Nursing Investigation Results -

Pennsylvania Department of Health
BRIARLEAF NSG AND CONV CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BRIARLEAF NSG AND CONV CENTER
Inspection Results For:

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BRIARLEAF NSG AND CONV CENTER - 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 December 20, 2019, it was determined that Briarleaf Nursing and Convalescent Center has a deficiency that has the potential for minimal harm to residents as related to the 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.


 Plan of Correction:


483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
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 it was determined that the facility failed to maintain a clean and homelike environment on four of five nursing units. (Station 2, 3, 4 and 5)

Findings include:

Observation between December 17, 2019, at 10:33 a.m. and December 18, 2019, at 10:20 a.m. on Station 2 revealed the following:

The walls in room 202 were marred and scratched.

The walls in room 203 were marred and scratched and the window blind was broken.

A wheelchair in room 205 had a blue spongy substance on both leg rests and dried food and participles on the seat, side, back and wheels.

The heating unit in room 206 contained dust on the vents.

There were stained ceiling tiles in the hallway between rooms 205 and 206.

The bathroom door vent in room 208 contained dirt at the base, the heating unit contained dust and rust on the vents, and they were marred and scratched.

The oxygen concentrator in room 208 contained dust on the filter.

The soiled linen room door had pieces missing.

The exit doors had pieces missing.

The floor tile in room 212 was missing at the head of the bed, the bathroom door vent contained dirt.

The bathroom door vent in room 215 was dirty, the floor title at base of bed was cracked, the heating unit had dirt on top.

The blind was broken in room 216.

In room 217 the blind was broken, the heating unit was dirty and rusty, the walls were marred and scratched, the bathroom vent was rusty, the bathroom base molding was loose from wall.

The heating unit in room 219 was marred and scratched.

The top of the partial wall at the Station 2 nurses' station was chipped.

The medication room door was dirty and had dried substance on outside.

The hallways between Station 2 and Station 5 had broken floor tiles.

The door of medication room contained dirt and dried substance on outside of door.

There was spilled liquid on the inside of the bottom of the medication refrigerator and dried substance noted on outside top and side.

Medication cart 1 and 2 had brown crumbs in the drawers.

Observation on December 17, 2019, at 12:44pm, Station 4 nursing unit revealed the walls in room 158 were marred and scratched.

Observation on December 18, 2019, at 9:20am, of the Station 3 medication refrigerator revealed spilled liquid on the inside on the bottom.

Observation on December 19, 2019, at 11:10am, on the Station 5 nursing unit revealed medication carts 1 and 2 had brown crumbs in the drawers. In the resident dining area there were areas of the ceiling that were peeling.

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



 Plan of Correction - To be completed: 01/28/2020

The walls in room 202 were spackled and painted
The walls in room 203 were spackled and painted. The window blind was replaced.
The wheelchair in room 205 was thoroughly cleaned.
The heating unit vents in room 206 were vacuumed.
The ceiling tiles in the hallway between rooms 205 and 206 were replaced.
The bathroom door vent was cleaned. The heating unit was prepped and painted.
The oxygen concentrator filter in room 208 was replaced.
The soiled linen room door was removed. Only empty linen carts are kept in this area.
The exit doors shall be repaired by 1/28/20.
Floor tile in room 212 at the head of the bed was replaced. The bathroom door vent was cleaned.
Floor tile in room 215 at the base of the bed was replaced. The bathroom door vent was cleaned. The heating unit was prepped and painted.
The window blind in room 216 was replaced.
The window blind in room 217 was replaced. The heating unit was prepped and painted. The walls have been repainted. The bathroom base molding was replaced.
The heating unit in room 219 was prepped and painted.
The partial wall at the Station 2 nurses station was prepped and painted.
The medication room door was thoroughly cleaned.
The hallway floor tiles between Stations 2 and 5 shall be replaced by 1/28/20.
The medication room door was thoroughly cleaned.
The medication refrigerator was thoroughly cleaned inside and out.
Medication carts 1 and 2 have been thoroughly cleaned.
Room 158 walls shall be been spackled and painted by 1/28/20.
The medication refrigerator has been thoroughly cleaned.
Station 5 medication carts 1 and 2 were thoroughly cleaned. The ceiling of the resident dining room was caulked and repaired.
An evaluation of all rooms and resident areas shall be completed on a monthly basis by the Housekeeping Department Head. Any environmental and housekeeping issues shall be addressed. NHA shall monitor monthly.
All medication carts shall be cleaned on a daily basis by nursing and monitored by the Consultant Pharmacist monthly. Medication refrigerators shall be cleaned on a weekly basis and monitored by the Consultant Pharmacist monthly.







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