Nursing Investigation Results -

Pennsylvania Department of Health
MANORCARE HEALTH SERVICES-NORTHSIDE
Patient Care Inspection Results

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MANORCARE HEALTH SERVICES-NORTHSIDE
Inspection Results For:

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MANORCARE HEALTH SERVICES-NORTHSIDE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint completed on February 12, 2020, it was determined that ManorCare North Side 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 related to 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.
Observations:
Based on observation and staff interview, it was determined that the facility failed to maintain a safe, clean, and homelike environment in 17 of 45 Resident rooms (Rooms 101, 102, 104, 105, 106, 107, 109, 118, 119, 120, 202, 205, 220, 223, 224, 225 and 226 ).

Findings Include:

During observation s from 8:30 a.m. through 9:10 a.m. the following was observed:

Resident rooms 101, 102, 105, 119, 120, and 226 had privacy and/or window curtains falling off clips and poles.

Resident rooms 104, 105 and 106 ceilings above resident beds peeling paint with chips falling off and in bathroom between Resident room 105 and 106 the bathroom ceiling paint was peeling.

Resident rooms 102, 106, 118, 202 and 205 had no trash can liners in can and the bathroom can in room between 118 and 119 had a soiled incontinence pad which left a strong odor emitting from bathroom. Resident bathroom between 101 and 102 had a strong feces and urine odor around toilet area.

Resident room 102, 104, 109, 205 and 220 had black substances on floor with papers and food debris on floor and overbed tables.

Resident room 107 heating unit was pulled away from the wall on the left side.

Quad Resident rooms 223, 224, 225 and 226 had strong urine and body odors emitting from entrances of rooms. Resident room 223 had peeling wallpaper under the window on the left side of the room.

During an interview on 2/12/20, at 9:47 a.m. the Nursing Home administrator and Director of Nursing confirmed that the facility failed to maintain a safe, clean comfortable homelike environment for the residents of the first and second floors of the facility.

28 Pa. Code: 207.2(a) Administrator's responsibility.


 Plan of Correction - To be completed: 03/12/2020

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein.
The identified curtains, paint, privacy curtains, and wallpaper will be remedied by maintenance director and/or a qualified contractor. The trash cans, floors, overbed tables, and odors identified by the inspection will be remedied by housekeeping services for findings in rooms 101, 102, 104, 105, 106, 107, 109, 118, 119, 120, 202, 205, 220, 223, 224, 225, and 226. Utilizing the environmental QAPI audit tool, a comprehensive environmental audit will be conducted throughout the building for similar situations. Corrections will be completed by housekeeping, maintenance, and qualified contractors. Housekeeping staff will be reeducated about the cleaning procedure of resident rooms by the Environmental Services Director/ designee. The Maintenance Director will be educated by the NHA/ designee on homelike environment using the Focus on Ftag 584. Nursing staff will be educated on reporting repair items through the maintenance work order system by the DON/ designee. The housekeeping manager will monitor the environment for corrections through daily rounds on scheduled work days. Resident areas will be audited weekly x 4 weeks using the Environmental QAPI tool by the Environmental Services Director/ Designee to monitor the environment for corrections. Monthly rounds with the NHA and housekeeping manager will occur to monitor ongoing progress. The results of these audits will be reviewed by the QAPI committee.

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