Nursing Investigation Results -

Pennsylvania Department of Health
VALLEY MANOR REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

VALLEY MANOR REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:
There are 156 surveys for this facility. Please select a date to view the survey results.

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VALLEY MANOR REHABILITATION AND HEALTHCARE 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, Civil Rights Compliance survey and an Abbreviated survey in response to two complaints completed April 26, 2022, it was determined that Valley Manor Rehabilitation and Healthcare Center, 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 as they relate to the Health portion of the survey.

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 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 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 observation and review of facility policy, it was determined that the facility failed to store food under sanitary conditions in the kitchen.

Findings include:

Review of the facility policy entitled, "Storage," dated March 29, 2022, revealed that food was to be stored in a safe manner. Dry goods were to be discarded after three months and refrigerated leftovers were to be labeled with the date of storage and discarded after 72 hours.

Observations during the initial tour of the kitchen on April 24, 2022, at 8:50 a.m., revealed a bag of opened crispy onions and two bags of opened coconut flakes that were undated in the dry storage area. There was two opened containers of sugars that were dated March 21 and April 13, 2021. In the walk-in refrigerator there was an opened container of peaches dated April 18, 2022, pickles dated March 29, 2022, a container of applesauce with no date, diced chicken dated April 16, 2022, and a large tray of turkey luncheon meat dated April 16, 2022. There were two opened containers of flour and thickener in the preparation area that were undated. The window fan above the ice cream freezer was covered in a large amount of brown dust. The ceiling tiles above the dishmachine area were covered with brown and black spots.

Plan of Correction - To be completed: 05/11/2022

1. All cited opened food that was not dated was immediately thrown out, and all opened food that was dated but expired was immediately thrown out. The window fan above freezer was immediately cleaned. The ceiling tiles above the dish machine were immediately cleaned.
2. Facility designee completed an audit of the kitchen to ensure proper storage of food and proper sanitation of the area is maintained.
3. Dietary Director to educate dietary staff on proper label/dating of food storage and following posted cleaning schedule. NHA educated Housekeeping Director on schedule to clean ceiling tiles and fans in kitchen.
4. NHA/designee will audit refrigerated and dry food weekly for 4 weeks and then monthly for 2 months to ensure items are dated and thrown out when expired. NHA/designee will audit ceiling tiles and fans weekly for 4 weeks and then monthly for 2 months to ensure they are free of debris.
5. Audits will be submitted to QAPI for review.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:

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.

�483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Observations:

Based on clinical record review and observation, it was determined that the facility failed to ensure that a resident's call bell was in reach to call for assistance from staff for one of 34 sampled residents. (Resident 147)

Findings include:

Clinical record review revealed that Resident 147 had diagnoses that included chronic obstructive pulmonary disease (emphysema), and weakness. The Minimum Data Set assessment dated April 5, 2022, indicated that the resident was not cognitively impaired and required extensive assist of one staff for most activities of daily living, including bed mobility. Review of the current care plan identified that the resident was at risk for discomfort related to neuropathic pain. There was an intervention to have the call bell in reach to allow the resident to request things, including pain medication. Observation on April 24, 2022, at 10:27 a.m. and 1:37 p.m., revealed that the resident was in his room in a wheelchair on the far side (from the door) of his bed. The call bell control was clipped on the top of the mattress on the opposite side of the bed. The resident could not reach the call bell. On April 25, 2022, at 8:43 a.m. the resident was positioned on his side facing the window. The call bell was clipped on the opposite (door side) of the bed on the vertical side of the mattress behind the resident's back. The resident's call bell was on the bed completely out of the resident's reach during all three observations.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 05/11/2022

1. Resident 147's call bell immediately placed in reach.
2. Facility completed baseline audit of call bells in each room to ensure they are within reach.
3. DON educated nursing, housekeeping, and therapy staff on placing call bells within reach.
4. Unit Managers/Designee will audit resident call bells to ensure they are within reach weekly for 4 weeks and then monthly for 2 months to ensure call bells within reach.
5. Audits will be submitted to QAPI for review.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

�483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

�483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

�483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to �483.70(e) and following accepted national standards;

�483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

�483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

�483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

�483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections on one of six nursing units. (Nursing unit 100)

Findings include:

Review of the facility policy entitled, "COVID-19 Infection Control Practices", dated March 29, 2022, revealed that personal protective equipment (PPE) specifically face masks were to be worn daily throughout the facility by all staff. In the event of an outbreak of COVID-19, all staff were to utilize N-95 face masks while on the nursing units.

In an interview on April 25, 2022, at 9:22 a.m., the Director of Nursing stated that the facility has been in a COVID-19 outbreak status since April 15, 2022, due to four residents who had tested positive for COVID-19.

Observation on April 24, 2022, at 11:30 a.m., revealed CNA 1 at the nursing desk on nursing unit 100 with only a surgical mask on, not an N-95 face mask on her face. CNA 1 had been observed immediately prior to being at the nursing desk walking in the corridor of Nursing unit 100 with only the surgical mask in place.

Observation on the same day at 12:03 p.m., revealed that CNA 1 was walking up and down the Nursing unit 100 corridor with the surgical mask pulled down beneath her chin and not covering her mouth or nose. In addition, at this time CNA 1 entered Resident Room 108 without the surgical mask fully covering her mouth or nose. At 12:16 p.m., CNA 1 was observed in the same room feeding Resident 125 her lunch while she was in bed. CNA 1 still had the surgical mask pulled down beneath her chin not covering her mouth or nose while she was with the resident.

In an interview on April 26, 2022, at 9:05 a.m., the Administrator stated that all staff was to wear an N-95 face mask at all times on the nursing units due to the recent outbreak and as per the facility policy.

28 Pa. Code 211.10 (a) Resident care policies.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 05/11/2022

1. Staff members will be re-educated on the proper use of PPE.
2. Facility completed an infection control audit to ensure staff are wearing and donning recommended PPE correctly.
3. Facility staff educated on the most recent Infection Control and Prevention guidance.
4. Facility will conduct daily infection control rounds daily for 5 days, weekly for 4 weeks, monthly for 2 months, or as deemed necessary by the QAPI Committee. All results will be reported to the QAPI Committee.
5. Date Certain: 5/11/22.

483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination:

�483.10(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

�483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

�483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

�483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

�483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.

Observations:

Based on clinical record review, observation, and resident interview, it was determined that the facility failed to ensure that a resident's preferred schedule in the morning was followed for one of 34 sampled residents. (Resident 204)

Findings include:

Clinical record review revealed that Resident 204 was admitted on April 5, 2022, with diagnoses that included congestive heart failure and chronic kidney disease. The Minimum Data Set assessment dated April 12, 2022, indicated that the resident was alert and oriented and required extensive assistance from staff for bed mobility, transfers, dressing and hygiene. Review of the current care plan identified the resident had a self care deficit with an intervention for staff to assist her with routine care. Review of admission nursing documentation dated April 5, 2022, revealed that the resident was alert and oriented and able to make her needs known. On April 18, 2022, a nurse noted that the resident understands and is able to be understood.

Observations on April 22, 2022, at 9:30 a.m., and 10:30 a.m., revealed that the resident was in bed and had not received assistance from staff with her morning care. At this time the resident stated that she preferred to be up, washed and dressed by 9:00 a.m., at the latest. In an interview on the same day at 12:28 p.m., the resident stated again that she preferred to be up and out of bed by 9:00 a.m., and that the staff had not assisted her with her routine morning care today until 11:30 a.m.. The facility failed to follow the resident's preferred schedule for routine morning care.

28 Pa. Code 201.29(j) Resident rights

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

Plan of Correction - To be completed: 05/11/2022

1. Resident 204 was care planned to be out of bed, cleaned, and dressed by 9am daily. Nursing staff educated on this resident's preferences.
2. Facility completed baseline audit on capable residents to identify if they have a morning routine. Facility completed care plan on these preferences.
3. Facility implemented new system by adding this question to Admission care plan meetings to ensure these preferences are care planned on admission. DON educated nursing staff on the importance of resident preferences.
4. DON/Designee will audit random residents weekly for 4 weeks and then monthly for 2 months to ensure their morning routine was met.
5. Audits will be submitted to QAPI for review.

483.25 REQUIREMENT Quality of Care:

� 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 on clinical record review and staff interview it was determined that the facility failed to ensure that physician's orders were implemented for one of 34 sampled residents. (Resident 43)

Findings include:

Clinical record review revealed that Resident 43 had diagnoses that included dementia and depression. On April 18, 2022, a physician's order directed staff to decrease Resident 43's antipsychotic medication (Seroquel) from 175 milligrams (mg) twice daily to 150 mg twice daily. A review of the current physician's orders and the April 2022 Medication Administration Records, revealed that Resident 43 still received 175 mg of Seroquel for his morning dose of the medication from April 18 through April 25, 2022.

In an interview on April 26, 2022, at 1:45 p.m., the Director of Nursing confirmed that Resident 43's current order for Seroquel was to be for staff to administer 150 mg twice a day and that Resident 43 was still receiving 175 mg of the antipsychotic medication for his morning dose.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 05/11/2022

1. Resident 43's Seroquel morning does was immediately corrected.
2. Facility completed baseline audit of psychiatric medication dose reductions in the last 30 days to ensure they were entered correctly.
3. Facility implemented new system that GDRs will be reviewed in morning clinical meeting to ensure they are entered correctly. DON educated licensed staff on entering medication orders correctly.
4. DON/designee will audit GDR medication orders weekly for 4 weeks then monthly for 2 months to ensure orders entered correctly.
5. Audits will be submitted to QAPI for review.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

�483.25(c) Mobility.
�483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

�483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

�483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Observations:

Based on clinical record review, observation and staff interview, it was determined that the facility failed to provide services and treatment to prevent further limitations in range of motion for one of one sampled resident who had limitations in range of motion and had a splint. (Resident 68)

Findings include:

Clinical record review revealed that Resident 68 had diagnoses of hemiplegia after a stroke affecting his right dominant side, muscle wasting of the right upper arm and weakness. Review of the Minimum Data Set assessment dated February 22, 2022, indicated that the resident was alert and oriented, required extensive assistance from staff for dressing and had limitations in range of motion on one side of both his upper and lower extremities. On July 1, 2020, a physician ordered for staff to apply a right resting hand splint on with evening care and to remove with morning care. Review of an occupational discharge therapy summary dated June 28, 2021, revealed that the resident was to wear a resting hand splint on the right hand for up to eight hours with minimal discomfort or pain. Review of the nursing documentation for the application of the right resting hand splint revealed that the splint was noted as "not applicable" for a total of 12 times on the evening shift for April 2022. There was no documented evidence that the right resting hand splint had been applied as ordered by the physican and recommended by occupational therapy on a consistent basis on the evening shift.

In an interview on April 26, 2022, at 9:00 a.m., the Director of Nursing stated that there was no consistent documentation that the right resting hand splint was being applied as ordered by the physician. In addition, she stated that there was no documented evidence that the resident had been refusing to wear the right resting hand splint.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 05/11/2022

1. Resident 68's resting hand splint was placed on resident per MD order.
2. Facility completed baseline audit of residents with orthotics to ensure it is placed on resident per MD order and ensure correct nursing documentation in place.
3. Facility implemented new system by updated POC task nursing documentation tabs to ensure documentation accuracy. DON educated nursing staff on this new POC task tab.
4. DON/designee will audit random resident's orthotics weekly for 4 weeks and then monthly for 2 months to ensure placement per physician order.
5. Audits will be submitted to QAPI for review.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

�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 and review of facility documentation, it was determined that the facility failed to provide adequate supervision for one of three sampled residents at risk for elopement (exiting the facility unsupervised). (Resident 77)

Findings include:

Clinical record review revealed that Resident 77 was admitted to the facility with diagnoses that included dementia and difficulty walking. On July 17, 2021, a physician ordered that Resident 77 wear a Wanderguard (a security apparatus worn by an at risk resident that prevents doors from opening to prevent elopement when the resident is nearby). The Minimum Data Set assessment dated November 3, 2021, indicated that Resident 77 was cognitively impaired and needed staff supervision with transfers and walking. Review of Resident 77's care plan revealed that he was at risk for elopement from the facility. The goal was that he would not exit the facility without staff knowledge and that staff was to monitor his whereabouts on an ongoing basis. Review of the nursing notes revealed that on January 5, 2022, at 10:40 p.m., Resident 77 was missing. Review the facility's incident investigation indicated that on January 5, 2022, at 10:15 p.m., staff noticed that the front door of the facility was ajar. At around 10:40 p.m. Resident 77 was identified as missing. Resident 77 was found outside of the facility on the ground at 11:30 p.m., Further review of the facility's incident investigation revealed that staff was unable to hear the alarm for the Wanderguard system on the nursing units and that the alarm was only audible in the front lobby. The facility failed to monitor Resident 77's whereabouts on an ongoing basis and failed to provide adequate supervision to prevent the resident from leaving the facility without the knowledge of staff.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 05/11/2022

1. Resident 77 did not suffer major injury from this elopement.
2. Facility corrected facility wide issue in January 2022 by installing additional audible alarm devices throughout the building to be heard by staff.
3. No new system needed as the correction in January 2022 has prevented elopements that staff was not able to hear alarms. DON will re-educate staff on elopement policy.
4. Maintenance Director/designee will audit alarm system weekly for 4 weeks then monthly for 2 months to ensure alarming correctly.
5. Audits will be submitted to QAPI for review.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

�483.25(e) Incontinence.
�483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

�483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

�483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on review of facility policy, clinical record review and observation, it was determined that the facility failed to provide care and services for one of five sampled residents who had indwelling catheters as per facility policy. (Resident 105)

Findings include:

Review of the facility policy entitled "Infection control-Indwelling Catheter Care", dated March 29, 2022, revealed that it was the policy of the facility to ensure that residents received care and services to prevent urinary tract infections in those residents with an indwelling catheter in accordance with standards of practice.

Clinical record review revealed that Resident 105 had diagnoses that included neuromuscular dysfunction of the bladder. The Minimum Data Set (MDS) assessment dated March 17, 2022, indicated that the resident was alert and oriented, needed extensive assistance with most care and that he utilized an indwelling catheter. Review of the current care plan indicated that Resident 105 used an indwelling catheter and that staff was to keep the drainage bag below the resident's bladder level. On April 24, 2022, from 11:30 a.m. through 1:00 p.m., and again on April 25, 2022, from 12:30 p.m. through 1:00 p.m., Resident 105 was observed in his wheelchair with his catheter drainage bag above his bladder level over the arm rest of his chair.

28 Pa. Code 211/12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 05/11/2022

1. Resident 105's catheter bag was immediately placed below his bladder. Resident 105 was educated to keep his catheter bag below his bladder, he stated he does not want that and was care planned to his preference in which he prefers to not always keep it below his bladder but on his wheelchair arm.
2. Facility completed baseline audit on residents with catheters to ensure they were kept below the bladder.
3. DON educated nursing staff on correct placement of catheters.
4. DON/designee will audit random residents with catheters weekly for 4 weeks and monthly for 2 months to ensure catheter placed below bladder.
5. Audits will be submitted to QAPI for review.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

� 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on policy review, clinical record review, observation and staff interview it was determined that the facility failed to ensure oxygen equipment was dated in accordance with facility policy for two of 34 sampled residents receiving oxygen therapy. (Resident 121, 150)

Findings include:

Review of the facility policy entitled, "Oxygen Administration and Therapeutics", dated March 29, 2022, revealed staff were to date humidification bottles and oxygen tubing.

Clinical record review revealed that Resident 121 was admitted to the facility on January 11, 2017, with diagnoses that included asthma and dyspnea (shortness of breath). Resident 121 had a physician's order for a nebulizer treatment every four hours as needed and oxygen therapy as needed. Observation on April 24, 2020, at 10:23 a.m., revealed Residet 121 was in bed with a nasal cannula in place. Review of the treatment record revealed that the resident's respiratory equipment and tubing was to be changed, labeled and dated weekly. On April 24, 2022, at 10:23 a.m., and again on April 25, 2022, at 9:36 a.m., the resident's humidifier bottle and tubing was observed without a label and date.

Clinical record review revealed that Resident 150 was admitted to the facility on February 7, 2022, with diagnoses that included congestive heart failure (heart does not pump blood as well as it should) and pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and right side of the heart). Resident 150 had a physician's order for oxygen therapy as needed. Observation on April 24, 2022 at 11:53 a.m., revealed Resident 150 was in a recliner chair at bedside with a nasal cannula in place. On April 24, 2022, at 11:53 a.m., and again on April 25, 2022, at 10:48 a.m., the resident's tubing was observed without a date.

In an interview on April 26, 2022, at 8:47 a.m., the Director of Nursing confirmed that the tubing and humidification bottle should have been dated.

28 Pa. Code 211.12(d)(5) Nursing services.

Plan of Correction - To be completed: 05/11/2022

1. Resident 121's humidifier bottle and tubing were immediately replaced and dated. Resident 150's O2 tubing was immediately replaced and dated.
2. Facility completed baseline audit on residents with oxygen equipment to ensure the equipment is dated per policy.
3. Facility corrected prior system of having night shift change and date tubing and bottles by adding this on their checklist to ensure it is completed. DON educated nursing staff on the addition to the checklist and how to change and label tubing and bottles.
4. DON/designee with audit random residents with O2 and nebulizers weekly for 4 weeks then monthly for 2 months to ensure oxygen equipment dated per policy.
5. Audits will be submitted to QAPI for review.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:

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.

�483.60(i)(4)- Dispose of garbage and refuse properly.

Observations:

Based on observation, it was determined that the facility failed to properly dispose of garbage and refuse properly.

Findings include:

Observation on April 24, at 9:00 a.m., during the initial environmental tour of the dumpster area, revealed that the side doors on all three dumpsters were open exposing garbage bags that contained paper, plastic and soiled personal care items. There were numerous disposable items found around the outside of the dumpster area, including numerous cigarette butts, soiled gloves, masks, and food wrappers.

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

Plan of Correction - To be completed: 05/11/2022

1. Dumpster doors immediately closed. Debris immediately cleaned.
2. Facility completed baseline audit of facility grounds to ensure no other debris was on ground
3. NHA educated all departments on ensuring dumpster doors are closed, and if debris falls on ground when disposing, you need to ensure it is thrown in dumpster.
4. Maintenance Director/Housekeeping Director will audit facility grounds and dumpster doors daily for 5 days then weekly for 3 weeks and then monthly for 2 months to ensure dumpster doors are closed and facility grounds are free of debris.
5. Audits will be submitted to QAPI for review.

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