Nursing Investigation Results -

Pennsylvania Department of Health
GLEN BROOK REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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GLEN BROOK REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

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GLEN BROOK REHABILITATION AND HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on December 9, 2021, it was determined that Glen Brook Rehabilitation and Healthcare Center was not in compliance with the following 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 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 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 clinical records, grievances lodged with the facility, observations, staff, and resident interviews, it was determined the facility failed to ensure effective management and execution of the duties and responsibilities of the facility's food and nutrition department to provide consistent planned meals and professional dietary and nutritional services to meet the nutritional needs of each resident.

Findings include:

A review of grievance dated November 18, 2021, indicated that Resident 4 had complaints about dietary services. The grievance noted that the resident was crying a visibly upset. The resident voiced concerns that she was not receiving food items of her choice.

An observation of the kitchen on December 9, 2021, at 8:50 AM revealed that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness.

Refrigerator fan cover was removed and laying on the top shelf next to food. Further an accumulation of dust and debris was noted on the refrigerator fan.

Two containers of cottage cheese and one container of mayonnaise were noted with standing water on the lids and black dust and debris located on the lids.

Boxes of food were placed directly on the floor in the in the refrigerator and dust noted on the boxes.

One container of beef base was opened and not dated as to when staff opened the container. Further a brown sticky substance was noted on the bottom of the beef base container.

A box of defrosting fish open to air was noted to be on a metal sheet pan. The box of fish was lying in a large amount of liquid that was accumulated on the sheet pan.

A box of pasteurized eggs was noted with a broken egg lying in the box.

The tray line cooler contained milk purchased by staff for residents from a local grocery store had expired on December 5, 2021.

Two containers of thicken lemon flavored water opened on November 4, 2021. Per the manufacturing instructions the water is to be discarded seven days after opening.

One tray of defrosted vanilla and strawberry nutritional health shakes and one tray of defrosted apple cranberry nutritional drinks were noted in the cooler. Manufacturing instructions indicated discard 14 days after defrosting. No dates were noted when the drinks were defrosted.

Three bags of white rolls and 14 bags of hot dog rolls purchased by staff for residents from a local grocery store had expired on December 3, 2021.

An interview with the certified dietary manager on December 9, 2021, at approximately 9:00 AM revealed that Employee 1 had purchased food because sufficient food items were not available at the facility. He was unaware that the products that had been purchased at the local grocery store were expired, and that all food should be checked for expiration.

An interview with Employee 1 on December 9, 2021, at 10:50 AM revealed had to go to the local grocery store to by food and cleaning supplies because the the facility was running out of food and supplies. The employee stated that the facility had not yet secured food service vendors to provide delivery service to the facility and she purchased all the bread products and milk from the local grocery store in November 2021. Employee 1 also stated that she went to the local grocery store to buy the following because the facility's supply was low or depleted:

November 21, 2021, multiple buns
November 22, 2021, Dawn dish soap
November 23, 2021, oregano, and lemon juice
November 24, 2021 bread
December 1, 2021 Lactaid milk.

A review of meal cart delivery times for December 9, 2021, revealed that lunch meal carts were to be delivered to the floor at the following times: North Hall 11:15 AM, Spruce 400 Hall at 11:30 AM, Spruce 200 Hall at 11:45 AM.

An observation of the lunch meal tray line service on December 9, 2021, at 11:00 AM revealed that Employee 2 cook began tray line by removing plates and plate warmers, assembling the plates and stacking them five high, touching each plate on which food was to be served and also decreasing the temperature of the plate warmers designed to maintain acceptable food temperature on service to the residents.

The dietary staff working the tray line were not communicating with each other to assure accuracy of resident meal service. Observation revealed that on multiple instances Employee 2 would plate the residents' food incorrectly. Employee 2 would have to stop, to correct her mistake, and replate the food causing a delay in tray line meal service.

Observations of the lunch meal service on December 9, 2021, review of clinical records, and interviews with staff it was determined that the facility failed to provide nutritional supplementation prescribed to maintain residents' nutritional status for two of eight residents reviewed (Resident 6, 7, and 8).

Resident 6's was not provided his Glucerna supplement at the lunch meal as ordered.

Resident 7's was not provided her Ensure Clear supplement at the lunch meal as ordered.

Resident 8's was not provided her Glucerna supplement at the lunch meal as ordered.

Resident 5 was not provided adaptive eating equipment for hot liquids when observed at the lunch meal on December 9, 2021.

Resident 1 was not served fruit salad as she indicated as her preference for this lunch meal.

Resident 2 received gray on her food, but her meal preferences indicated no gravy.

Resident 3 was served peaches at this lunch meal although the resident's tray card indicated that the resident was allergic to peaches.

The facility ran out of rolls at the lunch meal on December 9, 2021, and had to substitute sliced white bread.

The certified dietary manager dropped a loaf of bread on the floor and picked it up and the dietary staff served it the residents' meal trays.

Employee 3 dietary aide used her hands to grab bread from the loaf and place it on the residents' trays without performing hand hygiene or changing gloves prior to completing the task.

Due to the multiple plating errors, the Spruce 400 Hall lunch cart left the kitchen at 11:20 AM, 20 minutes late. The Spruce 200 Hall lunch cart left the kitchen at 12:15 PM, 30 minutes late.

Interview with Resident 4 on December 9, 2021, at approximately 2:00 PM revealed that the resident stated she frequently receives foods that she does not like although her preferences are identified. She stated the facility serves her the wrong food items and does not follow her food preferences. Resident 4 also stated that food is often delivered late.

Interview with Resident 1 on December 9, 2021, at approximately 2:01 PM revealed that the resident stated that she is occasionally served the wrong foods that she does not like, although her preferences were identified. Resident 1 also stated that meals are delivered late on occasion, such as they were at the lunch meal on December 9, 2021. Resident 1 also stated that meals are delivered late and not according to the scheduled time.

An interview with the Nursing Home Administrator on December 9, 2021, at approximately 3:00 PM confirmed the facility failed to ensure that facility staff support the nutritional well-being of the residents while respecting an individual's right to make choices about his or her diet and that issues remain in the overall systems in managing and executing its food and nutrition services.


Refer F692, F806, F810, and F812


28 Pa. Code 211.6 (a)(b)(c)(d) Dietary services

28 Pa. Code 201.29 (j) Resident rights









 Plan of Correction - To be completed: 01/11/2022



F800
1. R4 was seen by dietician to review preferences; Refrigerator fan was cleaned and cover was stored appropriately. Container of cottage cheese and mayonnaise was discarded. Boxes of food located on floor cleared of any dust and properly stored . Opened can of beef base was discarded; Box of defrosting fish was discarded. Broken egg discarded; Milk discarded based on expiration dates. Thickened lemon water discarded based on manufacture instructions; items (defrosted health shake and nutritional drinks) were discarded based on manufacture instructions; Rolls with expired dates were discarded. E1 was educated on reviewing expiry dates of products prior to purchase if utilizing outside local vendor. E2 cook was educated on accuracy in serving plates and sanitation during process; R6,7, 8 were served supplements based on orders; R5 was provided required adaptive eating equipment; R1, R2 and R3 was provided food based on their preferences and indications; CDM and E3 was educated on infection control practices in the kitchen; R4 and R1 was seen by dietician to review preferences and verify meals delivered timely and based on preferences.

2. The Dietary Staff shall be educated by the FSD/designee on the importance of verifying that food sent out on the meal tray is food that is listed on the resident's preference list, and meal ticket. Education shall also include storage and service of food to prevent potential of contamination and microbial growth in food, and timeliness of food served.

3. Dietary service department staff will be re-educated by then CDM on supporting the well being of residents by reviewing resident choices/preferences, maintaining sanitation requirements in the kitchen and acceptable practices for storage and service of food to prevent contamination.
Food committee to meet weekly x 1 month to discuss any concerns and problem solve issues identified.

4. FSD/designee will complete audits of kitchen, meal trays daily x 1 week, weekly x4 then monthly x2 or until 100 % compliance is achieved. Findings will be reviewed in QAPI committee.

5. Date of compliance 01/11/2022

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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(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 observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

A tour of the kitchen was conducted with the Director of Food Service/CDM (Certified Dietary Manager), on December 9, 2021, at 8:50 AM, that revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified:

Refrigerator fan cover had been removed and observed laying on the top shelf next to food. An accumulation of dust and debris was observed on the refrigerator fan.

Two containers of cottage cheese and one container of mayonnaise were observed with standing water on the lids and black dust and debris located on the lids.

Boxes of food were observed, placed directly on the floor in the in the refrigerator and dust observed on the boxes.

One container of beef base was opened and not dated when initially opened. A brown sticky substance was observed on the bottom of the beef base container.

An opened box of defrosting fish was observed uncovered, thawing on a metal sheet pan. The box of fish was lying in a large amount of liquid that was accumulated on the sheet pan.

A broken egg was observed inside a box of pasteurized eggs

The cooler on the tray line, which contained milk purchased by staff for residents from a local grocery store, had expired on December 5, 2021.

Two containers of thickened lemon flavored water opened on November 4, 2021. Per the manufacturing instructions the water is to be discarded seven days after opening.

One tray of defrosted vanilla and strawberry nutritional health shakes and one tray of defrosted apple cranberry nutritional drinks were observed in the cooler. Manufacturing instructions indicated that the products be discarded 14 days after defrosting. However, no dates were noted as to when the drinks were defrosted.

Three bags of white rolls and 14 bags of hot dog rolls purchased by staff for residents from a local grocery store had expired on December 3, 2021.

The above observations were confirmed by the food service director.

Interview with the NHA on December 9, 2021, at approximately 3:00 PM, confirmed that food should be stored, prepared, and served under sanitary conditions.

Refer F800


28 Pa. Code 211.6 (f) Dietary services.

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









 Plan of Correction - To be completed: 01/11/2022

F812
1. All identified areas were corrected to assure that facility stores, distributes and serves food in accordance with food safety practices.

2. Dietary manager will be educated by the Dietician on storage, distribution and serving of food in accordance with food safety practices.

3. The Dietary staff shall be educated by the FSD/designee on the storage,
distribution and serving of food in accordance with food safety practices.

4. FSD/designee will complete random audits of kitchen food safety daily x 1 week, weekly x4 then monthly x2 or until 100 % compliance is achieved. Findings will be reviewed in QAPI committee.

5. Date of Compliance 01/11/2022
.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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.
483.25(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 observations, review of clinical records, and interviews with staff it was determined the facility failed to provide nutritional supplementation prescribed to maintain residents' nutritional status for two of eight residents reviewed (Resident 6, 7, and 8) .

Findings include:


A review of Resident 7's clinical record revealed admission to the facility on July 2, 2021. The resident had a current physician order dated December 3, 2021, for Ensure Clear (nutritional supplement drink) three times a day for nutritional support.

A review of Resident 7's lunch meal ticket for December 9, 2021, revealed that Ensure Clear supplement was to be provided on the resident's lunch tray. Observations of the lunch meal service on December 9, 2021, at 11:00 AM revealed that Ensure Clear was not included on the resident's lunch meal tray as ordered.

A review of the clinical record of Resident 6 revealed admission to the facility on September 27, 2021. The resident had a current physician order dated December 3, 2021, for Glucerna (nutritional supplement) eight ounces twice a day for nutritional support.

Observations of the lunch meal trayline service on December 9, 2021, at 11:00 AM revealed that Resident 6's meal ticket indicated that the Glucerna supplement was to be provided on the resident's lunch tray. However, observation of the resident's lunch meal at this time revealed that the nutritional supplement was not present on the resident's lunch meal tray as ordered.


A review of Resident 8's clinical record revealed admission to the facility on May 11, 2021. The resident had a current physician order initially dated December 2, 2021, and revised December 8, 2021, for Glucerna twice a day with breakfast and lunch.

A review of Resident 8's meal ticket for the lunch meal on December 9, 2021, indicated that Glucerna supplement was to be provided on the resident's lunch tray. Observation of the resident' lunch meal tray revealed that the Glucerna supplement was not provided on the resident's lunch tray as ordered.

Interview with Employee 1 dietary manager on December 9, 2021, at approximately 12:30 PM confirmed that dietary staff failed to provide the residents with the physician ordered nutritional supplements on their lunch meal trays as prescribed for nutritional support.

Refer F800


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

28 Pa Code 211.10 (a)(c)(d) Resident care policies.

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








 Plan of Correction - To be completed: 01/11/2022

F692
1. Resident #6 ,7 and 8 shall receive their supplements on their trays as ordered for nutritional support.

2. Food Service Director will review current orders for supplements and assure that meal tray tickets are consistent with physician orders.

3. Dietary staff shall be educated by the FSD / designee on the need to verify and assure that supplements are placed on meal trays as ordered

4. The Food service supervisor/Designee will complete random audit of meals to assure that supplements are available based on physician order daily x 1 week, weekly x 4 weeks then monthly x2 or until 100 % compliance is achieved. . Findings will be reviewed in QAPI meeting.

5. Date of compliance 01/11/2022

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes: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(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 observations and resident and staff interviews, it was determined that the facility failed to provide food that accommodated residents' allergies and preferences for four residents of 8 residents reviewed (Resident 1, 2, 3, and 4).

Findings include:

An observation of lunch meal trayline service on December 9, 2021, at 11:00 AM revealed that
Resident 1's meal ticket indicated that resident wanted fruit salad on her tray for lunch. Observation revealed that fruit salad was not available and was not served to the resident as requested.

A review of Resident 2's lunch meal ticket indicated that the resident did not want gravy on her food. Observation of the resident's lunch meal on December 9, 2021, revealed that dietary staff placed gravy on the resident's entrwhen plating her food.

A review of Resident 3's lunch meal ticket indicated that the resident was allergic to peaches. Dietary staff placed peaches on the resident's lunch tray.

Interview with Resident 4 on December 9, 2021, at approximately 2:00 PM revealed that the resident stated she gets wrong foods, and foods that she does not like. Resident 4 that the facility does not follow her food preferences.

Interview with the Nursing Home Administrator on December 9, 2021, at approximately 3:00 PM confirmed that the dietary staff failed to accommodate the residents' preferences and allergies.

Refer F800

28 Pa. Code 211.6(c) Dietary services

28 Pa. Code 201.29(j) Resident rights.





 Plan of Correction - To be completed: 01/11/2022

F806
1. R1, 2, 3, 4 food preferences were reviewed to assure that meals served accommodated resident's allergies and preferences.

2. Current resident meals were reviewed by FSD/designee to assure that meals were served based on resident preferences and allergies

3. The Dietary Staff shall be reeducated by the FSD/designee on the importance of verifying that food sent out on the meal tray is food that accommodates the resident's allergies and preferences.

4. FSD/designee will complete random audits of meal trays daily x 1 week, weekly x4 then monthly x2 or until 100 % compliance is achieved. Findings will be reviewed in QAPI committee.

5. Date of compliance 01/11/2022




483.60(g) REQUIREMENT Assistive Devices - Eating Equipment/Utensils: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(g) Assistive devices
The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.
Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide adaptive eating equipment as required by one of eight residents reviewed (Resident 5 ).

Findings include:

A review of resident clinical records revealed that Resident 5 was admitted to the facility on May 10, 2020, and had a current physician's order dated November 24, 2021, for adaptive equipment, insulated mugs with lids for hot liquids.

Observation of the lunch meal service on December 9, 2021, at 11:32 AM revealed that Resident 5's tray was prepared without the physician ordered adaptive eating equipment provided to the resident.

Interview on December 9, 2021, at approximately 12:30 PM with the Employee 1, dietary manager, confirmed that the adaptive equipment was not provided to Resident 5 as per the physician order.


Refer F800

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

28 Pa. Code 211.6 (c) Dietary services




 Plan of Correction - To be completed: 01/11/2022

F810
1. R5 will be provided adaptive eating equipment as ordered.

2. Current resident orders for adaptive eating equipment will be reviewed by FSD to assure that meal trays have identified equipment in place.

3. The Dietary Staff shall be educated by the FSD/designee on the importance of verifying that adaptive equipment is placed on the tray for resident use before delivery to resident.

4. FSD/designee will complete random audits of meal trays for adaptive equipment daily x 1 week, weekly x4 then monthly x2 or until 100 % compliance is achieved Findings will be reviewed in QAPI committee

5. Date of compliance 01/11/2022





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