Every finding on record at Pine Grove Healthcare Center

Based on observation , interview, and record review the facility failed to store food in a sanitary manner for food safety. This had the potential to affect 64 residents who received nourishment by mouth. The facility census was 65. Findings include: Observation on 04/10/24 at 2:00 P.M. revealed the conference room refrigerator had undated squeeze tubes of mayonnaise, relish, mustard. Super Soft Pretzels and a four-quart Cookies and Cream ice cream tub was undated with no resident names on the food products. Interview on 04/10/24 at 2:00 P.M. with Dietary Supervisor #571 revealed resident food was stored in the employee breakroom and staff conference room to maintain safe food temperatures. Dietary Supervisor #571 verified the undated mayonnaise, relish and mustard squeeze tube, Super Soft Pretzels, and four-quart Cookies and Cream ice cream was not dated or labeled with resident names. Dietary Supervisor #571 also stated the kitchen did not purchase these food items. Observation on 04/10/24 at 2:10 P.M. of the 200 Unit nourishment refrigerator revealed two slices of pizza that was not dated or labeled with a resident name. Interview on 04/10/24 at 2:10 P.M. with Assistant Director of Nursing ( ADON)/ licensed practical nurse (LPN) # 507 revealed she was unsure if the pizza in the 200 Unit nourishment refrigerator belonged to a resident or staff member. ADON/ LPN # 507 also stated no resident had received any popsicles and if a resident wanted ice cream they would have to go to the kitchen. Snacks of a variety of sandwiches were delivered at 8:30 P.M. daily, if a resident wanted a sandwich stored the nurse would keep their food in the unit nourishment refrigerator in each nurse unit. Observation on 04/10/24 at 2:30 P.M. revealed the 100 Unit nourishment refrigerator had undated unlabeled Styrofoam container of pudding and undated and unlabeled pasta salad in the refrigerator. An undated, unlabeled Greek yogurt and an undated, unlabeled [NAME] Storm Energy Drink. Finally, a labeled peach tea with a staff member name in the resident nourishment refrigerator was observed. Interview with the ADON/LPN #507 verified there was no names or dates on the pudding, pasta salad, and Greek yogurt. She also stated the peach tea and Energy drink belonged to staff. Interview on 04/10/24 at 3:30 P.M. with the director of nursing (DON) revealed the facility used the employee breakroom, facility conference room and nurse unit nourishment refrigerator to store resident food. The DON stated there was no central nourishment refrigerator to store resident food and maintain labels and dates. Review of facility policy title Use and Storage of Food Brought in by Family and Visitors (dated 11/21/16, revised 08/01/23) revealed food items that are already prepared by the family or visitor must be labeled and dated and the facility may refrigerate items in the nourishment refrigerator.

Based on record review and interview, the facility failed to obtain and provide a speech therapy evaluation and treatment as ordered by the physician for Resident #66. This affected one Resident (#66) of three residents reviewed for change in condition. The facility census was 65. Findings include: Review of the medical record for Resident #66 revealed an admitted [DATE] and discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 12/20/21, revealed Resident #66 had severe cognitive impairment. Resident #66 required extensive two staff assistance for bed mobility, transfers, and toileting, extensive one staff assistance for dressing, eating and personal hygiene, and physical help one staff assistance in part of the bathing activity. The assessment indicated Resident #66 was always incontinent of urine and bowel and during the seven-day look back period, had no coughing or choking during meals or when swallowing medications, or complaints of difficulty or pain when swallowing. Review of the plan of care dated 12/17/21 revealed Resident #66 had altered health maintenance related to progressive physical and mental status due to dementia and [CONDITION(S)]; required assistance with activities of daily living (ADL) and was at risk for developing complications associated with decreased ADL self-performance due to cognitive impairment; and had potential for alteration in nutrition and hydration related to dementia with unavoidable and unplanned weight loss. Interventions included to administer medications as ordered; monitor of signs and symptoms of infection; provide assistance with ADL care as needed including eating; offer meal substitutes with food refusals; and provide supplements as ordered. Review of Resident #66's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of dietary progress note dated 12/28/21 at 3:25 P.M. revealed Resident #66 had a significant weight loss of 16 pounds in one month with an average of 60 percent meal intakes. Fortified oatmeal and a liquid supplement were recommended daily with breakfast, and the physician was notified. Resident #66's status was discussed with the interdisciplinary team. Review of dietary progress note dated 01/11/22 at 9:23 A.M. revealed Resident #66 had a total significant weight loss of 19 pounds in one month with an average of 55 percent meal intakes and was consuming 75 to 100 percent of fortified cereal and liquid supplements. Resident #66's weight loss was documented as unavoidable due to dementia. Liquid supplements were recommended for increase to four times daily with a liberalized diet, and the physician was notified. Interview on 02/12/22 at 12:57 P.M. with Speech Therapist (ST) #303 verified there was no speech therapy evaluation completed and/or treatment provided for Resident #66 prior to discharge on 01/24/22. Interview on 02/12/22 at 1:43 P.M. with Licensed Practical Nurse (LPN) #303 verified there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 02/12/22 at 1:54 P.M. with the Director of Nursing (DON) confirmed a speech therapy evaluation order was obtained as an intervention for weight loss and confirmed it was not completed prior to Resident #66's discharge. This deficiency substantiates Complaint Number OH 740.

Based on interview and personnel record review, the facility failed to ensure dietary manager (DM)#201 met the minimum qualifications to serve as the director of food and nutrition services. This had the potential to affected 56 residents who ate meals from the kitchen (Resident #51 and Resident #157 were ordered tube feedings). The facility census was 58. Findings include: Interview on 02/10/19 10:42 A.M. with DM #201 revealed she did not have a certified dietary manager certificate, certified food service manager certificate, a national certification for food service management and safety from a national certifying body or an associate degree in food service management. DM #201 had information on the regulation and information on how to become a certified dietary manager. DM #201 stated she had accepted the added role as dietary manager more than a year prior. Interview on 02/11/19 at 9:31 A.M. with registered dietitian (RD) #202 revealed she was not full time. RD #202 worked at the facility two days a week and consulted whenever needed. RD #202 knew the dietary manager was not yet certified. She had thought because DM #201 had been hired by the facility, even though it was in housekeeping, before 11/28/16 she had five years to become certified. Interview on 02/11/19 at 11:10 A.M. with the Administrator verified DM #201 did not have a certified dietary manager certificate, certified food service manager certificate, a national certification for food service management and safety from a national certifying body or an associate degree in food service management. The Administrator thought because DM #201 had been hired by the facility, even though it was in housekeeping, before 11/28/16 she had five years to become certified. Interview on 02/13/19 at 10:23 A.M. with the Administrator revealed DM #201 had been registered for the dietary managers certification course as of 02/13/19. Review of the dietary manager (DM) #201's personnel record indicated DM #201 was hired by the facility on 09/15/11 in housekeeping. On 08/31/17 DM #201 accepted the position as housekeeping, laundry and dietary manager. DM #201 had been acting as the dietary manager for more than a year and did not have evidence of a certified dietary manager certificate, certified food service manager certificate, national certification for food service management and safety from a national certifying body or an associate degree in food service management. Review of the 02/10/19 diet order report indicated all residents ate meals from the kitchen except Resident #51 and Resident #157 who were ordered tube feedings.

Based on record review and interview the facility failed to attempt nonpharmacological interventions prior to the administration of psychoactive and anti-anxiety medications or indicate the reason for the administration for one resident (Resident #36). This affected one of five residents reviewed for unnecessary medication administration. Findings include: Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the behavior intervention log and medication administration records (MAR) for May and June, 2015 revealed [MEDICATION NAME] (anti-anxiety medication) was given one time in May, 2015 and six times in June, 2015 without evidence of why it was given and without evidence of nonpharmacological interventions being attempted prior to administration. [MEDICATION NAME] (anti-psychotic medication) was administered one time in May, 2015 and seven times in June, 2015 without evidence of why it was given and without evidence of nonpharmacological interventions being attempted prior to administration. The above findings were reviewed and verified with the director of nursing and assistant director of nursing on 06/25/15 at 11:05 A.M.

Based on observation and interview, the facility failed to afford full visual privacy in nine resident two-bed rooms during the provision of care. Eighteen residents who resided in these rooms could potentially be affected. The facility census was 52. Findings include: During tour of the facility with Housekeeping-Laundry Supervisor #3 on 03/01/12, at 11:50 A.M., the following nine resident rooms were inspected: room [ROOM NUMBER]; room [ROOM NUMBER]; room [ROOM NUMBER]; room [ROOM NUMBER]; room [ROOM NUMBER]; room [ROOM NUMBER]; room [ROOM NUMBER]; room [ROOM NUMBER]; room [ROOM NUMBER]. Two beds were observed in each of these nine rooms. A privacy curtain was seen between each of the two beds in the nine resident rooms. These privacy curtains only extended between the beds. None of the privacy curtains could be extended around the door beds at the foot of these beds to afford full visual privacy for these residents during the provision of care. The residents who resided in the window beds would need to pass the door bed to either access the room bathroom or leave the room. Housekeeping-Laundry Supervisor #3 was interviewed during the tour and these observations were verified with her at that time. The administrator was also interviewed at 1:43 P.M. on 03/01/12 and the lack of full visual privacy for the door beds in the nine resident rooms was confirmed with him at that time.

Based on observation, record review and interview the facility failed to ensure interdisciplinary coordination of care planning and periodic reassessment related to the use of an indwelling Foley catheter. This affected one of 10 residents reviewed regarding care plans of 11 sampled residents on Stage 2. The census was 52 residents. Findings include: Resident #20 was admitted with [DIAGNOSES REDACTED]. The progress notes indicated the resident returned from the urologists office on 09/23/10 with an order to keep a Foley catheter in place for seven days and return to the office on 10/11/10. The notes on 10/12/10 indicated the urologist spoke with the power of attorney regarding treatment for [REDACTED]. There was no further reassessment or documentation regarding the continued use of the indwelling Foley catheter since October, 2010. An interview with Licensed Practical Nurse (LPN) #2 on 02/27/12 at 2:30 P.M. revealed the reason for the continued use of the indwelling Foley catheter as chronic [MEDICATION NAME]. The care plan dated 10/21/10 indicated the use of the indwelling Foley catheter was related to chronic [MEDICATION NAME]. The Foley catheter assessment dated [DATE] indicated the [DIAGNOSES REDACTED]. The assessment indicated a post void residual had been completed, there was supporting diagnostic testing or unsuccessful catheter-free trials documented, yet there were none of these documented. The resident was observed with the indwelling Foley catheter on 02/28/12 at 11:10 A.M. and 3:00 P.M., on 02/29/12 at 4:30 P.M. and on 03/01/12 at 11:00 A.M. An interview with the director of nursing (DON) on 03/01/12 at 10:00 A.M. verified there was no further documentation after October, 2010 regarding the medical justification for the continued use of the indwelling Foley catheter. There was no documentation of any further follow-up with the urologist since October, 2010. An interview with the DON on 03/01/12 at 11:15 A.M. verified there was no documentation or reassessments that included medical justifications for the continued use of the Foley catheter since October, 2010.

Based on observation, record review and interview, the facility failed to ensure an indwelling catheter was medically justified, comprehensively reassessed and monitored for Resident #20. This affected one resident of two residents with indwelling Foley catheters of 11 sampled residents. The census was 52 residents. Findings include: Resident #20 was admitted with [DIAGNOSES REDACTED]. The progress notes indicated the resident returned from the urologists office on 09/23/10 with an order to keep a Foley catheter in place for seven days and return to the office on 10/11/10. The notes on 10/12/10 indicated the urologist spoke with the power of attorney regarding treatment for [REDACTED]. There was no further reassessment or documentation regarding the continued use of the indwelling Foley catheter since October, 2010. An interview with the Licensed Practical Nurse (LPN) #2 on 02/27/12 at 2:30 P.M. revealed the reason for the continued use of the indwelling Foley catheter as chronic [MEDICATION NAME]. The care plan dated 10/21/10 indicated the use of the indwelling Foley catheter was related to chronic [MEDICATION NAME]. The Foley catheter assessment dated [DATE] indicated the [DIAGNOSES REDACTED]. The assessment indicated a post void residual had been completed, there was supporting diagnostic testing or unsuccessful catheter-free trials documented, yet there were none of these documented. The resident was observed with the indwelling Foley catheter on 02/28/12 at 11:10 A.M. and 3:00 P.M., on 02/29/12 at 4:30 P.M. and on 03/01/12 at 11:00 A.M. An interview with the director of nursing (DON) on 03/01/12 at 10:00 A.M. verified there was no further documentation after October, 2010 regarding the justification for the continued use of the indwelling Foley catheter. There was no documentation of any further follow up with the urologist since October, 2010. An interview with the DON on 03/01/12 at 11:15 A.M. verified there was no documentation or reassessments that included justifications for the continued use of the Foley catheter since October, 2010.

Based on observation, interview and record review, the facility failed to ensure adequate supervision was provided, floors remained dry and interventions were in place to prevent falls for Resident #11 and Resident #3. This affected two of nine residents reviewed for falls. The facility census was 55. Findings include: 1. Resident #11's medical record revealed [DIAGNOSES REDACTED]. The Minimum Data Set (MDS)-Version 3.0 annual assessment dated [DATE] revealed Resident #11 had difficulty focusing her attention, had disorganized thinking and required supervision with ambulation and locomotion. Review of the resident's fall care plan initiated on 06/02/09 and last updated on 01/11/11 revealed Resident #11 was at risk for falls due to her fast pace and use of psychoactive medications. The care plan's interventions to prevent a fall included maintaining a clear pathway, non-skid strips to the floor in her room, non-skid shoes and ambulate with wheeled walker with assist. Review of a nurse's note dated 01/11/11 at 7:50 P.M. revealed a nurse heard Resident #11 yell "help" from the south hall. Resident #11 was found on the floor and told the nurse she "slipped on water." The nurse documented the hall floor was wet with water from the resident's shoes after returning from their outside smoke break. Review of the "Fall/Incident Investigation" dated 01/11/11 revealed Resident #11 was found on the floor in the hall with her walker in front of her. The investigation revealed water was observed on the floor. The investigation did not indicate Resident #11 was supervised by the staff at the time of the fall. On 01/13/11 at 1:46 P.M. an interview with the director of nursing (DON) verified Resident #11 was not supervised by the staff when she was walking down the hall with her walker and was found on the floor by the nurse after yelling for "help." The DON verified the Resident #11 slipped and fell in water on the hall floor that residents had brought in from outside. On 01/13/11 at 3:25 P.M. the administrator revealed vents in the ceiling, in the dining room, near the smoking area exit were leaking water onto the floor. 2. Review of the medical record for Resident #3 revealed [DIAGNOSES REDACTED].#3 was severely impaired in her cognitive skills for daily decision making and was totally dependant on the staff for dressing, hygiene and toilet use. Review of the fall risk assessment dated [DATE] revealed Resident #3 was a high risk for falls. Review of a "Fall/Incident Investigation" report dated 11/25/10 revealed Resident #3 was found on the floor without shoes or socks on. The report revealed a "plan of action" indicating "staff to ensure resident has proper footwear on." Review of a nurse's note dated 11/28/10 at 12:58 P.M. revealed Resident #3 was lying in bed without any clothes on and the nursing assistants "prompted the resident to stand up to get dressed." The nurse's note revealed the resident stood up out of her bed, began to urinate, took a step and fell on the floor. On 01/13/11 at 11:30 A.M. an interview with the director of nursing (DON) verified the medical record did not provide evidence to indicate the nursing assistants applied foot wear to Resident #3 prior to instructing her to get out of bed. The DON verified Resident #3 was instructed to get out of bed without shoes or socks on, urinated on the floor, slipped and fell .