Health inspection·December 6, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on review of clinical records, Resident Council meeting minutes, and grievance records, as well as staff interviews, it was determined that the facility failed to make ongoing efforts to resolve grievances for the residents. The deficiency is being cited as past non-compliance. Findings include: The facility's policy regarding grievances, dated October 28, 2024, indicated that the facility would support each resident's right to voice grievances; to ensure that after receiving a complaint/grievance, the facility would take any immediate actions needed to prevent further potential violations of any resident rights; and would make prompt efforts to resolve grievances. The Grievance Official would take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form, and would keep the resident appropriately apprised of the progress towards resolution of the grievances. Resident Council meeting minutes, dated September 11, October 16, and November 5, 2024, revealed that the residents reported staff were slow with answering call bells. Interview with the Director of Nursing on December 6, 2024, at 11:11 a.m. confirmed that there was no documented evidence that prompt efforts were made to resolve the resident's grievances following the Resident Council meetings on September 11 and October 16, 2024. Interview with the Clinical Coordinator on December 6, 2024, at 12:13 a.m. confirmed that there were no prompt efforts to resolve the residents' grievance regarding the response to call bells to their satisfaction until November 5, 2024, and should have been. Following the identification that resident grievances were not resolved, the facility's corrective actions included: Nursing staff were provided education regarding the policy and procedures for responding to and resolving grievances, and answering call bells in a timely manner. Audits were completed to ensure that prompt efforts were made to resolve grievances and call bells were answered in a timely manner. Grievances and concerns would be added to the clinical worksheet and stay there until completely resolved. The Social Service Director would update and review daily in stand up and stand down meetings. The findings would be reviewed with the quality assurance performance improvement committee. Page 1 of 3 395860 395860 12/06/2024 Loyalhanna Care Center 535 McFarland Road Latrobe, PA 15650

F 0585 A review of the facility's corrective actions revealed that they were in compliance with F585 on November 16, 2024. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.29(i) Resident Rights. Residents Affected - Some 28 Pa. Code 211.12(d)(5) Nursing Services. 395860 Page 2 of 3 395860 12/06/2024 Loyalhanna Care Center 535 McFarland Road Latrobe, PA 15650

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies and information provided by the facility, as well as observations and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures. Residents Affected - Few Findings include: The facility's policy regarding taste and temperature control, dated October 28, 2024, revealed that the temperatures of all food items will be taken and properly recorded prior to service of each meal. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit (F). All cold food items must be stored and served at a temperature of 41 degrees F or below. Observations of the lunch meal service in the main kitchen on December 6, 2024, revealed that the second North unit cart containing a test tray left the main kitchen at 12:19 p.m. and arrived on North unit at 12:20 p.m. Trays were passed to the residents that were in their rooms 12:21 p.m. and the last resident was served at 12:29 p.m. The test tray was removed from the cart at 12:30 p.m. and the temperature of the iced tea was 60 degrees F. The Madarin oranges were 50 degrees F, the bratwurst on a bun was 134.6 degrees F, the green beans were 145.5 degrees F, and the steak fries were 55 degrees F. The steak fries were cold and not at a palatable or appetizing temperature. Interview with the Dietary Director at the time of observation confirmed that the steak fries on the test tray were not at an appetizing temperature. 28 Pa. Code 201.18(b)(1)(2)(e) Management. 28 Pa. Code 211.6(c) Dietary Services. 395860 Page 3 of 3