Pennsylvania Department of Health
AVALON SPRINGS PLACE
Patient Care Inspection Results

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AVALON SPRINGS PLACE
Inspection Results For:

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AVALON SPRINGS PLACE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed December 21, 2023, it was determined that Avalon Springs Place, 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.



 Plan of Correction:


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 on review of facility policy, observations, and staff interviews, it was determined that the facility failed to discard an open expired bottle of liquid protein (a supplement to help with wound healing) in one of two medication carts (West Two).

Findings include:

Review of facility policy entitled "Medical Nutritional Supplements" dated 3/2023, indicated that "unused supplements that were being used by the nurse at the medication cart may be labeled with the date opened, store in refrigerator and discarded after 48 hours."

Observation on 12/18/23, at 3:40 p.m. of the West Two medication cart revealed an opened bottle of liquid protein with an expiration date of 11/2023 and an opened date of 12/3/23.

During an interview with Licensed Practical Nurse (LPN) Employee E1 on 12/18/23, at 3:40 p.m. revealed that two residents receive liquid protein daily.

During an interview with LPN Employee E1 on 12/18/23, at 3:47 p.m. he/she confirmed that the opened bottle of liquid protein expired on 11/2023, and should have been discarded. He/she also confirmed that the bottle of liquid protein was opened on 12/3/2023, which was after the manufacturer's expiration date.

28 Pa. Code 201.18(b)(1) Management

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




 Plan of Correction - To be completed: 02/15/2024

"The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements."

1) The opened protein supplement was discarded all med carts and supply rooms checked to ensure all outdated supplements had been discarded.
2) The facility DON or designee will educate the facility nurses and central supply staff on the facilities Medical Nutritional Supplements policy. Including the process for dating, storing, and discarding open supplements.
3) The DON or designee will audit facility med carts weekly for one month and monthly for 3 months to ensure all items are stored properly.
4) Audit findings will be reviewed and tracked as part of the facilities QAPI process.

§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:


Based on review of facility staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 12 residents on both day and evening shifts, and one NA per 20 residents on the overnight shift, for five of 21 days reviewed for staffing ratio (11/24/23, 11/25/23, 12/16/23, 12/17/23, and 12/18/23)

Findings include:

Review of 21 days of nursing staffing documentation for day shift revealed:

On 11/25/23, facility census of 61 residents, five NA scheduled and six were required.
On 12/18/23, facility census of 67 residents, five NA scheduled and six were required.

Review of 21 days of nursing staffing documentation for evening shift revealed:

On 11/24/23, facility census of 61 residents, five NA scheduled and six were required.
On 12/16/23, facility census of 68 residents, four NA scheduled and six were required.
On 12/17/23, facility census of 68 residents, five NA scheduled and six were required.

Review of 21 days of nursing staffing documentation for overnight shift revealed:

On 12/16/23, facility census of 68 residents, three NA scheduled and four were required.

During an interview on 12/21/23, at 10:04 a.m. the Staff Scheduler confirmed that the facility failed to meet the minimum ratio requirements on the above dates and shifts.





 Plan of Correction - To be completed: 02/15/2024

1) The facility will meet minimum nurse aide to resident ratio each day by calculating out projected ratios needed at current census levels.
2) The Nursing Home Administrator will educate the DON, ADON, Nursing Supervisors and Scheduler on required ratios to ensure facility is meeting ratios.
3) System changes to help ensure proper staffing ratios are met include reviewing potential admissions to ensure proper census levels, increase agency use as needed, continue to offer extra shift bonus to current staff for picking up shifts, ensure all vacant positions are in recruitment.
4) The Director of Nursing or designee will audit to ensure that the facility meets the required minimum number of nurse aide to resident staffing ratio by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance. Audits will be completed weekly for one month, biweekly for one month and monthly for 3 months. Audits will be reviewed as part of the facilities QAPI committee and monitored for tracking and trending.


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