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

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GROVE AT NORTH HUNTINGDON, THE
Inspection Results For:

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GROVE AT NORTH HUNTINGDON, 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 August 2, 2024, it was determined that The Grove at North Huntingdon 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:


483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff: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)

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.
Observations:
Based on staff interviews and review of the Food Service Director's Job description, it was determined that the facility failed to employ a full-time qualified Food Service Director for six of six weeks (6/18/24 - 7/30/24).

Finding include:

Review of the facility's "Food Service Director's Job Description" indicated that the Food Service Director:
Must be a graduate of an accredited course in dietetic training approved by the American Dietetic Association.
Must be registered as a Food Service Director in Pennsylvania.
Must provide documentation of registry/certificate upon application for the position.

During an interview on 7/30/24, at approximately 12:30 p.m. Food Service Director (FSD) Employee E1, stated that while she is currently enrolled in classes to be a Certified Dietary Manager (CDM), she currently is not certified.

During an interview on 7/30/24, at 1:55 p.m. Registered Dietician Employee E2 stated that she works only one day per week, will be leaving the facility in two weeks, and further stated that she does not take any part in the operation and/or management of the dietary department, and has never done so.

During an interview on 7/30/2024, at 3:30 p.m. Nursing Home Administrator (NHA) confirmed that Food Service Director Employee E1 did not possess the appropriate qualifications as required.

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


 Plan of Correction - To be completed: 08/22/2024

The facility will employ staff to carry out the daily functions of the Dietary Department (Dietary Manager). The facility's Dietary Manager, hired on 4/21/24, is ServSafe certified and currently enrolled in an approved CDM course which is fast-tracked to be completed by 9/9/24. Facility also hired a new dietitian who is scheduled to work up to 32 hours per week. Dietitian will provide oversight to the dietary department and monitor dietary manager's progress in their CDM course until completeion on 9/9.

The facility's Dietary Manager is ServSafe certified and is also in the process of completing their CDM certification which is anticipated to be completed by 9/9/24. Facility also hired a new dietitian who is scheduled to work up to 32 hours per week. Dietitian will provide oversight to the dietary department and monitor dietary manager's progress in their CDM course until completeion on 9/9.

The Nursing Home Administrator will be educated by the facility's Regional Clinical Consultant or designee on federal requirement §483.60(a) which states the facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service.

Administrator or designee will complete ongoing monitoring of the Dietary Management position to ensure the facility employs qualified staff to carry out the daily functions of the Dietary Department.

These monitorings will be forwarded to monthly Quality Assurance and Performance Improvement Committee for review, recommendations, and frequency of audits.
483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:
Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to make certain that weight loss was identified and addressed and identify needs for increased nutrition for eight of eleven residents (Resident R1, R2, R3, R4, R5, R6, R7, and R8).

Findings include:

Review of the facility job description for the Registered Dietitian indicated "the primary purpose of the job position is to implement, coordinate, and evaluate the medication nutrition therapy for the residents, provide resident and family education, provide nutritional assessment and consultation to assist in planning, organizing, and directing the food and nutritional services of the facility." Included in the list of duties and responsibilities were: assist in developing a written dietary plan of care and to review nurse's notes to determine if the care plan is being followed.

Review of the facility policy, "Weight Monitoring and Weight Loss Intervention" last reviewed 11/30/23, indicated 'All residents will be weighed on admission, readmission and at least monthly. More frequent weights may be obtained as per facility policy."

Review of the Centers for Disease Control's "Adult BMI (body mass index) Categories" dated 3/19/24, indicated for adults ages 20 and over, the following distributions:
Underweight:Less than 18.5
Health weight: 18.5 - less than 25
Overweight:25 - less than 30
Obesity: 30 or greater

Review of the Code of Federal Regulations, Quality of Care Guidance indicated:
Parameters for significant weight loss is defined as:
-5% or greater in one month
-7.5% or greater in three months
-10% or greater in six months

Review of Resident R1's admission record indicated he was originally admitted to the facility on 5/20/24.

Review of the facility diagnosis list included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), the presence of a Stage IV pressure wound (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer), anemia (too little iron in the body causing fatigue), and severe protein-calorie malnutrition (PCM, refers to a nutritional status where reduced availability of nutrients leads to changes in body composition and function.

Review of Resident R1's most recently captured weight was 109.3 pounds, and height of 5 feet 11 inches. Resident R1's ideal body weight is documented to be 172 - 208 pounds.

Review of a physician's order dated 5/20/24, with an order end date of 5/22/24, indicated for Resident R1 to be weighed each evening shift for two days.

Review of Resident R1's weight record for 5/20/24 - 5/22/24, revealed no weights captured. Review of census information indicated Resident R1 was present in the facility.

Review of a physician's order dated 5/28/24, indicated for Resident R1 to be weighed weekly for four weeks.

Review of census information indicated Resident R1 was present in the facility during the above time from 5/28/24, through 6/14/24, and between 6/22/24, through 6/25/24. Review of Resident R1's weight record revealed one weight captured on 5/30/24 (120.0 pounds), and one weight captured on 6/12/24 (109.3 pounds), revealing an 8.9% weight loss in 13 days.

Review of a physician's order dated 6/30/24, with an order end date of 7/3/24, indicated for Resident R1 to be weighed each day shift for two days.

Review of Resident R1's weight record for 6/30/24 - 7/3/24, revealed no weights captured. Review of census information indicated Resident R1 was present in the facility.

Review of a physician's order dated 6/30/24, with an order end date of 7/25/24, indicated for Resident R1 to be weighed weekly for four weeks.

Review of census information indicated Resident R1 was present in the facility during the above order time from 6/30/24, through 7/6/24, and between 7/10/24, through 7/16/24. Review of Resident R1's weight record revealed that no weights captured during the time that Resident R1 was present in the facility.

Review of a physician's order dated 7/10/24, with an order end date of 8/7/24, indicated for Resident R1 to be weighed weekly for four weeks.

Review of census information indicated Resident R1 was present in the facility during the above order time from 7/10/24, through 7/16/24. and between 7/24/24, through 7/31/24. Review of Resident R1's weight record revealed that no weights captured during the time that Resident R1 was present in the facility.

Review of a physician's order dated 5/24/24, indicated Resident R1 was to receive 30 milliliters (mL) of liquid protein supplement three times daily. This order was renewed in 6/23/24, upon readmission from the hospital on 6/22/24. The order was discontinued on 6/30/24, upon readmission to the hospital.

Review of the physician orders revealed that the order was not renewed upon Resident R1's return from the hospital on 7/6/24, and only renewed on 7/17/24, related to a later hospital return on 7/16/24.

Review of dietician progress notes dated 6/4/24, 6/18/24 (during resident hospitalization), and 7/18/24, all indicated Resident R1 should be receiving a liquid protein supplement.

Review of Resident R2's admission record indicated she was admitted to the facility on 6/27/24.

Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 7/4/24, included diagnoses of alcoholic cardiomyopathy (disease in which the long-term consumption of alcohol leads to heart failure) and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness).

Review of nurse practitioner new patient assessment completed on 6/28/24, included in the listing of active medical problems "moderate protein energy malnutrition. '

Review of Resident R2's most recently captured weight was 105.3 pounds, and height of 5 feet, 6 inches. Resident R2's ideal body weight is documented to be 149 - 180 pounds.

Review of a physician's order dated 7/5/24, with an order end date of 8/2/24, indicated for Resident R2 to be weighed weekly for four weeks.

Review of Resident R2's weight record for 7/5/24 - 7/31/24, revealed an initial weight was captured on 7/5/24, and no additional weights captured until 7/26/24. Review of census information revealed that Resident R2 was in the facility during the above time.

Review of the clinical record indicated Resident R3 was admitted to the facility on 5/1/24, and readmitted on 6/10/24.

Review of the MDS dated 5/7/24, included diagnoses of anemia, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and age-related physical debility.

Review of Resident R3's most recently captured weight was 134.4 pounds, and height of 5 feet, 3 inches. Resident R3's ideal body weight is documented to be 135 - 164 pounds.

Review of a physician's order dated 6/10/24, with a start date of 6/19/24, and an order discontinuation date of 7/5/24, indicated for Resident R3 to be weighed weekly on Wednesdays, for four weeks.
Wednesday 6/19/24: Not documented.
Wednesday 6/26/24: 146.4 pounds.
Wednesday 7/3/24: Hospitalized.

Review of a physician's order dated 6/24/24, with a start date of 6/25/24, and an order end date of 7/2/24, indicated for Resident R3 to be weighed weekly on daily, for seven days.
6/25/24: 151.6
6/26/24: 146.4
6/27/24: 147.1
6/28/24: Not documented.
6/29/24: 147.4
6/30/24: 147.4
7/01/24: Not documented.

Review of a physician's order dated 7/12/24, with an order end date of 8/9/24, indicated for Resident R3 to be weighed weekly on Fridays, for four weeks.
Friday 7/12/24: 143.0 pounds.
Friday 7/19/24: 134.4 pounds.
Friday 7/26/24: Not assessed.

Review of Resident R3's weight record indicated:
6/11/24: 174.0 pounds.
6/15/24: 146.2 pounds.

Review of a dietician progress note dated 7/30/24, at 4:11 p.m. indicated that Resident R3 had a 17 pound loss due to inaccurate weight documentation, and that her BMI was 23.8 (classified as a healthy weight), documented as indicating obesity.

Review of the clinical record indicated Resident R4 was admitted to the facility on 4/29/24.

Review of the MDS dated 5/6/24, included diagnoses of COPD, anemia, and chronic kidney disease.

Review of a physician's order dated 4/29/24, with a start date of 5/8/24 and an order end date of 6/5/24, indicated for Resident R4 to be weighed weekly on Wednesdays, for four weeks.
Wednesday 5/08/24: Not assessed.
Wednesday 5/15/24: Not assessed.
Wednesday 5/22/24: Not assessed.
Wednesday 5/29/24: Not assessed.

Review of Resident R4's weight record revealed two weights captured; 4/30/24 - 341.0 pounds, and the exact same weight captured approximately six weeks later - 341.0 pounds.

Review of the clinical record indicated Resident R5 was admitted to the facility on 2/24/23.

Review of the MDS dated 5/20/24, included diagnoses of diabetes, multiple sclerosis (a disease that affects central nervous system), and heart failure (a progressive heart disease that affects pumping action of the heart muscles).

Review of Resident R5's plan of care dated 5/30/23, for nutrition risk indicated for staff to record and monitor weights.

Review of a physician's order dated 1/2/24, indicated for Resident R5 to be weighed monthly.

Review of Resident R5's weight record indicated:
February: 160.2 pounds.
March: 169.8 pounds.
April: Not documented.
May: Not documented.
June: 168.6 pounds.
July: Not documented.

Review of the clinical record indicated Resident R6 was admitted to the facility on 1/8/24.

Review of the MDS dated 5/15/24, included diagnoses of anemia, chronic kidney disease, and malnutrition.

Review of a physician's order dated 1/9/24, with a start date of 1/11/24 and an order end date of 2/8/24, indicated for Resident R6 to be weighed weekly on Thursdays, for four weeks.
Thursday 1/11/24: Not documented
Thursday 1/18/24: 181.0 pounds.
Thursday 1/28/24: Not documented
Thursday 2/01/24: 181.0 pounds.

Review of Resident R6's plan of care dated 3/12/24, for nutrition risk indicated for staff to record and monitor weights.

Review of Resident R6's physician orders failed to include any further orders for weight monitoring.

Review of Resident R6's weight record indicated:
2/1/24: 181.0.
3/7/24: 161.0, a loss of 20 pounds (11%) in 5 weeks.
4/2/24: 173.6, a gain of 12.6 pounds (7.8%) in 4 weeks.
5/2/24: 142.0, a loss of 31.6 pounds (22.8%) in approximately 4 weeks.
5/24/24: 155.0, a gain of 13 pounds (9.2%) in 3 weeks.
No June weight completed.
7/2/24: 147.2, a loss of 7.8 pounds (5.0%) in approximately 6 weeks.

Review of the clinical record indicated Resident R7 was admitted to the facility on 12/13/23.

Review of the MDS dated 7/10/24, included diagnoses of diabetes, history of a stroke, and malnutrition.

Review of Resident R7's most recently captured weight was 103.2 pounds, and height of 5 feet, 7 inches. Resident R7's ideal body weight is documented to be 153 - 185 pounds.

Review of a physician's order dated 12/13/24, with a start date of 12/23/24, and an order end date of 1/20/24, indicated for Resident R7 to be weighed weekly on Saturdays, for four weeks. Review of census information revealed Resident R7 was present in the facility between 12/23/24, through 01/20/24.
Saturday 12/23/23: Not documented.
Saturday 12/30/23: Not documented.
Saturday 01/06/24: Not documented.
Saturday 01/13/24: Not documented.

Review of a physician's order dated 2/8/24, with a start date of 2/9/24, and an order end date of 3/8/24, indicated for Resident R7 to be weighed every seven days for four weeks, "Due to resident's inconsistent weights."

Resident R7 was present in the facility between 2/9/24, through 6/28/24. Review of Resident R7's weight record from 2/9/24, through 6/28/24, revealed the following:
2/09/24: 143.8 pounds.
2/16/24: Not documented.
2/23/24: 157.8 pounds.
3/01/24: 103.2 pounds.
6/02/24: 103.2 pounds.

Review of Resident R7's progress notes revealed a nutrition note on 3/12/24, and no further nutrition notes until 6/18/24.

Review of the clinical record indicated Resident R8 was admitted to the facility on 1/16/23.

Review of the MDS dated 6/13/24, included diagnoses of multiple sclerosis (a disease that affects central nervous system), rheumatoid arthritis (chronic, painful inflammatory disorder affecting many joints, including those in the hands and feet), and a seizure disorder.

During an interview on 7/30/24, at 3:20 p.m. Resident R8 stated that she goes to an outside facility to get a monthly infusion for her rheumatoid arthritis. Resident R8 stated that outside facility staff ask her weight, but she "has to guess." Resident R8 stated that her dosage of this medication is dependent upon her weight.

Review of Resident R8's physician's orders revealed one physician order dated 4/17/24, for Resident R8 to receive an Orencia (intravenous infusion to treat rheumatoid arthritis) on 5/15/24.

Review of documents uploaded to the electronic medical record indicated Resident R8 received an Orencia injection on 6/12/24, and was scheduled to receive another on 7/10/24.

Review of Resident R8's progress notes revealed that she also had received an Orencia infusions on 3/20/24. Further review of Resident R8's progress notes indicated in the physician notes dating back to 1/19/23, that Resident R8 was receiving Orencia infusions.

Review of a physician's order dated 2/1/24, indicated Resident R8 was to be weighed monthly.

Resident R7 was present in the facility between 1/16/24, through 7/31/24, without any leaves of absence. Review of Resident R7's weight record from 2/1/24, through 7/31/24, revealed the following:
2/9/24: 167.4 pounds.
3/7/24: 167.2 pounds.
April:Not Documented.
May:Not Documented.
June:Not Documented.
6/2/24: 167.2 pounds.

During an interview on 7/30/24, at 3:30 p.m., the Nursing Home Administrator confirmed that the facility failed to make certain weight loss was identified and addressing a timely manner and to identify needs for increased nutrition for eight of eleven residents.

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

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


 Plan of Correction - To be completed: 08/22/2024

The facility will make certain that weight loss was identified and addressed to identify needs for increased nutrition for all residents and weights will be obtained per facility policy and as ordered by the physicain. Weights were obtained and addressed for residents R1-R7 in order to identify the need for increased nutrition. Resident R8 will have weights obtained for dependent medications received at outside facility to ensure correct dose.

The Director of Nursing or designee will complete a house audit of residents who have suffered a recent weight loss to ensure weights were addressed and appropriate interventions were put in place for increased nutritional value, and residents receiving weight dependent medication have weights to ensure accurate dosing. This audit will also include ensuring physician orders for weighs have been followed and weights were obtained per facility policy.

The facility's Regional Clinical Consultant will re-educate facility Nursing Home Administrator, Director of Nursing, and Dietitian on federal tag F-0692 and the facility's "Weight Monitoring and Weight Loss Intervention" policy which outlines the importance of ensuring resident weights are obtained as ordered and interventions are put in place as appropriate for residents with identified weight loss and weight dependent medication doses. The Director of Nursing or Designee will re-educate nursing staff on the facility policy and procedures for obtaining weights and following physician orders for weights.

The facility's clinical start-up process will be enhanced to review any residents with weight loss to ensure appropriate interventions are ordered and put in place for increased nutrition and weights are obtained on admission, readmission, and at least monthly and as ordered by the physician. Residents who return from the hospital will be reviewed to ensure previous nutrional interventions are ordered if indicated. Residents on weight dependent medications will be reviewed to ensure weights are obtained for accurate dosing.

An audit will be completed weekly x4 weeks and then monthly x3 months to ensure residents with weight loss have appropriate interventions ordered and in place and weights are obtained per facility policy and as ordered by the physician. Residents on weight dependent medication will be reviewed to ensure weights are obtained as appropriate.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
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 a review of facility policy, 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 11 of 18 residents (Resident R5, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17).

Findings include:

Review of the facility policy, "Nursing Department Staffing" dated 11/30/23, indicated "The facility will 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:
-Licensed nurses
-Other nursing personnel

During an observation on 7/30/24, at 2:12 p.m., Resident R9, when asked if there was sufficient nursing staff stated, "Some days yes. Sometimes they have three, and that's not enough." Resident R9 confirmed that he has been left in bed in urine soiled clothing and linen for an extended period of time.

During an interview on 7/30/24, at 2:13 p.m., Resident R10 stated he was in agreement with Resident R9, pertaining to a lack of nursing staff. Resident R10 further stated "Every light can be lit up and down the hall, no one answers."

During an interview and observation on 7/30/24, at 2:52 p.m., Resident R12's call light was alarming. Resident R12 stated she would like to get back into bed. Observation at this time revealed four staff seated at the nurses station.

During call lights observations on 7/30/24, beginning at 2:58 p.m. revealed:

2:58 p.m. - Residents R13/R14's room light alarming; Resident R15/R16's room alarming. Unknown start time.

3:02 p.m. - Resident R8/R10's room began alarming.

3:05 p.m. - Resident R5/R17's room began alarming.

3:11 p.m. - All four rooms remain alarming.

3:16 p.m. - Resident R5/R17's room responded to (11 minute duration). Residents R13/R14's and Resident R15/R16's room still alarming (observed time 18 minutes). Resident R8/R10's still alarming (14 minutes).

During an interview on 7/30/24, at 3:20 p.m., when asked about call light response, Resident R8 stated that she waits over an hour at times. Resident R8 further stated that she has been told that she cannot have her scheduled shower due to a lack of staff.

During an interview on 7/30/24, at 3:22 p.m., Resident R11 stated that she waits a long time for call light response and for pain medication after she asks for it.

During the above interviews with Resident R8 and Resident R11, a nurse aide responded to the alarming call light at 3:31 p.m., a 29 minute response time.

During an interview on 7/30/24, at approximately 3:30 p.m. the Nursing Home Administrator confirmed the facility failed to have sufficient nursing staff to provide nursing and related services to 13 of 16 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: 08/22/2024

The facility will ensure there is sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of residents. The facility cannot retroactively correct the concerns identified for residents R5 and residents R8 thru R17.

House surveillance will be completed by the Nursing Home Administrator (NHA) and Director of Nursing (DON )to validate sufficient staffing and that the resident needs are being met. In the event of high nursing demands, ancillary/supervisory staff will be pulled to the floor to assist with resident needs.

The Regional Clinical Consultant or Designee will re-educate the NH A and DON on Federal regulation 0725, detailing ensuring sufficient staffing to provide nursing care to residents and call bell response time. House education will also be completed with nursing staff regarding approrpriate call light response time.

The Director of Nursing or designee will complete an audit three times a week for four weeks then monthly for three months to validate the facility has sufficient staffing to meet the needs of the residents. NHA or designee will also complete call bell audits 10x/week x 4 weeks and then 10 audits monthly for three months to monitor appropriate call light response.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.
Observations:

Based on review of facility documents, staff interviews, and the results of the previous and current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to implement a good faith attempt to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively six of six weeks (6/18/24 - 7/30/24).

Findings include:

Review of the facility's "Food Service Director's Job Description" indicated that the Food Service Director:
Must be a graduate of an accredited course in dietetic training approved by the American Dietetic Association.
Must be registered as a Food Service Director in Pennsylvania.
Must provide documentation of registry/certificate upon application for the position.

During an interview on 7/30/24, at approximately 12:30 p.m. Food Service Director (FSD) Employee E1, stated that while she is currently enrolled in classes to be a Certified Dietary Manager (CDM), she currently is not certified.

Review of the facility survey ending 6/18/24, included a citation for the lack of a qualified Food Service Director.

Review of the facility's plan of correction submitted for this citation included as a corrective measure the availability of a Registered Dietician to provide dietary department oversight.

"This facility also employs a part-time qualified dietician who is available to assist with monitoring the dietary department."

During an interview on 7/30/24, at 1:55 p.m. Registered Dietician Employee E2 stated that she works only one day per week, will be leaving the facility in two weeks, and further stated that she does not take any part in the operation and/or management of the dietary department, and has never done so.

During an interview on 7/30/2024, at 3:30 p.m. the Nursing Home Administrator confirmed the facility's QAPI committee failed to implement a good faith attempt to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively six of six weeks

42 CFR 483.75(a)(2)(h)(i) QAPI Program/Plan, Disclosure/Good Faith Attempt.

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

28 Pa. Code 201.18(e)(2)(3)(4) Management.


 Plan of Correction - To be completed: 08/22/2024

The facility's Quality Assurance Performance Improvement (QAPI) committee will implement a good faith attempt to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively are followed.

The Regional Clinical Consultant or Designee will re-educate the Nursing Home Administrator on federal regulation F0867 and ensuring quality deficiencies are identified and corrected throughout QAPI process. NHA will also provide eduacation to Human Resources Director on federal tag F0801 and the requirement for sufficient dietary staff.

The QAPI committee will meet bi-weekly for three months and then monthly to review monitoring and compliance of federal tag F0801 and the requirement for the facility to employ a qualified dietary manager.

The Nursing Home Administrator or designee will be responsible to review issues and conduct audits to identify concerns and present these audits to the committee to formulate additional action plans should unsatisfactory performance be identified.

The Regional Clinical consult will attend the monthly QAPI committee to monitor compliance with the process.
§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:
Based on review of facility policy, nursing time schedules, and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of one nurse aide per 10 residents during the day shifts, one nurse aide per 11 residents on evening shift, and one nurse aide per 15 residents on night shift, on 15 of 21 days (7/7/24, 7/10/24, 7/12/24, 7/13/24, 7/14/24, 7/17/24, 7/18/24, 7/19/24, 7/20/24, 7/21/24, 7/22/24, 7/23/24, 7/24/24, 7/26/24, and 7/27/24).

Findings include:

Review of the facility policy, "Nursing Department Staffing" dated 11/30/23, indicated "The facility will 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:
-Licensed nurses
-Other nursing personnel

Review of the nursing schedules and census information for 7/7/24, through 7/27/24, revealed that the facility failed to meet the following:

7/07/24: Evening shift required 72.27 hours of nurse aide care, facility provided 56.21; night shift required 53.00 hours of nurse aide care, facility provided 52.50.
7/10/24: Evening shift required 72.27 hours of nurse aide care, facility provided 67.50.
7/12/24: Day shift required 78.00 hours of nurse aide care, facility provided 67.50, evening shift required 70.91 hours of nurse aide care, facility provided 63.75.
7/13/24: Night shift required 51.50 hours of nurse aide care, facility provided 37.50.
7/14/24: Day shift required 76.50 hours of nurse aide care, facility provided 45.00.
7/17/24: Evening shift required 69.55 hours of nurse aide care, facility provided 60.00.
7/18/24: Evening shift required 70.91 hours of nurse aide care, facility provided 61.75.
7/19/24: Day shift required 78.00 hours of nurse aide care, facility provided 45.00, evening shift required 70.91 hours of nurse aide care, facility provided 37.50.
7/20/24: Day shift required 74.25 hours of nurse aide care, facility provided 50.50, evening shift required 67.50 hours of nurse aide care, facility provided 56.25.
7/21/24: Day shift required 75.75 hours of nurse aide care, facility provided 60.00, evening shift required 68.86 hours of nurse aide care, facility provided 67.50.
7/22/24: Day shift required 76.50 hours of nurse aide care, facility provided 60.00, evening shift required 69.55 hours of nurse aide care, facility provided 56.25; night shift required 51.00 hours of nurse aide care, facility provided 45.00.
7/23/24: Evening shift required 70.23 hours of nurse aide care, facility provided 52.50.
7/24/24: Day shift required 78.00 hours of nurse aide care, facility provided 67.50, evening shift required 70.91 hours of nurse aide care, facility provided 60.00.
7/26/24: Day shift required 78.75 hours of nurse aide care, facility provided 67.50, night shift required 52.50 hours of nurse aide care, facility provided 45.00.
7/27/24: Day shift required 78.75 hours of nurse aide care, facility provided 60.00, evening shift required 71.59 hours of nurse aide care, facility provided 52.50; night shift required 52.50 hours of nurse aide care, facility provided 37.50.

During an interview on 7/30/24, at approximately 3:45 p.m. the Nursing Home Administrator confirmed that the facility administrative staff failed to provide a minimum of one nurse aide per 10 residents during the day shifts, one nurse aide per 11 residents on evening shift, and one nurse aide per 15 residents on night shift, on 15 of 21 days.


 Plan of Correction - To be completed: 08/22/2024

The facility will ensure state-required nurse aide ratios are met for all shifts. The facility cannot correct that nurse aide staffing ratios were not met on the following dates: 7/7/24, 7/10/24, 7/12/24, 7/13/24, 7/14/24, 7/17/24, 7/18/24, 7/19/24, 7/20/24, 7/21/24, 7/22/24, 7/23/24, 7/24/24, 7/26/24, and 7/27/24.

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

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 as needed.

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. :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 facility policy, nursing time schedules, and staff interviews, 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, one LPN per 30 residents during the evening shift, and one LPN per 40 residents during the night shift for 14 of 21 days (7/7/24, 7/9/24, 7/10/24, 7/11/24, 7/12/24, 7/13/24, 7/14/24, 7/15/24, 7/17/24, 7/18/24, 7/19/24, 7/20/24, 7/21/24, and 7/23/24).

Findings include:

Review of the facility policy, "Nursing Department Staffing" dated 11/30/23, indicated "The facility will 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:
-Licensed nurses
-Other nursing personnel

Review of the nursing schedules and census information for 7/7/24, through 7/27/24, revealed that the facility failed to meet the following:

7/07/24: Day shift required 33.92 hours of LPN care, facility provided 32.00.; evening shift required 28.27 hours of LPN care, facility provided 24.00.
7/09/24: Night shift required 21.00 hours of LPN care, facility provided 16.00.
7/10/24: Day shift required 33.92 hours of LPN care, facility provided 32.00.; night shift required 21.20 hours of LPN care, facility provided 16.00.
7/11/24: Night shift required 21.00 hours of LPN care, facility provided 16.00.
7/12/24: Night shift required 20.80 hours of LPN care, facility provided 16.00.
7/13/24: Night shift required 20.60 hours of LPN care, facility provided 16.00.
7/14/24: Night shift required 20.40 hours of LPN care, facility provided 16.00.
7/15/24: Night shift required 20.80 hours of LPN care, facility provided 16.00.
7/17/24: Night shift required 20.40 hours of LPN care, facility provided 16.00.
7/18/24: Night shift required 20.80 hours of LPN care, facility provided 16.00.
7/19/24: Night shift required 20.80 hours of LPN care, facility provided 16.00.
7/20/24: Evening shift required 26.40 hours of LPN care, facility provided 24.00; night shift required 19.80 hours of LPN care, facility provided 16.00.
7/21/24: Day shift required 32.32 hours of LPN care, facility provided 22.00.
7/23/24: Night shift required 20.60 hours of LPN care, facility provided 16.00.

During an interview on 7/30/24, at approximately 3:45 p.m. the Nursing Home Administrator confirmed the facility administrative staff failed to provide a minimum of one LPN per 25 residents during the day shift, one LPN per 30 residents during the evening shift, and one LPN per 40 residents during the night shift for 14 of 21 days.


 Plan of Correction - To be completed: 08/22/2024

The facility will ensure state-required LPN ratios are met for all shifts. The facility cannot correct that LPN staffing ratios were not met on the following dates: 7/7/24, 7/9/24, 7/10/24, 7/11/24, 7/12/24, 7/13/24, 7/14/24, 7/15/24, 7/17/24, 7/18/24, 7/19/24, 7/20/24, 7/21/24, and 7/23/24

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

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 as needed.

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.
§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, 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 3.2 hours of direct resident care for each resident.

Observations:
Based on review of facility policy, 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 (7/7/24, 7/10/24, 7/12/24, 7/13/24, 7/14/24, 7/15/24, 7/17/24, 7/18/24, 7/19/24, 7/20/24, 7/21/24, 7/22/24, 7/24/24, 7/26/24, and 7/27/24).

Findings include:

Review of the facility policy, "Nursing Department Staffing" dated 11/30/23, indicated "The facility will 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:
-Licensed nurses
-Other nursing personnel

Review of facility policy, nursing schedules, and census information for 7/7/24, through 7/27/24, revealed that the facility failed to maintain 3.20 hours of general nursing care to each resident in a 24-hour period on the following dates:

-7/07/24, Census 106. PPD 2.79.
-7/10/24, Census 106. PPD 3.11.
-7/12/24, Census 104. PPD 2.93.
-7/13/24, Census 103. PPD 3.19.
-7/14/24, Census 102. PPD 3.02.
-7/15/24, Census 104. PPD 3.16.
-7/17/24, Census 102. PPD 3.16.
-7/18/24, Census 104. PPD 3.05.
-7/19/24, Census 102. PPD 2.38.
-7/20/24, Census 99. PPD 2.59.
-7/21/24, Census 101. PPD 2.79.
-7/22/24, Census 102. PPD 3.07.
-7/24/24, Census 104. PPD 3.03.
-7/26/24, Census 105. PPD 3.00.
-7/27/24, Census 105. PPD 2.59.

During an interview on 7/30/24, at approximately 3:45 p.m. the Nursing Home Administrator confirmed that the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on 15 of 21 days.


 Plan of Correction - To be completed: 08/22/2024

The facility will ensure that the state minimum staffing requirement of 3.2 PPD is met in order to ensure the health and safety of all residents. Facility is unable to retroactively correct concern of minimum staffing requirement not being met on dates: 7/7/24, 7/10/24, 7/12/24, 7/13/24, 7/14/24, 7/15/24, 7/17/24, 7/18/24, 7/19/24, 7/20/24, 7/21/24, 7/22/24, 7/24/24, 7/26/24, and 7/27/24.

Facility will continue to ensure all efforts are exhausted to maintain the minimum staffing requirement of 3.2 PPD on a daily basis to ensure the health and safety of all residents. Facility will continue to acquire agency staff as needed to meet the 3.2 PPD requirement. Recruitment efforts are under way and a plan is in place. Bonuses will be offered to all staff to pick up shifts. Facility Admissions will be limited if staffing requirement cannot be met.

Regional Clinical Consultant will re-educate Administrator, Director of Nursing, and staffing coordinator on "Nursing Department Staff" policy which outlines the minimum staffing requirements and steps that are to be taken in order to ensure staffing requirements are met in order to ensure the health and safety of all residents.

Administrator or designee will audit staffing levels five times a week for four weeks and then monthly for three months to ensure the minimum staffing requirement of 3.2 PPD is met to ensure the health and safety of all residents.

Findings of audits will be reported to monthly Quality Assurance & Performance Improvement (QAPI) for review, recommendations, and frequency of audits.

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