Health inspection·October 25, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on review of facility policy and closed clinical records and staff interview, it was determined that the facility failed to notify a medical provider of a need to alter treatment due to resident symptoms and/or complaints for one of seven residents reviewed (Closed Record Resident CR1). Findings include: Facility policy entitled Physician Notification dated 6/27/24, revealed that staff are to communicate change in resident's condition to the physician and initiate interventions as needed / ordered. Further review of the policy revealed that staff are to document physician notification and response. Resident CR1's clinical record revealed an admission date of 6/5/24, with diagnoses that included depression, high blood pressure, and anxiety. Review of Resident CR1's clinical record revealed nursing progress notes dated 6/25/24, at 5:52 a.m. where Resident CR1 was demanding Benadryl (medication to help address allergies and symptoms) for complaint of itch and was informed he/she currently did not have a physician's order and it was early in the morning. Another progress noted dated 7/02/24, at 12:28 a.m. revealed Resident CR1 was requesting Benadryl for itchiness and was once again educated related to no physician's order for Benadryl. Resident CR1's clinical record contained a typed note to his/her physician uploaded into the electronic record on 6/18/24. The note indicated that Resident CR1 was asking for Benadryl for itching. Benadryl was circled by an unidentified/unknown source and below it was written 25 milligrams (mg) po (by mouth) every six hours as needed. The typed note and handwritten response also lacked a date and time. Resident CR1's clinical record lacked evidence that a progress note was completed that correlated with the typed note and/or response. Further review of Resident CR1's clinical record lacked any evidence that a medical provider was notified of his/her complaints and request for Benadryl on 6/25/24, or 7/02/24. During an interview on 10/25/24, at 11:41 a.m. DON confirmed the clinical record lacked evidence that Resident CR1's medical provider was notified of his/her complaints and their request for Benadryl on 6/25/24, or 7/02/24. 28 Pa. Code 211.5(f)(i)(iii) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing services Page 1 of 2 395003 395003 10/25/2024 Quality Life Services - New Castle 520 Friendship Street New Castle, PA 16101

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly maintain kitchen equipment and maintain sanitary operations in the main kitchen. Residents Affected - Many Findings include: Review of a facility policy entitled Dietary Oven and Stove Cleaning Schedule dated 6/27/24, revealed that on a daily basis the ovens and stovetops must be wiped down and staff are to wipe up spills and excess food that is left. The policy also revealed that on a monthly basis the ovens and stoves must be deep cleaned including all interior and exterior walls, oven racks, oven trays, stovetop burners, stove interior, and stove exterior. Review of a facility policy entitled Employee Sanitary Practices, dated 6/27/24, revealed that all employees shall wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. Observation on 10/23/24, at 11:02 a.m. revealed two stove tops with gas burners containing a large amount of dried food and debris, the front of the three oven doors contained what appeared to be dried liquid down the front of the outside of the doors, and the inside of the ovens contained dried food and debris including numerous small pieces of aluminum foil. Review of a facility document entitled Oven and Stove Monthly Cleaning revealed that the oven was to be cleaned on week two of each month and the stove was to be cleaned on week four of the month. The document also revealed that for 2024, the oven was cleaned on 4/09/24, and not again until 8/13/24, and the stove was cleaned on 4/25/24, and not again until 8/29/24. During an interview on 10/23/24, at the time of observation, the Dietary Manager confirmed that the stove tops and ovens were dirty and contained dried spills / food and large amount of debris. The Dietary Manager also confirmed that the oven had not been cleaned eight of the last ten months, and the stove had not been cleaned seven of the last nine months. Observation of tray line on 10/23/24, between 12:10 p.m. and 12:30 p.m. revealed Dietary Aide (DA) Employee E1 standing at tray line making coffee and filling resident's coffee cups without a beard restraint. During an interview on 10/23/24, at 12:31 p.m. Dietary Manager confirmed that DA Employee E1 should have been wearing a beard restraint due to the length of his/her beard. 28 Pa. Code 211.6(f) Dietary services 395003 Page 2 of 2