Deficiencies in Infection Control and Personal Property Management
Penalty
Summary
The facility was found to have deficiencies in infection control and management of residents' personal property. There was no evidence of infection control committee meetings after February 2024, indicating a lapse in ongoing infection control oversight. Additionally, a review of closed clinical records revealed that the facility failed to document the disposition of a resident's personal belongings following their discharge. Specifically, Resident 16, who was admitted on February 8, 2025, and passed away on March 5, 2025, had personal items such as prescription glasses, clothes, shoes, a cell phone, and a charger listed in their inventory. However, there was no documentation indicating what happened to these belongings after the resident's death. This was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
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. Resident 16 personal belonging inventory disposition was completed and reviewed with the resident's representative. 2. A retrospective review of the last 3 months of discharges was reviewed for the presence of a personal belonging inventory disposition and completed as indicated. 3. The Director of Nursing and/or designee will educate RNs, LPNs, and Housekeeping to ensure that the personal belongings inventory disposition is completed and reviewed with the resident/resident representative as indicated. 4. The Director of Nursing and/or designee will audit all closed records to ensure that the personal belongings inventory disposition is completed and reviewed with the resident/resident representative as indicated. The audit will be completed for 3 months or until substantial compliance is achieved. Results will be reviewed at the quarterly QA meeting.