Nursing Investigation Results -

Pennsylvania Department of Health
AVALON PLACE
Patient Care Inspection Results

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AVALON PLACE
Inspection Results For:

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AVALON PLACE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey, completed on February 7, 2019, it was determined that Avalon Place 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:


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:


Based on facility policy, observations, clinical records and staff interviews, it was determined that the facility failed to perform proper handwashing during medication passes and treatment for 6 of 9 residents (Residents R22, R25, R43, R46, R48, and R55), failed to proper sanitize glucose monitor, failed to make certain that the linens and laundry were handled in a sanitary manner in one of one laundry areas and failed follow transmission based precautions to prevent the potential for cross-contamination for one of one resident (Resident R55).

Findings include:

A review of the facility policy "Handwashing" last reviewed 10/4/18, indicated that the employees will be instructed to wash hands throughout the shift to prevent the spread on infection.

A review of the facility policy "Glucose Monitoring" last reviewed 10/4/18, indicated that the glucometer will be disinfected using a 10% bleach solution after each use.

During an observation on 2/4/19, at 8:30 a.m. of the Building 2 Shower/Tub room the following was observed: dirty linen hamper was uncovered, opened bar of soap, a brush and towel on the edge of the tub.

During an interview on 2/4/19, 10:06 a.m. Licensed Practical Nurse (LPN) Employee E6 confirmed that the facility created the potential for cross-contamination by soaps and care items being left for residents to share and leaving soiled linens uncovered.

A review of the clinical record revealed Resident R43 was admitted to the facility on 2/14/17, with the diagnoses that included difficulty walking, diabetes, coronary disease and muscle weakness.

A review of the clinical record revealed Resident R55 was admitted to the facility on 4/13/18, with the diagnoses that included falls, diabetes, pneumonia, irregular heart beat, difficulty walking, obesity, muscle weakness, MRSA (Methicillin-resistant Staphylococcus Aureus- a bacterium that causes infections in the body) infection of a buttocks wound.

A review of the Physician Orders dated 1/19, revealed that Resident R55 is on contact precautions related to a MRSA infection in a buttocks wound.

During the following observations on 2/5/19, at 11:02 a.m. through 11:09 a.m. of a medication pass with Registered Nurse (RN) Employee E2 entered Resident R43's room with gloved hands performed a blood glucose then went back to the medication cart in the hallway, removed gloves, obtained supplies for a breathing treatment went back to Resident R43 administered the breathing treatment, opened Resident R43's bathroom door and preformed handwashing then went back to the medication cart and reapplied gloves sanitized the glucose monitor, removed gloves failed to preform hand washing after RN Employee E2 removed gloves. RN Employee E2 reapplied gown and gloves then went in to Resident R55's room, preformed a blood glucose reading went to the Resident R55's shared bathroom opened the door with gloved hands and preformed hand washing. On the floor next to the bathroom door was an opened red biohazard bag that contained contaminated waste from treatments for Resident R55. Resident R55 Bathroom is a shared bathroom for two other residents in room 208.

During an interview on 2/5/19, at 11:40 a.m. RN Employee E2 confirmed that by touching door handles with gloved hands and not performing hand washing after each time gloves are removed and reapplying gloves prior to performing hand washing creates the potential for cross contamination. RN Employee E2 confirmed that biohazardous waste not being secured and the shared bathroom is were Resident R55's bed pans are emptied creates the potential for cross-contamination.

During an observation on 2/5/19, from 11:10 a.m. through 12:01 p.m. Licensed Practical Nurse (LPN) Employee E3 administered eye drops to Resident R25 removed gloves and then returned to the medication cart, applied gloves, prepared medication for Resident R48, removed gloves went to Resident R48's room administered medications, left Resident R48's room went back to the medication cart documentated in the Medication Administration Record (MAR), removed keys for his/her pocket, opened medication cart, prepared insulin injection(medication to lower blood sugar), applied gloves went into Resident R22's room and administered the injection, removed gloves, left the room and went back to the medication cart removed keys from his/her pocket removed the blood glucose monitor from the medication cart. LPN Employee E3 applied gloves then preformed a blood glucose check on Resident R46 in her room. LPN Employee E3 then removed one glove, with the ungloved hand removed keys from pocket and removed an alcohol pad and cleaned the blood glucose monitor then removed the second glove. LPN Employee E3 then documented on the MAR and reapplied gloves and prepared an insulin injection for Resident R46. After the insulin injection with the same gloved hands, LPN Employee E3 went to Resident R46's bathroom and obtained water to flush Resident R46's feeding tube. LPN Employee E3 then left Resident R46's room, removed gloved, documented on the MAR and then preformed hand sanitizing with an alcohol based sanitizer.

During an interview on 2/5/18, at 12:05 p.m. LPN Employee E3 confirmed that by not performing hand washing when gloves are removed and/or changing task and by not cleaning the blood glucose monitor per policy he/she created the potential for cross contamination.

During an observation on 2/7/19, 9:25 a.m. in the facility laundry area five boxes were on the concrete floor. One of the boxes closes to the entrance door was damaged and the contents were exposed.

During an interview on 2/7/19, at 9:30 a.m. the Director of Dietary/Housekeeping Employee E5 confirmed the boxes contain new whit resident bath towels and by storing them in contact with the floor it was determined that the facility failed to make certain that the linens and laundry were handled in a sanitary manner in one of one laundry areas

28 Pa. Code: 211.10 (d) Resident care policies.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
28 Pa. Code: 201.18 (b) (1) (e) (1) Management.
28 Pa. Code: 205.26(c) Laundry.










 Plan of Correction - To be completed: 04/01/2019

Five boxes in laundry were removed from the concrete floor. The red bag on the floor was removed. E3 will be re-educated on handwashing and glucometer cleaning & E2 will be re-in serviced including donning and removal of PPE, hand hygiene and glucometer cleaning to prevent cross contamination by the DON/Designee. Dirty linen hamper was closed, open bar of soap, brush and towel were removed from the shower room.
No other boxes were noted to be on the floor in laundry. No other red bags were noted to be on the floor in facility. The other facility shower room was checked for cross contamination items and any were removed.
Laundry staff will be re-educated by Laundry Manager/Designee on not storing items on the floor. Nursing staff will be re-in serviced on handwashing and glucometer cleaning including donning and removal of PPE, hand hygiene and preventing cross contamination by the DON/Designee. Nursing staff will be re-educated on cross contamination in the tub/shower rooms and proper handling and cleaning of bed pans to prevent cross contamination.
Monitoring to ensure compliance related to items being stored on the laundry room floor will be completed by Laundry Manager/Designee weekly x 4 and monthly x 2. Monitoring to ensure compliance of handwashing, glucometer cleaning, donning and removal of PPE, hand hygiene and cross contamination in the tub/shower rooms and cleaning of bed pans will be completed by the DON/Designee weekly x 4 and monthly x2.
Reports will be submitted to QA & A for recommendation.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to maintain resident privacy and dignity when entering rooms (room 204, 206, 209, 211, 212, 214 and 215) and failed to maintain privacy and dignity for three of 9 residents during medication administration and care (Resident R22, R25 and R46).

Findings Include:

The Facility "Medication Administration and Charting Guidelines" policy, last reviewed on 1/30/19, states that resident's privacy shall be maintained during medication administration.

A review of the Admission Packet provided to all residents on admission to the facility states that the resident shall be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care for the necessary personal and social needs.

During an observation of a medication pass on 2/5/19, at 11:02 a.m. Registered Nurse (RN) Employee E2 entered room 204W and 206W without knocking or requesting permission to enter resident rooms.

During an interview on 2/5/19, at 11:09 a.m. RN Employee E2 confirmed that resident privacy and dignity was not maintained by entering the rooms without asking for permission.

During an observation of a medication pass on 2/5/19, from 11:12 a.m. until 12:01 p.m. Licensed Practical Nurse (LPN) Employee E3 entered rooms 209D, 211D, 212W, and 215W without knocking or requesting permission to enter resident rooms.

A review of the clinical record revealed that Resident R25 was admitted to the facility on 2/13/18, with the diagnoses that included muscle weakness, difficulty walking, seizures, blindness, dysphagia, syncope (passing out), strokes, irregular heart beat and coronary artery disease.

During an observation on 2/5/19, at 11:10 a.m. of the medication pass, LPN Employee E3 entered Resident R25's room to administer eye drops. LPN Employee E3 failed to close the privacy curtain when providing care to Resident R25.

A review of the clinical record revealed that Resident R22 was admitted to the facility on 2/8/18, with diagnoses that included difficulty walking, anxiety, depression, mood disorder, dementia and diabetes.

During an observation on 2/5/19, at 11:30 a.m. of the same medication pass, LPN Employee E3 entered Resident R22's room and administered a subcutaneous injection of insulin while Resident R22 sat in the chair next to the roommate without closing the privacy curtain.

A review of the clinical record revealed Resident R46 was admitted to the facility on 9/13/18, diagnoses that included stroke, aphasia, diabetes, muscle weakness, difficulty swallowing and altered mental status.

During an observation on 2/5/19, at 11:39 a.m. of the medication pass, LPN Employee E3 entered Resident R46's room performed a blood sugar check, left room and returned, administered a subcutaneous injection (administering medication under the skin) of insulin then left room returned and flushed Resident R46's feeding tube. LPN Employee E3 failed to close privacy curtain when providing care to Resident R46. When LPN Employee E3 completed the care for Resident R46 she walked out of the room directly into room 214 without knocking or asking for permission to enter and performed hand washing in room 214 restroom.

During an interview on 2/5/19, at 12:01 p.m. LPN Employee E3 confirmed that resident's privacy and dignity was not maintained by entering the rooms without asking for permission, during the medication pass and the privacy and dignity of the residents was not maintained when administering medications and providing care without closing the privacy curtains.

28 Pa Code: 201.29 (j) Resident rights.

28 Pa Code: 211.10 (a)(b)(c)(d) Resident care policies.

28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.















 Plan of Correction - To be completed: 04/01/2019

E2 & E3 will be reeducated by DON/Designee regarding resident rights to privacy and dignity when entering rooms and privacy during medication administration and care.
Avalon place nursing staff will be re-educated by DON/designee regarding resident rights to privacy and dignity when entering rooms and privacy during medication administration and care.
Monitoring to ensure compliance related to privacy and dignity when entering rooms and privacy during medication administration and care will be completed by the DON/Designee weekly x 4 and monthly x 2.
Reports will be submitted to QA & A for recommendation.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:


Based on facility policy, observations and resident and staff interviews, it was determined that the facility failed to provide timely response to call bells for four of 15 residents (Residents R300, R301, R302 and R12).

Findings include:

Review of the "Resident Bill of Rights" provided to resident upon admission, indicated that residents have a right to reasonable accommodation of needs.

Review of facility policy "Call Light System" dated 10/4/18, indicated that the facility staff would respond to resident needs through a call light system.

During a group interview on 2/5/19, at 11:00 a.m. three residents Resident R300, R301 and R302 indicated that they have to wait a long time for their call bells to be answered.

A review of the Minimum Data Set (MDS- a periodic review of resident needs) dated 11/7/18, indicated that Resident R12 was admitted to the facility on 4/24/14, and had current diagnoses that included hemiplegia (one side paralysis), diabetes and difficulty in walking. Section G of the MDS related to functional status indicated that Resident R12 was totally dependent on staff assistance for toileting needs.

During an observation on 2/6/19, from 9:15 a.m. to 9:35 a.m. the call bell for Room 104 was noted to be illuminated for 20 minutes.

During an interview on 2/6/19, at 9:35 a.m. Resident R12 indicated she/he needed assistance using the bathroom, had been waiting for about an hour, and was very uncomfortable.

During an interview on 2/6/19, at 9:36 a.m. Nurse Aide Employee E1 confirmed that the call light had been on for a long time.


28 Pa. Code: 201.29(j) Resident Rights.











 Plan of Correction - To be completed: 04/01/2019

Avalon Place will accommodate the needs of the residents by responding timely to call lights.
Avalon Place nursing staff will be re-educated on answering call lights timely by DON/Designee.
Monitoring to ensure compliance related to answering the call bells timely will be completed by the DON/Designee weekly x 4 and Monthly x 2. Additionally, satisfaction monitoring will take place at the time of the call bell audit and documented.
Reports will be submitted to QA &A for recommendation.

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 facility policy, clinical record review and staff interviews, it was determined that the facility failed to follow physician orders for one of nine residents (Resident R46).

Findings include:

A review of the facility's policy "Nasogastric (NG-a tube entering the stomach via the nose or stomach and used for liquid nutrition) Tube Flush" last reviewed 10/4/18, indicated that staff will obtain orders for all water flushes for all residents with nasogastric/gastric tubes.

A review of Resident R46's clinical record revealed that she was admitted to the facility on 9/13/18, and had diagnoses that included stroke, aphasia, diabetes, muscle weakness, difficulty swallowing and altered mental status.

Resident R46 physician's order dated 1/19, indicated to flush the feeding tube with 150 milliliters (mls) of water.

During an observation of a medication pass on 2/5/19, at 11:29 a.m. Licensed Practical Nurse (LPN) Employee E3 measured four 30 mls cups of water pouring into a larger cup. LPN Employee E3 then went to Resident R46's room an flushed the feeding tube with the 120 mls of water.

During an interview on 2/5/19, at 11:42 a.m. LPN Employee E3 was asked how much water was used to flush the feeding tube. LPN Employee E3 verified that 120 mls was used. LPN Employee E3 confirmed that the physician order stated that 150 mls was to be used.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

28 Pa. Code 211.12(d)(3) Nursing services.






















 Plan of Correction - To be completed: 04/01/2019

E3 will be reeducated on the seven rights of medication administration which includes the right dosage by DON/Designee.
Avalon Place licensed nursing staff will be re-educated on the seven rights of medication administration which includes the right dosage by DON/Designee.
Monitoring to ensure compliance related to the seven right of medication administration to include the dosage will be completed by the DON/Designee weekly x 4 and Monthly x 2
Reports will be submitted to QA & A for recommendation.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:

Based on facility policies, observations and staff interviews, it was determined that the facility failed to properly store medications in one of two medication rooms (Building 2) and biologicals in one of two treatment carts (Building 2) and properly label medication in one of two medication carts (Building 2)

Findings include:

A review of the facilities "Medication Distribution System" policy last reviewed 1/30/19, indicated that the facility medication room should have a "medication only" refrigerator. Medication and biologicals are stored safely, securely, and properly follow manufacturer's guidelines and only accessible to licensed nursing personnel, or staff member lawfully authorized to administer medications. Refrigerated medications are kept in closed and labeled containers and food items are not stored in this refrigerator.

A review of the facilities "Medication Labels" policy last reviewed 1/30/19, indicated that prescription medication labels should include: resident's full name, specific directions, physicians name, date dispensed, quantity, expiration date, name, address and telephone number of providing pharmacy and prescription number.

During an observation on 2/5/19, at 10:09 a.m. in the Building 2 Storage room, which contained treatment supplies that are accessed by unlicensed staff, was the treatment cart unlocked and unsecured.

During an interview on 2/5/19, at 10:11 a.m. Licensed Practical Nurse (LPN) Employee E3 confirmed that the facility failed to secure the treatment cart and was accessible to non-licensed personal.

During an observation on 2/5/19, at 10:18 a.m. of the Building 2 Medication room was the medication refrigerator which contained two cups of pudding and two cups of apple sauce.

During an interview on 2/5/19, at 10:21 a.m. Registered Nurse Employee E2 confirmed that the facility failed to properly store medication and food items with medications creates the potential for cross-contamination.

During an observation on 2/5/19, at 11:10 a.m. Building 2 Medication Cart for room 209, contained an opened bottle of Blink Tears (lubricating eye drop) that did not contain a resident's full name, specific directions, physicians name, date dispensed, quantity, name, address and telephone number of providing pharmacy and prescription number.

During an interview on 2/5/19, at 11:13 a.m. LPN Employee E3 confirmed that the eye drops did not contain the proper labeling as required.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

28 Pa. Code 211.9 (f)(2)(g) Pharmacy services.






 Plan of Correction - To be completed: 04/01/2019

Applesauce and pudding were removed from the medication room refrigerator. The treatment cart was locked. The blink tears were disposed of and a new bottle was re-ordered that is properly labeled.
No food items were stored in the other facility medication room refrigerator. Treatment carts were checked to ensure they were locked. Lubricating eye drops were checked to ensure they are properly labeled.
Avalon place licensed nursing staff will be re-educated related storage of medication, locking of medication and treatment carts and labeling of medications by the DON/Designee.
Monitoring to ensure compliance related to storage of medication, locking of medication and treatment carts and labeling of medications will be completed by the DON/Designee weekly x 4 and monthly x 2.
Reports will be submitted to QA & A for recommendation.

483.90(g)(2) REQUIREMENT Resident Call System: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.
483.90(g) Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area.

483.90(g)(2) Toilet and bathing facilities.
Observations:

Based on a review of facility policy, observations, documentation and staff interview, it was determined that the facility failed to provide a functional resident call bell system for one of three tub/shower rooms (Building 2 central tub/shower room).

Findings include:

The facility policy entitled "Call Lights" dated 10/4/18, indicated that staff should report all defective call lights to maintenance.

During an observation on 2/4/19, at 8:10 a.m. Building 2 central tub/shower room did not have a pull cord attached to the wall unit near the shower and on inspection when the pull cord next to the toilet was pulled, the signal above the outside of the door did not light and was there was no signal at the nurses station.

During an interview on 2/6/19 at 10:20 a.m., Licensed Practical Nurse confirmed that the call bell was not working and there is no way for staff or resident to call for help.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(1) Management.

28 Pa. Code 201.18(b)(3) Management.

28 Pa. Code 201.18(e)(1) Management.

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





















 Plan of Correction - To be completed: 04/01/2019

Call cords in the building 2 shower room were replaced by a facility contractor during annual survey.
No other pull cords were noted to be missing in the facility.
Licensed nursing staff will be re-educated on the process of filling out work orders by the DON/Designee.
Monitoring to ensure compliance will be completed for missing call cords by the maintenance manager/designee weekly x 4 and monthly x 2.
Reports will be submitted to QA & A for recommendation


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