Pennsylvania Department of Health
WILLOWS OF PRESBYTERIAN SENIORCARE
Patient Care Inspection Results

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WILLOWS OF PRESBYTERIAN SENIORCARE
Inspection Results For:

There are  153 surveys for this facility. Please select a date to view the survey results.

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WILLOWS OF PRESBYTERIAN SENIORCARE - 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 March 20, 2024, it was determined that Willows of Presbyterian Senior Care 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 REQUIREMENT Provided Diet Meets Needs of Each Resident: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 Food and nutrition services.
The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.
Observations:

Based on a review of facility policy, observations, and staff interviews it was determined the facility failed to meet the daily nutritional and special dietary needs for one of six residents (Resident R1), and failed to have a structured meal delivery system to ensure residents received their meals accurately, and timely.

Findings include:

Review of the facility policy "Dietary-Frequency of Meals and Snacks" dated 12/6/23, indicated it is the responsibility of the Dining Services Department to see that each meal is served at the designated time unless there is an emergency.

Review of the facility policy "Skilled Nursing-Dietary Supplements" dated 4/12/23, indicated it is the policy of this community that nutritional and dietary supplements will be used to complement a resident's dietary needs in order to maintain adequate nutritional status and resident's highest practicable level of well-being.

Review of Resident R1's record indicated the resident was admitted to the facility on 4/20/15. Review of the admission record indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), chronic obstructive pulmonary disease (constricted airways cause difficulty or discomfort in breathing), and congestive heart failure (the heart doesn't pump blood effectively).

Review of Resident R1's current physician orders dated 3/20/24, indicated a regular diet, with mechanical soft, ground meat texture, and Boost Plus two times a day.

Review of Resident R1's care plan initiated 2/14/24, indicated the resident will maintain an adequate nutritional status as evidenced by maintaining weight. Interventions included provide and serve supplements as ordered Med Pass and Boost Plus two times a day (liquid supplements) at lunch and dinner. Report refusals to dietitian. Provide, serve diet as ordered and record every meal.

Review of facility grievance log dated 3/19/24, indicated Resident R1 did not receive a lunch tray on 3/18/24.

Interview on 3/20/24, at 11:30 a.m. Nurse Aide (NA) Employee E1 indicated staff take the meal tickets around in the morning and ask the residents who can answer what they'd like to eat in the morning.

Observation of meal service in the Dining Room on 3/20/24, at 11:30 a.m. revealed several staff serving meals. An unidentified female resident was seated in the dining room, and NA Employee E1 indicated she's from the other side but she usually eats over here with us. When Survey Agency (SA) asked NA Employee E1 if the female resident's meal ticket was in the stack she was serving from, she stated "I'm not sure, I think it's on the other side (middle dining area)".

Interview on 3/20/24, at 11:31 a.m. NA Employee E2 at the middle dining area indicated the female resident's tray ticket was on the first side.

Interview on 3/20/24, at 11:32 a.m. NA Employee E1 at the first dining area indicated she had located the female resident's tray ticket.

Observation on 3/20/24, at 11:35 a.m. Resident R1 was observed lying in bed, visiting with family who brought lunch from home for resident.

Interview with Resident R1's family on 3/20/24, at 11:35 a.m. indicated the other day, Resident R1 didn't receive a lunch tray and it's happened a few times before. Family also indicated he's supposed to be getting Boost Plus twice a day and he hasn't had it in a while.

Observation of lunch tray in room on 3/20/24, at 11:35 a.m. revealed ground Caribbean shrimp, liquefied cauliflower/cheddar soup, potato wedges, ground Italian vegetable blend, Boston crpie. Two iced teas. The tray ticket also indicated "Extra Items" of Boost Chocolate and strawberry ice cream. The tray had no Boost Chocolate and the strawberry ice cream was fat free.

During the observation in Resident R1's room on 3/20/24, at 11:37 a.m. NA Employee E3 brought another lunch tray in that had a chicken pot pie, mashed potatoes, gravy, two iced teas, and regular strawberry ice cream. There was not a Boost Plus on the tray.

When questioned, on 3/20/24, at 11:38 a.m. NA Employee E3 indicated she didn't realize someone had already brought him a tray. They must have brought it from the other side. She confirmed the first tray had fat free strawberry ice cream and that neither tray had Boost Plus on it.

Interview on 3/20/24, at 11:42 a.m. NA Employee E4 indicated the other side must have given Resident R1 a tray too and they did not realize there was not a Boost Plus on the tray.

Interview on 3/20/24, at 11:43 a.m. NA Employee E2 indicated "We haven't had Chocolate Boost Plus in a long time. I just give Resident R1 chocolate milk because he doesn't like vanilla and that's all they can get".

Interview on 3/20/24, at 1:01 p.m. Registered Dietitian (RD) Employee E5 indicated "We've had supply issues with the Chocolate Boost Plus on and off since the pandemic. Currently we can get Ensure but only in vanilla. RD Employee E5 confirmed the Boost Plus had 360 calories and 14 grams of protein, while the facility's chocolate milk provided only 211 calories and only eight grams of protein per serving, and that it was not an equivalent substitution.

Interview on 3/20/24, at 2:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to meet the daily nutritional and special dietary needs for one of six residents (Resident R1), and failed to have a structured meal delivery system to ensure residents received their meals accurately, and timely on a consistent basis.

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

28 Pa. Code: 201.12(d)(1)(3)(5) Nursing services

28 Pa. Code: 201.1(i)Resident rights.

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


 Plan of Correction - To be completed: 04/22/2024

R1's weights have been stable ( Feb 147 pounds , March 146.4 pounds). Resident had eaten breakfast that day and wife was observed to have brought lunch in the day of the incident as she does most days. Education was done by the DON and nursing management with nursing and dining staff on the new process and nutritional supplements. A new process was implemented where a census checklist will be used in each kitchen to indicate when residents get their meal delivered. The team will compare all checklists to ensure everyone received a meal before the food is removed from the steam table. Nurse manager or designee will do observations of meals delivered/trays picked up 5 times per week for 4 weeks on Woodside Gardens neighborhood.
The team was educated that there are to be no unapproved substitutions regarding nutritional supplements. Dietitian or designee will conduct random audits of all 4 neighborhoods to visualize that the correct nutritional supplements are delivered 5 times per week for 4 weeks.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that clinical records were complete and accurate for one of six residents reviewed (Resident R1).

Findings include:

Review of the facility policy "Medical Records-The Medical Record" date 12/12/23, indicated that the medical record will contain complete and accurate documentation, which clearly identifies the resident, justifies the diagnoses, condition, treatment, care approaches, and responses to the care provided.

Review of Resident R1's admission record indicated the resident was admitted to the facility on 4/20/15, with the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), chronic obstructive pulmonary disease (constricted airways cause difficulty or discomfort in breathing), and congestive heart failure (the heart doesn't pump blood effectively).

Review of Resident R1's current physician orders dated 3/20/24, indicated Boost Plus (liquid supplement) two times a day.

Review of Resident R1's Medication Administration Record dated March 2024, indicated Boost Plus was administered two times a day from 3/1/24, through 3/19/24.

Interview on 3/20/24, at 1:01 p.m. Registered Dietitian (RD) Employee E5 indicated "We've had supply issues with the Chocolate Boost Plus on and off since the pandemic. They are supposed to be giving Ensure in place of it."

Interview on 3/20/24, at 1:03 p.m. the Director of Nursing confirmed the nurses were documenting twice daily that Boost Plus was being administered, although they did not have Boost Plus in stock, and that the physician's orders should have been updated.

Review of Resident R1's current physician orders dated 3/20/24, indicated an order from 2/13/24, for a low air loss mattress (prevents pressure), to be checked by nurse for function every shift.

Observation 3/20/24, at 11:35 a.m. Resident R1 had a perimeter mattress on bed.

Interview on 3/20/24, at 1:30 p.m. the Director of Nursing confirmed the low air loss mattress was not in place and that the physician order needed updated.

Interview on 3/20/24, at 2:00 p.m. the Director of Nursing confirmed the facility failed to ensure that clinical records were complete and accurate for one of six residents reviewed (Resident R1).

28 Pa. Code 211.5(f) Clinical Records
28 Pa. Code 211.12(d)(1)(5) Nursing services.


 Plan of Correction - To be completed: 04/22/2024

R1 was given 2 chocolate boost plus's the day of the incident. Nursing and dining staff were educated on the new supplement substitution process and issuing the correct supplements by the DON and nursing management. There will be no nutritional supplements substituted unless approval by dietitian. If the preferred or ordered supplement is not available to purchase, the dietitian must suggest another equivalent product and change the physician order. Dietitian will audit if the ordered product is unavailable from the supplier and suggest a different product 5 times per week for 4 weeks.
Dietitian or designee will perform random audits of meals delivered to ensure the correct supplement is being provided 5 times per week for 4 weeks. DON and nursing management educated the nursing team on the correct process for ordering mattresses and implementing the correct mattress.
A whole house audit of air mattresses was completed to compare what is ordered versus what is present on the bed. DON or designee will audit new orders 5 times per week for 4 weeks to ensure that any specialty mattress ordered is present.


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