Kansas Health Care Association



May, 2014 Survey DataF155 Right to Refuse; Formulate Advance DirectivesNE: SS=D: Failed to honor res’ code status Closed record revealed CP did not address code status; computerized record indicated res was a DNR; nurse reported EMS arrived & took over treatment including CPR after nurse had started CPR; failed to honor res’ code statusF156 Notice of Rights, Rules, Services, ChargesNC: SS=D: Failed to acquire a signature for res reviewed for liability & provide proper liability & appeal forms for all res reviewedRecord review revealed liability notice not approved CMS form & failed to inform beneficiary of right to expedited review of service termination by QIO for multiple residentsFailed to obtain a signature from res to acknowledge res was aware of Med A svcs were being terminatedW: SS=C: Failed to provide, in writing, a list of items & services that are included in the nursing facility ancillary list for which res may or may not be charged for residents that received Medicaid servicesRecord review admission package revealed one ancillary charge list which did not differentiate covered & non-covered services for Medicaid residents; resp party state did not remember receiving a list that described covered & non-covered servicesNE: SS=E: Failed to provide denial letter; failed to inform/educate res on right to contact facility ombudsman or state agency r/t concernsLacked evidence facility issued CMS form 10123 prior to terminating res’ skilled svcs for multiple residentsObserved ombudsman notification & state hotline number posted on bulletin board outside DR but res interviews revealed multiple res didn’t know about right to contact ombudsman or state agency r/t concerns &/or complaints & multiple residents unaware of what ombudsman was; res council notes lacked documentation of education of state hotline number & ombudsmanF157 Notify of Changes (Injury/Decline/Room, Etc)NE: SS=D: Failed to notify 2 residents of changes in care & txRecord lacked documentation res or representative were notified of new orders for skilled therapies, dressing/tx changes, new med for insomnia & ABT; res revealed staff did not tell res about new orders when they were changedRecord revealed new order for ABT for pneumonia, order for medicated powder to stomach & order for tx to res’ heel & record lacked documentation res or family notified of orders; res stated staff did not tell res about tx chgs but did tell familyNC: SS=D: Failed to notify physician of changes in condition for multiple residents for respiratory changes, lack of BMs & behaviorsRes admitted with tracheostomy; no CAA completed; TAR revealed staff failed to document that staff provided ordered trach care on multiple occasions; observed trach care with multiple diversions from best practices; phys stated facility provided poor trach care & hosp & physician had trained facility staff on care; ER summary stated facility had not provided appropriate documentation when res transported so ER staff attempted to contact nurse but was unable to reach nurse at facility; failed to notify phys in timely manner to seek phys involvement r/t res’ low O2 saturations level until res in distressRes with bowel incontinence; CP lacked instruction for monitoring res’ BMs; res with orders for bowel protocol; res without BM for 5, 4, 5 days in Feb/Mar; record revealed staff had not provided interventions for lack of BMs; failed to seek involvement in timely manner r/t lack of BMsRes with anxiety with behaviors with Depakote, seroquel & Haldol for nonorganic psychosis; res with multiple refusals of antipsychotic meds & phys did not notify phys res had refused medsRecord revealed no documentation staff notified or contacted phys until 5 days after phys faxed about hemorrhoids without phys response; observed res in w/c moaning & crying & stating “bottom hurt”; physician stated facility had not notified phys of res’ lack of BMS & if notification would have occurred impaction could have been avoidedF159 Facility Management of Personal FundsNE: SS=E: Failed to notify res or resp party of personal fund account balance quarterlyRes reported not informed of how much money in personal account; staff reported sent out copies of ledgers when requested & did not keep copies of when personal und account balances sent outF160 conveyance of Personal Funds Upon DeathNE: SS=D: Failed to convey multiple res funds within 30 days of deathRes expired 11-30 & funds returned on 1-10Res expired 1-25 & funds returned on 4-3F161 Surety Bond-Security of Personal FundsNE: SS=E: Failed to maintain a surety bond in excess of value of res trust fund accountSurety bond was for $40,704 & res fund bank account balance of $52,544.11F164 Personal Privacy/confidentiality of RecordsSC: SS=D: Failed to ensure privacy of res by shutting window blinds while providing wound care to res’ buttocksNsg staff & therapy staff performed dressing chg on res by window by turning res with buttocks facing window, exposed buttocks & during procedure window blinds remained open; failed to ensure res privacy while changing res’ brief & providing wound careNC: SS=E: Failed to provide personal privacy to multiple residents by not knocking before entering res’ room & not waiting for res to respondObserved multiple staff knock on res’ door & walked in without being invited & res confirmed “it happens all the time”Observed multiple staff enter room without knocking on doorF166 Right to Prompt Efforts to Resolve GrievancesSC: SS=E: Failed to promptly address & resolve the concerns of residents IDd in res council meetingsReview of res council mtgs revealed res with food complaints multiple months with only 1 follow-up response 11 months previous to survey with continued complaints for food (selections & preparation & staffing)Res with staffing & call light concerns in multiple months & staff attitudes & res felt agency staff did not know how to care for residents; & concerns about baths in timely manner & request for hair dryer; concerns about ice water not passed & bedding Res with concerns about activities during multiple months & facility failed to respond for during yearRes interviews revealed res felt staff listened but did not respond or correct concerns; failed to address & resolve recurrent concerns res had r/t food, staffing & activitiesNE: SS=D: Failed to investigate an allegation of abuseRes with BIMS of 4 with supervision & set up for ADLs; NN revealed res reported being angry about 2 CNAs during night shift & shook finger at staff & followed staff member down hallway; record lacked documentation of grievance or investigation report for incidentF167 Right to Survey Results-Readily AccessibleNE: SS=C: Failed to ensure availability of right to examine results of most recent health resurvey & Life Safety Code surveyObserved notebook containing survey results not readily accessible to res to examine; sign posted on business office window directed that survey results located by employee time clock but survey books not there; when found notebook lacked last annual resurvey & LSC survey; res unaware of where survey results were; res council minutes lacked documentation of instruction on where books wereF174 Right to Telephone Access with PrivacyNC: SS=D: Failed to provide a private place in facility for res who used phoneObserved res sitting in chair outside nsg station using phone & staff stood over res waiting for res to finish phone call & staff faced res for duration of phone call; res stated facility’s resident portable phone brokenF221 Right to Be Free From Physical RestraintsSE: SS=D: Failed to ensure the least restrictive physical restraintMDS failed to ID use of restraint used in w/c; res with hx of rolling out of bed & res with side rails for boundary definition; CP lacked instruction sfor use of physical restraint of pommel cushion in w/c; observed res in w/c with pommel cushion; staff reported side rails used to keep res from rolling out of bed; lacked physician order for pommel cushionNC: SS=D: Failed to assess res for safe use of side railsRes with extensive assist of 2 r/t post-polio; CAAs revealed no mention of full length side rails; CP indicated res preferred bed rails when in bed; no side rail assessment completed; observed res in bed with side rails on multiple occasionsF223 Free From Abuse/Involuntary SeclusionNC: SS=D: Failed to provide an environment free from potential abuseRes with BIMS of 9 without behaviors with extensive assist; CP instructed staff to remind res not acceptable to be socially inappropriate & to monitor res’ behavior & response to meds; abuse investigation revealed staff assisted res to bed & res became agitated & yelled at staff & staff told res to put self to bed & left room; staff statement revealed staff told res to “lose the attitude”; investigation substantiated allegations; staff member involved in allegation stated facility had suspended during investigation but staff member had returned to work & continued to work on the floor & stated facility had not provided staff member with any training r/t ANE with any incident r/t allegations; failed to provide environment free from potential abuse by a staff member with a hx of verbally abusive behavior as substantiated by facility & no plan of action implemented by facilityF225 Investigate/Report Allegations/IndividualsNC: SS=D: Failed to thoroughly investigate &/or report 2 incidents r/t bruising of unknown origin & r/t to a fall with injuryRes with BIMS of 3 without behaviors with PU risk; CP revealed res without skin conditions, bruises or interventions to prevent bruising; NN indicated res with multiple bruises & staff sent fax to phys & phys response included to evaluate staff & environment to determine cause of res’ bruises & phys inquired if all bruised areas were on res’ wrists or if bruises were in different locations & if no apparent cause determined or multiple areas to obtain CBC; staff provided no facility investigation to ID root cause of res’ bruising or that staff had obtained a CBC as directed by phys; failed to provide skin assessments for res for current month when requested & record included no other documentation r/t res’ bruises; observed no foam protection located on edge of table; observed res in bed calling out for help & housekeeping staff notified nsg of res’ need & 38 min later nsg staff transferred res with mechanical lift as res screamed while res provided care to res; staff verified facility does not look into bruises of unknown origin & is staff were to know the cause of bruising facility does not do an investigation; failed to thoroughly investigate bruises of unknown origin as directed by physRes with BIMS of 6 with extensive assist with hx of falls & currently smokes; res with multiple unwitnessed fall some with injury; observed res on patio with personal alarm unhooked & alarming & exit door alarming then res attempted to transfer from patio chair to w/c with unsteadiness; staff confirmed State agency not notified of unwitnessed fall with injurySC: SS=D: Failed to report to state agency & investigate a suspicious injury Res without cog impairment then moderate cog impairment & without anticoagulant meds; lacked skin care CP; fax to physician revealed res with large bruise to leg & res stated rubbed on bed when getting in & out of bed; licensed staff reported unaware of why res received multiple skin tears & bruises & most occurred during night shift; failed to report to state agency & investigate suspicious injury for a cog impaired residentF226 Develop/Implement Abuse/Neglect, Etc PoliciesSE: SS=E: Failed to complete criminal background checks &/or reference checks for multiple employeesRecord lacked any reference checks & facility submitted CBC 25 days, 28 days, 36 days, 118 days after staff started working; licensed staff lacked reference checksNE: SS=E: Failed to implement policies & procedures for screening of employees for multiple employeesMultiple personnel files lacked evidence facility performed reference checks of employee; failed to screen employee with nurse aide registryW: SS=D: Failed to screen newly hired staff & obtain information about them from previous employers & personal referencesPersonnel file lacked documentation for 2 work or personal referencesF241 Dignity & Respect of IndividualityNC: SS=E: Failed to promote care in a manner to maintain & enhance each res’ dignity & respect by leaving a door open while res had no clothes on, staff referred to res who required assist with meals as “feeders”, staff making undignified remarks about food provided to res & res’ living arrangements, staff leaving catheter bag uncovered & staff leaving sputum in a suction container in a res’ roomObserved res with no clothes on, partially covered with blanket in bed with door open & bed located right in front of room door & numerous staff walked past room without shutting door or offering dressing assist to res; observed multiple hairs on chin ~1in longObserved staff point to table in DR where res required assist & stated “these are our feeders…”; observed staff comment on how bad popcorn smelled & asked surveyors how could stand the smell of it with res in room eating popcorn; observed multiple staff refer to res as “feeders”Observed res on smoking patio with catheter bag not in protective cover; observed bag uncovered on multiple occasionsRes with trach; observed suction bottle with phlegm ~5 hrs after res suctioned; failed to dispose of phlegm in suction bottle & left bottle visible in roomSE: SS=D: Failed to promote care in DR to enhance dignity & respect of multiple res during mealtimeObserved dependent res in DR with 2 other res & res sat & waited to be fed while other res fed selves & assisted by staff & res’ plate remained on table in front of res without any staff assist watching other tablemates eat their mealsRes with total assist; observed staff provided assisted res tables last & staff assisted res & staff got up & left this dependent res twice to assist other res & res had to wait to continue with meal on multiple occasions while other staff stood in front of DR talking among themselves while res waited to be assistedSC: SS=D: Failed to maintain dignity for res who wore a leg bag for urine drainageRes with Foley cath; CP lacked direction to staff r/t use & care of leg bag; observed res coming from shower & dressed so urinary collection bag remained visible below leg of res’ pants & bag with urine contained; observed res in common area with leg bag visible out bottom of pant leg on multiple occasionsNE: SS=D: Failed to provide a dignified existence for resAlert, dependent res with transfers per Hoyer lift stated embarrassed to use bedpan for BMs but not offered toileting with hoyer lift for BMs & did not like shower chair over toilet but that would be better than using bedpan; CP did not mention use of bedpanNC: SS=D: Failed to promote dignity & respect for res by not removing incontinent pads from recliners in living area of facilityObserved multiple recliners in living area with incontinent pads in seat & recliners not being used by a resident on multiple occasionsNC: SS=D: Failed to treat res with dignity in DRObserved res in w/c in DR at table independently eating dessert & staff grabbed fork out of res’ hand, placed it on table & moved res in w/c to let another res through then propelled res back to table & res did not eat another bite of foodF242 Self-Determination-Right to Make ChoicesSC: SS=D: Failed to ensure res received showers 3x/wk as preferredRes with CVA requiring assist with bathing; shower list revealed no scheduled shower for res; res stated would like to take 3 showers/wk & only received 2 showers/wkNC: SS=D: Failed to provide res a choice r/t food & not to go to DR at mealtimeObserved res in DR & served meal & res stated had ordered something different & dietary staff stated “this was what was on menu” & offered res a bread then res stated “never mind”; lacked policy r/t choices; observed staff serve res without asking res choice of breakfastRes with trach; nurse administered breathing tx & asked res if had been to lunch & res stated did not feel well & did not wish to go to lunch that day then nurse completed tx & took res to DR for meal despite res having stated did not want to go to meal that mealSE: SS=D: Failed to provide preferred type of bathing style CP lacked instruction for bathing for res; res reported could not choose type of bath to take because tub did not work but would love to take a bath & had told the nurse of preference; staff reported w/p had not worked for 4 yrsF244 Listen/Act on Group Grievance/RecommendationNC: SS=E: Failed to respond & act on Resident Council grievances & recommendations Review of minutes for multiple months revealed res requested creamed vegetables to added to menu & review of menus revealed no creamed vegetables included on menus; dietary mgr verified had received requests & had not address requestSC: SS=E: Failed to develop system to address complaints/concerns received during res council mtgs r/t call lights not being answered timelyRes council minutes revealed multiple issues expressed by residents; adm or council pres did not sign form stating form reviewed; review of notebook out of all reviews over last 11 months only 1 had a response; there were no response forms & no other resident concern forms filled out for any concerns; complaint of staff answering call lights a concern every month during current year & there were multiple complaints r/t food not being good & not having flavor; failed to develop a communication system to monitor & inform res of plans developed by facility to address complaints/concerns received during res council mtgsF246 Reasonable Accommodation of Needs/PreferencesNC: SS=D: Failed to provide res with accommodation of needs by not repairing a w/c tireRes with BIMS of 3 with verbal behaviors to others; observed on multiple days inner tube of w/c tire protruded through wall of tire; staff confirmed tire had been in disrepair for 2 wksNE: SS=D: Failed to accommodate individual needs & preferences for res by providing a different type of shower sling for res’ comfortRes with quadriplegia & chronic pain with total assist & full lift for transfers; res reported had been complaining shower lift sling didn’t work right for res, the way it fit between res’ legs, it would bind & pinch skin & lift caused blister & asked facility to get a different sling for showers but facility refusedF248 Activities Meet Interests/Needs of Each ResNE: SS=D: Failed to provide activities for multiple residentsRes with BIMS of 3; activity log lacked documentation of activity notes or activity log for 6 wks; res’ room lacked activity calendar; observed staff obtain vital signs & did not encourage res to attend activities with activity scheduled in 9 minutes; observed direct care staff provide cares & did not encourage res to attend activities & group activity planned in near future; record lacked evidence facility provided activities to meet cognitively impaired dependent res’ mental, physical, & psychosocial needsObserved res in room watching TV & nsg & activity staff did not invite res to activities; observed staff enter res’ room & did not encourage res to planned activity; failed to provide activities that met cognitively impaired dependent res’ mental & psychosocial needsSE: SS=D: Failed to failed to provide an individualized activity programObserved res on multiple occasions without activity participation; observation of res failed to reveal res in any meaningful activities of preference during any day of survey including planned activities which res indicated would be of interest but staff failed to facilitateRes with severe dementia with rejection of cares with IDd activity preferences; Act staff confirmed that res did not participate in any activities & res did not attend Bible study (preferred activity) as staff put res to bedNC: SS=D: Failed to provide multiple res activitiesRecord revealed no documentation r/t activities res attended for 6 months; review of activity calendar revealed 1 activity/wk which met res’ interests; failed to provide res with activities of interest & to document participation in activitiesObserved res with voice box asking for new batteries & res’ speech inaudible with soft tone; TV not on; records revealed no activity preferences & no documentation of activities attended since admission; observed multiple times & res did not participate in facility activities & did not leave room; failed to provide ongoing program of activities to meet interest & physical, mental, & psychosocial well-being of residentSE: SS=D: Failed to provide activities for resObserved res at nsg station, in DR & in bed; facility staff failed to provide res any meaningful activities; staff reported facility rarely does any activities during day except for occasional BINGO & on weekends & evenings no activities ever done for residents; observed activity staff failed to invite res to planned activities; failed to provide individualized activities according to res’ IDd preferencesF250 Provision of Medically Related Social ServiceNC: SS=E: Failed to provide social services for multiple residents, psychosocial needs for behaviors including resident to resident altercationsInvestigation revealed res involved in res to res altercation & had tried to hit another res; res with behaviors of taking items from other residents & crying because another res called res a man & slapped res across chest; res threw cold tea on another res in DR; another res grabbed res on wrist causing red area; res with multiple documented incidents of altercations with staff & other residents; record revealed no other documentation by social service r/t 1:1 visits r/t res’ behaviors, mood or res to res altercations by a licensed or certified mental health professional; record lacked behavior evaluation; direct care staff revealed no training on mental health issues & lack of communication r/t knowing what to do for residentsRes with head injury with multiple episodes of behaviors towards others; facility failed to provide behavior evaluation r/t res to res altercations; observed res with anger behaviors to others; observed res with wanderguard & res exited out of conference room door with door alarm sounding & no staff came to exit or went outside to check on res then res propelled self back into facility; nsg staff stated no training r/t res’ behaviors; staff verified no comprehensive CP for res to direct staff on how to intervene when res exhibited behaviors; failed to provide medically related social services to assist with res’ behaviorsRecord revealed lack of documentation of psychosocial follow up with res after facility-substantiated staff to res abuse incidentRes with antianxiety, antidepressant, & mood stabilizing meds; behavior monitoring sheets with multiple holes in documentation; failed to provide social services r/t psychosocial involvement for res who continued to cry, curse, & was physically aggressive to othersRes with socially inappropriate & disruptive behaviors; CP lacked specific target behaviors with specific instructions to staff on ways to intervene & provide support; res with elopement risk; holes in behavior monitoring sheets; res with altercation with other resident; res left facility followed by staff member; no documentation of attempted interventions or psychosocial support other than to assist res to obtain liquor; 2 months previously facility sent letter involuntary discharge letter r/t not following facility rules r/t behavior of leaving facility & consuming alcohol although facility staff assisted res in purchasing alcohol & letter stated facility would cancel 30 day notice if res’ behavior r/t alcohol stopped; NN documented SSD found res asleep on a bench on Main Street with empty bottle of vodka & note without documentation of monitoring res prior to or an intervention after incident; NN revealed local police recommended res avoid alcohol; multiple NN documented with alcohol consumption without interventions by staff; facility cancelled 30 day notice & planned to DC to inpatient treatment facility on 4-23 & as of 4-24 progress notes without documentation of transfer; failed to provide medically related social services for psychosocial needs for res who continued to have behaviorsFailed to provide medically related social services for psychological needs for res who continued to have increased agitation & altercations with other residents & staff in facility for multiple residentsRes with chronic pain with duragesic & Lortab for acute pain with hospice svcs; res with severe pain & nurse stated res had been on same dose of pain medication for 4 months; failed to provide res with medically related social services to assist with behaviorsRes with behaviors toward others including other residents with multiple psychoactive medsNE: SS=D: Failed to provide social svcs to maintain highest practicable well being for res; failed to provide psychosocial well being support for res receiving hospice svcsRes with depression & bipolar with recent admit with psychotropics & diuretics; behavioral CP revealed res did not feel comfortable in new environment & feared people of color trying to hurt res & sought out staff when feeling afraid; SS note revealed staff contacted guardian to ask for permission to allow res to go on unsupervised walks near facility to shop & guardian agreed; interview with “ancillary interviewee” who stated did not visit with facility previous day & did not agree res could have unsupervised walks & outings; SS note revealed res boarded a bus toward Kansas City then South Dakota; failed to provide social svcs to maintain highest practicable well-being of res Res admitted to hospice with dx of Alzheimers; record lacked evidence res received psychosocial support from facility; observed res without assistive devices; SS staff reported did not do anything with res & hospice social worker took over svcs; F253 Housekeeping & Maintenance ServicesNC: SS=E: Failed to provide & maintain a sanitary, orderly & comfortable interiorObserved black marks on outside of entrance door; scratched & torn walls; discolored walls; stained carpeting; BR call light cord soiled; window blinds bent/broken; peeling wallpaper; holes in BR wall where towel rack had been; brown substance at base of toilet; gouges in sheetrock; shed behind building with peeling paint & rot; fan with gray substance on edges on fan bladesSE: SS=E: Failed to provide housekeeping & maintenance svcs to maintain a sanitary & comfortable interiorObserved wallpaper & border peeling; therapy room with: sink with brown discoloration, flooring with torn, frayed edges, therapy mat used for supply storage, med records with floor storageObserved electrical room with hot water tank with brown debris over floor; missing cove base, stained ceiling tile, stained carpetingObserved brown debris in corners & black discoloration around tile edges; broken/missing tiles; personal care room lacked exhaust fanW/P room with toilet without tank lid; four wall outside corners lacked same wall paint as rest of roomDoor jams with marring & chips in paint; discoloration around toilets; flooring with raw edges at transition area between flooring types;; stool riser with rust; plastic sheeting around AC unit with crack with caulking filling crack & open gap; missing cove baseShower room with light fixture with bare wires, missing insulation; ceiling tile grid with rust; dust on exhaust vent; cove base with separations; rusty screws in metal transition strip; area on wall without paintDusty window blinds; cob webs in windowsNE: SS=E: Failed to provide services necessary to maintain a sanitary environment in beauty shopObserved beauty shop with multiple plastic drawers with hair rollers & brushes covered with hair strands of different colors & shadesNC: SS=E: Failed to provide housekeeping & maintenance services necessary to maintain a sanitary & orderly environment on interior & exterior of buildingObserved fan in res’ room with dust on fan blades; BR door with splintered edges; missing caulk around toilet base; stained caulking; missing floor tile; chipped floor tile; buckled floor tile; scuffed walls; stained floor tiles; missing screens Observed res room with multiple papers, food & dried spills on floor; floor tile with black thick grime between tiles & room with urine odorObserved mechanical lift with base with dust & grime on multiple occasionsObserved common BR with wadded up wash cloth with brown substance placed on back of sink & toilet riser with brown substance on tope & inside rise; dog food on napkin in closet; edge of rug ripplesCeiling fans with burnt out bulbs; DR chairs with cracks & tears in seatsSE: SS=E: Failed to provide housekeeping & maintenance servicesObserved privacy curtain with stains; loose foot board; leather recliner with open cracks, Br with toothbrush directly on back of toilet without res ID; multiple unlabeled personal items; safety floor mat with cracksw/c back with cracks in vinyl; bed pan on floor without ID; urinal without ID or cover sitting on res’ personal fridgeBedpan on floor; urinal without ID or cover on top of fridgeSC: SS=E: Failed to provide housekeeping & maintenance services necessary to maintain a sanitary & comfortable living environmentObserved: door frames marred & missing paint & multiple holes in walls along with screws protruding from walls of res rooms & BRs; stain on carpet; peeling wallpaper; cracked linoleum; marred wallsPreventive maintenance logs did not include res roomsNE: SS=E: Failed to provide a comfortable & clean environmentObserved personal BRs with stained tiles, discolored caulking around toilet bases & metal doorframes with rust bubbles; closet door missingNE: SS=E: Failed to provide a comfortable & clean environment for res; failed to provide an odor free environment; failed to provide clean unstained linen/pillowsObserved leaking sink drain, loose faucet base, chipped paint, no extension cord on BR call light chains, holes in BR walls, stains around base of toilet, missing caulking around toilet base; dirty floors, exposed bolts at base of toilets, dirty call light cords, rusty & dirty vents on ceiling, urine odor in res’ BRs; unlabeled care equipment in res’ BRBR staff with brown substance around toilet bowl & on stall wall; dirty floors; broken shelf on book case, stains on chairs, window without window blind, bent slates on window blindPillows lacked pillow case & stainedStained couch, 2 tone color of paint; electrical outlet spray painted & paint went beyond elect plate onto wallUrine odor in hall; fan with heavy build up no bottom drawers below closet; missing & cracked floor tile; black markings on wall; glue remnants from paper items on wall & doors; strong urine odor; leaking tub faucet; BR vent non-functional, rusty & dirtyStained office chairs; locked cabinet with holes; dirty wallsBroken window; soiled privacy curtains; dented vent; unlabeled towel racks in semi-private rooms; missing hooks on privacy curtainMissing window screen; chipped paint on fasciaMultiple areas with strong urine odorSE: SS=E: Failed to provide housekeeping & maintenance services to maintain a sanitary & comfortable interior for res of facilityObserved BR doors & door jams without finish &/or paint; BR flooring not adhered; res rooms with missing paint; holed in wall board exposing inner wall cavity; broken floor tiles; shower hoses able to reach floor drain in shower area & lacked back-flow prevention devices; shower with black build up on wall tile; shampoo/body wash stored on floor without a lidMultiple broken floor tiles in shower room; unlabeled, dirty hair brushes in cabinetGouges in wall board with missing paint; ceiling with replaced wall board with cracked edges missing finish exposing nails/screw heads & raw wall board; bedside table with missing laminate stripping along edge & edging dangling; hole in ceiling; brown discoloration around light fixture in BRW: SS=E: Failed to provide a sanitary environment in res BRsMultiple res BRs with yellow stains in commode bowl & sink basins; white hard water residue covered handles & middle portion of base on sink faucets; walls with chipped paint & gouges & plastered area needed paintSE: SS=E: Failed to provide housekeeping & maintenance svcs to maintain a safe & sanitary environmentObserved BR sink slow to drain water & reached overflow outlet; carpet with stains with urine odors present; BR with baseboard molding bulging off wall; closet door off rollers; BR door & frame with scuff marksW: SS=E: Failed to ensure proper preventative maintenance as evidenced by discolored ceiling tiles in res rooms & common areas & marring/holes on walls in res roomsObserved marring & holes on wall unrepaired; scratch marks & gouges on wall behind recliner; water spots in res rooms near vents above door in multiple rooms; discolored floorF257 Comfortable & Safe Temperature LevelsNC: SS=E: Failed to provide comfortable & safe room temps for multiple res in facilityMultiple res indicated room cold all the time; observation revealed room temp of 67, 65, 65 & 64 degreesF258 Maintenance of Comfortable Sound LevelsSE: SS=E: Failed to maintain a comfortable sound level for res in facilityRes reported facility “pretty noisy” at times esp in AMs & evenings; res reported aides yelling out to one another & slamming doors; observed staff members standing at opposite ends of hallways yelling back & forth to each other r/t res care on multiple occasionsF272 Comprehensive AssessmentsNC: SS=F: Failed to complete a CAA to develop individualized CP for triggered care areas for multiple residentsMultiple res MDS assessments lacked completion of triggered CAAsF273 Comprehensive Assessment 14 days After AdmitSE: SS=D: Failed to complete admission assessments in a timely manner for multiple residentsRes admitted on 7-22 & staff reported res’ 8-4-13 MDS submitted on 3-20-14Record revealed admission date of 3-3-14 & entry record MDS only MDS noted in recordRes admitted to facility on 3-21-14, discharge on 4-10-14 & re-admission on 4-14; record lacked an MDS available for res for 3-21 admissionStaff reported MDS are very far behind & when new MDS Coordinator started there were 70 MDSs late & in process & 50 remained in process & some were in computer but not printed r/t lack of ink cartridges & therefore not available to staffF274 Comprehensive Assess After Significant ChangeSE: SS=D: Failed to complete a significant change MDS for res when entered hospice careRes placed on hospice svcs per phys orderedNE: SS=D: Failed to complete a sig change assessment when indicatedFailed to ID need for & complete a sig change for res with declines in urinary continency, ADL abilities, skin integrity & started on therapyNE: SS=D: Failed to complete a significant change assessment in timely manner for res with hospiceRes with Alz dementia with hospice svcs; staff unaware timeframe that sig chg MDS for hospice needed to be completed according to guidelines; failed to complete sig chg assessment for res admitted to hsopiceF275 Comprehensive Assess at Least Every 12 MonthsSE: SS=E: Failed to complete annual comprehensive assessments for multiple residents to assess res’ individual needsAnnual MDS late by 170 days, 205 days, 198 days, 162 days, 36 days, 169 days, 365+ days for multiple residentsW: SS=E: 8 of 13 lacked completed CAAs within required time frameRecord review revealed CAAs 35 days, 60 days, 26 days, 33 days, 28 days, 30 days, 28 days after MDS F276 Quarterly Assessment at Least Every 3 MonthsSE: SS=E: Failed to complete quarterly assessments for multiple residents who needed quarterly assessmentsLast MDS completed on: 9-28-13, 9-15-13, 8-20-132 quarterly MDS missing for multiple res; failed to conduct timely MDS quarterly assessments for 14 residentsF278 Assessment Accuracy/Coordination/CertifiedNE: SS=D: Failed to accurately assess & complete MDS assessment for res5 day MDS indicated res weighed 109# & 14 day MDS revealed res weighed 100# & indicated “no or unknown” to res with 5% weight loss/gain in previous 1 month; 30 day MDS revealed res weighed 97# & MDS indicated “no or unknown” to res with 5% wt loss/gain in previous 1 month; CAA did not trigger for review; failed to develop a comprehensive MDS assessment which accurately reflected res’ wt lossNC: SS=F: Failed to ensure an RN verified the MDS assessments for accuracy & conducted &/or coordinated assessments for 25 of 25 res sampledMultiple MDS assessments had not been conducted &/or coordinated for accuracy by an RNNE: SS=D: Failed to accurately code res’ MDS for PUsAdm MDS revealed res with PU on heel but hosp records & admission nursing assessment revealed res without unstageable PU on admission but developed PU 3 days laterNE: SS=D: Failed to provide an accurate assessmentRes with Olazapine for vascular dementia; Zoloft for dysthymic depression; trazodone for psychosis; MDS noted no behaviors present & no indicators of psychosis; MDS noted no psychotropic or antidepressant meds; failed to accurately assess use of psychotropic & antidepressant meds on quarterly MDSF279 Develop Comprehensive Care PlansNC: SS=D: Failed to develop a comprehensive care plan for res who was assessed as an elopement risk, was to wear a wander guard alarm bracelet & left facility unattendedRes with dementia without behaviors; CP revealed no mention of res’ elopement risk, wanderguard placement or instruction to staff defining interventions to prevent res from elopement; NN revealed res followed another res out front door & nurses approached res to bring back into facility & res became combative & grabbed hold of chairs outside front door then staff able to bring res back into building but res continued to wander, exit seek & go into other res’ rooms; record lacked documentation staff checked placement of wanderguard bracelet or functionality for 3 monthsSame res’ NN revealed local business notified adm res had left building & was walking down street, then brought back to building; staff reported res frequently cut wanderguard bracelet off & frequently exit seeks; failed to develop a comprehensive CP for res to attain or maintain res’ highest practicable mental & psychosocial well-being for resNE: SS=D: Failed to develop individualized & comprehensive CPs for multiple residents for nutrition, wt loss & hospice careRes’ revised CP did not address res’ nutritional needs, food likes or dislikes, supplement use &//or wt loss status; res with significant wt loss in 1st 30 days of admission; failed to ID & develop CP for nutritional interventions to prevent wt loss for res at risk for nutritional problemsRes with hospice svcs with CP interventions; multiple staff unaware of what svcs hospice provided, how often svcs provided, what meds & supplies hospice provided; failed to have a comprehensive hospice CP for res who received hospice svcsSE: SS=D: Failed to develop a CP for individualized activitiesFailed to individualize activities CP for res to include activities choiceNC: SS=E: Failed to develop a comprehensive CP for multiple residents for falls, hospice, ADLs of bathing, behavior mgmt.CP revealed no individualized interventions for res whose behaviors included crying, sexual talk, paranoia, & physically threatening behaviors toward others & behavior monitoring sheets indicated res had multiple days with cursing, crying, & wanting to go homeFailed to develop comprehensive CP to address fall for res with fall riskFailed to develop an individualized comprehensive CP for shower preference & compliance for lack of acceptance of personal hygiene/grooming needsFailed to develop a comprehensive CP to instruct staff with individualized interventions for res’ behavior managementCP failed to address res’ terminal care, to document/correspond facility CP with hospice CP, to provide pain mgmt. & comfort measuresSE: SS=D: Failed to develop a plan of care to include use of physical restraints in bed & chair for res with use of side rails and pommel cushionCP lacked direction to staff r/t use of side rails and pommel seat cushion chair physical restraints to instruct staff on appropriate use of restraintsNE: SS=E: Failed to develop individualized comprehensive CPsCP failed to list res used a bedpan for dependent resCP lacked direction for staff of when to notify physician, family & responsible party, food preferences of res, specific meds r/t nutrition & specific diet ordered for resCP lacked individualization r/t res’ specific restorative programCP for ADLs lacked individualization r/t specific ADL cares provided by staff; nutrition CP lacked individualization r/t food preferences, ordered diet for res & frequency of wt monitoringCP failed to address use of an anchor for urinary cath & failed to ID res’ current woundCP lacked documentation r/t location of res’ port for dialysis, precautions for dialysis, specific cares r/t dialysis such as what diet res received & specific information r/t laboratory testing, which tests & frequency of testing; CP failed to show the res also received dialysis in facilityNC: SS=D: Failed to develop a comprehensive CP for res who used bilat quarter side rails at res’ requestCP revealed no mention of side rails or use of side rails; side rail assessment indicated res requested side rails be raised when res in bed & also for staff to place call light on side rail; observed railsNE: SS=D: Failed to develop individualized CPRes with dementia with hospice svcs; CP lacked documentation as to what supplies hospice would provide & what days hospice would visit resW: SS=D: Failed to develop a comprehensive CP r/t PUsRes with high risk for PUs; CP lacked instructions r/t bed mobility & failed to mention res posed risk for skin breakdown as reported in MDS & CAANC: SS=D: Failed to develop a comprehensive CP for urinary catheter careCP lacked any information to direct care for res’ urinary catheterW: SS=D: Failed to ensure comprehensive CP accessible to staff for urinary incontinenceNo CP present in res’ chart or CP book for res with change in incontinence from admission to quarterly MDSF280 Right to Participate Planning Care-Revise CPW: SS=D: Failed to revise CP to prevent accidents & fallsRes with dementia with behaviors with frequent incontinence with high fall risk with CP interventions; Res with unwitnessed unwitnessed fall with no new interventions noted on investigation & investigation revealed alarm failed to sound; failed to revise CP to ensure staff implemented planned interventionsSE: SS=D: Failed to review & revise multiple CPs for activities & intervention after fallCP failed to include individualized interventions based on res’ preferences; activity staff reported nothing special planned for res & lacked planning to provide 1:1 for res; failed to revise CP to include areas IDd as enjoyable to resRes with fall risk with generic CP interventions; CP failed to include new or different interventions after res experienced multiple fallsNC: SS=E: Failed to update/revise CP for multiple residents including res who no longer used sippy cups, res who no longer required wanderguard bracelet, for res with multiple fallsFailed to update or revise CP for res who no longer required a sipper cup for fluidsFailed to update or revise CP for res after staff determined res was not an elopement riskFailed to update & revise CP for res with severe cognitive impairment & continued to have falls monthly for previous 3 monthsFailed to update & revise CP for res who continued to have falls & independently exited facilitySE: SS=D: Failed to review & revise CPs for urinary incontinence & ADLsCP failed review & revision to include res’ frequent incontinence episodes with refusals & decline mental & physical abilities for ADLs when MDS & CP indicated res continent of bowel & bladder but ADL sheet revealed res with 35 episodes of incontinence during 1 month; lacked 3 day voiding pattern in extended time & observed res’ recliner with urine saturated incontinent pad in seat of chair & room with foul urine odorCP failed to review & revise with individualized toileting program to direct staff in res’ needed urinary caresSC: SS=E: Failed to update res’ CP to ID responsible party for performing oral care & include on CP recommendations set forth by dietitian for monitoring meal intake for an emaciated res with dental caries and at risk wt lossRes with dementia with obvious oral issues without sig wt chgs but with emaciation & low BMI & body weight; CP without nutritional approaches in place; nutritional CAA did not trigger; dental CAA indicated res admitted with inflamed bleeding gums with own teeth & numerous broken teeth & dentist found abscess, multiple fractured teeth & recommended extraction after referral to oral surgeon; CP failed to ID who performed BID oral care; failed to review & update CP to ID responsible party for oral care & to effectively monitor weights & follow recommendation of dietitian for monitoring meal intake for an emaciated res with dental caries & at risk for wt lossRes with BIMS of 6 with multiple falls; CP did not address supervision for res or give direction to staff r/t frequency of observation needed for res with hx of frequent falls; failed to update CP with new appropriate interventions including addressing amount of supervision res needed for multiple falls; failed to update res’ CP with changes after res fellRes admitted to facility with PU; CP lacked additional interventions after res’ PU re-opened & facility IDd res with shearing; facility IDd res with shearing on 2-11-14 & additional skin shearing occurred in all months since but staff failed to revise CP to address shearing to allow res’ skin to heal & prevent further shearing; failed to review & revise CP to develop & implement effective interventions to address falls & PUsRes with BIMS of 8 with CHF & C-diff & with assist for bathing with hospice svcs; CP instructed staff to w/p res 3 evenings/wk; observed hospice giving res sponge bath on completely different bath schedule than CPd; failed to update CP from receiving w/p to receiving hospice baths & sponge bathing in room r/t isolation precautionsNE: SS=D: Failed to revise CP after falls for res with fallsCP lacked documentation r/t res use of a perimeter mattressNE: SS=D: Failed to review & revise CP for falls, splint use & bathsCP lacked documentation res used a landing mat by bed, res’ bed placed in low position & broader mattress was usedCP lacked documentation res received baths twice a week during dayCP IDd res to wear splint on hand at night only; record review revealed splint DCd W: SS=D: Failed to review/revise CP r/t falls & PUsRes with high fall risk; res with fall & failed to include a new intervention to prevent further falls; res with 17 falls between 10-30 & 3-15; staff evaluated each fall for causal factors but failed to develop & implement new interventions on CP after 16 of 17 falls to prevent further fallsRes at risk for PUs; CP lacked instructions r/t bed mobility; failed to mention res at risk for skin breakdown as reported in MDS & CAA; res developed unopened blister & failed to review/revise CP with new interventions r/t blisterNE: SS=D: Failed to revise CP for multiple residentsCP revealed res to wear arm protectors due to res’ frail & thinning skin & MAR & TAR lacked documentation for arm protectors; observed res without arm protectors & staff revealed arm protectors were not removed from CP when no longer used for resCP for BBWs revealed res with Lasix; record lacked current order for LasixNC: SS=D: Failed to review/revise CP for dialysis treatmentsDialysis CP lacked documentation to indicate res on fluid restriction or direct staff for monitoring fluid intake; record lacked documentation/communication with dialysis provider, pre & post weights from dialysis provider & monitoring of res’ fluid intake dailyW: SS=D: Failed to update CPs for accidents & skin conditionsRes with fall & staff added new intervention of a chair/bed alarm & res stated being frustrated to have a “buzzer” all the time & the alarm sounded when just moved wrong in chair or bed & that bothered resNo CP revisions r/t facial bruising; CP lacked any information r/t large facial & neck bruising; failed to revise CP to DC interventions no longer in use for res with falls & add interventions r/t facial bruisingF281 Services Provided Meet Professional StandardsNC: SS=E: Failed to provide and arrange services to meet professional standards of quality by lack of follow-up of as needed medication & follow-up assessments by a licensed nurse for multiple residentsRes with BIMS of 6 with extensive assist; CP revealed res manipulated staff with crying & think others intend harm; CP without interventions for behaviors of crying, sexual talk, paranoia & physically threatening others; phys ordered Zyprexa PRN & administered by CMA on multiple occasions & record revealed no further follow up or assessment documentation by a licensed nurse in reference to res’ PRN med &/or behaviors for multiple months; CMA reported does not ask a licensed nurse prior to administration of any PRN med; failed to provide & arrange services to meet professional standards of quality by lack of follow up assessments for PRN med to determine effectiveness performed by a licensed nurseRes with phys order for PRN Benadryl for allergies, Morphine PRN for pain; MAR revealed multiple administrations of PRN meds & record revealed meds administered by CMA & no further follow up or assessment documentation by a licensed nurse those shifts in reference to res’ PRN med use for pain &/or allergiesRes with PRN pain med of Oxycodone; MAR revealed multiple administrations of PRN meds & record revealed meds administered by CMA & no further follow up or assessment documentation by a licensed nurse those shifts in reference to res’ PRN med use for painRes with behaviors with PRN Ativan ordered by phys, & PRN Klonopin & PRN Tylenol & PRN Lortab; MAR revealed multiple administrations of PRN meds & record revealed meds administered by CMA & no further follow up or assessment documentation by a licensed nurse those shifts in reference to res’ PRN med use for pain & behaviorsRes with PRN Lortab for pain; MAR revealed multiple administrations of PRN meds & record revealed meds administered by CMA & no further follow up or assessment documentation by a licensed nurse those shifts in reference to res’ PRN med use for painNC: SS=D: Failed to provide & arrange services to meet professional standards of quality by lack of follow up after administration of PRN medRes with Tramadol PRN for pain & Ativan PRN for anxiety; MAR revealed res received doses of PRN Tramadol & Ativan & effectiveness of med recorded by med aide without further follow up or assessment documentation by licensed nurse for pain or behaviorsF309 Provide Care/Services for Highest Well-BeingNC: SS=G: Failed to provide the necessary care & svcs, including thorough assessment & reassessment after a change in condition or to seek phys involvement following a change in condition for res with prior hx of pneumonia & changes in physical conditionRes with pulmonary insufficiency with CP interventions to monitor for complications r/t critical respiratory symptoms; NN indicated res c/o pain in calvs & O2 sat at 82% & nurse applied O2 at 2l & notified phys & res transported to ER & res admission to hospital; H&P revealed res with sepsis & with pneumonia; res readmitted to facility; in current month NN revealed staff & family noted increased coughing with mucous; NN did not indicate res’ O2 sat rechecked; daily vital record lacked consistent documentation of O2 sat & low O2sat without immediate re-check or nsg assessment of res’ respiratory status when O2 sat low or application of O2 as ordered; res admitted to hosp for pneumonia next day with pneumonia; failed to ensure staff completed a thorough assessment/reassessment, implement phys’ orders & failed to seek phys involvement for res with low O2 sat, coughing, increase anxiety/restlessness & a prior hx of pneumonia resulting in res admitted to hosp with dx of acute resp failureSC: SS=D: Failed to ensure multiple residents received meds as ordered by physicianRes with routine Ativan order & review of MAR all 3 doses on 1 day showed staff did not give drug as ordered r/t unavailability of med & staff did not note what they did in effort to correct situation or what doses referred to; staff failed to document administration on multiple other days without explanation of why; staff also noted on back of MAR multiple meds not given because facility did not have meds in stock for res; failed to ensure staff followed phys orders & administered all meds as orderedNC: SS=G: Failed to provide care & services to multiple residents for physician ordered interventions for a res with inflamed hemorrhoids who experienced pain with fecal impaction; failed to manage pain for res on hospice services; failed to monitor & provide individualized interventions for res who exhibited purging behaviors; failed to monitor bowel elimination & provide intervention; failed to monitor extensive bruisingRes with BIMS of 3 with occasional bowel incontinence & frequent urine incontinence with standing orders for laxatives & phys orders to assess res’ pain & document pain level q shift & PRN Lortab orders; res without BMs for 10 days, 5 days, 6 days; Staff administered 1 laxative during time res without BM without any as other PRN laxative administration; TAR revealed staff documented res’ pain as 0 q shift of month; NN revealed res with bowel impaction & without BM for 4 days & staff administered suppository with very small results; NN indicated staff administered Fleets enema with extra lg BM results; NN revealed nurse felt “a large ball” of stool when inserted suppository & had problems feeling rectal wall r/t amt of stool; record lacked any further follow up; 2 days later staff performed dig stim & sent fax to phys requesting daily stool & internal & external swelling with sl amt bleeding & requested tx for hemorrhoids with response 5 days later with phys order for Anusol HC PRN; record revealed no documentation staff notified phys after sending until phys resonded 5 days later; record revealed no further documentation r/t administration of Anusol or status of res’ hemorrhoids; Phys added Miralax on same day; 3 days later phys progress noted indicated phys saw res for constipation for 2 wks; progress note included res with constipation, abdominal pain, bloating, cramping, hemorrhoids, nausea & rectal bleeding & phys exam revealed res with copious hard stook in vault & phys dx of fecal impaction & phys manually removed impaction in phys office; observed res scream & cry in pain in abd & bottom & staff adm Lortab; observed res moan & grimace with each movement in w/c; observed res’ rectum with multiple layers of purple & red colored tissue protruding from rectum to urethra & staff verified Anusol suppository had not been administered as ordered by phys; phys stated, “facility had not notified of res’ lack of BMs in March & if facility had contacted phys res’ fecal impaction could have been avoided by prescribing res a daily bowel med”; phys also verified Anusol suppositories would have helped with res’ pain & inflammation of hemorrhoids; failed to provide res with phys ordered interventions to assist res with pain relief for inflamed hemorrhoids associated with continued constipation & failed to provide res with interventions to produce a bowel movement before impaction occurredRes with BIMS of 3 with extensive assist without skin conditions but at risk for PUs; CP without mention of bruises; NN revealed res with multiple bruising & phys directed facility to evaluate staff & environment to determine cause of res’ bruises & if no apparent cause, ordered CBC (investigation or determination documented & no lab performed); no skin assessments for current month provided; failed to implement interventions to prevent further bruises from developing for res with multiple bruisesRes with fx skull with cranial injury with behaviors; CP without ID of potential triggers for behavior & no individualized interventions for behaviors; res involved in res to res altercation & aggressive behaviors to staff; staff reported res ate meals in room then sticks finger in stoma to vomit food in trash basket & toilet; failed to assess & document psychosocial needs in order to provide necessary care & services to maintain highest practicable, physical, mental, & psychosocial well-beingRes with BIMS of 7 with total assist & extensive assist with scheduled pain meds; res with Duragesic patch & PRN Lortab; res with frequent requests for pain relief; Roxanal added & increased routinely with PRN Lortab with continued pain but Lortab not administered; staff confirmed res on hospice care but unaware of diagnosis; failed to adequately provide treatment for effective pain mgmt., follow physicians orders & notify physician of inadequate pain mgmt.Res with standing orders for bowel mgmt.; records revealed res without BM for 5 days, 4 days, 5 days & staff did not provide interventions for res’ lack of BMs & no staff assessment of res for lack of BMs as ordered by phys; failed to adequately monitor bowel mgmt. program, complete appropriate physical assessment & follow phys standing orders for bowel mgmt.NE: SS=D: Failed to follow dental orders for res; failed to develop an initial CP for res at risk for elopementDentist progress note with order for Crest sensitivity toothpaste to be brushed on lower teeth with no water once daily for gum recession added to TAR; toothpaste not available on 5 days in current month 1 day documented as provided in middle of missed days; staff reported toothpaste had not been observed in tx cart or in res room; failed to follow dental ordersFailed to develop initial CP to include interventions for prevention of elopement & elopement risk IDd per elopement risk assessment W: SS=D: Failed to assess & consistently monitor bruisingRes with multiple & frequent & current bruising; failed to assess & monitor bruisingF309 Provide Care/Services for Highest Well BeingNE: SS=D: Failed to assess res with dialysis; failed to complete neuro checks for res with fallsRes with fall risk with witnessed fall with injury including facial injuries; record lacked documentation neuro checks initiated after injury fall; res with unwitnessed but heard fall; record lacked documentation neuro checks initiatedRes with dialysis; record lacked documentation of res’ weight prior to dialysis on multiple occasions; res’ post-dialysis wt on multiple occasions; vital signs prior to dialysis on multiple occasions; vital signs post-dialysis on multiple occasions; assessment of res’ port-a-cath after dialysis on multiple occasions; weights & VS not consistently charged on TAR & dialysis communication formsNC: SS=D: Failed to establish & monitor a system to track fluid restriction as dialysis provider instructionRes with ESRD with dialysis & DM; Phys order for 1800 cal diabetic, renal diet & restrict fluid intake with weekly wts; record lacked documentation/communication with dialysis provider, pre & post weights from dialysis provider & monitoring residents fluid intake dailyF311 Treatment/Services to Improve/Maintain ADLsSC: SS=D: Failed to ensure res received assist needed from staffRes with dementia with extensive assist with all ADLs including eating; Observed res in bed in high fowlers position slumped to lt side in bed; with meal tray on table in front of res & res made no attempt to independently eat & no staff members assisted res to eat; observed staff delivered tray to res & cup of juice remained unopened on tray & staff left room without assisting res to eatNC: S=D: Failed to assess & document res was provided appropriate treatment & services to maintain or improve ability to communicateRes with unclear speech with slurring & mumbling & difficulty communicating some words or finishing thoughts; res with “voice box” without appropriate functioning; ST evaled & recommended new box & insurance & DME providers with multiple delays r/t payment; facility failed to ensure appropriate treatment & svcs were obtained to maintain or improve ability to effectively communicateNE: SS=D: Failed to provide a bath/shower as CPdElectronic record lacked documentation res received shower/baths as CPd on multiple occasions; res stated did not have a bath in a week F312 ADL Care Provided for Dependent ResidentsNC: SS=D: Failed to provide assistance with bathing for multiple residentsBathing log revealed res with bath intervals of 7 days, 20 days, 7 days, 7 days, 7 days, 7 days; no documentation res refused bathing; hosp documentation revealed res unkept, messy & neglected when arrived at hospital & when admitted to hosp res 10 days since last showerRes without bath for 5 days, 13 days, 14 days, 14 days, 13 days; no documentation of refusing baths or staff re-approaching res at later time; observed res with urine odor, greasy hair & O2 cannula caked inside tubing with light colored substance & res with multiple chin hairs ~1 inch long; observed glasses visibly dirty; failed to provide adequate ADL assist r/t bathing & grooming needsSC: SS=D: Failed to provide necessary services to maintain grooming by not shaving chin hair & cleaning of fingernails & providing oral hygiene Res with extensive assist with ADLs; res CPd for bathing 3x/wk; bath sheet indicated res had received baths as scheduled & some bath sheets included special instructions for other res such as shaving & nail care but bath sheet for this res had no special instructions to shave or do nail care; observed res with long fingernails with debris under nails & long chin hairs on multiple occasions; observed staff failed to offer oral care or assist res to do oral care; failed to provide necessary svcs to maintain grooming by not shaving chin hair, cleaning of fingernails & providing oral hygiene to resSE: SS=D: Failed to provide necessary assistance to maintain good grooming & personal hygiene CNA work sheet directed staff to assist with 1 for dressing; observed res with socks that did not fit feet & hung off ends of feet, pants too long that bunched up around feet & ankle on multiple occasions; observed res with no shoes with hair uncombed & in disarray & large shirt that did not fit properly as hng downward revealed res’ lt bare shoulder; observed res’ face with food spillageF314 Treatment/Svcs to Prevent/Heal Pressure UlcersW: SS=D: Failed to ensure multiple residents received necessary treatment & svcs (consistent assessment & documentation of wounds) to promote healingRes with hosp acquired PU & surgical wound with Unna Boot; record revealed Unna Boot DCd 9 days prior to last day of wound care at hospital; 3 Day Assessment lacked assessments r/t PU from 3-14 to 4-20 & on 4-20 & 4-23 assessment revealed area calloused with scab & dressings to each heel; every 3 day assessments lacked evidence of continued assessment with description of res’ heels, dressings, or surrounding tissue & measurements of wound; res with phys tx order to heel & record lacked evidence of any documentation or assessments to support need for a dressing for res’ heel; record lacked consistent documentation r/t condition of heel; failed to document skin assessments r/t unstageable PU on heel; lacked daily documentation of dressing & surrounding tissues, condition of wound & at least weekly measurements of woundRecord lacked consistent documentation of res’ stg 1 & stg 2 PUs, condition of wounds, dressings & surrounding tissues & weekly measurements of areasSC: SS=D: Failed to develop & implement interventions to address shearing & to implement planned interventions to prevent a res from developing a PURes with frequent incont & staff had not attempted a urinary toileting program & at risk for PUs; res admitted with 1 PU with CP interventions in place; CP directed staff to look in skin care plan for turning schedule but CP did not include a skin care plan; CP lacked additional interventions after res’ PU to rt buttocks re-opened & facility IDd res with shearing; res to wound clinic for 5 visits & on 11-8 phys declared wound healed & ordered DuoDerm for additional 6 wks to protect newly healed skin; weekly skin assessment on 1-2 revealed open area to coccyx with treatment followed by protective Mepilex; 1-20 soiled mepilex removed causing shearing which remained until 1-30 then reappeared on assessment on 2-11 then resolved & re-appeared on 3-12 and again on 4-17, 5-2 & 5-8; observed staff “scoot” res back on toilet by dragging under arms & under knees causing potential shearing on multiple occasions; observed Mepilex dsg on res even though Mepilex dsg had been DCd earlier in yr as a cause for shearing; observed res’ recliner without pressure relief & without repositioning; failed to develop & implement interventions to prevent shearing of skin for res at risk for PUMDS revealed res continent of B&B without skin risk with Parkinson’s with extensive assist; NN revealed res with open area to buttock & phys ordered Mepilex dsg; observed res transferred with sit to stand lift with staff assist; w/c lacked pressure relieving device as CPd on multiple occasions; failed to ensure res received necessary tx & svcs to prevent development of stg 2 PUNE: SS=D: Failed to prevent avoidable PUs for multiple residents & failed to consistently assess wounds for PUsRes entered facility without skin breakdown & developed heel ulcer within 3 days of admission; facility failed to prevent an avoidable PU for res admitted to facility without PURes with 1 stg 1 PU on admission; Adm CAA revealed res admitted from hosp with unstageable PU on hip; record revealed staff failed to assess wound from 12-9 to 1-14; 2 mos later res developed stg 2 on buttock & lacked assessment after 3-24 when wound still open; observed res without repositioning for 2 hr 38 min; failed to consistently assess res’ PUs til healed & failed to prevent an avoidable PU for res with hx of PUs who required extensive assist with ADLsNN IDd PU to coccyx on 3-29 & no further charting noted in NN r/t wound on coccyx from 4-4 to 5-5; failed to assess PU weekly per CPNE: SS=G: Failed to document, assess & put interventions in place for newly recognized PUs Res admitted with 1 stg 2 PU; developed multiple breakdown on foot; res with documented wt loss; breakdown progressed to infection & res admitted to hosp with wound infection; res returned with order for Magic Cup; wounds on foot declined & merged into 1 & stg 3; dietary note recommended prostat with subsequent order; record lacked evidence facility provided education r/t potential outcomes for refusing position chgs; observed res did not received Magic Cup & Prostat as ordered but signed on MAR as given; observed res without repositioning & surveyor requested skin check & found reddened buttocks with numerous open, undressed areas on both sides & on gluteal folds with numerous areas of red drainage on brief; observed res without repositioning for 2hr 41 minRes with skin risk; observed staff perform pericare & surveyor observed 2 scabbed areas on res’ buttocks near sacrum which merged into 1 larger open area during survey; record lacked evidence staff assessed res’ skin condition until it was documented in nursing progress note when 1st area foundSE: SS=D: Failed to implement effective interventions to prevent development of PUs for res with hx of PUs & at risk for development of PUsRes with quadriplegia with total asssit with full body lift with Foley catheter using electric w/c with skin risk & hx of PUs; NN revealed res with small open spot on buttock which worsened; res then developed shearing from lift sling which worsened; res reported admitted 2 mos previously without PUs & upset that now has 1 caused by lift sling; staff reported changed size of sling but not style & now res requires bed baths r/t sling discomfortW: SS=D: Failed to ensure multiple residents received necessary tx & svcs to promote healing & prevent infectionsRes developed open area to heel & outer aspect of foot; on 2-20 NN revealed skin pulled back from blister & skin was rolled back & steri-stripped & covered; 3-6 phys communication revealed res with PU to heel with 100% eschar & PU to right outer ankle; assessments lacked evidence of weekly measurements for 3-14; April assessments lacked evidence of weekly measurements; wound no assessed or measured in 2 weeks of previous month; record lacked evidence of daily wound assessments during res’ daily dsg chgs or concurrent weekly measurements of wounds; failed to document condition of heel & ankle wounds during daily dsg chgs; failed to consistently measure wounds weeklyCP lacked instructions r/t bed mobility; failed to mention res posed risk for skin breakdown as reported in MDS & CAA; failed to review/revise CP with new interventions r/t blister; record lacked consistent documentation of condition of wound; record failed to consistently mention condition of blisters; no documentation or wound measurements from 3-17 to 4-25 & between 4-27 & 5-20; failed to provide necessary tx & svcs to promote healing, prevent infection & prevent new sores from developing when staff failed to document condition of heel stg 2 blister on daily basis as instructed in p/pFailed to document condition of stg 3 PU on daily basis as instructed in policyNE: SS=G: Failed to develop & implement timely & effective interventions to promote healing of PU & res’ PU increased in sizeRes admitted with stg 2 PU & hi risk for further breakdown; adm nsg assessment did not include description or measurements of PU & NN did not document res with PU; record lacked documentation of PU on 2 occasions; record lacked any description of PU from 4-18 to 4-22 after admission with PU on 4-11; record lacked evidence facility assessed res’ tissue tolerance; record revealed staff did not always document effectiveness of pain med using pain scale; record lacked evidence facility thoroughly assessed res’ pain mgmt. program to determine if res would benefit from scheduled pain med to avoid peak & valleys of pain from PU; observed dressing chg & res c/o pain during treatment; observed res in bed without skin to skin protection between knees and heels; observed res in w/c without repositioning for 2hr 15 min; failed to develop an effective individualized turning/repositioning program, failed to timely assess res’ PU on admission; failed to prevent skin to skin contactF315 No Catheter, Prevent UTI, Restore BladderSE: SS=D: Failed to ensure res received necessary svcs to prevent development or UTIsRes with BIMS of 15 with quadriplegia with total dependence with suprapubic catheter; res developed multiple UTIs; Observed staff empty catheter bag of urine & failed to cleanse catheter port prior to emptying or after emptying urine from bag; adm nsg staff unaware of need to cleanse port; policy failed to direct staff to cleanse portNC: S=D: Failed to provide appropriate treatment & svcs for incontinenceRes with BIMS of 3 with frequent urinary incontinence; CP instructed staff to check & chg q 2 hrs & as needed; res with UTI; observed staff perform peri care & staff wiped res’ peri area in patting motion with piece of toilet paper & without cleansing res’ bottom then pulled dirty brief up along with res’ pantsSE: SS=D: Failed to provide an individualized toileting program to restore as much normal bladder function as possible for multiple residentsRes with frequent incontinence with toileting plan without improvement; physician order instructed staff to prompt/remind res to toilet q 2 hrs while awake & staff to provide incontinence care with any incontinent episodes & apply barrier cream; observed res without prompted toileting for 4hrs 46 minutes; failed to provide individualized toileting program to restore as much normal bladder function as possibleRes with BIMS of 5 with continent of urine without toileting program with multiple UTIs; observed res in w/c with pants & underclothing positioned down around knees & res’ buttocks sat directly on w/c cushion; observed res room with strong urine odor & saturated incontinent pad in recliner; observed staff failed to offer toileting assist as planned; failed to ID incontinence for res who declined mentally & physically & sat frequently on a saturated incontinent pad & implement an individualized toileting plan to assist res maintain as much normal bladder function as possibleSC: SS=D: Failed to provide proper peri care to prevent UIIs & to reassess res’ urinary continence pattern following a decline in ADLs MDS revealed res with frequent incontinence without a toileting plan; 3 day voiding diary with holes with plan to check & change every 2-3 hours; observed staff clean res’ peri area by wiping front to back then folded over wipe & wiped front to back again then with new wipe wiped front to back & folder & wiped again then repeating process again; observed staff transfer res to w/c without offering toileting prior to taking res from room; staff reported voiding diaries completed at time of admission an nothing further planned; failed to provide proper peri care to prevent UTIs & failed to re-assess res’ urinary continence pattern following decline in ADLs NE: SS=D: Failed to ensure an anchoring device was in place for a urinary cathObserved staff transfer res after cares provided & prior to getting res out of bed staff performed cath care but failed to secure catheter tubing to res’ leg; staff reported did not use an anchor for res’ cathNE: SS=E: Failed to encourage toileting; failed to provide a complete urinary incontinency assessment for multiple residents; failed to provide adequate pericare for res; failed to provide adequate catheter careVoiding diary lacked analysis of causal factor for res’ urinary incontinence; observed res without toileting from 10:30-12:15 & staff did not assist res with toileting then staff encouraged res to attend meal & res’ brief wet with urine & staff provided peri care but did not ask res if needed to use BR prior to taking res to DR; failed to asses res’ urinary incontinence & failed to encourage & toilet res who required assist with toileting as CPdRes with incontinence; assessment did not include analysis of res’ voiding pattern to determine an individualized toileting program; record lacked evidence staff analyzed data on 3 day voiding diary to determine a voiding pattern for res & diary lacked documentation on all 3 days from 7pm to 12am; observed staff did not offer to toilet res prior to meal as CPd; observed door to common BR locked & res without BRs in rooms; observed staff did not offer toileting after meal as CPd; failed to thoroughly access res’ voiding pattern to determine an individualized toileting program & failed to provide incontinent care after incontinent episodesCP for indwelling cath with no revision date revealed res with chronic recurrent MRSA; observed staff perform peri care without pulling res’ foreskin back & thoroughly cleaning penis then dabbed suprapubic cath with wipe that was used when performed peri care on multiple occasionsRes with foley for urinary retention; record lacked documentation staff changed catheter 8 months; observed staff perform peri care after res had BM; staff failed to clean entry point where catheter went into meatus & cleaned catheter from distal to proximalSE: SS=D: Failed to ensure urinary collection bag with attached tubing remained off floor to prevent possible UTIsRes with BPH with UTIs with foley cath; observed catheter tubing outside res’ pants, clipped to upper right on outside of sweat pants with visible urine in tubing on multiple occasions; observed 12 inches of catheter tubing dragging directly on floor; observed urinary drainage bag resting directly on floor on multiple occasionsFailed to provide appropriate svcs to ensure res’ drainage bag & tubing remained off floor to prevent potential UTIsNC: SS=D: Failed to provide svcs to prevent infections & provide comfort for res with indwelling urinary catheterCP lacked direction to staff for providing care for res indwelling urinary catheter; res with UTI with ABT; observed urinary catheter bag without protective cover & tubing touching floor on multiple occasionsW: SS=D: Failed to implement planned interventions for res with urinary incontinenceObserved res shouting & agitated with verbalization of need to urinate; observed staff fail to offer to take to toilet; failed to implement planned interventions for res with urinary incontinence F318 Increase/Prevent Decrease in ROMSE: SS=D: Failed to provide restorative nsg svcs to res IDd as cognitively impaired with impairment on 1 side in upper & lower extremity in functional limitation in ROMRes with CVA with hemiplegia & OA; phys orders for 3 months revealed orders for restorative nsg; CP documented restorative svcs DCd prior to phys orders & not restarted; observed lack of positioning devices to prevent contractures; failed to provide phys-ordered restorative svcs for dependent res after started on hospice svcsNE: SS=D: Failed to provide a res with limited ROM & appropriate tx svcs to increase ROM &/or to prevent further decrease in ROMCP IDd res with splint on rt hand at noc; res with hemiplegia; observed res without splint during ordered hours; TAR revealed no documentation indicating staff applied splint at noc of observation on multiple occasions; TAR revealed splint not applied on multiple days in previous months; failed to provide res with limited ROM appropriate tx & svcs to increase or prevent further decrease in ROMSE: SS=D: Failed to provide treatment & svcs to prevent further decrease in ROMRes with extensive assist; current restorative record lacked any documentation of completion of ordered ROM program & log revealed note of “Hospice” & staff reported if res are on hospice res don’t get therapiesF320 No Behavior Difficulties Unless UnavoidableNC: SS-G: Failed to ensure psychosocial needs of res were met & res did not display a pattern of decreased social interaction &/or increased withdrawal, anger or depressive behaviors or lead to behaviors of alcohol consumptionRes with hx of broken leg, anxiety state, non-organic psychosis & alcohol dependency; MDS indicated res without behaviors; CAA revealed res short tempered & easily annoyed & res with delusions & displayed verbal behaviors to others; CP update indicated res shoved another res but CP did not provide interventions specific to res’ behaviors; 2-14 CP stated res with socially inappropriate & disruptive behaviors & directed staff to intervene if necessary but lacked specific target behaviors with specific instructions to staff on ways to intervene & provide psychosocial support; CP stated res walked to liquor store & purchased & consumed alcohol against phys orders & facility rules & CP lacked specific education to use or who to contact to inquire about alcohol anonymous mtgs; targeted behavior sheets revealed res yelled & cursed several days but lacked documentation of res’ behaviors on multiple days; NN revealed res demanded wanderguard be removed or res would slash staff member’s tires & staff removed bracelet without educating res prior to removal; NN stated res knocked over other res’ walkers & threw things without documentation of any specific interventions; phys order for res not to drink alcohol r/t dependency; NN revealed res with altercation with another res requiring local law enforcement but no other interventions; NN revealed staff took res to liquor store where res purchased liquor & consumed the liquor despite phys order for no alcohol on multiple occasions & res fell asleep on bench in front of facility & staff brought res back into building; local citizen reported to facility res laying in private driveway 1 block from facility & staff found res but no documentation of other interventions; facility issued 30 involuntary discharge notice r/t res consuming alcohol despite staff assisting res to purchase alcohol; Staff found res asleep on bench on Main Street with empty bottle of Vodka & no documentation of monitoring res prior to or intervention after incident & police came to facility & searched res room & found bottle of Vodka & police strongly encouraged res not to purchase any more alcohol; res fell at end of driveway & stated was drunk; res observed standing in front of a house by facility, drinking & threw bottle in driver’s seat of staff member’s care without interventions documented; facility cancelled 30 day notice & planned to discharge res to inpatient treatment facility in another town but on day after transfer planned, res still in facility; res with multiple other episodes of drinking to become drunk in & away from facility; failed to provide treatment & svcs for psychosocial adjustment without the increase of decreased social interaction, aggressive behavior & alcohol consumptionF322 NG Treatment/Services-Restore Eating SkillsNE: SS=D: Failed to educate staff on proper use of a Declogger (a device used to break up blockages in a feeding tube)Res with NG feeding tube; CP instructed staff could use coca cola or juice to open enteral tube & clean blockage as needed & could use Declogger (house stock) for clogs as needed; TAR documented no size for Declogger when phone phys order for French # 14F323 Free of Accident Hazards/Supervision/DevicesNC: SS=J: Failed to ensure res who facility had assessed as an elopement risk had adequate supervision to prevent res from leaving facility without staff supervision placing res in immediate jeopardyRes with dementia without behaviors; CP revealed no mention of res’ elopement risk, wanderguard placement or instruction to staff defining interventions to prevent res from elopement; NN revealed res followed another res out front door & nurses approached res to bring back into facility & res became combative & grabbed hold of chairs outside front door then staff able to bring res back into building but res continued to wander, exit seek & go into other res’ rooms; record lacked documentation staff checked placement of wanderguard bracelet or functionality for 3 monthsSame res’ NN revealed local business notified adm res had left building & was walking down street, then brought back to building; staff reported res frequently cut wanderguard bracelet off & frequently exit seeks; failed to develop a comprehensive CP for res to attain or maintain res’ highest practicable mental & psychosocial well-being for res; staff reported had noticed res at door & staff left res by door & failed to redirect res away from door for res with hx of following other people out doorFailed to ensure staff completed daily checks on wander guard bracelets for res staff assessed as an elopement risk res & left facility without staff knowledge; abated to DNE: SS=D: Failed to provide interventions as planned for fallsRes with fall risk with CP interventions; res with multiple falls; CNA jot sheet lacked documentation for res to wear hipsters as CPd; staff unaware res wore hipsters; failed to put fall interventions into place as planned for cog impaired res at high risk for fallsW: SS=E: Failed to implement interventions to prevent accidents & falls by failing to have a working alarm system & having too hot water in BR sinksObserved water temps in res’ rooms with temps of: 131.2, 131.6, 131, 133.8, 132, 133.4, 130.1, 131.5, 131.4; staff reported plumbers replaced water heater 2 days prior & left valve open allowing hot water from one tank to go into other & staff closed valve with subsequent temps of 122 degreesRes with high fall risk r/t dementia & weakness with planned interventions; res with unwitnessed non-injury fall & investigation revealed alarm failed to sound; failed to implement interventions to prevent accidents & falls by failing to have a working alarm systemSE: SS=D: Failed to ensure multiple res received adequate supervision to prevent accidents/elopement from facility without staff knowledge; failed to ensure res’ environment remained free of accident hazards as possibleFailed to implement new fall interventions after a fall, failed to educate staff r/t fall preventions in place & failed to provide adequate supervision when res had hx of dosing off while sitting on side of bed & falling on multiple occasions; res lowered to toilet when “knee gave out” & resulted in fx femurRes IDd with elopement risk r/t wandering behaviors; res approached staff angrily & reported wanted to leave facility & to call a local inpatient adult psychiatric unit then res went outside to smoke & became upset when staff informed res not allowing res to go outside unattended then res walked away from facility while staff followed res without losing visual monitoring of res; res then transferred to psych unit; res returned to facility by local police after res attempted to enter private home; in another incident res went out to smoke, became angry & took off while being followed by staff & police brought res back to facility; on one occasion res left building without supervision; failed to maintain a safe environment with adequate monitoring when res outside facilityObserved DR door with lighted exit sign above door failed to open & staff reported door cannot be opened now due to building settlementShower room with GFCI without covering plate allowing gap into electrical box; lacked toilet paper holder exposing 2 metal brackets with sharp edgesNC: SS=E: Failed to provide an environment free of accident hazards for multiple residentsRes with elopement risk with smoking safety CP; res with unwitnessed injury fall & multiple unwitnessed non-injury falls; observed res seated on patio chair with w/c next to res with personal alarm unhooked & alarming & exit door alarming then unable to self-transfer r/t unsteadiness; no staff responded to sounding alarms until surveyor notified staff; failed to provide interventions for res who was cognitively impaired had falls & left building without staff knowledge or supervisionFailed to provide interventions for cognitively impaired res who had a fall that resulted in abrasion Failed to provide interventions for res with increased agitation & altercations with other residents & staff in facilityFailed to implement individualized interventions for res with severe cognitive impairment who continued to have falls & provide effective behavior mgmt. r/t multiple resident to resident altercationsFailed to implement individualized interventions for res who continued to have falls, continued to independently exit facility & display behaviorsObserved accessible hazardous items in unlocked storage closet including chemicals & toolsObserved staff transfer res with sit to stand lift when res unable to hold on to handles of lift; failed to assess for appropriate transfersFailed to ensure res free from accident hazards & received adequate supervision to prevent falls when facility allowed & facilitated res to continue to drink against phys ordersFailed to ensure res received supervision & assistance to prevent accidents r/t res’ continued behaviorsW: SS=D: Failed to ensure res environment remained free of accidents hazards with a box cutter left in unlocked hall’s clean utility roomObserved box cutter in open drawer in clean utility roomSE: SS=D: Failed to ensure timely & appropriate supervision &/or assistance devices to prevent repeated falls for multiple residents with accidents; failed to ensure safe environment for multiple residents r/t accessible hazardous chemicalsRes with severe cog impairment with fall prevention interventions to “remind” & “re-educate” inappropriate interventions; res found caught between bed & transfer pole & staff enforced to res to use call light & staff failed to update res’ CP & fall not witnessed; investigation IDd contributing factor was unsteady gait but res fell from bed; observed res w/o CP fall prevention interventions in placeRes with fall hx with BIMS of 5; CP intervention included inappropriate intervention of educating res about fall risk & CP lacked updated intervention following fall; further fall intervention included inappropriate intervention of encouraging res to ask for assistObserved rubbing alcohol bottles directly on floor beside res’ recliner for multiple daysSC: SS=G: Failed to provide adequate supervision to prevent a fall resulting in laceration to arm that required sutures; failed to thoroughly investigate root cause of falls for multiple residents & failed to assess & investigate possible accident hazards as cause of res’ large, frequent skin tears & bruisesRes with BIMS of 4 with independence with ADLs; res with fall with laceration requiring sutures r/t res with shoes on wrong feet causing stumble; 4 days later res with non-injury fall; CP did not address for need for increased supervision for res or give direction to staff r/t frequency of observations needed for res with hx of frequent falls; last review of CP without fall preventions changes; Fall with investigation lacked any follow up from monitoring of VSs to determine if changes in BP were causal factor of fall & failed to develop effective interventions to prevent additional falls including increased supervision of res; another investigation failed to address res’ need for supervision & newly developed interventions lacked direction to staff to increase supervision; Another investigation lacked finding after monitoring of BP or determination of causal factors of fall & staff were not directed to increase monitoring/supervision of res after second episode of dizziness & recent fall where res struck head; Another investigation lacked ID of when staff last observed res & failed to develop effective interventions after determining causal factors of fall; Another investigation failed to include a root cause analysis to determine causal factors of fall & interventions were ineffective at preventing additional falls by not addressing staff’s responsibility to monitor/supervise res; Another investigation lacked root cause analysis to determine causal factors to develop effective interventions; observed res on multiple occasions with door closed & res in unsafe position & staff did not open door to check on res; failed to conduct root cause analysis in an effort to determine causal factors for falls including need for increased supervision for confused res that wanted to remain independent & res experienced multiple falls including fall with significant injuryRes with dementia with high fall risk; res with multiple falls; on investigation revealed CPd fall alarm not working & no new interventions added to CP; another investigation lacked root cause of res’ fall; another investigation revealed fall alarm not sounding; another investigation did not ID when staff last toileted res; another investigation did not include when staff last toileted res or what res was trying to do; another investigation did not indicate when res last toileted or what res trying to do & did not ID cause of res’ fall; failed to ensure staff implemented planned intervention of pad alarm by failure to check alarm functionality regularly; failed to thoroughly review each fall to determine root cause of fallRes without falls & without anticoagulant; res developed bruise of unknown origin; observed res with multiple large reddish, purple bruises to forearms & a gauze dsg to forearm & bruise to wrist, tennis-ball sized bruise to calf and another tennis ball sized bruise to knee along with scabbed area to anterior shin with steri-strips; res reported bumping arms on bed rails & also bumping shin on bed rails; bed without lower rails observed; failed to investigate for accident hazards as possible causes of res’ large bruises & skin tearsNE: SS=G: Failed to provide adequate supervision & timely interventions to prevent accidents; failed to ensure environment free of accident hazardsFailed to ensure res received adequate staff supervision to prevent falls when multiple res on unit & no staff on unit to provide supervision; & failed to place timely effective interventions for res with hx of multiple falls & res fell & sustained hip fxFailed to implement timely & effective interventions for res with hx of falls to prevent further fallsFailed to perform post fall neuro assessments & failed to investigate causal factors for repeated falls for dependent res with hx of falls with injuryObserved transfer bars with openings that measured 7 inches x 11 ? inches & FDA recommends greatest side rail gap to prevent head entrapment is 4.75 inchesObserved multiple sharp edges sticking out from bed framesObserved broken window in beauty shop & glass on floorFailed to provide adequate supervision to prevent cognitively impaired & independently mobile res from leaving facility staff without staff/facility knowledgeFailed to initiate & complete fall interventions/monitoring for physically impaired res as CPdSE: SS=E: Failed to provide res environment free of accident hazardsObserved therapy room with hydrocollator not on ground fault circuit interrupterW: SS=E: Failed to ensure res environment remained free of accident/hazards (chemical in areas accessible to residents)Observed soiled utility room with multiple hazardous chemicals accessible to residents in unlocked cabinet under sinkSE: SS=D: Failed to ensure adequate supervision &/or assistive devices to prevent repeated fallsRes with dementia; res with fall hx with fall interventions & hi fall risk; info on investigation form not transferred to CP; observed multiple fall prevention interventions CP but not implemented; CP interventions were added that were already CPd and in place; failed to provide planned assistive devices to prevent repeated falls & failed to implement interventions timely NE: SS=D: Failed to implement timely & effective interventions to prevent fallsRes with hi fall risk; res with fall hx; observed res without CPd interventions in place; failed to implement fall interventions as plannedNE: SS=D: Failed to ensure environment free of accident hazardsCP lacked documentation r/t res’ use of bed cane or grab bar on side of bed; observed bed cane with rail 7 inches vertically from a mesh bag to top of rail & without mesh bag & 7 inch vertical opening extended to floor; positioning bar measured 11 ? inches wide (greater than 4 ? inches recommended by FDA which created potential entrapment hazard for res; failed to maintain environment free of accident hazards for resNC: SS=D: Failed to provide a safe environmentObserved multiple unlocked cabinetx under sink with hazardous chemicals; observed accessible hazardous chemicalsW: SS=E: Failed to thoroughly investigate all falls & implement appropriate fall interventions to prevent accidents; failed to properly secure chemicalsRes with Huntington’s with hx of frequent falls injury & non-injury; review of 15 minute check sheets with holes for prolonged time periods; observed res without alarm as CPd on multiple occasions; failed to thoroughly investigate root cause of res’ falls & implement planned interventions including supervisionRes with total dependence on staff for ADLs; res with fall with injury; failed to implement appropriate interventions to prevent further falls & implement planned interventionsObserved accessible chemicals F325 Maintain Nutrition Status Unless UnavoidableNE: SS=D: Failed to monitor % intake of supplements for residentRes with COPD with poor appetite on therapeutic diet with phys order for high calorie supplement BID for wt loss; record review revealed lack of documentation for % of supplement consumed by res & res lost 10.8# in 2 wks; failed to monitor % intake for nutritional supplementsNE: SS=D: Failed to document %s of supplement consumed for multiple residentsCP directed staff if res ate less than 50% bolus fdg should be administered; MAR revealed no documentation of intake r/t April meals & no documentation r/t if res received any supplements; intake sheets revealed res ate less than 50% of 27 meals in April; record lacked documentation r/t res receiving any bolus feedings for AprilRes with hx of significant wt loss over several months; April MAR revealed staff did not record intake of supplement ordered by physSE: SS=D: Failed to develop & implement interventions to prevent weight lossRes with dx of abnormal wt loss with mechanically soft & therapeutic diet with mouth, facial pain, discomfort or difficulty with chewing; CAA lacked analysis of findings; MDS revealed res with own teeth but observation revealed res with dentures; record revealed res with 13.13% wt loss in 6 months & 6.52% in 30 days; observed res fed self without any encouragement from staff on multiple occasions; observed Ensure not served as ordered; failed to monitor & implement planned interventions to address res with dental & physical problems who continued to lose weightSC: SS=D: Failed to effectively monitor weights & follow recommendation of dietitian for monitoring meal intakeRes with dx of: frailty, dental caries, & anemia; nutritional CAA did not trigger; CP revealed res at risk for wt loss & hx of malnutrition with reg diet; staff made dental appt; RD revealed no wt hx & res underweight with recommendation to monitor wt & meal intake; recorded wts fluctuated with weekly wts in April/May: 103.2, 98.5, 103.4, 130.2, 134.2 documented; meal intakes records with multiple holes in documentation & documentation of refusals on some occasions; failed to effectively monitor weights & follow recommendation of RD for monitoring meal intake for emaciated res with dental caries & at risk for weight lossNE: SS=D: Failed to obtain weekly wts as CPd for res with 10# loss in 3 wksRes with phys order for supplements 6x/day for nutritional supplement; CP called for weekly wts; record revealed wts documented on 3-5, 4-11 & 5-6; observed res with minimal intake at multiple meals; failed to obtain weekly wts as CPd for res with wt lossNE: SS=D: Failed to follow up on dietitian’s orders Res with 8lb (5.5%) loss in 30 days; RD recommended res receive health shakes & lacked documentation res received health shakes or that CDM spoke with res r/t RD’s recommendationsSE: SS=D: Failed to implement interventions to maintain weight Res with dementia with behaviors requiring verbal cues for eating with instructions for res to sit upright for 30 min after eating on pureed diet with nectar thick liquids; res with documented wt loss with interventions then increased wt; observed staff members walk past res but failed to provide any prompting or cues to res to eat; observed res in DR at 4:30pm with food but pushed self away from table; at 4/52pm staff assisted res back to table & told res staff would help eating “in a minute” then at 5?04pm staff tried to assist but res refused & became upset; res requested breakfast at 7:12 & was served at 7:40 & at 7:50 res refused to eat then at 8:42 staff requested new tray & cued res 1:1 & res ate 75%; failed to assist res with eating as directed by CP to increase amt of foods taken by res to maintain adequate nutritional adequacyF328 Treatment/Care for Special NeedsSC: SS=D: Failed to ensure res received prescribed amount of feeding each dayRes with dementia with extensive assist with Huntington’s; res then received tube feeding for nutrition; MAR revealed Jevity 1.5 240mL bolus 6x/day & previous month MAR revealed 8 of 24 days missed doses at 2pm; observed Jevity container hanging from pole with feeding running through pump & amt indicated only 3 bolus tube fdgs administered from container; failed to provide nutrition as prescribed for res totally dependent on nutrition via feeding tubeNC: SS=G: Failed to ensure multiple residents received proper treatment & care for tracheostomy & respiratory serves to prevent URI Res with Chronic Resp Failure, hypoxia, COPD with BIMS of 15 with trach; phys order for routine trach care with inner cannula, trach suctioning as needed; TAR revealed staff had not documented staff provided phys ordered trach care on multiple days; observed res with gurgling noise with breathing; observed staff washed hands & removed valve & inner cannula & placed them directly on res’ night stand with no barrier, res coughed & expelled lg amt phlegm then staff asked res if needed to be suctioned & res shook head yes, res cont to struggle by gasping air but staff unable to find suction catheter so staff activated call light & requested other staff retrieve catheter 16 min after res initially displayed resp difficulty; 4 min later staff brought catheter; staff picked up valve from nightstand & placed it back on trach then res coughed & valve flew off trach & landed under bed, staff opened trach clean kit then looked for valve which never found, then placed cap in trach kit & sprayed with sterile saline, wiped off with gauze & placed back onto res’ trach then placed sterile gloves on res bed & donned then picked up catheter packet & stated “I guess I should have opened this first” then went to closet but unable to open closet door without contaminating gloves so removed gloves & res still had not been suctioned & continued to breath with pursed lips & coughed; nurse then opened catheter package & poured saline into trach care tray, donned another pair of gloves & attached catheter to suction machine then took trach cap off, placed it back onto res night stand & began to suction; staff picked up inner cannula from night stand placed it back into trach & put cap back on & res remained SOB & used pursed lips to catch breath; staff then asked if wanted breathing tx & res shook head yes; staff confirmed no thorough respiratory assessment completed; oxygen tank empty & had to be changed & staff unaware of how long tank lasted & confirmed facility had no system to document when staff changed O2 tanks; Observed res sitting on side of bed with breathing trouble & CMA tested oximetry at 79% & immediately applied res’ humidified air connected to O2 concentrator which increased O2 sat to 83% then got the nurse who tested at 93% with a different meter & obtained BP then assessed res’ lungs, heart rate, & obtained res’ BP then res began to cough & face turned red & wanted to lay down; then observed res in room alone on side of bed with obvious resp gurgling & color pale & had difficult time speaking & continued to sit on side of bed alone with resp distress until 2 ambulance staff assisted res; nurse reported facility had not trained to perform trach care or suctioning; adm staff reported facility had been trained on trach care by respiratory staff at hosp but no recent tng for new nurses & staff did not complete nurse competency tests; phys stated there had been a hx of poor trach care & hospital provided education to facility stff & stff did not contact hospital r/t res’ until in distress; ER tx record revealed hosp attempted to contact facility nurse but unable to reach & facility failed to provide adequate information; failed to ensure provision of prompt trach care to avoid respiratory distressRes with O2 therapy/nasal cannula @ 4l; res with multiple ABT for URI; Observed res in room with nasal cannula/O2 concentrator & cannula caked with light colored substance around nose piece & throughout tubing; observed res’ mouth piece to nebulizer unbagged on bedside tableF329 Drug Regimen if Free From Unnecessary DrugsNC: SS=D: Failed to monitor for adverse reactions for multiple residents; failed to adequately monitor BMs; failed to follow blood sugar parameters & effectiveness of pain medsRes with bowel mgmt. orders; BM record revealed no BM for 5 daysNE: SS=D: Failed to CP & accurately monitor use of anti-coagulant medRes with CVA with anti-coagulant with lab orders to monitor med; phys ordered dose adjustments; Revised CP lacked documentation to indicate res received Coumadin with BBW; failed to monitor BBW side effects of CoumadinNC:SS=D: Failed to ensure multiple residents drug regimens were free from unnecessary medsFailed to monitor effectiveness & adverse effects of meds & to obtain blood lab test as physician ordered for mood stabilizing med Res with Depakote, Seroquel; record revealed staff did not notify phys when res refused medsW: SS=D: Failed to ensure residents did not receive unnecessary meds when staff failed to adequately monitor res’ med us (monitoring of blood pressures & blood sugarsRes with CHF with Digoxin with ordered holding parameters; res received anticoagulant; record with multiple omissions of pulse rates in multiple monthsMAR revealed omission of multiple BP readings for res with Lisinopril & Norvasc & no pulses for multiple occasionsRes with diabetes with ordered blood sugars weekly & notification parameters & Metformin for BP with weekly BP orders; record revealed accucheck log with multiple omissions of readings & multiple missing BP readingsSE: SS=D: Failed to ID & monitor for adverse effects of meds with BBWs & failed to monitor labsRes with Depakote ER & lacked ordered serum level q 6 months as orderedRes with Haldol; CP lacked actual BBW information; failed to ID & monitor res for adverse consequences associated with adm of meds with BBWRes with Depakote & Seroquel; CP lacked BBW information for both drugsSC: SS=D: Failed to ensure res did not receive Miralax for an excessive durationRes with phys order for Miralox 17 gms po BID for constipation until results then change to Miralax daily for constipation as needed; April MAR revealed res received Miralax BID except 1 day; May MAR revealed res received Miralax BID all days to date; daily charted revealed res with at least 1 BM on all days in current month except 3 days; failed to ensure res did not received Miralax for excessive durationNE: SS=D: Failed to complete AIMS in timely manner; did not perform bowel monitoring for 2 residentsRes with Dulcolax suppository qod; & MOM PRN; res without documented BM for 8 days with MOM adm on day 3 without documented results; 6 days, 4 days & 4 days when X-ray done for constipation; 8 days, 4 days & 4 days; failed to effectively monitor BMs & provide treatment as orderedPOS lacked pulse parameters for Toprol & Tiazac; res with multiple days without BM without interventions; failed to have pulse parameters for meds that affect pulse & effectively monitor BMs to ensure proper medsRes with Seroquel & Ativan; Record revealed AIMS completed on 8-19 & 12-16 & policy directed staff to complete q 3 mos; failed to complete AIMS in timely manner & failed to attempt a GDR for SeroquelNC: SS=D: Failed to adequately monitor therapeutic laboratory levels for multiple residents receiving Coumadin & adequately monitor & provide appropriate interventions for constipationRecord revealed no documentation of blood lab tests to monitor therapeutic levels for res’ Coumadin as recommended by manufacturer in 2 consecutive months BM Report revealed no documentation res had BM for 7 consecutive days & no documentation staff assessed res &/or provided bowel mgmt. med to res as orderedRecord revealed no documentation of lab test for Pro time r/t Coumadin during one month as ordered by physNE: SS=E: Failed to monitor targeted behaviors & did not monitor bowel movements meds for effectivenessRes with Haldol & Seroquel; MAR & CP lacked IDing targeted behaviors for res’ antipsychotic & antidepressant medsRes without documented BM for 5 days; 3 days; 4 days & record lacked evidence facility consistently implemented bowel mgmt. regimen program if res without BM for 3 days; res with Seroquel, Celexa, Lorazepam & record lacked evidence to support facility monitored res for targeted behaviors r/t multiple psychotropic medsFailed to monitor effectiveness of RisperdalFailed to monitor BMs & provide PRN meds for constipation for res with hx of constipationRecord lacked documentation staff monitored res for targeted behaviors for multiple psychoactive medsSE: SS=D: Failed to monitor meds for constipationRes with phys order for MOM daily PRN; res without BM for 5 days w/o BM then 4 days & ordered MOM not given; failed to adequately monitor res’ BMs; failed to provide phys ordered MOM for res’ lack of BMsNE: SS=D: Failed to consistently monitor behaviors to assess effectiveness of meds for multiple residentsCP failed to ID specific targeted behaviors for antipsychotic meds; res with Celexa, Temazepam, Olanzapine, Haldol; Failed to monitor effectiveness of psychoactive meds for res with cog impairment for multiple residentsNC: SS=D: Failed to adequately monitor BMs to prevent constipationRes without BM for 24 days, 8 days & no documentation staff administered a laxativeRes with orders for constipation; res without BM for 8 days, 5 days, 5 days without documentation staff administered bowel meds as orderedW: SS=E: Failed to provide appropriate indications for meds; failed to consistently monitor behaviorsRes with Huntington’s with Benztropine, Clonazepam, Risperdal & Zoloft; Order for Zenazine for Huntington’s without phys order indication; failed to appropriately provide medication indications for res with high risk medsRes with dementia with behaviors & PRN Ativan for anxiety; res with multiple episodes of anxiety requiring PRN Xanax & PRN Ativan cream per record but behavior monitoring sheets without indication of behaviors; observed res with yelling & physically aggressive behaviors; Res with routine Haldol but lacked indication for administration; failed to provide med indications & consistent behavior monitoring for PRN Xanax & scheduled HaldolRes with Zoloft without indication, Risperdal without indication & PRN Xanax for anxiety/agitation; failed to provide medication indications for res taking PRN antianxiety & antipsychotic medsFailed to ensure appropriate indications for meds & consistently monitor behaviors for res exhibiting behaviorsF332 Free of Medication Error Rates of 5% or MoreNE: SS=E: Failed to ensure med error rate less than 5%; with error rate of 7.14%Res with Omeprazole & MAR included to administer on empty stomach; MAR included res to receive 17gms of Miralax & MAR did not include how much liquid staff should mix with med; observed staff administer omeprazole after eating full breakfast; res drank ? of Miralax & staff stated “okay that was enough” & res handed cup of med with remainder of Miralax solution in cupFailed to administer Fluticasone nasal spray as ordered as staff reported unable to find medF333 Re Free of Significant Med ErrorsSE: SS=D: Failed to monitor meds to prevent a significant med errorPhys order for Lamictal 100mg BID; observed staff administer Lamictal 200mg from a med card labeled 200mg; failed to monitor & administer res Lamictal 100mg BID as ordered by phys to prevent adverse drug reactionsF334 Influenza & Pneumococcal ImmunizationsSE: SS=C: Failed to ensure influenza vaccine information statement sent to families/resp parties explaining risk v benefit for current years influenza vaccineStaff reported some consents were obtained while family visiting at facility & no consents or information was given to families who gave phone consentsF353 Sufficient 24-hr Nursing Staff Per Care PlansNC: SS=F: Failed to provide nursing & related services to attain or maintain highest practicable physical, mental & psychosocial well-being of each resident as determined by res assessments & individual CPReferenced F157, F241, F246, F250, F272, F279, F280, F281, F309, F311, F312, F315, F318, F323, F328, F329, F441, F497SC: SS=F: Failed to provide adequate staffing to meet needs of residentsRes council minutes from May, 2013 to April, 2014 revealed res voiced concerns r/t staff every month with multiple months res c/o baths & txs not being done timely & staff coming in & turning off call lights & telling res they were busy & would come back then taking long time to return; minutes also included c/o staff taking long time to answer call lightsMultiple observations of call lights with re-pagers when not answered in timely manner; observed call light to be yellow indicating 1 re-page with 2 direct care staff down hall talking then 2 staff member walked past res’ room; observed staff without pager r/t “light duty”; family interview revealed prolonged call light responses on numerous occasions; staff interview revealed facility lacked sufficient staffing; failed to provide sufficient staffing to ensure needs of residents metNE: SS=F: Failed to provide sufficient staff to ensure enhancement of res’ needs for multiple days of surveyObserved res requested to get up & staff returned 1 hr 11 min later to assist resObserved no direct care or licensed nursing staff on unit when res present on multiple occasionsObserved res activate call light at 9:06 & staff answered at 9:09 when res requested to use BR & staff left to get assistance & at 9:37 res turned light back on & reported now incontinent of bowel & staff assisted at 9:45amRes reported facility did not have enough staff; staff revealed facility occasionally worked short & problem was not worse on any specific unit; staff reported staff worked understaffed more often than worked fully staffed & res complained about call lights not answered timely & not getting meds on time; res reported prolonged call light response times & weekends especially bad & used a lot of agencySE: SS=F: Failed to provide adequate nursing staff to provide necessary care for res’ of facilityAdm staff revealed multiple res have complained about call lights not being answered timelyRes interviews revealed multiple res reported prolonged call light response times & not enough staffObserved multiple evening shift staff aides did not leave facility for 1 ? hrs after scheduled end of shift r/t completion of required documentationStaff acknowledged that night shift with 1 nurse & 1 aide; licensed staff reported being asked to stay over r/t state in building; direct care staff reported chronic understaffing & had reported to administration lack of staffingW: SS=F: Failed to maintain adequate staffing to meet needs of residentsObserved DR & res did not receive assist for extended period of time; observed food not delivered timely; observed there were 2 staff members to assist 3 res with eating; observed prolonged assist times with residentsObserved call light alarming for 21 minutes 30 seconds & 3 other call lights alarming while staff sat in commons area with res playing Wii bowlingRes stated short staffing especially on weekends & waited 45 minutes for call light response; other res reported short staffing; staff reported feeling rushed with work; staff reported night shift short lately;F354 Waiver-RN 8Hrs 7 Days/Wk, Full-Time DONNE: SS=E: Failed to have RN coverage for 4 weekends during February-May, 2014Review of multiple months schedule revealed multiple weekend days without RN coverage; staff reported was acting DON & RN covering nurse for multiple days; failed to provide RN coverage, other than DON when census was above 60 residentsF356 Posted Nurse Staffing InformationSC: SS=C: Failed to post nurse staffing data daily & at beginning of each shiftObserved no current staffing sheet posted on multiple occasions; failed to post nurse staffing sheet in prominent place readily accessible to visitorsNE: SS=C: Failed to post daily nsg staffing data in a prominent place readily accessible to residents & visitors for multiple days of surveyObserved daily nursing staffing data taped to side of file cabinet located in business office & observed office closed periodically during dayW: SS=C: Failed to post daily total number of hours worked by nursing staff in facilityObserved nsg staff forms not filled out & posted F363 Menus Meet Res Needs/Prep in Advance/FollowedSE: SS=E: Failed to serve diet as planned on menuObserved res received hamburger on Texas toast instead of bun as planned on menu; observed res received same portion of pie & menu called for res on LCS to receive ? slice of pieF364 Nutritive Value/Appear, Palatable/Prefer TempNE: SS=E: Failed to provide food prepared by methods that conserved flavor & appearance & was palatable, attractive & at proper tempObserved test tray with soup that was bland, casserole that was bland & did not look appetizing & plate that had no variety of color & did not look appetizing & tasted bland; pizza at 133.5 degrees, zucchini at 126 degrees & brown in color & did not look appetizing & carrot soup that tasted bland; purred tray revealed pizza at 133 degrees, zucchini at 130 degrees & soup at 128 degrees; tator tots at 135 degrees; res interviews revealed multiple residents stated food did not taste good, did not look appetizing, was not served hot, soup was always cold &/or was too spicy; failed to serve palatable, attractive food at proper tempsSE: SS=F: Failed to indicate expiration dates of food products to ensure nutritional value & stability were maintained for res of facilityObserved multiple food packages lacked expiration datesSC: SS=E: Failed to ensure foods maintained appropriate temps & palatabilityRes council notes revealed res had concerns about food quality every month including multiple specific complaints; review of temp logs revealed multiple occasions when hot foods below facility policy temps; multiple res interviews revealed complaints that food “just did not taste good, was too salty, had to wait a long time and it was cold, even the soup is cold”; observed res stated chicken finger sandwich “hard as a rock” & observed res tap bun & it was hard then tapped piece of meat & put in mouth & tried to chew it; res stated food usually cold but since state there, they had shaped up a little bit & res feel not enough dietary or nursing staff r/t to 1 cook & 1 dietary aide for over 50 people; failed to ensure foods tasted good & served at proper temperature to ensure res’ satisfactionNC: SS=E: Failed to serve food at proper tempObserved dietary staff placed liquids on tables in DR at 10:47am & 1 hr 56min later res entered DR & seated self with liquid in front of res then surveyor requested temp check of liquid & temp was 63.5 degrees then surveyor requested dietary staff replace liquids which remained on tables on multiple occasions; failed to serve milk & juice at proper tempsW: SS=F: Failed to follow recipes to ensure foods were prepared by appropriate methods to conserve nutritive value, flavor & appearanceObserved res look at menu & comment “just had” menu item; res stated food not very good; res stated food “terrible” without variety; res stated food too salty, meat toughObserved staff prepare pureed foods & never followed a recipeFailed to follow recipes when preparing pureed foods & failed to prepare meat that was palatable to residentsF366 Substitutes of Similar Nutritive ValueNC: SS=F: Failed to provide food substitutes with equal nutritive value & a sweetener substitute as requested by residentPosted lunch failed to match monthly menu planObserved res request sugar substitute & staff revealed facility ran out but res could have regular sugar & drank tea without any sweetenerObservation of dining service 3 days revealed res’ alternate choice of food for lunch & supper was a hot dog but kitchen staff did not have a substitute for vegetable or potatoesF371 Food Procure, Store/Prepare/Serve-SanitaryNC: SS=E: Failed to prepare & serve food under sanitary conditionsObserved staff served meals while touching inside rim of platesObserved hair hanging outside of hair net on side & backObserved mop board under sink loose, wall with peeling paint; bent filter on ice machine & not secured to ice machineNE: SS=F: Failed to store food under sanitary conditions & at appropriate temps & clean dishes & utensils under sanitary conditions; failed to have appropriate drainage of ice makersObserved walk in cooler with open, undated plastic storage bags of food items & cheese slices partially wrapped in plastic wrap sitiing in pickle juice covering bottom of wrap; observed multiple broken thermometers in fridge; lg amount of crumbs noted between ledges of oven; rinse temp of dishwasher was 137 degrees; sticky floor in kitchen; observed fridge with temp of 48 degreesObserved ice machines without air gapsObserved fridge logs with multiple days over 2+ months with temps exceeding 41 degrees or temps not recordedDishwasher temp logs with wash temps did not consistently reach 150 degrees & rinse temps did not reach 180 degrees or were absentW: SS=F: Failed to store & serve foods in sanitary manner by not having open dates or use by dates on perishable food items that were open & partially used in kitchen fridge & walk in freezerObserved kitchen fridge with juice, milk, & bacon that lacked open date or use by date; freezer with muffins open to air with expired dates on food & partially used bag of egg rolls without open date or use by dateSE: SS=F: Failed to prepare & distribute food in sanitary mannerObserved back splash with dried food particles &/or grease; freezer/fridge without thermometer; unlabeled & undated food items; inside of microwave with accumulation of food particles; cabinets with clothing protectors with shelf with accumulation of dirt & debris & cobwebs; jar of home canned pickles with date of 2010 lacking res’ nameObserved res served & trays without covering when taken from kitchen & across a hallwayFreezer with frost on all sides; skillets needing cleaning &/or discarding; skillet with Teflon coming off; baking sheets with accumulation of black substance in cornersConcentration level of sanitizing solution tested with 10PPM & staff had logged reading at 100PPM on multiple daysNC: SS=F: Failed to prepare, store, distribute & serve food under sanitary conditions Multiple observes of dietary staff without a hair net cover on & appropriately covering hair during food prep & serviceObserved staff picked up glass by drinking surface & handed it to resObserved dietary aide without gloves on removed used dishes from table, cleaned table with cloth soaked in liquid from red bucket then without performing hand hygiene picked up coffee cups & replaced coffee cups while touching drinking surface back in front of residentsObserved staff made popcorn & popcorn maker with thick white film that covered glass of machineW: SS=E: Failed to follow proper food handling practices while serving residents in DRObserved dietary staff wore gloves to push handle of utility cart with desserts then passed cookies to res with contaminated glovesSE: SS=F: Failed to store, prepare & serve food in a sanitary manner Observed ovens with build-up of black flaky substance; AC in kitchen & next to stove with accumulation of dust build-up on filter with air blowing across food prep areas; AC in dry storage room with dust build-up; front of cabinet doors with chipped paint; faucet handles with build-up of white hard substance; dry food storage shelf with brown colored substance; wash basins with thick white substance build-up; cart with gougesObserved sanitizing basin with solution & hot water & basin with build-up of thick white substanceSC: SS=E: Failed to distribute & serve food under sanitary conditions by failure to ensure staff distributed fluids in a sanitary manner & failed to maintain potentially hazardous foods at 135 degrees F; failed to ensure proper sanitation r/t drain hose of ice machine Observed staff touch res’ w/c handles, tables & other items in DR then going into satellite kitchen & got glass of water, carried it by rim & gave it to res without washing hands prior to preparing; observed staff distribute drinks by handling cups by drinking surface; observed staff remove paper from straw & touch uncovered surfaces of straw with bare hands then place on table; multiple occurrences of staff carrying glasses by rim without washing handsReview of food temp logs revealed multiple occasions of meat at 130 degrees F & multiple days that lacked holding temps documentation & some without pre-serving tempsObserved holding temp of pureed meat at 120 degrees; 2 trays of cottage cheese sitting out without ice & temps at 42 degrees; observed multiple foods with wide variations of temps & staff unaware of when thermometers were last calibrated; observed staff open cans of soup & warm in microwave then serve without temping soups; failed to ID problems r/t calibration of food thermometers & monitoring of food temps prior to serving & maintaining of holding temps equal to or greater than 135 degreesObserved ice machine in main kitchen with drain hose that was in floor drain & hose with mildew & white debris on bottom 2-3 inches of drain with black slime hanging from inside hoseNE: SS=F: Failed to store foods in a sanitary manner & failed to properly sanitize tables in DRObserved soiled dry food storage room floor; opened outdated food items; undated opened foods; items located on soiled rack below bug light; microwave soiled; milk glasses not covered; lettuce brown & undated; red debris inside fridge; snack carts with white debris on top of cart; soiled outlet by food processor; freezer with sticky container & lid not on tight & undated & openedObserved staff cleaned DR table with rag dipped in bucket & staff unaware of what was in bucket & unaware if facility had sanitizer test strips; when surveyor tested, each bucket measured 0 sanitizer concentration levelSE: SS=F: Failed to store, prepare & distribute food under sanitary conditionsObserved opened undated foods; unlabeled foods; floor storage in walk in freezer; observed meat temps at 120 & 125 degreesObserved cart with white debris; glasses with brown staining; stacked plates, bowls & saucers & small bowls exposing eating side; glasses with water on inside; steam table pans with brown build up; stand mixer unclean; oven with black build up; stove burners with black & brown debris; microwave with debris; scoops with water on inner food surface; prep table with food debris; mixing bowls in stacked fashionDining area with drink dispenser with red liquid unlabeled & undated; ice machine drain without back flow preventionW: SS=F: Failed to remove expired mild from use; failed to hold cheese at proper cold temp on salad barObserved milk in fridge with past expiration dateObserved staff brought cart of cold food items from kitchen & placed containers into ice on salad bar then measured temps & cheese cubes at 44.2 degreesSE: SS=F: Failed to store, prepare, distribute & serve food under sanitary conditions to prevent spread of food borne illnesses to residentsObserved dry storage room with discoloration on all shelving; numerous food containers with layer of white powder on lids; opened peanut butter container with dried peanut butter on outside in numerous areas; outside of flour storage bins with gray discoloration build up; canned foods with layer of dustTop of ice machine with layer of grime; fan above dishwasher with grime; can opener with dried food particles on blade; knife handles with gougesNE: SS=E: Failed to have an air gap on ice machine in DRObserved drain pipe from ice machine without air gap between floor & pipeNE: SS=F: Failed to maintain hair restraints in multiple kitchensObserved staff in serving area of DR with hairnet that was not all inclusive & hair hanging out from behind ear & below hairnet on multiple occasionsW: SS=F: Failed to ensure safe temps for potentially hazardous foods, properly handle res dishware, effectively restrain hair & maintain proper hand hygiene when preparing & serving foodsObserved staff touch bread item with ungloved hand to open roll & add butter; observed staff with hair net on but without covering hair in back; observed staff touch food items with contaminated gloves; observed staff did not temp brisket in crockpot until surveyor asked; observed salad with temp of 49 degrees, 50 degrees, 50 degrees on various DRs; cottage cheese at 42 degrees; observed staff did not sanitize blender between foods; failed to ensure safe temps of foods, properly handle dishware, effectively restrain hair, maintain proper hand hygiene when preparing & serving foodsF406 Provide/Obtain Specialized Rehab ServicesSE: SS=D: Failed to provide res with specialized rehabilitative services as orderedCP lacked ID of therapy svcs; res returned from hosp with order for PT, OT to eval & treat under Med A svcs; PT eval revealed res discharged from PT per facility request secondary to facility believing res could not have Med A with only 1 service provided; record lacked physician’s order to DC PT; failed to provide specialized rehab PT as ordered following hosp stayNE: SS=D: Failed to provide mental health services for res as outlined in res’ PASRRRes with schizophrenia; lacked CP r/t psychiatric or mental health care; record lacked documentation from a mental health professional after 12-4-13; staff revealed facility without psychiatrist consultant at facility but psychologist visits facility monthly & PCP manages meds; failed to provide mental health svcs for res as directed by level 2 PASRR for res with schizophrenia & depressive disorderF425 Pharmaceutical Svc-Accurate Procedures, RHPSC: SS=D: failed to provide pharmaceutical svcs to ensure accurate acquiring, receiving, dispensing & administering of all meds for multiple resStaff did not give Ativan and multiple other meds as ordered on multiple days because of unavailability of med & staff did not note what done in effort to correct situation or what doses referred to &multiple holes in MAR without explanationMAR revealed res with order for Lorazepam TID & did not receive med on 6 consecutive doses without explanation & staff reported attempted to contact pharmacy but could not reach all weekend & did not ask any other nurse for advice on how to handle situationNE: SS=D: Failed to properly administer meds for res observed during med administrationRes with Ativan 1mg TID & OxyContin 10mg BID; observed direct care staff punch out Ativan & placed it in med cup then exited unit then licensed nurse punched out OxyContin & placed it in same med cup then exited unit & direct care staff administered meds to res; licensed nurse failed to observed CMA passing meds; failed to ensure meds administered according to standard of practiceNE: SS=D: Failed to follow order to rotate site of medication patchRes with Exelon Patch for dementia & precaution attached to order to rotate site & not repeat for 14 days; review of MARs revealed staff failed to rotate sites on multiple occasions during multiple months; failed to rotate administration site for Exelon patch as orderedF428 Drug Regimen Review, Report Irregular, Act OnNE: SS=D: Consultant pharmacist failed to recognize facility did not monitor for BBW for use of anti-coagulant medCited findings noted in F329SC: SS=D: Failed to ID & report irregularities of missed med doses to physician & DON for multiple residentsCited findings noted in F425NC: SS=D: Pharmacy consultant failed to report drug irregularities to phys or DONCited findings in F329W: SS=D: Failed to ensure consultant pharmacist IDd irregularities, reported those irregularities to physician & DON & acted on recommendations r/t med monitoring (vital signs & blood sugars) for multiple residentsCitied findings noted in F329SE: SS=D: Pharmacist failed to ID drug irregularities of ID & monitor meds with BBW & failure to monitor ordered lab valuesCited findings noted in F329 SC: SS=D: Pharmacist failed to ID & report to phys & DON an irregularity of administration of MiralaxCited findings noted in F329NE: SS=D: Failed to follow pharmacy consultant recommendations for multiple residentsRes with Wellbutrin, Celexa & Ambien; DRR revealed recommendation to change Norco & no response to recommendation & recommendation to DC Ativan due to non-use; Norco DCd 5 months laterCited findings noted in F329; facility failed to follow up on pharmacy recommendation & pharmacist failed to recognize irregularities with bowel monitoring for multiple residentsPharmacist failed to ID facility did not complete AIMSNE: SS=D: Failed to monitor targeted behaviors; failed to effectively monitor BMs; failed to have pulse parameters; failed to have monthly pharmacy review for res reviewed for med effectivenessCited findings noted in F329; facility failed to respond to pharmacy recommendations for hold parameters for res with Atenolol; failed to conduct a DRR in 1 monthNE: SS=D: Pharmacist failed to recognize & notify facility of failure to consistently monitor behaviors to assess effectiveness of medsCited findings noted in F329NC: SS=D: Pharmacist failed to ID & report drug irregularities to phys or DON r/t adequately monitoring res’ BMs to prevent constipationCited findings noted in F329; pharmacist reported did not monitor charts for BMsW: SS=E: Pharmacist failed to ensure appropriate indications for meds & consistent behaviors monitoringCited findings noted in F329 F431 Drug Records, Label/Store Drugs & BiologicalsNC: SS=D: Failed to ensure drugs used in facility were labeled in accordance with currently accepted professional practicesObserved multiple insulin vials with expired open dateSE: SS=E: Failed to appropriately store res’ meds, held for destruction &/or return to pharmacyObserved fridge in med room with bottle of liquid Vancomycin with expired date & staff reported res no longer in facility; observed cabinet in med room with stacks of bubble packed meds & ID as DCd meds that were not yet logged for destructionNE: SS=D: Failed to properly dispose of expired meds in med room & treatment cart Observed med room fridge with expired pneumovax & flu vaccine; observed expired ear drops on tx cartNC: SS=E: Failed to properly label & date opened insulin pensObserved open Levimir insulin pen marked with res’ name with no documentation of date opened on multiple occasions; some insulin pens with no name & no opened dateNE: SS=D: Failed to timely dispose of expired meds; failed to label envelope with meds in med cart; failed to date when opened a multidose vial in med cart; failed to properly secure a narcotic in med roomObserved liquid Morphine in unlocked fridge; observed multiple expired meds on med cart; med cart contained envelope dated 4/28 but lacked names of meds & res meds belonged to; failed to ensure security & safeguarding of meds; failed to date multidose vials when opened & failed to timely dispose of expired medsObserved unlabeled Advair Diskus inhalerW: SS=E: Failed to store controlled substance meds in double locked storage compartments in multiple med rooms & med carts; failed to ensure storage of meds under proper temp controls in multiple med fridges; failed to ensure meds available for res use were not expired in multiple med roomsObserved expired stock meds; med room lacked logs of fridge temps & temp at 38 degrees in multiple med roomsObserved failed to double lock multiple narcotics in multiple med cartsNE: SS=D: Failed to store medication in original container & properly label an opened multidose vial of Tuberculin Observed med cup of green pills in top drawer of med cartObserved Tuberculin vial not labeled with open dateNC: SS=D: Failed to ensure appropriate labeling of insulin vialsObserved multiple insulin vials not dated when openedF441 Infection Control, Prevent Spread, LinensNC: SS=F: Failed to provide a safe & sanitary environment to help prevent the development & transmission of disease & infection Observed room with orange sign outside room & container of sanitizing wipes outside room marked “C-diff wipes”; observed room with carpet on all floor surfaces except BR; observed dietary staff delivered tray with disposable service ware & dietary staff walked across carpeted room with no gloves or shoe covers on & placed tray on table in front of res then left room & returned to kitchen; observed housekeeping staff don gloves, gathered supplies & entered room, put Clorox cleaner in toilet & used toilet brush in toilet then sat brush in container & placed it on floor next to toilet then left room, changed gloves, removed cloth soaked in disinfectant & returned to BR then picked up toilet brush, held it in one hand while wiped down BR fixtures then removed soiled gloves & donned clean gloves without washing hands & returned to room with broom & dustpan & swept BR then mopped BR floor after changing gloves without washing hands then pushed cart down hallways before stopped at closet & removed soiled mop head; observed disinfectant without indication effective on C-diff; floor cleaner without indication of any bleach & no indication cleaner killed any viruses; Clorox cleaner called for 5 minute contact time then rigorous wiping & scrubbing; housekeeping staff unaware why res was in isolationNE: SS=E: Failed to transport clean clothing/linen to prevent spread of infection; failed to properly clean res’ rooms & BRsObserved staff parked a laundry cart in hallway, picked up hangers of clothing & folded items, proceeded into isolation room then left off clothing then went to multiple more rooms leaving clothing at each room; failed to handle clean clothing/linen in manner to prevent infectionObserved housekeeper cleaned non-isolation room & isolation rooms & used same cloths for toilet pieces & other fixtures; failed to allow recommended wet times for disinfectants & used same toilet bowl brush for both roomsSE: SS=F: Failed to maintain an ongoing infection control program to investigate, control & prevent further infections in facility; failed to use proper infection control procedures for isolation rooms; failed to appropriately clean reusable devices such as glucometers, hoyer lift & shower chairStaff reported facility uses hot water sanitization for laundry; water temp at 142 degrees & staff reported laundry uses same water tank as kitchen & “tank can only do so much”; staff reported water temp checked 2-3 x/wk & week prior water temp was 140 & failed to do anything about itFacility’s IC monitoring system revealed lack of documentation for any tracking or trending for previous 2 monthsObserved staff obtain blood sugar value while res in beauty shop then walked across hall to res’ room; staff placed glucometer directly onto res’ Bible on bedside table completed test then picked up glucometer & supplies & returned glucometer directly to tray without cleaning glucometer; staff took tray to next room & sat tray on isolation bedside table outside room then staff removed required equipment & entered res’ room, sat glucometer directly on over bed table, obtained blood sugar level then picked up glucometer & exited room & returned glucometer to tray without cleaning glucometerCP lacked instructions to staff r/t isolation for res with infected wound with enterococcus & pseudomonas; observed staff wore gowns & gloves after entering room, then used mechanical lift to transfer res from bed to shower chair, then completed shower for res & pushed lift from room & used wash cloth with alcohol gel hand sanitizer to wipe down lift then used spray bottle of disinfectant to sanitize shower chair in soiled linen roomRes with positive scabies scraping & staff reported res had rash for several days; observed res in room without any signage referring visitors or cautioning staff r/t isolation needs; observed lab tech enter room & placed equipment on floor & paper work in chair & tech reported unaware of any required precautionsObserved staff perform peri care appropriately but failed to remove gloves before touching multiple items in roomSC: SS=E: Failed to ensure use of an effective disinfectant to kill c-diff spores in multiple rooms where res with c-diff residedObserved housekeeping staff don gown & gloves & entered room then sprayed all surfaced with disinfectant & immediately wiped surfaces dry; observed used gowns & gloves in regular trash can & no red bag or barrel in place; housekeeper took trash bag out of can & put it in regular trash on housekeeper cart & placed soiled rags in same bag as all other soiled rags & no red bagNC: SS=F: Failed to provide a safe, sanitary & comfortable environment to help prevent development & transmission of disease & infection; failed to provide appropriate incontinent care; failed to follow contact precautions; failed to properly store respiratory & oxygen therapy equipment to prevent transmission of disease; failed to properly sanitize common blood glucose testing meter between res useRes with suprapubic catheter with multiple UTIs; NN stated res continued on contact precautions & observed contact precaution sign on res’ door & res seated in a chair in commons area touching sides of chair; observed staff passing ice water & entered room without donning personal protective equipment then removed plate from room, placed it on top of ice cart & walked down hallObserved tubing & mask from oxygen unbaggged ; observed nebulizer mask & tubing unbagged & laying on res’ chest on multiple occasionsObserved laundry staff pushed uncovered clean linen cart down hallObserved housekeeping staff state did not know what C-Difficule was or if staff cleaned res’ rooms different & stated no training r/t infection control practices for facilityObserved nurse with gloves on used alcohol prep pad & wiped res’ index finger then used lancet & pricked res’ finger on hand & obtained drop of blood then applied drop of blood to a blood glucose test strip & placed test strip into blood glucose monitor then removed gloves & sanitized hands but did not sanitize glucometer then completed testing & placed glucometer on top of tx cartObserved suction machine ? filled with phlegm & oxygen tubing laying on floor unbagged & 2 wash cloths laying on floorObserved res on toilet in room & 2 staff assisting; revealed res with dry brief with 2 smears of stool in back of brief & staff member performed peri care without cleaning bottom then pulled dirty brief up along with res’ pants then with same gloves used mechanical lift & touched lift pad, the lift, door handles & resident & with same soiled gloves removed res’ shoes & applied heel protectors, covered res with blanket & pulled res up in bed then removed soiled glovesW: SS=F: Failed to provide a sanitary environment to prevent development & transmission of disease & infection; failed to adequately sanitize res’ rooms & w/p during cleaningObserved housekeeping staff clean inside toilet bowl, scrubbed inside bowl then used same scrubber on toilet seat; flushed toilet & used rag to wipe seat then riser handles & grab bars on wall with 1 rag; manufacturer instructions lacked mention of using product on toilet seat & lacked evidence cleanser killed any pathogens; other cleaners lacked evidence killed any pathogens; disinfectant instructed wet time of 5 minutes; failed to provide effective infection control measures by failing to adequately sanitize rooms during cleaningObserved staff fill w/p tub with water, poured in 4 cups disinfectant, scrubbed top & bottom of seat then used same rag & scrubbed chair back rest, handles, walls & floor of tub then continued to fill tub then ran jets & allowed nozzle to sit in w/p water then used nozzle to rinse sides of w/p & disperse bubbles; instructions directed to add 1 ounce disinfectant to each gallon water & wet time of 10 minutes; p/p instructed staff to add 6 cups disinfectant & allow wet time of 10 minutesNE: SS=F: Failed to maintain an infection control program, failed to follow facility’s policy for cleaning res’ room; failed to properly handle soiled linensObserved housekeeping staff clean res’ room & failed to clean call lights, bed controls & light switches; staff wore gloves & cleaned toilet seat & base of toilet & failed to change gloves prior to starting to sweep room; failed to clean & disinfect frequently touched surfaces & change gloves appropriately during daily res room cleaningReview of infection control log revealed facility failed to include recognition, surveillance, education & investigation of infections in facility; staff revealed did not have actual infection control logNC: SS=E: Failed to provide a safe, sanitary & comfortable environment to help prevent development & transmission of diseases & infection; failed to implement infection control measures for diabetic res utilizing facility’s glucometer machine to check blood glucose levelsObserved housekeeping staff obtained cloth from cleaning cart, sprayed res’ BR toilet & sink with disinfectant & allowed dry time of 2-3 minutes before wiping skink & toilet with dry cloth but recommendations for 10 min wet timeObserved nurse perform blood glucose fingerstick & failed to use any disinfectant to clean glucometer before, during or after obtaining blood glucose finger stickNC: SS=E: Failed to implement an infection control tracking system to prevent or reduce number of infections & provide infection control practices for oxygen therapy on multiple daysObserved oxygen tubing & cannula rolled up & lying on top of oxygen concentrator unbagged on multiple occasionsObserved breathing mask laying on top of breathing treatment machine unbaggedFacility unable to provide infection tracking system on request & staff reported no system in placeNC: SS=E: Failed to provide a sanitary environment to prevent development & transmission of disease & infection for res Observed housekeeping staff cleaning res’ room, applied gloves, grabbed duster from cart then dusted shelves, picture frames, window sill, headboard, light fixture in BR & top of door then grabbed cloth of duster with gloved hands & discarded cloth into cart trash bag & with same soiled gloves on, reached into shirt pocket to get keys to cart, unlocked cart, gathered cleaning supplies then returned to res’ BR & cleaned with same soiled gloves on during entire process; failed to allow 10 min wet time as recommendedNE: SS=F: Failed to store oxygen tubing in appropriate manner; faield to dispose used disposable razors in appropriate manner; failed to clean w/p chair in manner to prevent spread of infection; failed to wash hands prior to installation of dispensing eye drops; failed to provide clean bath tub; failed to clean an accucheck machine prior to use & wash hands after procedures; failed to wash hands before & after accucheck procedure; failed to have a clean lift; failed to maintain hot water for washing machinesObserved staff obtained blood sugar without washing hands before & after procedureObserved oxygen tubing laid on floor behind a doorObserved BR with red Sharps container full beyond fill line & used razors stuck out top of containerObserved plastic foam cushion in w/p chair cracked, peeling & cushion torn in halfObserved bath tub surface peeled & scarredObserved dirty sit to stand lift & schedule for lift cleaning not presentHot water temp from sink in janitor’s closet with temp of 65 degrees & staff reported hot water temp checks for washing machine checked from that sink; hot water from clean laundry room temped at 105.5 degrees; staff reported water should be above 160 degreesObserved staff did res’ blood glucose check using another res’ machine r/t res’ machine without working batteries & staff did not wipe blood sugar machine with disinfecting wipe before or after performing test & did not perform hand hygiene after performing test before entering another unidentified res’ roomObserved med pass observation & staff administered eye drop without washing or sanitizing hands prior to administrationW: SS=D: Failed to handle contaminated items appropriately after providing treatment to res with infectionObserved nurse administer eye drops & staff did not remove gloves between eyes then with contaminated gloves still one, placed container back in box then placed box in pocket of uniform, then removed gloves & washed handsSE: SS=E: Failed to thoroughly track & trend infections in facility; failed to effectively sanitize glucometerObserved staff complete glucose level & then cleansed glucometer with benzalkonium chloride antiseptic towelette & directions on packet advised staff to use towelette to cleanse skin; glucometer instructions failed to document cleaning of glucometer for multiple residentsIC logs lacked indication of nosocomial or community acquisition for all months & lacked consistent tracking & trending to determine antibiotic usage & appropriateness (sensitivity results); failed to consistently document all components of infection control log to ensure tracking & trending of infections, antibiotic usage & source of infection to prevent spread of infection amongst res of facilityNE: SS=E: Failed to properly store clean mop headsObserved clean mop heads hanging on wall in soiled linen receiving & sorting area; failed to store clean mop heads in clean environmentNC: SS=D: Failed to provide a sanitary environment to prevent development & transmission of disease & infections for res with oxygen &/or respiratory therapyObserved multiple nebulizer machine masks placed on top of machine face down & not in plastic bag; nasal cannula on bed laying on bed; cannula not bagged; cannula touching floorW: SS=E: Failed to ensure staff followed appropriate procedures to prevent infection during room cleanings; failed to ensure appropriate infection control measures during perineal care & equipment cleaning for res using mechanical liftsObserved peri care when staff used wipes & put barrier cream on res without changing gloves then used dirty gloves to move wipes container to bedside table then removed dirty brief, put on clean bried then grabbed lit sling & placed it under res with same glovesObserved housekeeping staff did not change gloves after wiped down toilet then rinsed mop head in mop bucket water & rinsed another cloth in mop water with same gloves used for cleaning toilet then wiped down counters & handrails in BRF456 Essential Equipment, Safe Operating ConditionSE: SS=F: Failed to maintain essential equipment including res’ self service ice machine & lift chair for w/p in safe operating conditionMultiple res reported ice machine quit working 6-8 months ago & res now have to ask kitchen for ice if someone is in thereRes stated would like to try w/p but staff reported lift chair did not work for w/pNE: SS=F: Failed to maintain essential laundry equipmentObserved 3 running dryers in clean laundry room & unlocked upper panel doors which housed gas pilot light system were propped open & visual flames notes & clothes hung from bar suspended above 1 dryer & were positioned up against one of the running dryers with an open pilot light panel & res was in clean laundry room folding clothing at counter while panels to dryers were open; staff reported dryers did not function properly when panels were closed & stated fire marshall stated it was ok to run dryers with panels open as long as entry door to laundry room was closed & only staff were present; staff reported had not checked or cleaned behind dryer units since employment started 2 months priorSE: SS=D: Failed to maintain w/p tub in working orderFailed to maintain w/p tub in working orderF463 Resident Call System-Rooms/Toilet/BathSE: SS=E: Failed to maintain a functioning call system from res’ rooms & BRsObserved multiple call stations/areas failed to light over door or panel at nurses desk & system failed to make any audible sound; observed call station lacked button end of system exposing bare wires; call light check logs revealed 15 of 66 & 21 of 66 documented as “NO”NE: SS=D: Failed to maintain a working call light system; failed to provide a preventative maintenance log for call lightsObserved BR light in res room did not light up at door or at panel; staff revealed no records of call light checks prior to employment in 4-14NE: SS=E: Failed to maintain a functioning call light/pager systemObserved multiple call lights did not alert pager when activated; observed BR call lights did not appear on call light computer monitoring screen; staff stated did not do routine call light functioning testingF464 Requirements for Dining & Activity RoomsNE: SS=E: Failed to provide res with sufficient space for dining Observed staff could not get 1 res in a reclining modified w/c up to table & placed res beside table in a way res could not reach drinks unassistedObserved staff positioned res in a reclining w/c in a way that res was not up to table & had to move res after getting res placed at table to fit another res at table then ran other res into res’ legsNC: SS=E: Failed to provide adequate DR space in DR for res who ate meals in DRObserved noon meal & res in w/c entered & staff had to move a res at the table closest to DR entrance to side of table on opposite side of DR & res had been eating meal at the time on multiple occasions; staff verified facility lacked adequate space for staff to provide & assist res with meal serviceNC: SS=D: Failed to provide sufficient space to accommodate needs for res who eat meals in DRObserved staff move res seated in geri-chair from place in DR to let another res get to their place at table on multiple occasionsObserved staff move res so another res could get to res’ place at tableF465 Safe/Functional/Sanitary/Comfortable EnvironmentSE: SS=F: Failed to maintain a safe, functional & sanitary environment for res, staff, & publicObserved electrical room with hot water tank with brown debris over entire floor; public restroom & staff restroom with metal brackets with sharp edges, exhaust vent with layer of dust & light fixture above mirror with rust; sink in soiled utility room with white & brown build-up on inside of compartments & area of rust along flat back edge; handicap BR with stored w/cs & chairs & staff lockers with missing ceiling tile; nsg storage area with floor storage of supplies; MDS Coord office with broken & missing floor tiles & black build-up on tiles; Asst Adm office with broken & stained floor tilesOutside building observed raised flower bed with weathered & rotting wood; gazebo with rotted wood; multiple sewer cleanouts uncapped exposing hole; hole in yard with standing waterObserved kitchen floor in front of dish machine with missing floor coveringSE: SS=E: Failed to maintain a functional sink in med room; failed to ensure a sanitary environment in kitchen area of facilityObserved med room sink without functioning water supplyObserved floor in front of steam table with cracked floor tiles; floor area tiles with build-up of discolored brown substance; dishwasher chemical storage area floor tiles discoloredNE: SS=D: Failed to provide a safe & functional environment Observed soffits with gapsNE: SS=E: Failed to provide a comfortable & clean environment for resObserved soiled utility with hole in wall; missing window screen & chipped paint on fasciaSE: SS=E: Failed to maintain a safe, sanitary & comfortable environment for res, staff & publicObserved janitor closet with missing floor covering exposing raw concrete; housekeeping closet with missing floor covering exposing raw concrete & flooring in closet with brown debris & grimeEDU room floor with piles of accumulated lint/dust & dead bugs & staff reported room never cleanedStaff office with cardboard duct-taped in window with AC unit presentFiberglass insulation debris on floor; staff offices with cardboard duct-taped in window with AC unitLaundry area with hole in wall & corners missing ball board at wall baseSprinkler room with leaves & debrisOutside lacked guttering & down spoutsSE: SS=E: Failed to provide a safe & sanitary environment in biohazard storage shed & kitchen Observed outside storage shed with biohazard sign on front & shed with 5 filled large packing boxes labeled biohazard waste & wooden doors to unit were splintered with pieces of wood missing, revealed incomplete closure & 1 side of unit with outward bowing for 4 ft horizontal crack along bowed areaObserved floor in dry storage room with layer of grime, light to dark brown in color on floor; kitchen with discoloration in numerous areas of floor & wallsF468 Corridors Have Firmly Secured HandrailsW: SS=E: Failed to have firmly secured handrailsObserved handrails not secured firmly to wallsF490 Effective Administration/Resident Well-BeingNC: SS=F: Failed to use its resources effectively & efficiently to attain or maintain highest practicable physical, mental & psychosocial well-being for residentsReferenced: F157, F164, F174, F223, F225, F241, F246, F248, F250, F253, F257, F272, F278, F279, F280, F281, F309, F311, F312, F315, F318, F323, F328, F329, F366, F371, F441, F464, F497NE: SS=F: Failed to manage facility in an appropriate mannerReferenced: F155, F156, F160, F161, F166, F167, F226, F250, F253, F274, F278, F279, F280, F281, F309, F311, F314, F315, F318, F323, F325, F329, F332, F353, F354, F356, F371, F406, F425, F428, F431, F441, F456, F463, F514, F520, S770, S1146, S1354, S1358, S1364F497 Nurse Aide Perform Review-12 Hr/Yr InserviceNC: SS=F: Failed to provide regular in-service training to staff to effectively manage behaviors of res with special needsRes with extreme & frequent aggressive behaviors; staff stated did not know how to redirect res & verified had not received training on mental illness & staff reported major issue of lack of communication amongst staff in knowing what to do for residents; failed to provide training to staff to manage res’ behaviors for multiple residentsF501 Responsibilities of Medical DirectorNC: SS=F: Failed to provide a licensed medical directorReview of dept heads list signed by Adm revealed no medical director for facility; staff stated facility has not had a medical director for 8-9 months & no medical director had attended QAA quarterly meetingsF514 Res Records-complete/Accurate/AccessibleNE: SS=D: Failed to produce accurate recordsSS noted documented SW called res’ guardian who gave permission to CP unsupervised walks & to allow res outings & guardian was in favor of res walking unattended near facility to shopping; guardian revealed guardian had not visited with facility & did not agree res could have unsupervised walks & outings; failed to document accurate informationNE: SS=D: Failed to maintain a clinical record that included restorative svcsRes with CP for restorative exercises with phys order; record lacked documentation of restorative svcs res’ receivedF520 QAA Committee-Members/Meet Quarterly/PlansSE: SS=F: Failed to maintain a QA committee that developed & implemented appropriate plans of action to ID quality of care concerns for res of facility; failed to conduct quarterly QA mtgs as planned with a minimum attendance of DON & physician of facility’s choice along with 3 other employees of facilityStaff reported medical director does not attend mtgsReferenced: F315, F318, F323NE: SS=F: Failed to develop & implement appropriate plans of action to correct IDd quality deficienciesReferenced: F253, F322, F325NC: SS=F: Failed to provide good faith efforts to ID multiple issues of concernReferenced: F157, F164, F174, F223, F225, F241, F242, F246, F248, F250, F253, F257, F272, F278, F279, F280, F281, F309, F311, F312, F315, F318, F323, F328, F329, F366, F371, F441, F464SE: SS=F: Failed to maintain a QA committee that developed & implemented appropriate plans of action to ID quality of care & quality of life concerns for residents of facilityReferenced: F221, F241, F315, F323, F325NE: SS=F: Failed to ensure physician designated by facility attended QAA committee meetings at least quarterlySign in sheets for previous year revealed physician did not attend meetings quarterlyNC: SS=F: Failed to designate a qualified medical director &/or physician attend QAA meeting quarterlyFailed to ensure QAA committee composed of appropriate members including a designated phys &/or med director attended quarterly meetingsNE: SS=F: QAA failed to ID & remedy issues that required an action planReferenced: F155, F156, F159, F160, F161, F166, F167, F226, F250, F253, F274, F278, F279, F280, F281, F309, F311, F314, F315, F318, F323, F325, F329, F332, F353, F354, F356, F371, F406, F425, F428, F431, F441, F456, F463, F490, F514, S770, S1146, S1354, S1358, S1364S600 Dietary ServicesNC: SS=C: Failed to employ a full time CDMObserved staff overseeing meal prep; staff reported had no certification as CDM & was currently enrolled in CDM classNC: SS=C: Failed to provide services of a full time qualified dietary managerStaff reported no CDM & staff started taking classes in Jan 2013 & had not obtained certification currentlyNE: SS=D: Failed to maintain a clinical record of services provided to res for adult day careRes with ADC 3x/wk; record lacked evidence of a CP, diet order or med orders, evidence facility had assessed res for self-administration of medsSE: SS=F: Failed to employ a CDM full timeStaff reported not currently certifiedSE: SS=F: Failed to retain svcs of a FT CDM Staff reported would be CDM in 2-15NE: SS=F: Failed to employ a full-time CDMStaff revealed scheduled to take certification test in October, 2014S950 Laundry ServicesNE: SS=E: Failed to properly cover soiled linens in laundry receiving areaObserved soiled linens in uncovered barrels in soiled linen receiving areaS970 Nursing Facility Support SystemsNE: SS=F: Failed to ensure call system escalated to a different staff member within 3 minutes if not answeredEscalation of call light system set to repeat to CNA after 1st call, then at 6 minutes 4 minutes same CNA pager sounded; 6 minutes same CNA pager, 8 min same CNA pager & CNA from adjacent hall sounded; 12 minutes nurses’ pager soundedS1146 Laundry ServiceNE: SS=F: Failed to properly cover soiled linen in laundry receiving areaObserved unbagged, uncovered linens in uncovered unlined laundry baskets in soiled linen receiving area of laundry area; failed to place soiled linens in a closed lidded container for holding prior to washingNE: SS=F: Failed to have soiled linen bins covered Observed soiled linen bins in laundry room with soiled linen & were not covered with a lidS1173 Nursing Facility Support SystemW: SS=E: Failed to have an emergency call button within res reach next to each shower or tubObserved call light did not reach to w/p in multiple bathing suitesS1354 Heating, Ventilation & ACNE: SS=E: Failed to provide ventilation to common area BRObserved hall way BR without ventilation or a window to outside & room was humidW: SS=E: Failed to establish adequate ventilation in beauty shop while residents received servicesObserved beauty shop without vents that had suction to hold up a tissue; staff unaware of any vent in beauty shop & did not use ventilationS1358 Plumbing & Piping SystemsNE: SS=Failed to provide back flow valve on beauty shop sinkObserved beauty shop sink without back flow valveS1364 Electrical RequirementsNE: SS=E: Failed to have a ground fault circuit interrupter electrical outlet for beauty shop hair dryerObserved beauty shop hair dryer used a standard electrical outlet & a ground fault circuit interrupter electrical outlet was 10 ft awayNE: SS=F: Failed to ensure proper connection for hydrotherapy equipment in therapy roomHydrocollator plugged into regular 120 volt wall outlet & not a GFCIS1173 Nursing Facility Support SystemSC: SS=E: Failed to ensure there was an emergency call button or cord next to each toilet or urinal available for res useObserved shower room without a call light or cord within reach next to toilet located in shower roomObserved men’s public BR without call light or cord within reach of urinalS1360 Plumbing & Piping SystemsNE: SS=Failed to provide water temps between 98 to 120 degrees FObserved hot water temps of 79.9, 84.2, 97.5 & 95.6 degrees; 94.2, 94, 91.2, 93.2, 97.7, 95.6, 96.8 & 96.6 degrees; res approached & reported water not hot during shower; failed to provide hot water between 98 to 120 degrees F for res roomsS1364 Electrical RequirementsNE: SS=E: Failed to have a hydrocolator plugged into a ground fault circuit interrupter electrical outletObserved PT hydroculator plugged into a standard electrical outlet; failed to have hydroculator plugged into ground fault circuit interrupter electrical outletW: SS=F: Failed to ensure hydrotherapy unit plug-in had a ground-fault circuit interrupterObserved hydrotherapy unit plug-in did not have a ground-fault interrupter ................
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