Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT STEVENS, THE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS AT STEVENS, THE
Inspection Results For:

There are  73 surveys for this facility. Please select a date to view the survey results.

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GARDENS AT STEVENS, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey and State Licensure, Civil Rights Compliance Survey, and an abbreviated survey in response to a complaint, completed on March 10, 2022, it was determined that The Gardens At Stevens, 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 for the Health portion of the survey process.

































































 Plan of Correction:


483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.25(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:


Based upon clinical record review and observation, it was determined that the facility failed to timely identify and treat a pressure ulcer causing actual harm to two of four residents reviewed (Resident 36 and Resident 53).

Findings include:

Review of Resident 36's diagnosis list revealed diagnoses including Vascular Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), muscle weakness, Congestive Heart Failure (excessive body/lung fluid caused by a weakened heart muscle) and abnormal posture.

Review of Resident 36's quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated November 18, 2021, revealed Resident 36 required the extensive assistance of two staff members for turning and repositioning in bed, transferring between surfaces and required total dependence on staff members for bathing.

Review of Resident 36's Weekly Skin Review dated November 1, 2021, revealed "open area to coccyx. Treatment in place."

Review of Resident 36's Weekly Skin Review dated November 8, 2021, revealed "dry pre-existing skin condition" with no further information noted.

Review of Resident 36's Weekly Skin Review dated November 15, 2021, revealed "skin intact".

Review of Resident 36's Weekly Skin Review dated November 24, 2021, revealed "dry pre-existing skin condition and left eyebrow healing skin tear."

Review of Resident 36's clinical progress notes dated November 27, 2021, revealed "coccyx wound identified, 1/2 cm [centimeter] with drainage."

Review of Resident 36's clinical record including the November 2021 Treatment Administration Record (TAR) failed to reveal any evidence that treatments were performed on the coccyx/sacral wound during the month of November 2021.

Review of Resident 36's Vohra Wound Physicians Wound Evaluation and Management Summary dated December 2, 2021, revealed a Stage 4 Pressure Wound Sacrum, Full Thickness with 100 percent necrotic [dry, black] tissue. The Wound Summary further revealed that an excisional debridement procedure was conducted on December 2, 2021, to remove some of the devitalized tissue and necrotic muscle in the wound.

Review of Resident 36's clinical record including the December 2021 TAR revealed that treatments were initiated on December 3, 2021, one day after being treated by the Vohra Wound Physician.

Observation conducted for Resident 36's wound treatment on March 9, 2022, at 1:30 p.m for infection control procedures.

The facility documentation presented including care plans, progress notes, and wound assessments did not reveal any wound treatments in place for Resident 36 from November 1 until December 3, when seen by the wound specialist. According to the documentation presented; the wound treatment began when the specialist debrided the wound and ordered treatment. The facility failed to timely identify and treat Resident 36's coccyx/sacral pressure ulcer prior to the wound developing to a Stage 4 causing harm to Resident 36.

The above information was conveyed to the Nursing Home Administrator and Director of Nursing on March 10, 2022, at approximately 1:00 p.m.

Review of Resident 53's diagnosis list included immobility due to infection in right knee prosthesis, Diabetes and stage 4 Kidney Disease.

Review of Resident 53's clinical record dated February 15, 2022, new admission skin assessment revealed that the resident was admitted to the facility with a left and right buttocks stage 2 pressure ulcer (an ulcer involving loss of the top layers of the skin). Left buttock measured 1.5 x 1.0 cm and the right buttock wound measure 1.0 x 0.5 cm.

Further review of the clinical record revealed there was no documentation that the physician was notified about this wound and no treatment initiated.

Physician's note from the wound clinic dated February 18, 2022, revealed a Stage 3 (ulcer involving the full thickness of skin loss, exposing tissue) pressure wound on the sacrum measured 0.7 x 0.6 cm with moderate serous exudate and 50% granulation tissue. The wound was debrided to promote healing. A treatment order was given for border foam dressing three times a week.

Review of Resident 53 clinical record including care plans revealed, staff are to conduct treatment as ordered but did not identify wound stage or specific treatment. The care plan also indicated a consult for wound care specialist, reduction cushion on wheelchair, and staff are to turn and reposition resident every 2 hours. Progress notes reviewed only indicated observation of a Stage 2 wound on resident's bilateral buttocks.

An interview conducted with the Director of Nursing on March 10, 2022, at 1:00 p.m. revealed that the facility was unclear if the sacral pressure wound was new or if the two bilateral Stage 2 buttock wounds merged. The Director of Nursing confirmed the lack of wound progression knowledge. The Director of Nursing confirmed the only wound treatment administered for the two buttock wounds was barrier cream, present upon admission.

The facility failed to timely assess and treat Resident 53's sacral wound which resulted in actual harm of an advanced stage pressure ulcer.

28 Pa. Code 211.12(c)(d)(1)(3) Nursing services
Previously cited 1/19/22




















 Plan of Correction - To be completed: 04/12/2022

F0686
1. Resident 36 will have pressure ulcers identified timely and treated. Resident 53 was discharged from the facility on March 10, 2022.
2. Residents will have a thorough skin assessment completed per facility policy to identify skin issues and will have treatments initiated. VOHRA Wound Physicians Evaluation and Management Summary will be reviewed by nursing upon completion and orders will be initiated.
3. Professional Nursing staff will be educated by the DON/Designee on proper identification of wounds and completion and documentation of wound treatments.
4. Audits will be completed by the DON/Designee on Progress Notes, Skin Assessments and Wound Evaluations and Management Summaries for new onset of skin impairments and initiation of treatments. These will be completed five times per week for four weeks. The results will be reviewed in the facility QAPI meeting for further actions needed.


483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based upon review of facility policy and procedure, grievance forms and clinical records, it was determined that the facility failed to report an allegation of abuse to the State agency for one of 24 residents reviewed (Resident 41).

Findings include:

Review of facility policy and procedure titled "Abuse Policy" revealed "all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ("abuse") shall be promptly reported to local state and federal agencies (as defined by current regulations) and thoroughly investigated by the administrator and/or designee."

Review of Resident 41's clinical progress notes dated February 7, 2022, revealed "residents daughter stated to nurse that resident stated someone may have hit her. She stated it was prior to second shift. She mentioned it was during care, and may have been call bell that tapped her in the back. This nurse expressed that it may have been an accident due to call bell not being clipped onto something to keep it from swinging. Resident could not recall who gave her care. Daughter stated when she came in at first, [resident] was upset, this nurse expressed that she did not note her upset at the beginning of the shift, [resident] responded pleasant when nurse entered room at 1530 [3:30 p.m.]"

Further review of Resident 41's clinical progress notes dated February 8, 2022, revealed "SS [social services] interviewed resident regarding DTR [daughter] reporting that resident had been hit by staff or call bell. Resident said that she did not recall anything happening. Resident said that she felt safe here, but wanted to go home. Resident was tearful and said that she wanted to just go home. Resident said that she was getting her medications and liked her roommate. SS phoned residents DTR discussed that nursing had provided care and repositioning and residents call bell was behind her attached to the sheet. DTR said that staff had repositioned resident again and had reclipped call bell when she had arrived. DTR said that her mother told her that someone had just hit her in the back. DTR said that she immediately told the nurse and nurse and DTR had resident lean forward to see if there were any marks, did not see any, DTR said that resident is very upset at not being at home and may make statements about being upset at her situation and may make statements about staff care to family and friends. DTR said that resident has struggled to adjust to short term care in the past. Care plan updated to include providing comfort and support to resident, and reporting any concerns to nursing and IDT [interdisciplinary team], SS will continue to follow up and assist with any concerns."

Interview with the Director of Nursing on March 9, 2022, at approximately 10:00 a.m. confirmed that the facility did not report the allegation of abuse to the State agency.

28 Pa. Code 201.18(b)(1)(2) Management
Previously cited 1/9/22; 10/23/20







 Plan of Correction - To be completed: 04/12/2022

Initial Disclaimer; The statements made on this plan of correction are not an admission to or do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all state and federal regulations, the center has taken or will take the following actions set forth in the following plan of correction. The following plan of correction constitutes this centers allegation of compliance such that all alleged deficiencies have been or will be corrected by the date indicated. It is the practice of this facility to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being in accordance with the comprehensive assessments and plan of care.
F0609
1. Resident 41 will have all events reported to the State Agency as required.
2. Concern/Grievance forms for the past 30 days will be reviewed for reporting requirements in regards to Allegations of Abuse. These results will be reviewed by the DON/Designee.
3. The DON/Designee will review the Event Reporting Guidelines for reporting Allegations of Abuse.
4. Audits will be completed by the DON/Designee on Concern/Grievance Forms and Progress Notes for compliance with reporting. These will be completed five times per week for four weeks. The results will be reviewed in the facility QAPI meeting for further actions needed.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based upon review of facility policy and procedure, grievance forms, and clinical records, it was determined that the facility failed to investigate an allegation of abuse for one of 24 residents reviewed (Resident 41).

Findings include:

Review of facility policy and procedure titled "Abuse Policy" revealed "all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ("abuse") shall be promptly reported to local state and federal agencies (as defined by current regulations) and thoroughly investigated by the administrator and/or designee."

Review of Resident 41's clinical progress notes dated February 7, 2022, revealed "residents daughter stated to nurse that resident stated someone may have hit her. She stated it was prior to second shift. She mentioned it was during care, and may have been call bell that tapped her in the back. This nurse expressed that it may have been an accident due to call bell not being clipped onto something to keep it from swinging. Resident could not recall who gave her care. Daughter stated when she came in at first, [resident] was upset, this nurse expressed that she did not note her upset at the beginning of the shift, [resident] responded pleasant when nurse entered room at 1530 [3:30 p.m.]"

Further review of Resident 41's clinical progress notes dated February 8, 2022, revealed "SS [social services] interviewed resident regarding DTR [daughter] reporting that resident had been hit by staff or call bell. Resident said that she did not recall anything happening. Resident said that she felt safe here, but wanted to go home. Resident was tearful and said that she wanted to just go home. Resident said that she was getting her medications and liked her roommate. SS phoned residents DTR discussed that nursing had provided care and repositioning and residents call bell was behind her attached to the sheet. DTR said that staff had repositioned resident again and had reclipped call bell when she had arrived. DTR said that her mother told her that someone had just hit her in the back. DTR said that she immediately told the nurse and nurse and DTR had resident lean forward to see if there were any marks, did not see any, DTR said that resident is very upset at not being at home and may make statements about being upset at her situation and may make statements about staff care to family and friends. DTR said that resident has struggled to adjust to short term care in the past. Care plan updated to include providing comfort and support to resident, and reporting any concerns to nursing and IDT [interdisciplinary team], SS will continue to follow up and assist with any concerns."

Interview with the Director of Nursing on March 9, 2022, at approximately 10:00 a.m. confirmed that no investigation of staff or other caregivers was conducted regarding the above allegation.

The facility failed to ensure that a complete and thorough investigation was conducted regarding an allegation of abuse of a resident.

28 Pa. Code 201.18(b)(1)(2) Management
Previously cited 1/19/22; 10/23/20






 Plan of Correction - To be completed: 04/12/2022

F0610
1. Resident 41 will have all allegations of abuse investigated which includes staff interviews.
2. Reports of allegations of abuse will be thoroughly investigated including interviews of staff and or caregivers.
3. Facility staff will be educated by the DON/Designee on the facility policy and procedure for reporting allegations of abuse.
4. Audits will be completed by the DON/Designee on nursing documentation and concern/grievance forms for compliance with investigations of abuse. These will be completed five times per week for four weeks. The results will be reviewed in the facility QAPI meeting for further actions needed.


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 upon clinical record review, observation, and interview, it was determined that the facility failed to follow physician orders for the treatment of pressure ulcers and failed to provide treatment for a pressure ulcer for one of four residents reviewed (Resident 36).

Findings include:

Review of Resident 36's diagnosis list revealed diagnoses including Vascular Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), muscle weakness, Congestive Heart Failure (excessive body/lung fluid caused by a weakened heart muscle) and abnormal posture.

Review of Resident 36's Weekly Skin Review dated November 1, 2021, revealed "open area to coccyx. Treatment in place."

Review of Resident 36's Weekly Skin Review dated November 8, 2021, revealed "dry pre-existing skin condition" without further information provided.

Review of Resident 36's Weekly Skin Review dated November 15, 2021, revealed "skin intact".

Review of Resident 36's Weekly Skin Review dated November 24, 2021, revealed "dry pre-existing skin condition and left eyebrow healing skin tear."

Review of Resident 36's clinical progress notes dated November 27, 2021, revealed "coccyx wound identified, 1/2 cm [centimeter] with drainage."

Review of Resident 36's Wound Physicians Wound Evaluation and Management Summary dated December 2, 2021, revealed a Stage 4 Pressure Wound, Sacrum; Full Thickness with 100 percent necrotic [dry, black] tissue.

The Wound Summary further revealed that an excisional debridement procedure was performed on December 2, 2021, to remove some of the devitalized tissue and necrotic muscle in the wound.

Review of Resident 36's November 2021 Treatment Administration Record (TAR) failed to reveal evidence that any treatments were administered on the coccyx/sacral wound during the month of November 2021.

Review of Resident 36's December 2021 TAR revealed that treatments were initiated on December 3, 2021, one day after being seen and treated by the Wound Physician.

Review of Resident 36's January 2022 physician orders revealed orders to cleanse sacrum with NSS [normal saline solution], apply Dakins solution [wound treatment] to 4 x 4 gauze and cover with comfort foam BID [two times per day] every day and evening shift for wound healing.

Review of Resident 36's January 2022 TAR revealed that no treatments were performed during day shift on January 1, January 2, January 5, January 11, January 12, January 14, January 17, January 18, and January 22, 2022.

Further review of Resident 36's January 2022 TAR revealed that no treatments were performed during evening shift on January 13, 2022.

Review of Resident 36's March 2022 physician orders revealed an order for Morphine Sulfate Solution 20 mg/ml (milligrams per milliliter) Give 5 mg by mouth every 4 hours as needed for pain (4-10).

Interview with Licensed Employee E3 on March 9, 2021, at approximately 1:30 p.m. revealed Resident 36 was to be pre-medicated prior to receiving wound treatment.

Review of Resident 36's March 2022 physician orders failed to reveal an order for pain medication as needed prior to wound treatment.

The facility failed to follow physician orders for the treatment of Resident 36's pressure ulcer.

The above information was conveyed to the Director of Nursing on March 10, 2022, at approximately 12:00 p.m.

28 Pa. Code 211.12(c)(d)(1)(3) Nursing Services
Previously cited 1/19/2022









 Plan of Correction - To be completed: 04/12/2022

F0684
1. Resident 36 will have physician orders followed for the treatment of pressure ulcers and administration of pain medications. Pressure Ulcer Treatments will be completed as ordered.
2. Residents will have physician orders followed for treatment of pressure ulcers and administration of pain medications. Pressure Ulcer Treatments will be completed as ordered and documented.
3. Professional Nursing staff will be educated by the DON/Designee on following physician orders for treatment of pressure ulcers, administration of pain medications and documentation of Pressure Ulcer Treatments.
4. Audits will be completed by the DON/Designee on physician orders, progress notes, Medication Administration and Pressure Ulcer Treatment Records for compliance in completion of treatments and administration of pain medications. These will be completed five times per week for four weeks. The results will be reviewed in the facility QAPI meeting for further actions needed.


483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:


Based upon facility policy and clinical records review, it was determined that the facility failed to address a significant weight loss for one of three residents reviewed (Resident 36).

Findings include:

Review of facility policy and procedure titled "Weight Assessment and Intervention" revealed, "any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Physician and Dietitian."

Further review of facility policy and procedure revealed "The Dietitian and/or Certified Dietary Manager will review the individual weight records to follow individual weight trends over time, making recommendations as appropriate. Negative trends will be evaluation for whether or not the criteria for "significant" weight change has been met."

Review of Resident 36's Weights and Vitals Summary revealed Resident 36's weight on February 2, 2022, was 129.7 pounds.

Further review of Resident 36's Weights and Vitals Summary revealed Resident 36's weight on March 4, 2022, was 114 pounds indicating a 15.7 pound weight loss in one month.

Review of Resident 36's Interdisciplinary Note dated March 9, 2022, revealed "IDT [Interdisciplinary Team] met to review residents weights, resident needs a re-weight. Resident has lost weight over the past month. IDT discussed benefit of Hospice services, over current plan of comfort care. Resident will meet with RD, will discuss with resident and family if a Hospice eval would be appropriate."

Review of Resident 36's Weights and Vitals Summary revealed that a re-weight was conducted on March 4, 2022, confirming Resident 36's weight loss.

Further review of Resident 36's clinical record failed to reveal evidence that any interventions were put into place on March 4, 2022, or after to address Resident 36's significant weight loss.

The facility failed to address resident's significant weight loss timely.

The above information was conveyed to the Director of Nursing on March 10, 2022, at 11:00 a.m.

28 Pa. Code 211.12(c)(d)(3) Nursing Services
Previously cited 1/19/2022





 Plan of Correction - To be completed: 04/12/2022

F0692
1. Resident 36 will have all weights reviewed timely to address significant weight loss.
2. Residents will be reviewed timely by the Dietician and Nursing to address significant weight loss per facility policy and procedure. The clinical alerts for weights will be reviewed at morning clinical meeting for significant weight loss and interventions will initiated timely.
3. The Dietician, Interdisciplinary Team and Professional Nursing Staff will be educated by the DON/Designee on the facility Policy and Procedure for Weight Assessment and Intervention.
4. Audits will be completed by the DON/Designee on resident weights for significant weight loss and interventions. These will be completed five times per week for four weeks. The results will be reviewed in the facility QAPI meeting for further actions needed.

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 upon observation, it was determined that the facility failed to ensure that treatment supplies were stored appropriately for two of 24 residents reviewed (Resident 27 and Resident 39).

Findings include:

Observation of Resident 27's room on all four days of the survey revealed a pink plastic basin containing bandage scissors, bandage dressings and wound cleanser stored on Resident 27's bedside table and dresser.

Interview with the Director of Nursing on March 10, 2022 at approximately 11:00 a.m. confirmed that all treatment supplies are to be stored in the treatment cart which is stored on the nursing unit.

Observations of Resident 39's room on all four days of the survey revealed three tubes of Betamethasone, one tube of Triamcinolin, and 1 tube of Nystatin (medications used to treat skin conditions) on the resident's bed.

The facility failed to properly store treatment supplies in the treatment cart stored on the unit.

28 Pa. Code 211.12(c)(1)(2)(3) Nursing Services
Previously cited 1/19/2022








 Plan of Correction - To be completed: 04/12/2022

F0761
1. Resident 27 and 39 treatment supplies were removed from the rooms and stored in the treatment cart.
2. Resident rooms were reviewed for treatment supplies and items were removed.
3. The nursing staff will be educated by the DON/Designee on facility policy for storage of treatment supplies.
4. Audits will be completed by the DON/Designee for storage of treatment supplies in residents rooms. These will be completed three times per week for four weeks. The results will be reviewed in the facility QAPI meeting for further actions needed.


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