Pennsylvania Department of Health
EMBASSY OF WOODLAND PARK
Patient Care Inspection Results

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EMBASSY OF WOODLAND PARK
Inspection Results For:

There are  96 surveys for this facility. Please select a date to view the survey results.

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EMBASSY OF WOODLAND PARK - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a complaint survey completed on January 29, 2024, it was determined that Embassy of Woodland Park 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:


483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(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 81°F; and

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


Based on observations and staff interviews, it was determined that the facility failed to ensure that residents had a clean and homelike environment by failing to ensure that three medication carts and two mechanical lift machines were free of dirt and debris.

Findings include:

Observations on January 29, 2024, at 10:00 a.m. revealed that there was one stand-up lift machine parked in the hall that had a large accumulation of dirt, dust, debris, and food on the base of the machine. Observations of the full-body lift in the shower room at that time revealed that there was an accumulation of dirt, dust, and debris on the base of the lift.

Interview with Nurse Aide 1 on January 29, 2024, at 10:11 a.m. revealed that she was not sure who was supposed to clean the mechanical lift machines. She stated she just uses them and did not notice the dirt or debris on the bases.

Observations on January 29, 2024, at 10:18 a.m. revealed that one medication cart on the 300 hall had a large accumulation of hair, dirt, and debris on both of the rear casters.

Interview with Licensed Practical Nurse 2 on January 29, 2024, at 10:18 a.m. revealed that she wipes her cart down at the start of her shift and at the end of her shift, but she does not routinely check the wheels of the carts. She stated the rear wheels do need cleaned and should not have a large build up of hair, dirt, and debris.

Observations on January 29, 2024, at 10:20 a.m. revealed that both medication carts on the 200 hall had a large accumulation of hair, dirt, and debris.

Interview with Licensed Practical Nurse 3 on January 29, 2024, at 10:20 a.m. revealed that there used to be a housekeeper that would take care of everything, including the wheels on the medication carts; however, she has since retired. He said he had not thought to check the wheels on the carts but that they did need cleaned.

Interview with the Maintenance Director on January 29, 2024, at 11:12 a.m. revealed that he does check the equipment, such as the mechanical lifts, for functionality and safety, but he does not clean them. He said that if he notices hair build-up around the casters he takes it off, but he does not routinely clean them.

Interview with the Director of Nursing on January 29, 2024, at 12:12 p.m. revealed that the nurses are responsible for maintaining their medication carts and that staff were recently given cleaning schedules in order to maintain the equipment.

28 Pa. Code 201.29(j) Resident Rights.

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


 Plan of Correction - To be completed: 02/14/2024

A baseline audit was completed of casters on all med carts to evaluate for debris, any debris was removed on 1 30 24

A baseline audit of of all facility lifts was completed for debris on 1 30 24 and lifts were thoroughly disinfected.

Nightshift nursing staff were educated on the routine cleaning schedule of lifts and medication carts.

Maintenance staff to complete monthly inspections of all casters on medication carts to assure that they are free of debris.

Nursing staff will complete nightly checklist to include sanitation of facility lifts and med carts

The Director of Nursing or designee
will complete random audits of medication carts and facility lifts weekly x 4 weeks to assure they are free of debris


Results of the audits will be reported and trended in the facilities Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after the initial audits are completed and results are reviewed according to the trends recommendations and guidance via the facility Quality Assurance Improvement Plan.



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