Nursing Investigation Results -

Pennsylvania Department of Health
GROVE AT LATROBE, THE
Patient Care Inspection Results

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GROVE AT LATROBE, THE
Inspection Results For:

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GROVE AT LATROBE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on complaint survey completed on March 4, 2019, it was determined that The Grove at Latrobe was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:


Based on review of policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were compete and accurately documented for four of seven residents reviewed (Residents 2, 3, 4, 6).

Findings include:

The facility policy regarding bathing/showers, dated February 26, 2019, indicated that baths and showers were to be documented in each resident's clinical record.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 12, 2019, revealed that the resident was alert and oriented, required extensive assistance from staff for personal hygiene, and was dependent on staff for bathing. A bath/shower record for February 1 through 28, 2019, revealed that the resident was scheduled to receive showers on Mondays and Thursdays. There was no documented evidence that the resident received showers as scheduled on Mondays, February 4, 11, 18 and 25, 2019, and Thursdays, February 7, 14 and 28, 2019.

Interview with Resident 2 on March 4, 2019, at 11:00 a.m. revealed that he received showers two days a week, as he was supposed to.


A quarterly MDS assessment for Resident 3, dated February 8, 2019, revealed that the resident was moderately cognitively impaired, required extensive assistance from staff for personal hygiene, and was dependent on staff for bathing. A bath/shower record for February 1 through 28, 2019, revealed that the resident was scheduled to receive showers on Wednesdays and Saturdays. There was no documented evidence that the resident received showers on Wednesdays, February 6, 13, 20 and 27, 2019, and Saturdays, February 2, 9, 16 and 23, 2019. The report did not indicate if a shower was offered and refused on these dates or that any type of bathing was provided on these dates.

Interview with Resident 3 on March 4, 2019, at 8:45 a.m. revealed that she did not always want to receive showers and will ask for a bed bath instead. She was not able to provide any specific dates when she refused showers.


A quarterly MDS assessment for Resident 4, dated February 19, 2019, revealed that the resident was alert and oriented, was independent for personal hygiene, and was independent for bathing. A bath/shower record for February 1 through 28, 2019, did not reveal a schedule for when the resident was to receive a shower and did not indicate that the resident received a shower during the month. The report indicated that the resident received a bed bath on February 4, 11, 18 and 25, 2019. There was no documentation to indicate if the resident was offered and refused a shower on any date.

Interview with Resident 4 on March 4, 2019, at 5:45 p.m. revealed that she was always showered two times per week and could not remember ever missing any showers.


A quarterly MDS assessment for Resident 6, dated February 19, 2019, revealed that the resident was alert and oriented, required extensive assistance from staff for personal hygiene, and was dependent on staff for bathing. A bath/shower record for February 1 through 28, 2019, revealed that the resident was scheduled to receive a shower on Mondays and Thursdays. There was no documented evidence that the resident received a shower as scheduled on Mondays, February 4, 11 and 25, 2019, and Thursdays, February 7, 21 and 28, 2019.

Interview with Resident 6 on March 4, 2019, at 1:55 p.m. revealed that she was always showered twice a week. She stated that at times, her shower may be a day late, but she always received at least two showers per week.

Interview with the Director of Nursing on March 4, 2019, at 5:40 p.m. confirmed that shower documentation was incomplete and/or not accurate for Residents 2, 3, 4 and 6.

42 CFR 483.20(f)(5), 483.70(i)(1)-(5) Resident Records - Identifiable Information.
Previously cited 9/6/18.

28 Pa. Code 211.5(f) Clinical Records.
Previously cited 10/17/18, 9/6/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 10/17/18, 9/6/18.





 Plan of Correction - To be completed: 03/25/2019

Residents 2, 3, 4, and 5 reported they received showers as scheduled. Staff provided the showers and bed baths residents requested, but failed to provide proper documentation of the shower.
House surveillance by Director of Nursing to ensure showers were being documented and given per resident preference.
Re-education provided by the Director of Nursing to licensed staff on updating kardex for resident shower preferences. Re-education by the Director of Nursing/designee to direct care giver staff on documenting showers given in point click care.
Audits of showers will be done by Director of Nursing/designee twice weekly x3 and then monthly x3. Daily facility clinical start up process will include review of kardex for new admissions to ensure shower preferences addressed. Audits will be presented to the monthly Quality Assurance Performance Improvement meetings for further tracking and trending.
483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at 483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:


Based on clinical record reviews, and staff and resident interviews, it was determiend that the facility failed to maintain the privacy of a resident's medical information by failing to follow a resident's wishes related to not notifying a family member about the results of medical tests for one of seven residents reviewed (Resident 3).

Findings include:

A facsimile (fax) to Resident 3's physician, dated November 6, 2018, revealed that a government agency requested verification that Resident 3 was capable of making her own decisions, and the resident's physician sent a fax to the facility, dated November 7, 2018, indicating that the resident was capable of making medical decisions, including a decision to stay in the facility.

A facility form, dated January 31, 2019, indicated that Resident 3 informed the staff that she did not give permission for the facility to notify her daughter about any medical information. A social services note for Resident 3, dated January 31, 2019, indicated that the resident did not wish to have any medical providers contact her daughter related to medical issues, the resident would determine what information she wanted released, and would inform her daughter herself, with a facility staff member present in the room.

Nursing notes, dated February 6, 2019, indicated that Resident 3 attended a consultation appointment with a cardiologist (heart doctor), and the facility contacted the resident's daughter to inform her about the appointment and the results of the appointment.

Interview with the Director of Nursing on March 11, 2019, at 2:30 p.m. confirmed that Registered Nurse 1 notified Resident 3's daughter about the consultation with the cardiologist. She stated that Registered Nurse 1 may not have been aware of the resident's wishes, and she contacted the family member in accordance with the facility's policy.

28 Pa. Code 201.29(j) Resident rights.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 10/17/18, 9/6/18.




 Plan of Correction - To be completed: 03/25/2019

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.


F 0583
Resident 3 daughter was left a voice message regarding follow up appointment, there was no call back and no information was given out. Root cause analysis, Resident's 3 face sheet contained daughter's contact information and RN followed standard facility policy. The Face Sheet and Electronic Record were updated to reflect R3's request.
In house surveillance by Social Service Director to ensure that residents' rights and medical information are protected.
Director of Social Services re-educated facility staff on Resident Right to Privacy and Release of Medical Information.
Audits of Privacy of Medical Information will be performed by Social Services/Designee weekly x3 and then monthly for 3 months. Audits will be presented to the monthly Quality Assurance Performance Improvement meetings for further review and recommendations. The Social Services Director will review/update contact information. This will also be reviewed quarterly, annually and as needed.
483.25(a)(1)(2) REQUIREMENT Treatment/Devices to Maintain Hearing/Vision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
483.25(a) Vision and hearing
To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-

483.25(a)(1) In making appointments, and

483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.
Observations:


Based on clinical record reviews, and resident and staff interviews, it was determined that the facility failed to assist a resident to obtain assistive devices to maintain hearing abilities for one of seven residents reviewed (Resident 3).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 8, 2018, revealed that the resident had minimum difficulty hearing and did not have a hearing aid.

A facsimile (fax) to Resident 3's physician, dated November 6, 2018, revealed that a government agency requested verification that Resident 3 was capable of making her own decisions, and the resident's physician sent a fax to the facility, dated November 7, 2018, indicating that the resident was capable of making medical decisions.

A nursing note, dated January 24, 2019, indicated that Resident 3 expressed a desire to obtain a hearing aid to hear better and the resident was scheduled to see a consultant for an exam and to receive recommendations on February 4, 2019. A consultation report, dated February 4, 2019, indicated that the resident had a history of cerumen impaction (build-up of ear wax) with some hearing loss at times, that the resident did not wear hearing aids, and that impacted cerumen in the right ear was removed. There was no indication that the resident's ability to hear or the need for a hearing aid was addressed, and no documented evidence that any further actions were taken by the facility to determine if the resident required a hearing aid.

Interview with Resident 3 on March 4, 2019, at 8:45 a.m. revealed that she still felt that she needed a hearing aid and would like to have one. She also stated that she could not afford the cost of a hearing aid.

Interview with the Director of Nursing on March 4, 2019, at 2:30 p.m. confirmed that there was no documented evidence of follow-up actions after the appointment on February 4, 2019, to determine if Resident 3 required a hearing aid or of any assistance provided by the facility in obtaining a hearing aid for the resident.

28 Pa. Code 201.29(j) Residents rights.

28 Pa. Code 211.12(d)(3)(5) Nursing services.
Previously cited 10/17/18, 9/6/18.




 Plan of Correction - To be completed: 03/25/2019

Resident 3 is scheduled to meet with the audiologist to address her request for hearing aides.
House surveillance to ensure residents with need for hearing/vision devices are being scheduled with professionals specializing in provision of vision/hearing assistive devices.
Daily facility clinical start up process will review residents who are in need of vision/hearing assistive devices to ensure they are being addressed timely.
Administrator provided re-education to Social Services staff on providing resident referral information to the Audiologist.
Social Services/designee will audit weekly x3 and then monthly x3 residents who are in need of hearing/vision devices. Audits will be presented at the monthly Quality Assurance Performance Improvement meetings for further review/recommendations.
483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified about an elevated blood sugar level, that medications were provided as ordered by the physician, and that a follow-up blood sugar level was obtained as ordered by the physician for one of seven residents reviewed (Resident 1) .

Findings include:

The facility's policy regarding medication administration, dated February 26, 2019, indicated that medications were to be administered in accordance with the written orders of attending physicians. Should there be any questions concerning the administration of the medication, the physician was to be contacted for clarification. The administration of the medication was to be documented on the Medication Administration Record (MAR).

Resident 1's MAR for January 2019 revealed that the resident had diagnoses that included diabetes mellitus (a disease that interferes with blood sugar control), the resident's blood sugar level was to be checked three times a day with meals, and she was to receive insulin (injectable medication used to control blood sugar levels) based on a sliding scale (the amount of the insulin administered is based on the result of a fingerstick blood sugar test). Sliding scale insulin orders, dated October 23, 2018, revealed that the resident was to receive 8 units of Admelog Solostar Solution (a fast-acting insulin used to lower blood sugar levels) for a blood sugar level between 351 and 400 milligrams per deciliter (mg/dL) (normal levels are between 70 and 100 mg/dL), and for blood sugar levels below 70 or above 400 mg/dL, the physician was to be notified. Physician's orders, dated January 7, 2019, included an order for the resident to receive 20 units of Admelog Solostar Solution before meals at 8:30 a.m., 11:30 a.m., and 5:30 p.m.

A nursing note for Resident 1, dated January 24, 2019, at 5:43 p.m. revealed that the resident's blood sugar levels were checked before the evening meal, the result was 502 mg/dL, and the registered nurse supervisor was notified. The registered nurse supervisor indicated that the routine insulin order (the order for 20 units of insulin before meals) was to be given, and she would notify the on-call physician for further instructions related to the sliding scale insulin order. However, there was no documented evidence that the physician was notified about the resident's blood sugar level that was above 400 mg/dL, and the MAR for January 2019 revealed no documented evidence that the resident received any sliding scale insulin, and there was no documented evidence regarding why it was not administered.

Nursing notes for Resident 1, dated January 25, 2019, at 4:48 p.m. and 5:03 p.m. indicated that the registered nurse supervisor was notified that the resident's blood sugar level was 432 mg/dL, and the physician was notified. Physician's orders, dated January 25, 2019, revealed that the resident was to receive 2 additional units of Admelog Solostar Solution, and staff were to recheck the resident's blood sugar level one hour after administering the insulin. The resident's MAR for January 25, 2019, revealed that the 2 additional units of insulin were administered at 5:30 p.m. However, there was no documented evidence that staff rechecked the resident's blood sugar level one hour after administering the insulin.

Interview with the Director of Nursing on March 4, 2019, at 3:30 p.m. confirmed that there was no documented evidence that the physician was notified when Resident 1's blood sugar level was above 400 mg/dL on January 24, 2019, that staff administered any Admelog Solostar Solution on January 24, 2019, based on the sliding scale orders, and no documented evidence that the resident's blood sugar level was rechecked as ordered by the physician on January 25, 2019.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 10/17/18, 9/6/18.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 10/17/18, 9/6/18.





 Plan of Correction - To be completed: 03/25/2019

Resident 1 physician was made aware of blood sugar January 24 and 25 no new orders given, as Resident 1 has been without any adverse effects as a result. Licensed nurse failed to document recheck of blood sugar after 1 hour.
In house surveillance of residents who receive insulin and accuchecks to ensure parameters are followed and physician notification made when indicated, also follow up blood sugars are done as ordered.
Re-education by the Director of Nursing to licensed staff on physician notification, specifically as it applies to notification and documentation of blood sugars. Interdisciplinary team monitors daily reports for evidence of physician notification.
Director of Nursing/designee will audit in house residents receiving sliding scale insulin 5x per week for 2 weeks, then weekly for 4 weeks, and then monthly for 3 months to ensure notification to physician and documentation of re-checking blood sugars has been completed when indicated. Audits will be presented at the monthly Quality Assurance Performance Improvement meetings for further review/recommendations.
483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assessed a resident after an injury of unknown origin for one of seven residents reviewed (Resident 5).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals.

The facility's policy regarding investigating and recording accidents and incidents, dated February 26, 2019, indicated that all accidents or incidents must be investigated, and that the registered nurse would conduct an assessment and provide any emergency interventions.

A nursing note for Resident 5, dated January 25, 2019, indicated that Licensed Practical Nurse 2 was notified by a nurse aide that the resident had a bruise to her right leg above the right knee. The licensed practical nurse documented that the bruise was light purple and yellow in color and measured 6.0 x 3.0 centimeters (cm). A facility bruise investigation form, dated January 25, 2019, indicated that the bruise was located above the right knee, measured 6.0 x 3.0 cm, was light purple and yellow in color, and the Director of Nursing was notified. There was no documented evidence that the bruise was assessed by a registered nurse.

Interview with the Director of Nursing on March 4, 2019, at 2:20 p.m. confirmed that there was no documented evidence that a registered nurse assessed Resident 5's bruise.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 10/17/18, 9/6/18.



 Plan of Correction - To be completed: 03/25/2019

Documentation made by licensed staff that the in house supervisor was notified. Bruise assessment and investigation was completed 1/28/2019 by the Director of Nursing on Resident 5. The RN Supervisor did the original assessment, but failed to document the findings.
Director of Nursing reviewed facility policy investigation and documenting assessments, accidents/incidents with the RN Supervisor as well as to licensed staff.
A registered nurse in the facility will be responsible for an assessment of any resident injury. Charge nurses will be responsible for timely reporting on any incident to a Registered Nurse. Facility monitors incident reports and the 24 hour report to ensure timely assessments and documentation.
Director of Nursing/designee will audit RN Assessments following injury for follow up and documentation 5x a week for 2 weeks, weekly for 4 weeks, then monthly for 3 months. All outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is 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 observations, and resident and staff interviews, it was determined that the facility failed to provide bed linens that were in good condition for two of seven residents reviewed (Residents 4, 5).

Findings include:

Observations on March 4, 2019, at 1:20 p.m. revealed that Resident 4 was seated on the side of her bed, which was not made. The resident stated that the bed was stripped earlier that morning, but was not yet remade at the time of the observation. Observations on March 4, 2019, at 5:35 p.m. revealed that the resident's bed was made and the bottom sheet had six individual small holes ranging in size from 1/5 inch to 1/4 inch in diameter and a cluster of seven small holes of various sizes, with the largest being approximately one-quarter inch in diameter.

Upon interview with Resident 4 on March 4, 2019, at 1:20 p.m. and 5:35 p.m. she indicated that approximately two or three weeks previously, her bed was made using a sheet that had multiple holes in it.


Observations on March 4, 2019, at 11:12 a.m. revealed that the bottom sheet on Resident 5's bed had approximately twelve holes in it, with the smallest being a round hole approximately one-fifth inch in diameter and the largest being rectangular in shape approximately one-half inch by two inches in size.

Interview with Licensed Practical Nurse 2 on March 4, 2019, at 11:16 a.m. confirmed that Resident 5's bottom sheet should not have been placed on the bed because it had holes in it.

Interview with the Director of Nursing on March 4, 2019, at 5:40 p.m. confirmed that there was a problem at the facility related to bed sheets that had holes in them.

42 CFR 483.10(i)(1)-(7) Safe/Clean/Comfortable/Homelike Environment.
Previously cited 9/6/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 9/6/18.

28 Pa. Code 207.2(a) Administrator's responsibility.
Previously cited 9/6/18.





 Plan of Correction - To be completed: 03/25/2019

Residents 4 and 5 bed sheets were immediately replaced.
House surveillance to ensure if there were any damaged linens, they were removed from service and replaced.
Facility will maintain linens in good condition for Residents. Director of Environmental services provided re-education to staff on home-like environment, specific to not utilizing sheets that are damaged.
The Director of Environmental Services will conduct audits of incoming linens weekly x3 , and then monthly x3 to ensure linens are in good repair without holes. Audits will be reviewed monthly at the facility Quality Assurance Performance Improvement meeting for tracking and trending. Housekeeping manager is responsible for overseeing incoming linen from laundry service 3 times weekly.


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