Nursing Investigation Results -

Pennsylvania Department of Health
BUFFALO VALLEY LUTHERAN VILLAGE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BUFFALO VALLEY LUTHERAN VILLAGE
Inspection Results For:

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BUFFALO VALLEY LUTHERAN VILLAGE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a Complaint Investigation, completed on March 14, 2019, it was determined that Buffalo Valley Lutheran Village was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observation, review of facility documentation, and staff interview, it was determined that the facility failed to provide a clean, comfortable environment on five of five nursing units (Blue Jay, Pheasant Ridge, Chestnut, Country Lane, and Bison).

Findings include:

A review of Resident Council minutes from March 7, 2019, revealed a concern with toilet cleaning, primarily the base of the toilet. A review of minutes from February 7, 2019, revealed a concern with a resident room needing dusted.

A review of facility resident concern forms revealed a resident family concern dated March 13, 2019, regarding the cleanliness of a resident's room.

Observations during a tour of the facility on March 14, 2019, starting at 10:00 AM revealed the following:

The bathroom in Room 135 had buildup of dust and black debris in corners of the bathroom and door jambs.

The adjoining bathroom of Resident rooms 139 and 140 had a buildup of dust and debris in corners of the bathroom, around the base of the toilet, and door jamb. The shower drain cover contained a large amount of dried hair/debris.

The bathroom in Room 138 had a dirt buildup on the corners of the bathroom and door jam, and under the sink area.

The adjoining bathroom of resident rooms 122 and 124 had dirt and debris build up in the corners of the bathroom and base of the toilet.

The adjoining bathroom of resident rooms 129 and 130 had a significant amount of dirt/debris buildup in the corners of the bathroom and toilet base. The shower drain cover contained a large amount of dried hair/debris. The base of the cabinetry was damaged.

Country Lane unit kitchenette contained crumbs and debris along wall edges, and corners. The top edge of base boards contained a significant amount of dust buildup.

The adjoining bathroom of resident rooms 222 and 224 had a buildup of dust/dirt in floor corners, wall edges, and around toilet base. A buildup of dust and hair was identified under the sink.

The adjoining bathroom door of resident rooms 229 and 230 has significant marring down to bare wood, on the door and door frame. The baseboard top ridge outside the bathroom, and the resident rooms had significant dust buildup.

The bathroom door and door frame in resident room 226 had significant marring, exposing bare wood. The bathroom floor had significant buildup of dirt/debris around the toilet base. The room had dust buildup throughout on the top edge of baseboards.

The bathroom in Room 236 had a large amount of dirt/debris on the floor, floor corners, and under the sink. The bathroom door and door frame contained significant marring. Shreds of wood were lying on the floor by the door frame. The baseboard top edge outside the bathroom extending into the resident room contained dust buildup.

The wall heating unit located in the kitchenette area of Blue Jay Way had dust/debris build up, the top edge of baseboards throughout the kitchenette contained dust buildup.

The adjoining bathroom of resident rooms 113 and 115, and 119 and 120 had buildup of dirt/debris in corners of the bathroom and base of the toilet. The bathroom doors had deep marring exposing bare wood.

The wall heating unit of the kitchenette in Chestnut Trail unit contained dust buildup. The floor of the kitchenette had crumbs and debris along wall/baseboard edges.

The top edge of the baseboard throughout the Chestnut Train unit and dining room had dust build up.

Resident room 220 had a large amount of crumbs/debris throughout the carpet.

The adjoining bathroom of resident rooms 205 and 207 had significant dirt/debris buildup around the base of the toilet, under sink, and corners.

The Bison unit kitchenette floor contained dirt/debris along floor edges, the dish room floor was visibly soiled with dried debris, the hanging white light fixtures over the serving area were covered in a significant amount of dust.

Resident bathroom 252 had dirt/debris on the floor, corners, under the sink and around the toilet base. The raised surfaces of the bathroom door had dust buildup. The top edge of the baseboard throughout room 252 had dust buildup.

The top ridge of the white back plate behind the handrails in the hallways throughout Country Lane, Blue Jay Way, and Bison contained a significant amount of dust.

These findings were reviewed with the Nursing Home Administrator on March 14, 2019, at 3:00 PM.

28 Pa. Code 207.2(a) Administrator's responsibility



 Plan of Correction - To be completed: 04/16/2019

Correction does not constitute an admission or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality care and to comply with all applicable state and federal regulatory requirements.

The adjoining bathroom of resident rooms 122 and 124 will be cleaned and the bulid up will be removed.

The bathroom in room 135 will be cleaned. The door jams will be cleaned.

The resident bathroom for rooms 139 and 140 will be cleaned to include the base of the toilet, door jamb and drain cover to the shower.

The bathroom in room 138 will be cleaned including the door jam and sink area.

The bathroom for resident rooms 129 and 130 will be cleaned to include the toilet base and shower drain cover. The base of the cabinet will be repaired.

Country Lane Kitchenette will be cleaned including wall edges and corners. The top edge of the base board will also be cleaned.

The bathroom of rooms 222 and 224 will be cleaned to include the toilet base and underneath the sink area.

The bathroom for rooms 229 and 230 marring will be repaired on the door and door frame. The baseboard top ridge outside of the bathroom and the resident room will be cleaned.

The bathroom door frame in room 226 will be repaired. The bathroom will be cleaned including the toilet base. The baseboards will be cleaned in the room as well.

The bathroom in room 236 will be cleaned to include underneath the sink.

The bathroom door will be repaired. The baseboard will be cleaned.

The wall heating unit in Blue Jay kitchenette will be cleaned as well as the base boards in the kitchenette area.

The resident bathrooms for rooms 113, 115, 119 will be cleaned to include the base of the toilets. The bathrooms doors will be repaired.

The wall heating unit on the Chestnut kitchenette unit will be cleaned.

The kitchenette unit will be cleaned.

The base board on the Chestnut Unit kitchenette unit will be cleaned.

Resident room 220 carpet will be swept.

Resident bathroom 205 and 207 will be cleaned to include the base of the toilet, under the sink and the corners.

The Bison kitchenette floor will be cleaned including the dish room floor.

The hanging white fixture lights will be cleaned.

Resident room 252 will be vacuumed and the bathroom cleaned to include under the sink and around the toilet base.

The baseboard in room 252 will be cleaned. The raised surfaces of the bathroom door will be cleaned.

The white back plates behind the hand
rails on Country Lane, Blue Jay Way and Bison will be cleaned.

Resident care/living areas will be audited and cleaned/repairs done as needed.

Housekeeping staff will be re-educated on the cleaning process for resident care/living areas.

The Nursing Home Administrator or Designee will conduct weekly audits for four weeks and monthly times three to ensure resident care/living areas are cleaned and repairs are done as needed.

Date of compliance is April 16, 2019.



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