Pennsylvania Department of Health
HERMITAGE NURSING AND REHABILITATION
Patient Care Inspection Results

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HERMITAGE NURSING AND REHABILITATION
Inspection Results For:

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HERMITAGE NURSING AND REHABILITATION - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint Survey completed on February 7, 2024, it was determined that Hermitage Nursing and Rehabilitation 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:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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.
§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on observations and staff interviews, it was determined that the facility failed to ensure a safe environment for residents residing on two of three units regarding a soiled utility room area (Unit 1 and Unit 2).

Findings include:

Observations on 2/7/24, at 9:51 a.m. of the soiled utility rooms on Unit 1 with the Housekeeping/Laundry Director, revealed the following:

To enter the soiled utility room, observed above the key number entry mechanism were two separate strips of tape with a four digit key code identified on each strip. The numbers were located at a level that any resident could visualize and open the soiled utility room door. The Housekeeping/Laundry Manager utilized the numbers identified on the strip to enter the soiled utility room. Observed inside the room was an uncovered red bag disposal area, a large tote with clear plastic bags with soiled attends and large styrofoam cups, a bag on the floor with dirty linens, and multiple empty boxes piled up from the floor to the countertop. A full gallon of apea care shampoo and body wash was sitting on the counter opened without a lid.

During an interview at the time of the observation, the Housekeeping/Laundry Director stated that the numbers above the key pad are numbers utilized to open the soiled utility room door. The four digit numbers were tested and each four digit number opened the soiled utility room door.

Observation of Unit 2 soiled utility room identified two strips above the entrance keypad with a separate four digit number on each strip. When tested, each four digit number opened the door. Inside the room was a large tote with clear plastic bags with garbage. An opened container lined with a red bag was also observed inside. The keypad and four digit number sequence was located at a level that any resident could visualize and open the door.

During an interview on 2/07/24, at 10:05 a.m. the Director of Nursing confirmed the numbers were above the keypad and used to enter the soiled utility room.

28 Pa. Code 201.14(a) Responsibility of licensee



 Plan of Correction - To be completed: 03/06/2024

0689
No residents were found to be affected by deficiency.
1. Codes were immediately removed from doors and no longer visible to any person not employed by facility.
2. Staff educated to keep codes private at all times, and potential hazards and risk to residents if not.
3. Monitoring of codes being placed on doors will be included 5 times weekly, in rountine rounding of facility by administrative staff. Written audits will continue for 4 weeks , and reviewed by IDT weekly for 4 weeks.
4. Audits will be reviewed in QAPI to monitor performance effectiveness.

§ 205.33(b) LICENSURE Utility room.:State only Deficiency.
(b) Facilities for flushing and rinsing bedpans, such as a spray attachment for the clinical sink or a separate bedpan flusher, shall be provided in the soiled workroom of each nursing unit, unless bedpan flushing devices, together with bedpan lugs on toilets are provided in each resident ' s toilet for this purpose.

Observations:

Based on observations, review of facility policy and staff interviews, it was determined the facility failed to provide a functional bedpan flusher in one of three soiled utility rooms (Unit One soiled utility room).

Findings include:

Review of a facility policy entitled, "Facility/Non Facility/Appliance Guideline" dated 12/28/23, revealed "the Maintenance Director/designee and other staff should be alert for items that do not meet the guidelines for use, are not functioning appropriately or are in need of repair or replacement."

Observations on 2/07/24 at 9:51 a.m. of the soiled utility room on Unit One with the Housekeeping/Laundry Director, revealed the following: a paper placed on the front of the bedpan flusher that stated "Out Of Order." The bedpan flusher was covered with a green garbage bag.

During an interview on 2/07/24, at 9:53 a.m. the Housekeeping/Laundry Director confirmed that the bedpan flusher was covered with the green garbage bag with a sign on the bedpan flusher that indicated the bedpan flusher was out of order. The Housekeeping/Laundry Director could not confirm how long the bedpan flusher was out of order.

During an interview on 2/07/24, at 2:05 p.m. the Maintenance Director confirmed that the Unit One bedpan flusher was covered with a green garbage bag with an out of order sign on the front of the bedpan flusher. The Maintenance Director confirmed the bedpan flusher was not working and could not confirm how long the bedpan flusher was out of order.



 Plan of Correction - To be completed: 03/06/2024

3610

No residents were found to be affected by deficiency.
1. Bed Pan flusher on Unit 1 in soiled utility room was immediately repaired on 2/8/2024.
2. Bed Pan flushers will be audited by Maintenance Director or designee 3 days week for 4 weeks to monitor equipment is working properly, and monthly thereafter. These audits will be reviewed in morning assembly meetings with IDT team.
3. Staff educated to report equipment immediately to supervisor and in communication binder on each nurse station. Nursing supervisors Educated to call Maitenance Director immediately for urgent repairs needed.
4. Communication binders will be reviewed each week day by administrative staff.
5. Audits will be reviewed in QAPI to monitor effectiveness.


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