Nursing Investigation Results -

Pennsylvania Department of Health
WINDBER WOODS SENIOR LIVING & REHABILITATION CENTER
Patient Care Inspection Results

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WINDBER WOODS SENIOR LIVING & REHABILITATION CENTER
Inspection Results For:

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WINDBER WOODS SENIOR LIVING & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a complaint survey completed on September 18, 2019, it was determined that Windber Woods Senior Living 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.








 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:


Based on review of policies, observations and staff interviews, it was determined that the facility failed to ensure that residents' water pitchers were clean and sanitized.

Findings include:

The facility's policy regarding water distribution, dated September 18, 2019, revealed that the nursing staff were to collect the water pitchers for sanitation per the cleaning schedule or provide the residents' with disposable foam cups daily. The dietary department was to completely sanitize water pitchers and return them to the unit.

The facility's water pitcher/cup/tray cleaning schedule, dated December 21, 2016, revealed that the day shift (7:00 a.m. to 3:00 p.m.) staff were to collect the pitchers/cups/trays by 1:30 p.m. and pick up the cleaned pitchers/cups/trays at 2:45 p.m. The schedule indicated that water pitchers were collected and cleaned once a week on each unit:

Monday - Willow
Tuesday - Elm
Wednesday - Maple
Thursday - Spruce

Observations on the Willow unit on Tuesday, September 17, 2019, at 10:45 a.m. and Wednesday, September 18, 2019, at 11:30 a.m. revealed that Resident 1's water pitcher was half-full of water and had a removable, brown film/substance on the inside. Interview with the Director of Nursing on September 18, 2019, at 11:31 a.m. confirmed that the water pitcher needed replaced.

Observations on the Willow unit on September 17, 2019, at 10:49 a.m. and September 18, 2019, at 11:40 a.m. revealed that Resident 11's water pitcher lid had a removable substance on it. Interview with the Director of Nursing on September 18, 2019, at 11:50 a.m. confirmed that the lid needed replaced.

Interview with the Director of Nursing on September 18, 2019, at 3:25 p.m. revealed that there was no documented evidence that the water pitchers on the Willow unit were cleaned as scheduled on Monday, September 16, 2019.

42 CFR 483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve-Sanitary.
Previously cited 1/16/19.

28 Pa. Code 211.6(f) Dietary services.
Previously cited 1/16/19.



 Plan of Correction - To be completed: 10/14/2019

1. In order to correct the deficient practice the water pitchers identified were immediately replaced and fresh water was provided.
2. In order to identify other residents having the potential to be affected by the same deficient fresh water was provided to all residents, the water pitchers were checked and were clean thus no other residents were affected.
3. In order to prevent the deficient practice from recurring Education will be performed with the dietary staff and Nursing assistants to ensure they are knowledgeable of the cleaning schedule.
4. Weekly audits will be performed to ensure the deficient practice does not recur. If any water pitcher does not appear clean, it will be immediately replaced.
5. Corrective action to be completed by: October 14, 2019


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 observations and staff interviews, it was determined that the facility failed to ensure that two call lights were functional and allowed residents to call for assistance from staff for three of 11 residents reviewed (Residents 8, 9, 10).

Findings include:

Observations on Elm unit on September 18, 2019, at 11:00 a.m. revealed that the call light in the bathroom of Residents 8 and 9's room did not light or sound when pulled by the Director of Maintenance, who confirmed at that time that the call light did not work.

Observations on the Willow unit on September 18, 2019, at 11:07 a.m. revealed that the call light in Resident 10's room did not light up in the hallway for the staff to see. Interview with the Director of Maintenance at that time confirmed that the call light was not fully functional.

Interview with the Director of Maintenance on September 18, 2019, at 11:28 a.m. revealed that call lights were repaired when staff completed a work order and there were no work orders for the two non-functioning call lights.

28 Pa. Code 207.2(a) Administrator's responsibility.
Previously cited 1/6/19.



 Plan of Correction - To be completed: 10/14/2019

1. In order to correct the deficient practice the call bells that were identified as not functioning properly were immediately fixed by maintenance.
2. To identify other residents having the potential to be affected by the same deficient practice all call bells were checked to ensure proper functioning. No other call bells were identified as being non-functioning thus no other residents were affected.
3. And 4. The Maintenance department currently performs weekly random checks of call bell functioning as part of routine preventative maintenance of resident rooms. In addition, random Weekly audits will be conducted by the Interdisciplinary Team as implemented during a Quality Assurance Performance Improvement meeting to ensure the same deficient practice does not recur. Education will be performed with the staff to ensure they are knowledgeable of the process for submitting repair requests if call bells are identified as being non-functional. If any call bells are found to be non-functioning, maintenance will be notified to correct the issues immediately. If the call bell is unable to be fixed, the resident will be temporarily moved to another room until the call bell system can be repaired.
Corrective action to be completed by: October 14, 2019


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