Health inspection·August 18, 2023

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and job descriptions, clinical records, and staff interviews, it was determined that the facility failed to adhere to acceptable standards of practice related to participation in interdisciplinary meetings, monitoring of Food Service operations, and completion of Nutrition Assessments by the Registered Dietitian for three of three residents reviewed (Residents R13, R24, and R96). Residents Affected - Many Findings include: The Pennsylvania Code, Title 49, Chapter 21, Professional and Vocational Standards: Responsibilities of the Licensed Dietitian/ Nutritionist Section 21.711 Professional Conduct indicated that the Licensed Dietitian/ Nutritionist shall provide information which will enable patients to make their own informed decisions regarding nutrition and dietetic therapy, including the reasonable expectations of the professional relationship. Review of the signed Registered Dietitian's job description, states that dietitian participates in routine team, care planning, wound team, and weight team meetings and routinely audits kitchen and serving areas to assure sanitation, work practices, equipment, record documents, and time schedules meet established standards and provides routine staff in-services and training Will inspect food storage rooms, utility/janitorial closets, etc. for upkeep and supply control. Be sure hazardous materials are properly labeled and stored. It also stated that the dietitian will interview residents or family members, as necessary to obtain diet history and participate in obtaining history of resident's food likes and dislikes and visit residents periodically to evaluate the quality of meals served, likes and dislikes, mealtimes, bedtime snacks, food substitutions, etc. It also states that the dietitian will make weekly inspections of all food service functions to assure that quality control measures are continually maintained. Dietitian works in office areas as well as throughout the facility's food service areas (i.e., dining rooms, resident rooms, activity room, etc.). Review of facility policy Weight Monitoring Including Losses and Gains last reviewed 1/5/23, indicated that upon admission the dietitian will estimate calorie, nutrient and fluid needs and will identify whether the resident's current intake is adequate to meet his or her nutritional needs, upon admission the dietitian will assess the resident's likes and dislikes. During an interview on 8/15/23, at 10:08 a.m., Dietary Manager Employee E2 and Dietetic Technician Employee E3, stated that they had one Registered Dietitian, Registered Dietitian Employee E4, who worked eight hours per month and worked remotely. Review of the clinical record revealed that Resident R13 was admitted to the facility on [DATE]. Page 1 of 6 395629 395629 08/18/2023 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

F 0658 Level of Harm - Minimal harm or potential for actual harm Review of Resident R13's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 7/5/23, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), hypertension (high blood pressure in the arteries), and hearing loss. Review of Resident R13 ' s admission Nutrition assessment dated [DATE], was completed by Dietetic Technician Employee E3 Residents Affected - Many Review of clinical record revealed Resident R24 was admitted to the facility on [DATE]. Review of Resident R24's MDS dated [DATE], indicated diagnoses of atrial fibrillation (irregular rhythm of heart), dysphagia (difficulty swallowing), and muscle weakness. Review of Resident R24's admission Nutrition assessment dated [DATE], was completed by Dietetic Technician Employee E3. Review of clinical record revealed Resident R96 was admitted to the facility on [DATE]. Review of Resident R96's MDS dated [DATE], indicated diagnoses of diabetes, abnormal posture, and hypertension. Review of Resident R96's admission Nutrition assessment dated [DATE], was completed by Dietary Manager Employee E2 During an interview on 8/17/23, at 12:28 p.m., Registered Dietitian (RD) Employee E4 stated that she worked eight hours per month and typically just reviewed residents who were deemed high risk and had such issues as weight changes, pressure ulcers (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin), tube feeding (a tube inserted through the wall of the abdomen into the stomach and can be used to provide liquid food, drugs or liquids), and dialysis (a treatment that helps the body remove extra fluid and waste products from your blood when the kidneys are not able). RD Employee E4 stated that she did this process remotely and did not come into the facility. She stated that she acquired the required information from reviewing the notes and documentation in the computer. RD Employee E4 also stated that she does not complete admission Nutrition Assessments or visit residents at mealtime and that her process was described as it's limiting. During an interview on 8/18/232, at 12:10 p.m. Dietary Manager Employee E2 and Dietetic Technician Employee E4 confirmed that the facility failed to have a Registered Dietitian on premises that participated in interdisciplinary meetings, monitor Food Service operations of completed Nutrition Assessments. 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 211.12(d)(1) Nursing Services. 395629 Page 2 of 6 395629 08/18/2023 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, incident reports, facility documents, employee file, employee statements, and staff interviews, it was determined that the facility failed to ensure that a resident was free from an accident by not providing the appropriate amount of supervison needed for bed mobility, for one of three residents reviewed (Resident R32). This was identified as past non-compliance for Resident R32. Findings include: Review of American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2018, indicated that Section G: Functional Status, Question G0110 A indicates Bed Mobility is how the resident moves to and from lying position, turns side to side, and positions body while in bed. The RAI User's Manual further defines bathing as solely how the resident takes a full body bath, shower or sponge bath, including transfers in and out of the tub or shower. Review of the clinical record indicated Resident R32 was admitted to the facility on [DATE], with diagnoses that included senile degeneration of the brain (severe cortical atrophy and brain cell loss), traumatic brain injury, muscle weakness, and history of falls. Review of Resident R32's MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 12/29/22, indicated that the diagnoses remained current. Review of Resident R32's physician orders initiated 2/13/22, and remain current, indicated that Resident R32 was to be transferred with extensive assistance of two people. Review of Resident R32's bed mobility evaluation dated 4/15/22, the only one that was completed, indicated that Resident R32 needed extensive assistance of two people for bed mobility. A review of Resident R32's care plan initiated 10/3/17, and remains current, indicated that Resident R32 had impaired mobility and to see care plans for mobility, ADL's cognitive deficit and communication. A review of facility documents dated 2/23/23, indicated Nurse Aide (NA) Employee E1 was doing incontinent care at 4:15 a.m., on Resident R32 without a second person. While NA Employee E1 was rolling Resident R32 over to clean her, Resident R32 left leg came over her right leg and the bed moved a little resulting in Resident R32 falling to the floor. Registered Nurse (RN) Employee E2 then was called to the room where Resident R32 was noted to be on the floor with her left leg twisted underneath her body. EMS services were notified at 4:32 a.m. and arrived at 4:48 a.m. for stabilization of the leg and transport to the ER. Review of NA Employee E1's signed witness statement, dated 2/23/23, stated that NA Employee E1 was 395629 Page 3 of 6 395629 08/18/2023 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

F 0689 Level of Harm - Minimal harm or potential for actual harm preparing to give the Resident R32 a bed bath when he noticed some stool. NA Employee E1 then rolled Resident R32 towards him and Resident R32's left leg came overtop of her right leg and the nightstand was away from the bed. The Resident then reached for the night stand and NA Employee E1 then opened the drawer for the wipes and the air mattress was not inflated all the way. Statement goes on to state the bed bottom kicked out and the resident fell to the floor hitting her head on the drawer of the night stand. Residents Affected - Few A review of NA Employee E1's employee file indicated that NA Employee E1 received education on Fall Prevention, Safe Care Giving Techniques and Abuse training on 7/11/22, as well Safe Transfer training on 7/11/22. During an interview on 8/18/23, at 11:40 a.m., NA Employee E3 stated that a resident's bed mobility and transfer status is marked on the charting system under the point of care, under the residents photo there is a special instructions tab. Call made to attempt phone interview of NA Employee E1 on 8/18/23, 1:00 p.m. Message was left and no call backs were received. During an phone interview on 8/18/23, at 1:15 p.m., RN Employee E2 also confirmed that NA Employee E1 acted alone probably thought he could handle it alone. RN Employee E2 also stated that NA Employee E1 was training a newly hired employee at the time but the newly hired employee was not in the immediate area to help. RN Employee E2 also confirmed that the Residents also have a mobility status that is taped to the headboard of the beds. Observation of all resident beds on 8/18/23 at 1:25 p.m., did show that the facility is using a red, yellow, green status for bed mobility that is taped to every resident bed. The red indicates a two person assist with bed mobility. During an interview on 8/18/23, at 1:35 p.m., RN Employee E4 also confirmed the above process and added that there are colored stickers on the residents beds that indicated that a resident required assistance of two people for safe bed mobility. It was also stated that Resident R32 was on NA Employee E1's assignment on the day of the incident. During an interview on 8/18/23, at 1:45 p.m. the Director of Nursing (DON) confirmed the facility failed to ensure that a resident was free from an accident by not providing the appropriate amount of supervision for bed mobility, for Resident R32. This was identified as past non-compliance for Resident R32. The facility implemented a plan of correction that included the following: · Immediate suspension of NA Employee E1 during the investigation which resulted in termination. · Facility initiated education on 2/23/23, for all nursing staff including Registered Nurse's (RN's), Licensed Practical Nurses (LPN's), and Nurse Aides (NA's) to ensure that transfers were performed as ordered. 395629 Page 4 of 6 395629 08/18/2023 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

F 0689 · Level of Harm - Minimal harm or potential for actual harm Audits of bed mobility status completed to ensure that they were up to date and accurate and that this information was reflected on the nursing assistant assignment sheets. Residents Affected - Few · Daily audits by DON or designee to determine if there are any issues or trends related to care. · Results from audits are submitted in the quarterly Quality Assurance Performance Improvement (QAPI) process for two quarters. The facility has demonstrated compliance with the above since 2/23/23. Information was verified via review of Plan of Correction binder. During an interview on 8/18/23, at 2:15 p.m. with the DON and a review of the facility's immediate actions, education, and review of the QAPI monitoring process, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are provided adequate safety interventions for bed mobility. 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(b)(1)(e)(1) Management. 28 Pa Code 201.29(a)(j) Resident rights. 28 Pa Code 211.12(d)(1)(5) Nursing services. 28 Pa Code 211.12(d)(3) Nursing services. 395629 Page 5 of 6 395629 08/18/2023 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for one of six residents reviewed. (Resident R11). Residents Affected - Few Findings include: Review of the facility policy Treatment and Care of Dialysis Residents dated 05/08/2023, indicated that there will be shared communications between the dialysis facility and the nursing home, and that communication process is to occur through dialysis communication sheet with each facility responsible for completing a portion of the document. Review of the clinical record revealed that Resident R11 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD, an inability of the kidneys to filter the blood), hyperlipidemia (high levels of lipids (fats) in the arteries) and malnutrition (lack of sufficient nutrients in the body). Review of Resident R11 MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/08//23, indicated the diagnoses remain current. Review of a physician order dated 04/06/23, indicated that Resident R11 goes to dialysis (a process to mechanically clean the blood) on Monday, Wednesday, and Friday. Review of the dialysis communication sheets failed to include documentation from the nursing home for 19 of 34 dialysis visits 5/3/23, 5/5/23, 5/8/23, 5/29/23, 6/19/23, 6/28/23, 7/3/23, 7/12/23, 7/17/23, 8/18/23, and an additional 9 forms with missing documentation from the nursing home were not dated. During an interview on 8/18/23, at 12:25 p.m. Licensed Practical Nurse Employee E5 confirmed documentation was not completed for Resident R11 by the facility prior to dialysis treatment, and stated I can see several sheets were not completed. 28 Pa. Code: §211.5(f)(g)(h) Clinical records. 28 Pa. Code: §201.14(a)(b)(3)(e)(1) Management. 28 Pa. Code: §211.10(c) Resident care policies. 28 Pa. Code: §211.12(c)(d)(1)(3)(5) Nursing services. 395629 Page 6 of 6