Nursing Investigation Results -

Pennsylvania Department of Health
WESTMINSTER VILLAGE
Patient Care Inspection Results

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Severity Designations

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

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WESTMINSTER VILLAGE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on October 3, 2019, it was determined that Westminster Village was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirments for Long Term Care 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 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.
483.60(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 observation, it was determined that the facility failed to ensure that food was stored in a sanitary manner in the food service department.

Findings include:

Observation on September 30, 2019, at 8:57 a.m., revealed there was a used white kitchen towel on a food tray containing prepared foods in the preparation/storage refridgerator.

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




 Plan of Correction - To be completed: 10/28/2019

1). Upon being aware of the kitchen towel on the food tray in the storage refrigerator, it was immediately removed.
2).Protecting other residents.
The DDS and Assistant DDS went through each of the storage areas to insure that all storage was in compliance.
3). Systems
Re-education will be provided for the dining staff regarding appropriate/sanitary storage of these dining areas.
4). QA
The DDS/ designee will audit these areas daily to insure compliance for 3 months and then randomly each week thereafter. Any concern will be corrected at time of discovery. Any needed changes or need for review will be presented at Quality QAPI for potential adjustments.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on clinical record review, observation and staff interview, it was determined that the facility failed to adequately supervise one cognitively impaired resident to prevent the resident from exiting the facility without staff's knowledge (elopement) for one of 21 sampled residents. (Resident 75)

Findings include:

Clinical record review revealed that Resident 75 was admitted to the facility on February 24, 2019, with diagnoses that included dementia (cognitive impairment) and Parkinson's disease (progressive nervous system disorder that affects movement). A Minimum Data Set assessment completed on September 6, 2019, revealed that the resident had memory impairment. The care plan identified that the resident was at risk to fall and sustain an injury. The care plan also identified that the resident had poor safety awareness. A nurses' note on June 25, 2019, at 5:28 p.m., revealed that the resident had exited the building from the multi-purpose room without staff knowledge and went down the hill and the wheel chair overturned. There was no evidence to support that the activity staff provided supervision to Resident 75 when the activity program ended and the staff had started returning the other residents to their units.

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



 Plan of Correction - To be completed: 10/28/2019

1). R75- Had been reviewed at the time of the event and interventions were put in place at that time. There was no harm to the resident.
2). Protecting other residents.
The Interdisciplinary team reviewed the event immediately upon occurrence and developed a process to protect other residents in a similar situation.
3). Systems
Re-education was provided to Community Life and Nursing staff. A program operating procedure was developed and finalized to provide
on-going guidance to these situations.
4). Q.A.
The Procedure will be reviewed by the Director of Community Life/designee for the effectiveness of the process with each off-neighborhood event for 3 months and randomly each month thereafter. Any concern will be corrected at time of discovery. Any needed changes or need for review will be presented at the QAPI meeting for potential adjustments.

483.60(g) REQUIREMENT Assistive Devices - Eating Equipment/Utensils: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(g) Assistive devices
The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.
Observations:

Based on clinical record review and observation it was determined that the facility failed to ensure that a special plate was provided to one of 21 sampled residents. (Resident 5)

Findings include:

Clinical record review revealed that Resident 5 had diagnoses that included diabetes with diabetic retinopathy (damage to the eyes which causes vision impairment) and dementia (memory impairment). The Minimum Data Set assessment dated July 7, 2019, indicated that the resident required supervision with eating. Review of a physician order dated July 1, 2019, revealed that the resident was to have a handled mug with lid for all liquids and a lipped plate at meals. Review of the current care plan included an intervention that staff provide a lipped plate and a handled mug with lid for fluids.

Observation on September 30, 2019, at 12:25 p.m., revealed Resident 5 in the dining area with her lunch, however, there was no lipped plate. The resident was served a hot liquid in a regular handled mug without a lid. Observation on October 2, 2019, at 1:01 p.m., revealed that the resident received her lunch tray, however there was no lipped plate and the liquid was in a regular handled mug with a lid and straw.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 11/19/18



 Plan of Correction - To be completed: 10/28/2019

1). R5- Upon awareness of the need for a lipped plate and 2-handled mug with lid, it was immediately provided.
2). Protecting other residents.
The Dietitian ran a report for all residents who are ordered specialized eating equipment and determined it was in place.

3). Systems.
Re-education of the dining staff and nursing team members to review the meal tickets for specialized eating equipment and make sure it is provided.
4). Q.A.
The Dietician/DDS or designee will run the report of designated specialized eating equipment to be provided each month. They will audit the distribution of that equipment with each meal for 3 months and then randomly each month thereafter. Any concern will be corrected at time of discovery and the audits presented to the QAPI meeting. Any needed changes or need for review will be presented at Quality QAPI for potential adjustments.


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