Facility Fails to Maintain Safe and Secure Environment
Penalty
Summary
Embassy of Scranton was found to be non-compliant with the requirements for maintaining a safe, clean, and homelike environment as per 42 CFR Part 483 Subpart B and the 28 PA Code. During a state revisit and abbreviated complaint survey, it was observed that the facility failed to maintain the kitchen and laundry room entrance doors in proper working condition. The kitchen's dishwasher entrance doors were broken, unable to be properly closed or locked, and swung off their hinges, posing a challenge for staff transporting tray carts. The Dietary Manager, who was hired in December 2024, confirmed the doors were already in disrepair at that time but could not specify the duration of the issue. Additionally, the laundry room entrance door was also found to be broken, unable to fully close or be secured with a lock. A review of documents revealed that a repair quote for the replacement and installation of both doors was received on August 21, 2024, but there was no evidence that the facility acted on this quote or made any repairs. The Nursing Home Administrator confirmed the broken condition of both doors during an interview, indicating a failure to address the maintenance issues in a timely manner.
Plan Of Correction
The replacement doors for the Kitchen and the Laundry Room entrances have been ordered and will take 6-8 weeks to be manufactured. Once they are received, they will be replaced. The Maintenance Director/designee will conduct an initial audit of existing doors in the facility to ensure that they are in good working order. The Administrator/designee will ensure identified concerns are rectified in a timely manner. The Maintenance Director/designee will educate staff to notify the maintenance department of any safety concerns or repair needs. Any identified needs will be entered into the preventive maintenance program (TELS) by issuing a work order for repair. The Maintenance department will repair the identified concern and/or involve the Administrator to gain approval for purchase of a timely replacement if necessary. The Maintenance Director/designee will audit existing doors in the facility on a weekly basis as part of the preventative maintenance program to ensure that they are in good repair. The Administrator/designee will ensure identified concerns are rectified in a timely manner. The results of these audits will be discussed at the facility QAPI meeting monthly for further review and recommendations.