed Resident R16 had missed a shower.

2/20/24: Resident R17 entered a concern that she does not have a regular aide on the day shift, and that she would like to get up between 7:30 a.m. and 8:00 a.m., but is not able to as staff come in late. Review of grievance resolution provided a plan to attempt to have regular staff, but did not address Resident R17's concern with not being assisted to get up at her desired time.

During an interview on 2/26/24, at approximately 2:00 p.m. the Director of Nursing confirmed the facility failed to have sufficient nursing staff to provide nursing and related services to 13 of 15 residents.

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)(5) Nursing services.

Plan of Correction - To be completed: 04/10/2024

Resident R1.R2,R5,R6,R7,R8,R9,R10,R11,R12,R13,R14,R15,R16,and R17 have had their concerns of call bell response time and showers addressed by the DON or Designee to attain or maintain the highest practicable physical mental and psycho social well being .
A shower audit was completed for the previous 2-week period on residents by the DON or Designee. Areas of concern were addressed by the DON or Designee. A daily staffing meeting with the nursing management staff will be completed to address the need for sufficient nursing staff to provide timely care for the residents.

Nursing Staff will be educated by the DON or Designee on the need for timely response to the resident call bells and the need to complete the shower schedule. Nursing Supervisors will be educated by the DON or Designee on the calculation of a staffing PPD or Ratios and policy for reporting to Administration or Designee staffing levels below the required levels to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well being of the residents.
Call bell audits will encompass all shifts to include 10 residents per each unit for 3 weeks then biweekly for 3 months. Shower audits will be completed daily for those residents scheduled for a shower that day for 3 weeks then biweekly for 3 months, All findings will be reported to Quality Assurance Performance Improvement Committee (QAPI) who will determine the need for continuing audits.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

�483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in �483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

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

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

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

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

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

Plan of Correction - To be completed: 04/10/2024

Residents R1, R2 and R3 were assessed by the DON and NP to have no negative outcome from missing a medication due to the medication being unavailable.
A medication cart to medication availability audit was completed for in-house residents. Any concerns were addressed, and Medications are available according to the physician order.
Education will be provided by the DON or Designee to the licensed staff on Pharmacy ordering for New Admission resident and for newly ordered medications.
Inventory of emergency medication system will be reviewed by the DON and Medical Director, and frequently used medications will be added to the inventory. The facility will enroll in the pharmacy "Never Miss a dose Program "which will provide communication between the facility and Pharmacy on requested medication.
Medication cart to medication availability audit will be completed by monthly for 3 months by the pharmacy consultant or designee and the results will be reported to the Quality Assurance Performance Improvement Committee (QAPI) who will determine need for continuing audits.

� 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: 04/10/2024

Nursing Supervisors and Nursing Staff Scheduler will be educated by the DON or Designee on the calculation of the staffing Ratios of the required nurse aide to resident as effective July 1, 2023, and education on the policy for reporting to Administration/Designee staffing levels below the required to provide nursing care.
Facility has evaluated and increased pay rates for nursing staff. The facility does use Agency staff to supplement our staff. Facility has increased educational opportunities for nursing staff to attend. A retention committee has been created of nursing staff for input on staff retention.
Staffing Ratios Audits will be conducted by the Administrator/Designee daily to ensure that the minimum number of nurse aide to resident is maintained these audit will be ongoing.

� 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: 04/10/2024

Nursing Supervisors and Nursing Scheduler will be educated by the DON or Designee on the calculation of the staffing Ratios of the required LPN to residents as effective July 1, 2023, and education on the policy for reporting to Administration or Designee staffing levels which are below the required amount to provide nursing care.
Facility has evaluated and increased pay rates for nursing staff. The facility does use Agency staff to supplement our staff. Facility has increased educational opportunities for nursing staff to attend. A retention committee has been created of nursing staff for input on staff retention.

Staffing Ration Audits will be conducted by the Administrator or Designee daily to ensure that the minimum number of licensed staff (LPN) to resident is maintained.Audits will be ongoing.

� 211.12(i)(1) LICENSURE Nursing services.:

(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 nine of 21 days (1/29/24, 1/31/24, 2/2/24, 2/7/24, 2/9/24, 2/12/24, 2/13/24, 2/15/24, and 2/17/24).

Findings include:

Review of the nursing schedules and census information for 1/29/24, through 2/18/24, 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:

-1/29/24, Census 100. PPD 2.56.
-1/31/24, Census 103. PPD 2.80.
-2/02/24, Census 103. PPD 2.85.
-2/07/24, Census 105. PPD 2.76.
-2/09/24, Census 106. PPD 2.76.
-2/12/24, Census 106. PPD 2.78.
-2/13/24, Census 101. PPD 2.84.
-2/15/24, Census 104. PPD 2.66.
-2/17/24, Census 101. PPD 2.36.

During an interview on 2/26/24, at approximately 2:00 p.m., the Director of Nursing confirmed the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on nine of 21 days.

Plan of Correction - To be completed: 04/10/2024

Nursing Supervisors and Nursing Scheduler will be educated by the DON or Designee on the calculation of a staffing PPD of 2.87 as effective July 1, 2023, and educated on the policy for reporting to Administration or Designee if the staffing levels fall below the required amount to provide nursing care.

Facility has evaluated and increased pay rates for nursing staff. The facility does use Agency staff to supplement our staff. Facility has increased educational opportunities for nursing staff to attend. A retention committee has been created of nursing staff for input on staff retention.

PPD Audits will be conducted daily by the Administrator or Designee to ensure that the PPD of 2.87 as effective July 1, 2023, is maintained. Audits will be ongoing.

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