Pennsylvania Department of Health
 GREENTREE SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GREENTREE SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  167 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
GREENTREE SKILLED NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to a complaint, completed on March 22, 2024, it was determined that Greentree Skilled Nursing and Rehabilitation Center, was not in compliance with the requirements of 42 CFR part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.


 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 review of dish machine temperature/sanitation logs, observations, and staff interviews, it was determined that the facility failed to follow proper sanitation and temperature procedures for the dish machine operation allowing for the potential for cross contamination in the main kitchen for seven of nine months (July 2023, August 2023, October 2023, November 2023, January 2024, February 2024 and March 2024).

Findings include:

During a observation of the staff use of the low temperature dish machine, the Assistant Dietary Manager Employee E4 stated that she did not know what the temperatures of the dish machine wash should be or the sanitation level that is required to make certain the dishes and items being washed were sanitized and clean for resident use.

During an review of the dish machine temperature logs from January 2024 through March 2024. The previous logs from July 2023 through December 2023 identified wash temperatures required to be 120 degrees and sanitation levels at 50 to 100 parts per million (PPM).

Further review of the logs indicated the following:

July 2023 6 of 31 days the wash temperature did not reach 120 degrees
August 2023 the sanitizer documented level was a line from 8/1 through 8/31.
October 2023 two of 31 days the wash temp was below 120 and two of 31 days the documented wash temp was not completed. on 5 of 31 days the sanitization level was not documented.
November 2023, the wash temperature was 140 through the 15th then a line indicated the temp, no number. on 1 of 30 days a sanitization level was not indicated.
January, February and March 2024, the log had no indication of a value that needed to be met to ensure cleanliness and sanitation levels were met.
January log had 3 of 31 days of wash temp not documented or not met for breakfast. There were three days of wash temps documented for lunch and none for dinner. Sanitation levels were documented on 11 days for breakfast only.
February log had not sanitation levels documented as being completed.
March had no sanitation levels completed.

During an interview on 3/19/24, at 9:42 a.m., Dietary Manager Employee E5 confirmed that the facility failed to to follow proper sanitation and temperature procedures for the dish machine operation allowing for the potential for cross contamination in the main kitchen for seven of nine months reviewed.

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


 Plan of Correction - To be completed: 05/09/2024

Dietary Manager adjusted Dish Machine temperature and chemical disinfectant log to include published parameters and documentation of test results.

All staff will be educated on Dish Machine temperature and chemical disinfection log to include understanding of published parameters and documentation of test results. In addition to not utilizing dishes if they do not meet washing requirements and immediately notifying the Dietary Manager.

Dietary Manager/designee will monitor accurate completion and response to logs 3x a week x 2 weeks; weekly x 2 weeks; then monthly thereafter with reporting through Quality Assurance and Process Improvement Committee for review and/or recommendation ongoing.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:
Based on review of facility policy, resident group meeting and resident and staff interview, it was determined that the facility failed to demonstrate a response to grievances for resident group meeting for five of six residents held during the annual survey (Residents R100, R101, R102, R103, R104).

Findings include:

A review of the facility "grievance procedure" policy last reviewed on 1/23/24, with a previous review date of 7/19/23, indicated that all concerns can be written and placed in the concern form collection box and five locations identified or residents can seek out Administration team or staff member with concerns. Concerns presented to the Administrator is typically responded to within 72 hours.

During the Resident Council Meeting on 3/20/24, at 10:15 a.m., the resident consensus indicated that they have no idea who the grievance officer is and they do not know where and how to file an anonymous grievance and they have told staff about issues and have never heard back from anyone when they have brought concerns up. Staff just tell them they'll get back to them and don't.

During an interview on 3/20/24, at 12:40 p.m., the Nursing Home Administrator (NHA) were made aware of the resident concerns related to resolution of grievances and inability to identify the officer. During this interview, the NHA confirmed she was the grievance officer.

28 Pa. Code: 201.18(e)(4) Management.


 Plan of Correction - To be completed: 05/09/2024

The statements included are not an admission and do not constitute agreement with the alleged deficiencies herein. The plan of correction is completed in the compliance of state and federal regulations as outlined. To remain in compliance with all federal and state regulations the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance.

On 03/20/24 Administrator updated grievance postings with the current administrator's name at designated locations. Postings will maintain information on how to file an anonymous complaint.

Social Services/designee will conduct interviews with all cognitive residents and resident representatives for those without cognition for any outstanding grievance(s).

Residents will be educated at the resident council on who is the grievance officer and how to file an anonymous grievance, the grievance process and who the grievance offer is. Staff will be educated on who is the grievance officer and how residents may file an anonymous grievance, the grievance process and who the grievance offer is. Administrator will receive education from the Market president on the same.

Director of Life Enrichment will document Council concerns/problems in Resident Council Minutes. Individual concerns, will be addressed on a grievance/concern form and turned into the Administrator upon completion of the Resident Council meeting. Nursing Home Administrator will monitor timely addressment of grievances, 3x a week x 2 weeks; weekly x 2 weeks; then monthly thereafter with reporting through Quality Assurance and Process Improvement Committee for review and/or recommendation ongoing.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:
Based on facility policy, observation, and staff interview, it was determined that the facility failed to provide a safe and sanitary environment to help prevent the potential for cross-contamination for two of four medication carts (2nd A/B Hall Treatment Cart and B/C Hall Treatment Cart).

Findings include:

Review of the facility policy "Storage and Expiration Dating of Medications, Biologicals" dated 1/23/24, indicated the facility should ensure that medications and biologicals are stored in an orderly manner and that external use medications and biologicals are stored separately from internal use medications and biologicals.

During an observation of the "2nd A/B Hall Treatment Cart" stored in the medical supply room, it was noted that the drawer containing treatment supplies was divided into four sections.
Top, left section:
(1) tube of triamcinolone (prescription skin cream) for Resident R112, not in a bag.
(1) tube of Santyl (prescription wound ointment) for Resident R40, not in a bag.
(1) tube of Premarin conjugated estrogen (prescription vaginal cream), for Resident R96, not in a bag.

Top, right section:
(1) tube of lidocaine cream (prescription pain relief cream) for Resident R300, not in a bag. This resident discharged from the facility on 4/13/23.
(1) tube of Venelex (prescription ointment for pressure wounds) without a resident name, not in a bag.
(1) empty box of Santyl for Resident R40, with the tube next to the box, not in a bag.

Bottom, right section:
(1) tube of hemorrhoid cream, with a room number written on it for the first floor, not in a bag.
(1) tube of hemorrhoid cream, without a name or room number written on it, not in a bag.
(1) tube of Santyl for Resident R40, opened, not in a bag.
(1) tube of Nystatin (antifungal) cream for Resident R17, not in a bag.

Additionally, observed in other drawers in the cart were:
(1) tube of Mupirocin ointment (prescription antibacterial ointment), for Resident R301 not in a bag. This resident discharged from the facility on 6/21/23.
(1) tube of moisturizing cream for Resident R37, not in a bag. This resident has not resided on the Second-Floor nursing unit since 4/3/23.


During an observation of the "B/C Hall Treatment Cart" stored in the medical supply room, it was noted that the drawer containing treatment supplies was divided into four sections.
Top, left section:
(2) tubes of triamcinolone for Resident R100, not in a bag.
(2) containers of Nystatin powder for Resident R102, not in a bag.
(1) tube of Clotrimazole cream (antifungal cream) for Resident R79, not in a bag.
(1) tube of Bacitracin cream (antibacterial cream) for Resident R63, not in a bag.

Bottom, left section:
(1) tube of Clotrimazole cream (antifungal cream) for Resident R79, not in a bag.
(1) tube of ammonium lactate cream (prescription skin cream) for Resident R86, not in a bag.

Top, right section:
(1) tube of Bacitracin cream for Resident R63, not in a bag.
(1) tube of athlete's foot cream, with a room number written on it for the first floor, not in a bag.

Bottom, right section:
(1) tube of Diclofenac gel (prescription pain relieving gel) for Resident R112, not in a bag.
(1) tube of Premarin conjugated estrogen, for Resident R96, not in a bag. A "Hazardous Drug" sticker was affixed to the tube.

Additionally, observed in other drawers in the cart were:
(1) tube of antifungal cream, without a name or room number written on it, not in a bag.
(1) tube of triamcinolone for Resident R63, opened and undated.
(1) tube of stomahesive paste (skin barrier paste used with colostomies), without a name or room number written on it, not in a bag.
(1) tube of triple antibiotic ointment, without a name or room number written on it, not in a bag.

During an interview on 2/21/24, at approximately 12:15 p.m. Unit Manager Employee E1 confirmed the above observations, and further confirmed that the co-mingling of multiple residents' medications and medications with different administrative routes created the potential for cross-contamination.

During an interview on 3/22/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Infection Preventionist Employee E2 confirmed that the facility failed to provide a safe and sanitary environment to help prevent the potential for cross-contamination for two of four medication carts.

28 Pa. Code: 201.14(a) Responsibility of licensee.

28 Pa. Code: 211.10(d) Resident care policies.

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

28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.


 Plan of Correction - To be completed: 05/09/2024

Upon notation, the second floor Nurse Unit Manager removed all unbagged topical medications from the treatment cart and replaced them with correctly labeled and dated storage bags.

All treatment carts will be audited for topical medications that are not correctly labeled or in storage bags to prevent cross contamination. Identified deficiencies will be corrected upon notation.

All nurses will receive education on proper storage of topical medications in compliance with biological storage guidelines and infection control practice to prevent cross contamination.

Director of Nursing and/or designee will complete audits of proper storage of topical medications in compliance with biological storage guidelines and infection control practice to prevent cross contamination and Central Supply coordinator 3x a week x 2 weeks; weekly x 2 weeks; then monthly thereafter with reporting through Quality Assurance and Process Improvement Committee for review and/or recommendation ongoing.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:
Based on review of facility policy, Centers for Disease Control (CDC) documents, observations, and staff interview, it was determined that the facility to make certain that medications and medical supplies were properly stored and/or disposed of on one of two nursing units (Second-Floor Nursing Unit).

Findings include:

Review of the facility policy "Storage and Expiration Dating of Medications, Biologicals" dated 1/23/24, indicated the facility should ensure that:
-Medications and biologicals are stored in an orderly manner.
-External use medications and biologicals are stored separately from internal use medications and biologicals.
-Medications and biologicals that have an expired dated on the label are stored separate from other medications until destroyed or returned to the pharmacy or supplier.

Review of the CDC's "NIOSH (National Institute for Occupational Safety and Health) List of Antineoplastic and Other Hazardous Drugs in Healthcare, 2016" dated September 2016, indicated that conjugated estrogens are "Known to be human carcinogens."

During an observation of the Second-Floor Nursing Unit on 3/19/24, at 11:31 a.m. the following was observed in the medication room and in the medical supply room:
(13) feeding pump bags, with an expiration date of 12/31/22.
(20) packages of Xeroform (dressing impregnated with petrolatum and an antimicrobial compound) with an expiration date of 06/2022.
(24) packages of Xeroform with an expiration date of 01/2023.
(1) package of Xeroform with an expiration date of 08/2023.
(7) packages of Xeroform with an expiration date of 3/10/24.
(13) colostomy bags with an expiration date of 4/24/23.
(8) colostomy wafers with an expiration date of 6/22/23.
(1) package of Fibracol (collagen wound dressings) with an expiration date of 7/31/22.
(7) packages of Fibracol with an expiration date of 12/31/22.
(2) packages of Fibracol with an expiration date of 1/31/23.
(1) Molnlycke Melgisorb (gelling fiber dressing) with an expiration date of 12/28/23.
(1) urethral catheter, with an expiration date of 6/28/22.
(8) packages of Hydrofera Blue (antibacterial foam dressing) an expiration date of 4/1/22.
(1) package of Hydrofera Blue an expiration date of 2/1/24.
(1) Urinary catheter stabilizer with an expiration date of 04/2022.
(1) Urinary catheter stabilizer with an expiration date of 02/2023.
(25) packages of Steri-strips (skin closure adhesive strip) with an expiration date of 06/2021.
(1) Intravenous (IV) access start kit with an expiration date of 1/17/22.
(1) Sterile field towel with an expiration date of 10/2015.
(1) Sterile dressing change kit, open to air, with an expiration date of 9/18/23.
(1) Sorbaview Shield (clear covering for IV access) with an expiration date of 05/2023.
(1) Sorbaview Shield with an expiration date of 05/2023.
(7) packages of lubricating jelly with an expiration date of 03/2023.

During an observation of the "2nd A/B Hall Treatment Cart" stored in the medical supply room, it was noted that the drawer containing treatment supplies was divided into four sections.
Top, left section:
(1) tube of triamcinolone (prescription skin cream) for Resident R112, opened, undated, not in a bag.
(1) tube of triamcinolone for Resident R112, opened and undated.
(1) tube of Santyl (prescription wound ointment) for Resident R40, opened, undated, not in a bag.
(1) tube of Premarin conjugated estrogen (prescription vaginal cream), for Resident R96, opened, undated, not in a bag. A "Hazardous Drug" sticker was affixed to the tube.

Top, right section:
(1) tube of lidocaine cream (prescription pain relief cream) for Resident R300, opened, undated, not in a bag. This resident discharged from the facility on 4/13/23.
(1) tube of Venelex (prescription ointment for pressure wounds) without a resident name, opened, undated, not in a bag.
(1) empty box of Santyl for Resident R40, with the tube next to the box, opened, undated, not in a bag.

Bottom, right section:
(1) tube of hemorrhoid cream, with a room number written on it for the first floor, opened, undated, not in a bag.
(1) tube of hemorrhoid cream, without a name or room number written on it, opened, undated, not in a bag.
(1) tube of Santyl for Resident R40, opened, not in a bag.
(1) tube of Nystatin (antifungal) cream for Resident R17, opened, undated, not in a bag.

Additionally, observed in other drawers in the cart were:
(1) tube of Mupirocin ointment (prescription antibacterial ointment), for Resident R301, opened, undated, not in a bag, with an expiration date of 12/2022. This resident discharged from the facility on 6/21/23.
(1) tube of moisturizing cream for Resident R37, opened, not in a bag. This resident has not resided on the Second-Floor nursing unit since 4/3/23.
(1) package of rolled gauze, not in packaging.
(5) partially used, open to air, packages of Xeroform.

During an observation of the "B/C Hall Treatment Cart" stored in the medical supply room, it was noted that the drawer containing treatment supplies was divided into four sections.
Top, left section:
(2) tubes of triamcinolone for Resident R100, opened, undated, not in a bag.
(2) containers of Nystatin powder for Resident R102, opened, undated, not in a bag.
(1) tube of Clotrimazole cream (antifungal cream) for Resident R79, opened, undated, not in a bag.
(1) tube of Bacitracin cream (antibacterial cream) for Resident R63, opened, undated, not in a bag.

Bottom, left section:
(1) tube of Clotrimazole cream (antifungal cream) for Resident R79, opened, undated, not in a bag.
(1) tube of ammonium lactate cream (prescription skin cream) for Resident R86, opened, undated, not in a bag.

Top, right section:
(1) tube of Bacitracin cream for Resident R63, opened, undated, not in a bag.
(1) tube of athlete's foot cream, with a room number written on it for the first floor, opened, undated, not in a bag.

Bottom, right section:
(1) tube of Diclofenac gel (prescription pain relieving gel) for Resident R112, opened, undated, not in a bag.
(1) tube of Premarin conjugated estrogen, for Resident R96, opened, undated, not in a bag. A "Hazardous Drug" sticker was affixed to the tube.

Additionally, observed in other drawers in the cart were:
(1) tube of antifungal cream, without a name or room number written on it, opened, undated, not in a bag.
(1) tube of triamcinolone for Resident R63, opened and undated.
(1) tube of stomahesive paste (skin barrier paste used with colostomies), without a name or room number written on it, opened, undated, not in a bag.
(1) tube of triple antibiotic ointment, without a name or room number written on it, opened, undated, not in a bag.

During an interview on 2/21/24, at approximately 12:15 p.m. Unit Manager Employee E1 confirmed the above observations.

During an interview on 3/22/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that medications and medical supplies were properly stored and/or disposed of on one of two nursing units.

28 Pa. Code: 201.14 (a) Responsibility of licensee.

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

28 Pa. Code: 211.9 (a)(1) Pharmacy services.

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


 Plan of Correction - To be completed: 05/09/2024

Upon notation, the second floor Nurse Unit Manager disposed of expired supplies, treatments and medications and replaced them with unexpired supplies, treatments and medications.

All units and storage areas will be audited for expired supplies, treatments and medications. Expired supplies, treatments and medications will be disposed of.

Nurses will receive education regarding verification of expiration dates for supplies, treatments and medications prior to use and disposal of items noted to be expired. Central Supply Coordinator will receive education on checking expiration of items in areas that Central Supply stocks and disposal of expired supplies.

Director of Nursing and/or designee will complete audits of each unit to include medication and treatment carts and supply storage areas 1 x weekly for 3 weeks, then monthly thereafter with reporting through Quality Assurance and Process Improvement Committee for review and/or recommendation ongoing.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:
Based on review of the facility policy and clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for eight of the twelve residents reviewed (Resident R16, R21,R29, R32, R39, R44, R47, R67, R68, R127, R134, R142).

Findings Include:

A review of the facility policy "Advanced Directives" on 7/19/2023, 1/23/2024, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive.

A review of the medical record indicated Resident R16 was admitted to the facility on 5/3/2022, with diagnoses that included diabetes, high blood pressure and dementia.

A review of the clinical record failed to reveal an advance directive or documentation that Resident R16 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R21 was admitted to the facility on 6/22/2023, with diagnoses that include diabetes, high blood pressure and end stage renal disease (ESRD-kidneys no longer work).

A review of the clinical record failed to reveal an advance directive or documentation that Resident R21 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R29 was admitted to the facility on 9/21/2019, with diagnoses that include cerebral palsy (difficulty walking and affects muscles), weakness, weight loss.

A review of the clinical record failed to reveal an advance directive or documentation that Resident R29 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R32 was admitted to the facility on 1/27/2022, with diagnoses that include diabetes, depression and high blood pressure.

A review of the clinical record failed to reveal an advance directive or documentation that Resident R32 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R39 was admitted to the facility on 5/11/2022, with diagnoses that include high blood pressure, muscle weakness and anxiety.

A review of the clinical record failed to reveal an advance directive or documentation that Resident R39 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R44 was admitted to the facility on 2/24/2024, with diagnoses that include diabetes, ESRD, heart failure (heart is weak and does not pump blood like it did).

A review of the clinical record failed to reveal an advance directive or documentation that Resident R44 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R47 was admitted to the facility on 10/5/2023, with diagnoses that include diabetes, low blood pressure and parkinson's disease (affects movement and can include tremors).

A review of the clinical record failed to reveal an advance directive or documentation that Resident R47 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R67 was admitted to the facility on 1/18/2024, with diagnoses that include End stage renal disease (kidneys no longer work), diabetes, dementia.

A review of the clinical record failed to reveal an advance directive or documentation that Resident R67 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R68 was admitted to the facility on 3/2/2024, with diagnoses that include diabetes, depression, ESRD.

A review of the clinical record failed to reveal an advance directive or documentation that Resident R68 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R127 was admitted to the facility on 8/8/2023, with diagnoses that include depression, anxiety, anemia (not enough blood).

A review of the clinical record failed to reveal an advance directive or documentation that Resident R127 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R134 was admitted to the facility on 7/18/2023, with diagnoses that include depression, heart failure and chronic obstructive pulmonary disease (COPD-blocks airflow making it difficult to breathe).

A review of the clinical record failed to reveal an advance directive or documentation that Resident R134 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R142 was admitted to the facility on 12/12/2023, with diagnoses that include anemia, orthostatic hypotension (blood pressure drops when standing up), dysphagia (difficulty swallowing).

A review of the clinical record failed to reveal an advance directive or documentation that Resident R142 was given the opportunity to formulate an Advanced Directive.

During an interview on 3/22/2024, at 12:32 p.m. the DON confirmed that the clinical record did not include documentation that Resident R16, R21, R29, R32, R34, R44, R47, R67, R68, R127, R134, and R142, were not afforded the opportunity to formulate Advance Directives.

28 Pa. Code 201.29 (j) Resident rights.


 Plan of Correction - To be completed: 05/09/2024

Advance directive was completed By NP on Resident R16; R21; R29
R32; R39; R44; R47; R67; R127; R134; R142; R68; and R34

All Licensed staff including MD and NP will be educated on providing all residents the opportunity to formulate an advance directive or documentation in medical record that written information was provided to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the residents option, formulate an advance directive.

Whole house audit will be completed to ensure all residents the opportunity to formulate an advance directive or documentation in medical record that written information was provided to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the residents option, formulate an advance directive.

An audit will be completed to ensure all resident the opportunity to formulate an advance directive or documentation in medical record that written information was provided to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the residents option, formulate an advance directive 3x a week x 2 weeks; weekly x 2 weeks; then monthly thereafter with reporting through Quality Assurance and Process Improvement Committee for review and/or recommendation ongoing.

483.10(j)(1)-(4) REQUIREMENT Grievances:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:
Based on the facility policy, observations, Resident group meeting and staff interview, it was determined that the facility failed to provide residents access to grievance forms, failed to provide the right to file grievances anonymously, and failed to post the name of the Grievance Official for residents to file a grievance orally (meaning spoken) for 155 of 155 residents at the facility.

Findings include:

A review of the facility "grievance procedure" policy last reviewed on 1/23/24, with a previous review date of 7/19/23, indicated that all concerns can be written and placed in the concern form collection box and five locations identified or residents can seek out Administration team or staff member with concerns. Concerns presented to the Administrator is typically responded to within 72 hours. The posted procedure indicated the second previous Administrator as the grievance officer.

Review of the facility "Resident Admission Packet" indicated that the facility follows the resident rights of being able to file a grievance.

During an observation on 3/19/24, from 9:00 a.m. through 10:00 a.m. throughout the facility there was no grievance forms found in the bins identified as the grievance forms in any of the identified areas on the grievance procedure.

During a group interview on 3/20/24, at 10:15 a.m., Residents R100, R101, R102, R103 and R104 indicated they did not know how to file a grievance and were never told they could, where the forms are or how to file an anonymous grievance.

During an interview on 3/20/24, at 12:40 p.m., the Nursing Home Administrator and Director of Nursing indicated that the facility currently has no grievance officer information posted and forms are not available to file a grievance.

28 Pa. Code: 201.18(e)(4) Management.

28 Pa. Code: 201.29(a)(j) Resident rights.


 Plan of Correction - To be completed: 05/09/2024

On 03/20/24 Administrator ensured that grievance forms were available at designated locations. Postings include information on who is the Grievance Officer and how to file an anonymous complaint.

Social Services/designee will conduct interviews with all cognitive residents and resident representatives for those without cognition for any outstanding grievance(s).

Residents will be educated at the resident council on who is the grievance officer and how to file an anonymous grievance, the grievance process and who the grievance offer is. Staff will be educated at the resident council on who is the grievance officer and how to file an anonymous grievance, the grievance process and who the grievance offer is. Administrator will receive education from the Market President on the same.

Grievance officer posting and Grievance forms availability will be monitored by the Administrator 3x a week x 2 weeks; weekly x 2 weeks; then monthly thereafter with reporting through Quality Assurance and Process Improvement Committee for review and/or recommendation ongoing.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:
Based on review of facility policy, review of resident council meeting minutes, facility concern/grievance log and clinical records, and resident and staff interviews, it was determined that the facility failed to investigate potential abuse and/or neglect for three of 35 residents(Resident R209, R302 and R37).

Findings include:

Review of the facility "Abuse Prohibition" policy reviewed on 1/23/24, with a previous review date of 7/19/23, indicated that the facility Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, injuries of unknown origin, etc. The facility will protect the residents from further abuse during investigation and the investigation will begin within 24 hours. All allegations will be reported to the state agencies in accordance with state law.

Review of the clinical record indicated Resident R209 was admitted to the facility on 2/20/24, with diagnoses which included sepsis(infection), breast cancer, cute kidney failure, acute pulmonary edema (too much fluid in the lungs causing shortness of breath). Resident R209 had required a intravenous line to her heart for her antibiotics for an infection of her chest wall which also required a wound treatment. An MDS(Minimum Data Set-a periodic assessment of resident care needs) dated 2/26/24, indicated the diagnoses remained current.

Review of Resident R209's "Order Summary Report" dated from 2/20/24, through 3/31/24, indicated Resident R209 required her left chest port to be cleansed with saline solution, patted dry, packed with iodoform(a strip embossed with iodine) and covered with s sterile dressing twice a day.

Review of Resident R209's Treatment Administration Record (TAR) the treatment had not been completed from 2/23/24, evening shift through 2/27/24, dayshift, missing missing six treatments.

Review of the clinical record indicated that Resident R302 was admitted to the facility on 1/19/24, with diagnoses of a fracture of her left leg, lung disease, malnutrition, communication deficit with constipation and diarrhea both identified. Resident R302 was on stool softeners. An MDS dated 1/25/24, indicated the diagnoses remained current.

Review of a grievance placed by CMS Immediate Advocacy Program dated 2/6/24, indicated that the nursing Home Administrator and Director of Nursing were notified of a concern placed related to Resident R302 being left to sit in a soiled brief for an "extended time".

During an interview on 3/22/24, at 10:02 a.m., the Director of Nursing confirmed that the facility failed to identify the concern as neglect, failed to investigate the concern and failed to notify the state agencies as required.

Review of the clinical record indicated that Resident R37 was admitted to the faiclity on 8/11/22, with diagnoses which included heart failure, traumatic brain injury, cirrhosis of the liver with intermittent ascites related to disease. An MDS dated 2/16/24, indicated the diagnoses remained current.

During the Resident Council meeting on 3/20/24, at 1015 a.m., Resident R37 stated that he had continued neck pain and headaches after he had another resident fall onto him from behind while he was seated in his wheelchair. Resident R37 stated t happened around Christmastime. He went on to state he had xrays which did not "show anything" and a CT scan that the facility had not told him the results and the doctor had not come back in to review with him. He stated that he feels like his hearing is worse now also.

Review of a progress note dated 12/24/23, indicated Resident R37 was examined by the Medical Director and told him about the incident and that's when xrays were ordered.

During an interview on 3/20/24, at 2:16 p.m., the Director of Nursing stated that an incident report and investigation was not completed as "Resident R37 had a brain injury and we decided his memory could be cloudy."

Review of Resident R37's xray report of the cervical spine dated 12/26/23, indicated that a fracture could not be excluded and a repeat xray and CT scan were recommended.

During a review of the clinical record, the CT scan report had not been obtained by the facility.

During a phone interview with the Medical Director on 3/21/24, at 10:00 a.m., the Medical Director stated that he remembered Resident R37's conversation and that he had reviewed the CT scan at the hospital and it showed arthritis and no fracture. The facility then received the report to provide to the survey team, the CT scan had been completed on 1/26/24.

During an interview on 3/21/24, at 10:20 a.m., the DON stated that the facility failed to investigate the incident although Resident R37's continued pain and recollection of the incident never changed.


28. Pa Code 201.14(a) Responsibility of licensee.

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

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



 Plan of Correction - To be completed: 05/09/2024

R209 had a DOH and APS reports were filed and investigation completed. Resident no longer resides at the center.
R302, grievance was filed and addressed with resident. Resident no longer resides at the center.
R37s allegation of injury incident was completed, physician aware, negative results of CT scan reviewed with resident. R37 had an audiology appointment on 04/30/2024 regarding complaints of worsening hearing.

Whole house audit will be completed for the last 3 months of grievances and incidents to ensure all abuse, neglect, exploitations and mistreatments are reported and thoroughly investigated to prevent further abuse, neglect, exploitations, and mistreatment by NHA/designee.

All staff will be educated on any allegations of abuse, neglect, exploitation, or mistreatment will be reported and thoroughly investigated to prevent further abuse, neglect, exploitation, or mistreatment. All reports will go to the Abuse Coordinator and/or Administrator and to officials in accordance with State law, including the state survey agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.The Director of Nursing will be educated by NHA on identifying the concern for neglect, investigating a concern, and reporting requirements to state agencies.

Administrator or designee will complete audits on all all incidents and grievances to ensure that abuse, neglect, exploitations and mistreatments are reported and thoroughly investigated 3x a week x 2 weeks; weekly x 2 weeks; then monthly thereafter with reporting through Quality Assurance and Process Improvement Committee for review and/or recommendation ongoing.

483.25 REQUIREMENT Quality of Care: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 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 observations and resident and staff interviews, it was it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for four of four residents (Resident R20, R45, R83, and R145).

Findings include:

Review of Resident R20's admission record indicated he was admitted to the facility on 2/22/24.

Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 3/7/24, included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels) and a seizure disorder.

Review of an active physician order dated 3/10/24, indicated Resident R20 should have ACE wraps applied to both legs, on in the morning and off at the hour of sleep.

During an observation on 3/20/24, at approximately 11:35 a.m. Resident R20 had his ACE wraps applied in the direction from the knees to the toes.

Review of Resident R45's admission record indicated she was admitted to the facility on 12/29/23.

Review of the MDS dated 3/6/24, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and high blood pressure.

Review of a physician order dated 1/20/24, indicated Resident R45 should have ACE wraps applied to both lower extremities every morning and off at the hour of sleep.

During an observation on 3/20/24, at approximately 11:40 a.m. Resident R45 failed to have ACE wraps applied.

Review of Resident R83's admission record indicated she was admitted to the facility on 6/28/18.

Review of the MDS dated 12/28/23, included coronary artery disease and high blood pressure.

Review of a physician order dated 3/9/24, indicated Resident R83 should have ACE wraps applied to both lower extremities every morning and off in the evening.

During an observation on 3/20/24, at approximately 11:43 a.m. Resident R83 had her ACE wraps applied in the direction from the toes to the knees, and then in the direction from the knees to the toes again.

During an interview and observation on 3/21/24, at approximately 11:25 a.m. Resident R83 stated that she had removed the ACE wrap on her left leg due to it being painful from being too tight. Observation of the right leg revealed that the ACE wrap was applied tightly, particularly over the ankle, with significant swelling both above and below the ankle.

Review of Resident R145's admission record indicated he was admitted to the facility on 12/27/23.

Review of the MDS dated 2/2/24, included diagnoses of malnutrition (lack of sufficient nutrients in the body) and high blood pressure.

Review of a physician order dated 2/27/24, indicated Resident R145 should have compression stockings applied to both lower extremities every morning and off at the hour of sleep.

During an observation on 3/20/24, at approximately 11:42 a.m. Resident R145 was noted to have fluid seeping through his compression stocking on outer side of the lower left leg. Further observation of the stocking revealed a circle of dried fluid larger than the current area of seepage.

During an observation on 3/21/24, at approximately 11:15 a.m. Resident R145 was noted to have fluid seeping through his compression stocking on outer side of the lower left leg. Further observation of the stocking revealed areas of dried fluid.

During an interview on 3/21/24, at 11:17 a.m. Unit Manager Employee E1 confirmed that Resident R145 had seepage present on his compression stockings and that it appeared that new stockings were not applied when the previous were soiled.

During an interview on 3/22/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to make certain that residents were provided appropriate treatment and care for four of four residents.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.29(a)(c)(d)(j) Resident rights.

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

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


 Plan of Correction - To be completed: 05/09/2024

Resident R20 had no ill effect from ACE wraps being applied in the direction from knees to the toes. Nurse on duty corrected wraps upon notation.
R45 had no ill effects from ACE wraps not being applied, nurse on duty applied wraps upon notation.
R83 had no ill effect from ACE wrap tension or wrap being applied from knees to the toes. Nurse on duty corrected wraps upon notation.
R145 had no ill effects from seepage on compression stockings. Nurse on duty changed compression stockings.

All residents with compression stockings, ted hose and ace wraps will be audited for correct application. Identified deficient practice will be corrected upon notation with 1:1 education and return demonstration competency as indicated.

To prevent future occurrence, nurses will receive education on maintenance and use of compression stockings, ted hose and ace wraps.

Director of Nursing and/or designee will complete audits of maintenance and use of compression stockings, ted hose and ace wraps 3x a week x 2 weeks; weekly x 2 weeks; then monthly thereafter with reporting through Quality Assurance and Process Improvement Committee for review and/or recommendation ongoing.

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 review of clinical records and staff interviews, it was determined that the facility failed to make certain that weight loss was identified and addressed and failed to identify needs for increased nutrition for one of five residents (Residents R78).

Findings include:

Review of Centers for Medicare and Medicaid Services GUIDANCE indicated that 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

Altered Nutrient intake, absorption, and utilization: Poor intake, continuing or unabated hunger, or a change in the resident's usual intake that persists for multiple meals, may indicate an underlying condition or illness. Examples of causes include, but are not limited to:
-An inadequate amount of food or fluid, including insufficient tube feedings.
-Diseases and conditions such as cancer, diabetes mellitus, advanced or uncontrolled heart or lung disease, infection and fever, liver disease, kidney disease, hyperthyroidism, mood disorders, gastrointestinal disorders, pressure injuries or other wounds, and repetitive movement disorders (e.g., wandering, pacing, or rocking).

Review of the clinical record indicated Resident R78 was admitted to the facility on 2/13/24.

Review of the Minimum Data Set (MDS- periodic assessment of resident care needs) dated 2/19/24, included diagnoses of dysphagia following cerebral infarction (difficulty swallowing following a stroke) and malnutrition (lack of sufficient nutrients in the body). Section K: Swallowing / Nutritional Status revealed the use of a feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) while a resident.

Review of Resident R78's plan of care for the "Need for feeding tube/ potential for complications of feeding tube use related to dysphagia" initiated 2/15/24, indicated that Resident R78 is to consume nothing by mouth.

Review of Resident R78's plan of care for "Alteration in nutritional status" initiated 2/19/24, included the goal that Resident R78 will maintain adequate nutritional status as evidenced by maintaining weight within (90)% of (current body weight).

On 3/16/24, an order was placed to document Resident R78 ' s weight "one time only for three days" with the notation that "This schedule will appear on the administration record as of the specified start date and will remain until administered or the schedule's end date."

Review of a "Dietary Screening for Malnutrition, At Risk for Malnutrition, Morbid Obesity" dated 2/14/24, indicated Resident R78 was as risk for malnutrition. An additional screening was initiated on 3/1/24, but showing as incomplete.

Review of a "Nutritional Assessment" dated 2/14/24, indicated Resident R78 did not receive any nutrition by mouth, and utilized a nasogastric tube for tube feeding. An additional screening was initiated on 3/1/24, but showing as incomplete.

Review of Resident R78's weight record since admission (2/13/24) revealed the following weights:
2/13/24205.0 pounds
3/19/24171.8 poundsa loss of 16.20% in 35 days.

Review of nurse practitioner's progress notes dated 2/14/24, 2/21/24, 2/27/24, 3/1/24, 3/4/24, 3/13/24, and 3/15/24, all included the verbiage, "Based on my clinical judgement, the following statements most accurately reflects this patient's current nutritional status. Pt is at risk for protein malnutrition. Dysphagia s/p (status post) CVA (cerebral vascular accident, stroke), currently on TF (tube feed) for nutrition. Current weight is 205# on 2/13/24 with BMI (body mass index) of 27.8."

Review of a nutrition note completed by Registered Dietician Employee E3 on 3/18/24, at 4:55 p.m. revealed "Weight is 205# on 2/13/24. No weight changes noted."

During an interview with the DON and Dietician Employee E6 on 3/21/24, at 2:16 p.m., indicated that weights are generally done on admission then weekly times four then monthly unless there is a concern then adjusted accordingly.

During an interview on 3/21/24, at 2:19 p.m., the Director of Nursing and Dietician Employee E6 confirmed that Resident R7,should have been placed on weekly weight assessments upon admission, and further confirmed that Resident R78's weight loss was not addressed in a timely manner.

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: 05/09/2024

Dietician reassessed the nutritional status of R78. Revisions were made to the care plan and interventions revised.

All new residents admitted in the past 4 weeks will have admission weights reviewed by the Registered Dietician. Identified weight losses will have care plans and interventions in place. The Director of Nursing/designee will place orders in all resident charts for weights in accordance with weight monitoring schedules.

The Registered Dietitian, Unit Managers and House Nurse Practitioners will be educated on significant weight change triggers and responses. The Registered Dietician will monitor weights to identify significant changes making adjustments to care plans and interventions as indicated.

Weights obtained from the previous week will be used to identify residents with significant changes, care plans and interventions will be reviewed in weekly weight meetings with revision as indicated. This will be monitored by the Director of Nursing/designee weekly with monthly reporting through Quality Assurance and Process Improvement Committee for review and/or recommendation on going.

§ 201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:
Based on state regulations, staff interview, and review of the facility's Infection Control Committee attendance records, it was determined that the facility failed to ensure that two of the nine required multidisciplinary members were present at the Infection Control Committee meetings (the Laboratory Personnel Member and the Community Member).

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L. 154, No. 13), known as the Medical Care Availability and Reduction of Error (MCARE) Act, Chapter 4, Section 403(1) Infection Control plan states, "A health care facility... shall develop and implement an internal infection control plan that shall include... a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility." A review of the applicable members at infection control meetings include medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plan personnel, patient safety officer, a community member, and a member of the infection control team.

Review of the facility's Infection Control Committee Attendance Log forms dated 6/29/23, 9/25/23, and 11/14/23, failed to reveal that a laboratory personnel member or a community member was in attendance.

During an interview on 3/22/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that two of the nine required multidisciplinary members were present at the Infection Control Committee meetings.


 Plan of Correction - To be completed: 05/09/2024

Unable to correct past deficient practice.
Infection Control Coordinator will be educated by the Director of Nursing Services on multidisciplinary participation requirements to include the lab and a community member.
Multidisciplinary, required participants will include representatives from medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plan personnel, patient safety officer, a community member and a member of the infection control team moving forward.
Director of Nursing Services/designee will monitor meeting participant attendance monthly with reporting through Quality Assurance and Process Improvement Committee for review and/or recommendation moving forward.


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