Pennsylvania Department of Health
PINE RUN HEALTH CENTER
Patient Care Inspection Results

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PINE RUN HEALTH CENTER
Inspection Results For:

There are  56 surveys for this facility. Please select a date to view the survey results.

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PINE RUN HEALTH CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and a Civil Rights Compliance survey completed on March 22, 2024, it was determined that Pine Run Health Center 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.






 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on observation, it was determined that the facility failed to store food under sanitary conditions in the kitchen.

Findings include:

Observation of the kitchen on March 19, 2024, at 11:50 a.m. revealed the following:

The bottom row of shelves in the reach-in freezer were missing. Multiple food items were stored on the bottom floor of the freezer. There was a box of raw chicken cheesesteak meat that was open, other food items were stored on top of the box. There was an open bag of French fries that was not dated.

The slicer handle was broken. There was a muffin tin and round cake pan stored on top of a transformer. There were two muffin tins on the floor between the storage shelf and the transformer. There was water leaking from the nozzle of a hose behind the kettle while food was being cooked. There was an accumulation of debris under the stovetop and grille. There was cocktail sauce with a use-by date of March 15, 2024, and blue cheese dressing with a use-by date of March 16, 2024, in the walk-in refrigerator. There was a container of popcorn with a use-by date of January 23, 2024, in dry storage. There were two trays of croquettes in the walk-in freezer that were not completely sealed and were open to air.

28 Pa. Code 201.18(b)(3)(e)(2.1) Management.










 Plan of Correction - To be completed: 04/29/2024

Plan of Correction F812 (Food Procurement, Store/Prepare/Serve-Sanitary)

1) All areas that were found to be out of compliance in relation to storage, preparation, distribution, and food service in accordance with professional standards for food safety are now in compliance.

2) The Dining Director or designee performed an audit of the kitchen and found no additional issues in relation to storage, preparation, distribution, and food service in accordance with professional standards for food safety.


3) The Dining Director or designee will provide education to dining team members on the community policy for storage, preparation, distribution, and food service in accordance with professional standards for food safety.


4) The Dining Director or designee will audit the kitchen twice weekly for four weeks and then twice monthly for two months to ensure compliance with storage, preparation, distribution, and food service in accordance with professional standards for food safety. Audits results will be brought to the Quality Assurance meeting for review and recommendations.


5) Date of completion is scheduled for April 29, 2024.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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.
483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on clinical record review and observation, it was determined that the facility failed to ensure that dignity was maintained for two of 18 sampled residents. (Residents 45, 222)

Findings include:

Clinical record review revealed that Resident 45 had diagnoses that included stroke, hemiplegia to the left side, depression, and muscle weakness. Review of the care plan revealed that the resident preferred activities that identified with his prior lifestyle and staff were to include the resident's preferences in rendering care and services. On March 19, 2024, at 1:33 p.m., Resident 45 was observed in bed. The white board on the wall in his room displayed March 11, 2024, and identified an assigned nurse and nurse aide for that date. During the observation, the resident stated that he preferred the white board to be updated daily with accurate and current information and he does not recall the last time staff updated the board. Observations on March 20, 2024, at 11:52 a.m., and March 21, 2024, at 11:20 a.m., revealed that the resident's white board still displayed March 11, 2024, with the same staff names.

Clinical record review revealed that Resident 222 had diagnoses that included obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow) and neurogenic bladder (lack of bladder control due to brain, spinal cord or nerve problems). Resident 222 was ordered by the physician to utilize a foley catheter for urination. Observations on March 19, 2024, from 11:04 a.m. through 1:00 p.m., and March 21, 2024, from 10:39 a.m. through 11:15 a.m., revealed Resident 222 sitting in a wheelchair in the common area. The foley catheter bag was not covered and contained urine. Multiple residents and staff were present in the same area during those time periods. During an interview on March 22, 2024, at 10:49 a.m., the Director of Nursing confirmed that Resident 222 had a foley catheter without a dignity bag.

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



 Plan of Correction - To be completed: 04/29/2024

Plan of Correction F550 (Resident Rights)

1) Resident 222 was provided a dignity bag for their Foley Catheter on March 21, 2024. Resident 45's whiteboard was updated to reflect daily notices and correct date on March 22, 2024.

2) The Director of Nursing or designee will complete an audit of current residents with Foley Catheters to ensure dignity bags were provided and are in proper use. Director of Nursing or Designee will audit whiteboards of current residents to ensure information is up to date with accurate and current information.

3) The Director of Nursing or designee will provide education to nursing team members on the proper use of dignity bags for residents with Foley catheters. Director of Nursing or Designee will provide education to nursing team members on the requirement to ensure resident whiteboards include up to date with accurate and current information.


4) The Director of Nursing or designee will conduct an audit of two random residents with Foley catheters weekly for four weeks and then two random residents with Foley catheters monthly for two months to ensure dignity bags are utilized. The Director of Nursing or designee will conduct an audit of two random residents' whiteboards weekly for four weeks and then two random residents' whiteboards monthly for two months to ensure resident whiteboards are up to date with accurate and current information. Audits results will be brought to the Quality Assurance meeting for review and recommendations.


5) Date of completion is scheduled for April 29, 2024.



483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 18 sampled residents. (Resident 15)

Findings include:

Clinical record review revealed that Resident 15 had diagnoses that included pleural effusion, dysphagia (difficulty swallowing), and lymphedema. Review of the care plan revealed that Resident 15 was at risk for dehydration and weight changes and staff were to monitor weights and report changes to the physician. On November 17, 2023, the physician ordered for the resident to be weighed daily. There was no evidence that weights were obtained on March 4, 7, 9, and 17, 2024.

On January 19, 2024, there was an order for staff to notify the physician of a two pound (lb.) weight gain or loss in one day or a five lb. weight change in one week. Review of the resident's weight record revealed that she experienced weight changes of greater than two pounds in one day on the following dates:

A loss of 3.6 lbs. from January 31, 2024, through February 1, 2024.
A gain of 3.6 lbs. from February 15 through 16, 2024.
A loss of 3.8 lbs. from February 18 through 19, 2024.
A gain of 4.2 lbs. from February 19 through 20, 2024.
A loss of 4.4 lbs. from February 20 through 21, 2024.
A gain of 2.6 lbs. from February 26 through 27, 2024.
A loss of 4.8 lbs. from March 5 through 6, 2024.

There was no evidence that the physician was notified of the weight loss or increase of greater than two lbs. in one day as ordered.

In an interview on March 22, 2024, at 11:08 a.m., the Director of Nursing confirmed that Resident 15's weights were not obtained as ordered and that the doctor was not notified of the weight changes as ordered.

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



 Plan of Correction - To be completed: 04/29/2024

Plan of Correction F684 (Quality of Care)

1. Resident 15's suffered no ill effects from the omitted dates identified and the resident's weight records for the past month have been reviewed by the Physician.

2. The Director of Nursing or designee will conduct an audit of current residents' weight records to ensure weights are obtained per Physician orders and follow up Physician notification occurs if necessary to ensure compliance.

3. The Director of Nursing or designee will provide education to nursing team members on obtaining and documenting weights per Physician orders and follow up Physician notification if necessary.

4. The Director of Nursing or designee will audit four random residents weight records weekly for four weeks and then two random residents weight records monthly for two months to ensure weights are obtained and documented as ordered and if needed follow up notifications have occurred. Audits results will be brought to the Quality Assurance meeting for review and recommendations.

5. Date of completion is scheduled for April 29, 2024.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) of transfer(s) in writing upon transfer from the facility for two of two sampled residents who were transferred to the hospital. (Residents 2, 23)

Findings include:

Clinical record review revealed that Resident 2 was transferred and admitted to the hospital on December 30, 2023, after a change in condition. There was no documentation to support that the resident and/or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital.

Clinical record review revealed that Resident 23 was transferred and admitted to the hospital on March 6, 2024, after a change in condition. There was no documentation to support that the resident and/or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital.

In an interview on March 22, 2024, at 10:36 a.m., the Assistant Administrator confirmed that written notice regarding transfer from the facility was not provided.




 Plan of Correction - To be completed: 04/29/2024

Plan of Correction F623 (Notice Requirements before Transfer/Discharge)

1) Residents 2 & 23 were provided notice of discharge documentation form April 2, 2024.

2) The Admission Director or designee will complete an audit of currently hospitalized residents to ensure the Transfer/Discharge form was provided to the resident or representative.

3) The Admissions Director or designee will provide education on the Transfer/Discharge form with residents at resident council. The Director of Nursing or designee will provide education to licensed nursing team members on the Transfer/Discharge form and process.

4) The Admission Director or designee will audit two random residents who were transferred to the hospital weekly for four weeks and then one random resident who was transferred to the hospital monthly for two months to ensure the Transfer/Discharge form was provided to the resident or representative. Audits results will be brought to the Quality Assurance meeting for review and recommendations.


5) Date of completion is scheduled for April 29, 2024.



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