Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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ELKINS CREST HEALTH & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey in response to two complaints completed on February 20, 2019, it was determined that Elkins Crest Health and Rehabilitation Center 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 for the Health portion of the survey process.

 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.

Based on observation, resident and staff interview and facility documentation review, it was determined that the facility failed to provide residents with a safe, clean, comfortable and homelike environment on three of three nursing care units (first-floor, second-floor and third-floor).

Findings include:

Interview with Resident R5 on February 20, 2019 at 11:30 a.m. revealed the closet doors get stuck, bind, squeak and make jarring noises (included in list below). The resident stated he had reported these concerns to a member of staff in January 2019.

Interview with a resident who wished to remain anonymous on the first-floor on February 20, 2019 at 12:21 p.m. revealed the bathroom cord was too short and could not be reached or positioned safely when using the toilet (included in list below). The resident stated these concerns were reported to the facility in the past and nothing improved.

Review of facility maintenance request reports revealed one report dated January 4, 2019 of the closet door in resident room 211 being stuck and hard to open. This same problem was identified during the facility tour on February 20, 2019 (included in list below). A second undated maintenance request report that was marked as completed on January 6, 2019 for the bathroom shared between rooms 210 and 211 revealed the toilet would not flush. This same problem was identified during the facility tour on February 20, 2019 (included in list below).

Observations during a tour of all resident rooms and resident bathrooms with the Director of Maintenance on February 20, 2019 starting at 11:15 a.m. revealed the following groups of observations in the respective rooms.

1.Constantly flushing toilets, toilet not flushing, toilet with minimal flushing and/or toilet flushing with loud squeaking noises in the bathrooms for resident rooms 116, 120, 208, 211, 215, 221, 222, 223, 306, 321, 326 and 327;
2.Closet doors stuck in position, closet doors jarring, closet doors binding, closet doors squeaking, closet doors off their tracks and unstable, closet door handles missing and/or closet door handles falling off for resident rooms 102, 112, 114, 115, 116, 120, 121, 203, 205, 207, 208, 210, 211, 218, 221, 223, 310, 311, 313 and 318;
3.Plastic corner protectors falling off with screws exposed and/or kick plates falling off bathroom doors in resident rooms 105 and 309;
4.Low faucet pressure and/or no water coming out of a cold tap in resident rooms 113 and 123;
5.Faucets squeaking during rotation and/or wobbly faucet handles in resident rooms 113, 123 and 221;
6.Bathroom call bell cord length approximately six inches long in the bathrooms for resident rooms 102, 106, 110, 112, 113, 114, 117, 118, 121, 123, 318, 328 and 329;
7.Bathroom call bell wired incorrectly such that the light activated when it is set to "off" and deactivated when it is set to "on" and the light being left in the "on" or down position by staff so that the light did not run, rendering the cord useless if residents were to pull the call bell in resident room 218;
8.Cracked sharp tiles at toe height in the bathroom for resident room 319;
9.Bathroom hardware such as the sink or soap/alcohol dispenser detaching from the wall for bathrooms in resident rooms 108, 316, 327 and the alcohol dispenser at the second-floor nursing station;
10.No bathroom trash can or the bathroom trash can missing in resident rooms 202, 208, 222, 325, 327 and 328;
11.Bathroom door handle falling off in resident room 115;
12.Metal screw lying on bedroom floor in resident room 118;
13.Foley catheter (a type of urinary catheter to drain urine from the bladder) bag with urine hanging in a shared bathroom on the shower rails in resident room 119;
14.No gloves available in the bathrooms for resident rooms 117, 222, 327, 328 and 329;
15.Electrical outlets hanging off the wall and exposing wires underneath in resident rooms 219 and 327;
16.One window falling out of its frame resulting in a large exposed opening in resident room 219;
17.Flickering and buzzing bathroom light in resident room 218;
18.Freestanding wardrobe wobbly and securement brackets not attached to the wall in resident room 327, and
19.Bathroom handrail falling off the wall in resident room 329.

Interviews with the Director of Maintenance on February 20, 2019 starting at 11:15 a.m. during the full facility tour revealed confirmation of all the above listed maintenance problems. The facility started to address the maintenance problems during the tour.

The facility failed to provide residents with a safe, clean, comfortable and homelike environment.

28 Pa. Code 207.2(a) Administrator's responsibility
Previously cited 10/20/17

 Plan of Correction - To be completed: 03/27/2019

1.Resident R5 closet doors have been replaced
Toilet fixed in room 210 and now properly flushes
Toilets repaired in rooms 116,120,208,211,215,221,222,223,306,321,326 and 227. Toilets now flush properly and are free of loud squeaking noises.
Closet doors replaced in the following rooms 102,114,112,115,116,120,121,203,205,207,208,210,211,218,221,223,310,311,313,318 and now function properly
Plastic corner protectors and kick plates replaced in rooms 105 and 309
Faucets replaced in rooms 113 and 123 and 221 and now function properly
Call bell Chord replaced in all resident bathrooms and resident shower rooms. Call bell chords now reach 4 inches from the floor per regulation
Call bell rewired and now functions correctly in room 218
Sharp tiles in room 319 replaced
Bathroom hardware soap dispenser was replaced in room 108, 316, and 327
Trash cans were placed in rooms 202,208,222,325,327 and 328
Bathroom door handle replaced in room 115
Metal screw removed from room 118
Foley catheter drainage bag removed from room 119
Gloves were placed in rooms 117, 222,327,328 and 329
Electrical outlets were repaired in rooms 219 and 327
Window in room 219 was repaired
Bathroom light fixed in room 218
Wardrobe closet replaced in room 327
Handrail repaired in room 329.

Audits completed by maintenance supervisor or designate to ensure that
All residents have the potential to be affected. An audit of all resident closet doors, bathroom call bells strings, bathroom floor tiles, and resident toilets for function and safety was completed. Along with this an audit of soap/hand sanitizer dispensers and trash cans was completed to ensure that they remained replenished. The Maintenance Director audited all resident electrical outlets, resident bathroom lighting, resident bathroom handrails, and resident windows for function and safety. Resident wardrobes were audited to ensure that they were effectively anchored to the wall.

All staff in-serviced on reporting broken equipment or damage observed in resident care area.

Maintenance staff educated on prompt repair
In-service completed by staff educator

All Staff in-serviced on proper utilization of maintenance repair logs and identifying areas requiring repair. In-service completed by Maintenance director or designee

The Maintenance
Audits to be completed weekly for 90 days by maintenance Supervisor or designee. Audits will be trended and results to be reported to QAPI committee monthly.
Audits to be completed by Unit Manager to ensure that
Gloves are stored and available for use in each resident's bathroom
Foley Catheter bags are properly stored away when not on resident person and not hung in the residents bathroom

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