| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0553 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0553 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) refused. | |
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, the facility failed to maintain the dining room and | |
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 2) on duty; -The administrator must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or were discovered after hours, the administrator and DON must be called at home or must be paged and informed of such incident; -Sexual abuse is defined as, but not limited to, non-consensual sexual contact of any type, including sexual harassment, sexual coercion, or sexual assault. Further review of the facility’s undated policy titled, Reporting Abuse to Facility Management, showed when an alleged or suspected case of mistreatment, neglect, injuries of unknown source or abuse is reported, the facility Administrator, and his/her designee, will immediately (within 24 hours of the alleged incident) notify the following persons or agencies of such incident: -The state licensing/certification agency responsible for surveying/licensing the facility; -The local/state ombudsman; -The resident’s representative of record; -Adult Protective Services; -Law Enforcement Officials; -The attending physician; -The medical director. Record review of the facility’s undated policy titled Abuse and Neglect: Clinical Protocol showed the management and staff, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. 1. Record review of Resident #3’s electronic health record showed the resident was most recently admitted to the facility on [DATE]. His/her [DIAGNOSES REDACTED]. -Unspecified Dementia with Behavioral Disturbance (Common behavioral disturbances can be grouped into four categories: mood disorders (e.g., depression, apathy, euphoria); sleep disorders ([MEDICAL CONDITION], hypersomnia, night-day reversal); psychotic symptoms (delusions and hallucinations); and agitation (e.g., pacing, wandering, sexual disinhibition, aggression); -Altered Mental Status, Unspecified (general changes in brain function, such as confusion, amnesia (memory loss), loss of alertness, disorientation (not cognizant of self, time, or place), defects in judgment or thought, unusual or strange behavior, poor regulation of emotions, and disruptions in perception). Record review of the resident’s most recent Admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, used for care planning purposes, dated 6/14/18, showed the resident: -Had a BIMS (brief mental interview status) of 3, meaning he/she was severely cognitively impaired. -Stated, during the Resident Mood interview, he/she had little pleasure or interest in doing things several days, felt down, depressed or hopeless several days, had trouble falling or staying asleep or sleeping too much, and had trouble concentrating on things such as reading the newspaper or watching television; -Had no presence of behaviors during the seven day look-back period and no overall presence of behaviors; -Had no presence of wandering; -Needed only supervision, encouragement or cueing with bed mobility, walking, locomotion, and eating; -Needed extensive assistance with personal hygiene and bathing; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 3) -Used a walker for mobility assistance; -Had frequent pain; -Received antipsychotic, antidepressant and opioid medications; -Used a wander/elopement alarm daily. Record review of the resident’s Nurse’s Note, dated 6/13/18, showed the following: -At 3:32 A.M., the resident was found in another resident’s room (identified as Supplemental Resident #29); -The resident (Resident #3) was on the bed with Resident #29; -Staff heard smacking lips; -Resident #3 was kissing Resident #29; -Resident #3 stated he/she had known Resident #29 for years; -Resident #3 was easily redirected to his/her room. Record review of Supplemental Resident #29’s electronic medical record showed the resident was most recently readmitted to the facility on [DATE]. The resident’s [DIAGNOSES REDACTED]. Record review of the resident’s admission MDS, dated [DATE], showed the resident: -Was cognitively intact; -Had no hearing or vision impairment; -Did not display any indicators of mood disturbance; -Did not have the presence of any behaviors; -Needed only supervision, encouragement or cueing with transfers, walking, locomotion, and eating; -Needed limited assistance with bed mobility, dressing, toilet use and personal hygiene; -Used a wheelchair for mobility assistance. Record review of the resident’s Nurses’ Notes, dated 6/13/18 at 3:34 A.M., showed: -A resident of the opposite sex (identified as Resident #3) went into the resident’s room, laid in bed with the resident and was kissing the resident; -The resident did not appear to be in distress; -When the Certified Nursing Assistant (CNA) told the resident he/she was going to empty his/her Foley bag (bag to collect the urine that drains through a catheter), the resident said I thought you were talking about this old bag as the resident was rubbing Resident #3 on his/her back; -The resident was easily redirected. During observation and brief interview in the course of the initial tour of the facility on 1/7/19, at 11:00 A.M., Resident #29 had no concerns. Further observations showed: -The resident was not very responsive; -He/She remained covered in bed and closed his/her eyes; -He/She did not wish to be interviewed. During an interview as of part of the survey initial pool process on 1/7/19 at 2:10 P.M., Resident #3 said he/she had no problems getting along with other residents, and did not recall any concerns or issues encountered. During an interview on 1/11/19 at 1:14 P.M., Resident #3’s responsible party said: -He/She was not told about the incident that occurred on 6/13/18; -He/She had only been told about an incident that occurred in (MONTH) (YEAR), and occurrences such as skin tears. 2. Record review of Resident #39’s initial care plan dated 7/31/18 showed the resident: -Used a walker; -Had a [DIAGNOSES REDACTED]. Record review of the resident’s admission MDS dated [DATE], showed the following staff |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 4) assessment of the resident: -Cognitively intact; -Did not have any hearing or vision impairment; -Had clear speech; -Understands others and others understand him/her; -Did not display any behaviors; -The most assistance he/she required during the look-back period was: –Limited assistance of one person with moving around in his/her bed; –Limited assistance of two people with dressing; –Supervision when walking and transferring from one surface to another such as from standing to sitting on his/her bed or chair. Record review of the resident’s nurse’s note, dated 10/8/18 showed: -The nurse went into the resident’s room about 5:00 A.M.; -The resident was standing next to his/her bed naked; -The nurse found Resident #3 laying on his/her back in the resident’s bed with his/her pants down around his/her ankles; -The nurse asked the resident what was going on and he/she said that he/she did not know; -The resident told the nurse that nothing happened between him/her and Resident #3; -Resident #3 said, What? Do you think I’m crazy? when asked if anything happened between the two residents; -Resident #3 initially refused to leave the resident’s room, but staff were able to remove Resident #3 from the resident’s room. Record review of the incident report dated 10/8/18 at 5:00 A.M. showed: -Resident #3 was found in Resident #39’s room; -Resident #3 was lying on Resident #39’s bed with his/her pants pulled down to his/her ankles; -Resident #39 was naked and standing next to Resident #3; -Resident #39 denied touching Resident #3; -Resident #3 said, What? Do you think I’m crazy? when asked if anything happened between the two residents; -Notification of the physician was left blank; -There was no documentation regarding whether the incident was reported to the Administrator; -The incident was reported to the Assistant Director of Nursing (ADON); -The incident report was signed by Licensed Practical Nurse (LPN) C. Record review of the resident’s late entry nurse’s note dated 10/8/18 at 7:22 A.M., showed LPN D spoke with the resident’s family member regarding the 10/8/18 incident. Record review of the resident’s significant change MDS dated [DATE], showed the staff assessment of the resident showed the resident was cognitively intact. During an interview on 1/11/19 at 10:05 A.M., LPN A said: -LPN C wrote the note about the 10/8/18 incident between the resident and another resident of the opposite sex who resided on a different hall; -He/She was told that nothing happened. During an interview on 1/11/19 at 10:30 A.M., the Wound Nurse said: -When an incident occurs, the physician and families/responsible party should be called; -The incident (referring to the incident on 10/8/18) should have been reported to the state agency; -It was reported to the DON; -There have been no further incidents between the two residents. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 5) During an interview on 1/11/19 at 10:46 A.M., CNA D said: -He/She was not at work the day Resident #3 was found in Resident #39’s room on another hall, lying in bed with his/her pants down; -Incidents should be reported to the charge nurse; -He/She would report an incident to the ADON next and then to the DON if he/she felt it wasn’t being addressed. During an interview on 1/11/19 at 10:52 A.M., the DON said: -Resident #3 is happily confused; -Resident #3 roams and wanders into rooms; -All that was reported to him/her regarding the incident that occurred on 10/8/18, was that Resident #3 was found in Resident #39’s bed, and that Resident #39 went to go to bed and Resident #3 was in his/her bed; -LPN C, who was the charge nurse at the time of the incident, said Resident #39 was naked and they weren’t sure what happened; -They didn’t do a full investigation, because LPN C thought Resident #3 only wandered into Resident #39’s room. During an interview on 1/11/19 10:57 A.M., the Administrator said: -He/She knew of the incident between Resident #3 and Resident #39; -He/She didn’t know exactly what happened; -He/She probably heard about the incident later; -Sometimes things don’t come straight to him/her, for example if it happened on a Sunday, they might have talked to him/her about it in Tuesday morning meeting; -He/She must not have known the full extent of the occurrence; -A full investigation should have been done and it should have been reported to him/her immediately. During an interview on 1/11/19 at 11:18 A.M., the ADON said: -The night shift charge nurse called him/her at around 5:00 A.M. and the charge nurse reported he/she went to Resident #39’s room to check his/her blood sugar that morning. When he/she walked in, Resident #39 was standing by his/her bed using the urinal. He/She noticed Resident #3 in Resident #39’s bed, and asked Resident #39 what Resident #3 was doing there. Resident #39 said I don’t know. I want him/her out of my bed. When he/she asked Resident #3 what he/she was doing there, Resident #3 said he/she didn’t know. Both residents denied anything inappropriate happening. They couldn’t explain why Resident #3’s pants were down to his/her ankles; -Resident #3 is confused; -Resident #39 is not confused; -Staff immediately separated the two residents; -Resident #3 wanders down Resident #39’s hall and into resident rooms; -He/She asked the day shift nurse to notify the residents’ Durable Power of Attorney (DPOA)/responsible party; -Resident #3’s responsible party said he/she was not upset by it. He/she knew exactly what happened; -Staff notified Resident #39’s family member; -He/She reported the incident to the DON and Social Services; -He/She told the DON that Resident #3 was in Resident #39’s bed naked; -He/She didn’t remember if the physician was notified; -The ADON reviewed notes in front of this writer and said he/she did not see any documentation that showed the doctor was notified, but it should be documented if the doctor was notified; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 6) -They should have notified the physician. -He/She didn’t know if anyone reported the incident to the administrator; -He/She said he/she did not make any notes about the incident; -CNA F was one of the aides present; -CNA F helped get the Resident #3 out of Resident #39’s bed; -Staff reported Resident #3 was sleepy and not happy about having to get out of bed; -Resident #39 doesn’t typically take his/her clothes off; -He/She interviewed the night shift CNA; -He/She did not talk to CNA G who was the CNA on the other hall. -He/She told the charge nurse to watch Resident #3 closely and to prevent Resident #39 from wandering down that hall; -He/She instructed Resident #39 to call if Resident #3 wandered down the hall or into his/her room; -He/She didn’t document what his/her investigation consisted of; -Typically the DON or Social Services report to state agency; -He/She told the DON that day, 10/8/18, about the incident; -He/She was not aware of any further incidents between the two residents; -He/She had never seen Resident #39 be inappropriate with any other residents; -They don’t take statements from staff interviewed; -The nurse said there was no bruising, no redness and no semen; -They said Resident #39 was facing the bed and Resident #3 was in the bed lying in bed in a normal position; -The urinal was at the resident’s bedside on the trash can and there was urine in it; -The call light was not on; -According to the night shift CNA, he/she thought the last time he/she checked that room was around 4:00 A.M. During an interview on 1/11/19 at 2:00 P.M., CNA F said: -He/She was working on Resident #39’s hall during the incident on 10/8/18; -The charge nurse was the one who found the residents; -He/She did not see what happened; -The charge nurse told him/her that Resident #3 was in Resident #39’s bed with his/her pants down and that Resident #39 was standing by the bed naked; -The charge nurse told him/her that Resident #39 said nothing happened. During an interview on 1/11/19 at 2:20 P.M., LPN C said: -He/She went into Resident #39’s room on 10/8/18; -Nothing was going on when he/she walked into Resident #39’s room; -It was very dark in the room and he/she did not notice Resident #3 was there until he/she sat some supplies on the bed and felt Resident #3’s leg; -Resident #3 was lying in Resident #39’s bed; -Resident #3 was on his/her back with his/her pants down to his/her ankles; -Resident #39 was standing next to the bed and was naked; -Resident #39 told him/her that he/she was trying to use his/her urinal, which was on on his/her bedside table; -Resident #3 was almost asleep; -He/She did not assess Resident #3; -He/She tried to get Resident #3 to get out of Resident #39’s bed and Resident #3 was very argumentative; -He/She assisted Resident #3 in pulling his/her pants up and got him/her out of Resident #39’s room; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 7) -Resident #3 and Resident #39 said nothing happened, so he/she did not assess Resident #3; -Another staff member took Resident #3 to his/her room. -He/She thinks he/she notified both the ADON and the DON regarding the incident; -He/She completed an incident report; -He/She told the day shift nurse in report about the incident and that the family and physician still needed to be notified; -He/She asked staff to keep an eye on both residents; -He/She did not talk to any other residents about whether they had any problems with any resident(s) wandering into their rooms. During an interview on 1/11/19 at 3:00 P.M., LPN D said: -He/She was told by the night shift charge nurse about the incident on 10/8/18; -He/She was told to pass on to staff to keep Resident #3 off of Resident #39’s hall; -They try to keep Resident #3 up toward the front of the hall; -He/She talked to the ADON and DON about what needed to be done regarding the incident on 10/8/18; -Resident #3 said nothing happened; -He/she didn’t know he/she was supposed to call the doctor (that was not passed down from the night shift as something that still needed to be done); -He/She called both families. During an interview on 1/11/19 at 3:20 P.M., the resident said: -Another resident (Resident #3) came into his/her room early one morning around 4:00 A.M. or 4:30 A.M. and woke him/her up; -It scared him/her when the other resident came into his/her room; -The other resident went over by his/her window; -He/She asked the other resident what he/she was doing; -He/She told the other resident he/she was in the wrong place; -He/She told the other resident that he/she thought he/she needed to leave; -The other resident got into his/her bed; -He/She then got out of his/her bed by himself/herself; -A nurse came in to check his/her blood and told the other resident he/she needed to go to his/her own room; -The nurse asked him/her if anything happened between him/her and the resident that came into his/her room and he/she told the nurse no; -The other resident tried to come into his/her room about a week after the first incident, but he/she had not tried to come in his/her room since then. During a telephone interview on 1/15/19 at 5:58 P.M., CNA G said: -He/she works the night shift; -During the 10/8/18 incident he/she first saw Resident #3 at the nurse’s station; -The charge nurse asked him/her to take Resident #3 back to his/her room and ask the Resident #3 what happened; -Resident #3 said nothing happened; -Currently staff try to keep an eye on Resident #3, checking on him/her four times during every eight hour shift; -He/she said if he/she were to find residents in inappropriate situations, he/she would make sure the residents were safe and separate them, then would tell the charge nurse. During an interview on 1/16/19 at 10:48 AM, the DON said: -The incident reports are filled out by the nurse and the nurse gives the incident report to him/her; -He/She did not read the nurse’s note regarding the incident; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 8) -The incident was reported to the ADON, because the ADON was on call; -He/She would not have expected the ADON to call him/her with what the ADON was told; -If the ADON knew both residents were naked, the ADON should have called the DON and the DON would have called the Administrator; -Family was probably called the next morning; -Their process for notification of the physician if it’s non-emergent was to send a fax or call next day; -They should have called the doctor; -They were lacking in communication. | |
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Respond appropriately to all alleged violations. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 9) Record review of the facility’s undated policy titled Abuse and Neglect: Clinical Protocol showed the staff, with the physician’s input (as needed), will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes. 1. Record review of Resident #3’s electronic health record showed the resident was most recently admitted to the facility on [DATE]. His/her [DIAGNOSES REDACTED]. -Unspecified Dementia with Behavioral Disturbance (Common behavioral disturbances can be grouped into four categories: mood disorders (e.g., depression, apathy, euphoria); sleep disorders ([MEDICAL CONDITION], hypersomnia, night-day reversal); psychotic symptoms (delusions and hallucinations); and agitation (e.g., pacing, wandering, sexual disinhibition, aggression); -Altered Mental Status, Unspecified (general changes in brain function, such as confusion, amnesia (memory loss), loss of alertness, disorientation (not cognizant of self, time, or place), defects in judgment or thought, unusual or strange behavior, poor regulation of emotions, and disruptions in perception). Record review of Resident #3’s Nurse’s Note dated 6/13/18, showed the following: -At 3:32 A.M., the resident was found in another resident’s room (identified as Resident #29); -The resident (Resident #3) was on the bed with Resident #29; -Staff heard smacking lips; -Resident #3 was kissing Resident #29; -Resident #3 stated he/she had known Resident #29 for years; -Resident #3 was easily redirected to his/her room. Record review of the resident’s most recent Admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, used for care planning purposes, dated 6/14/18, showed the resident: -Had a BIMS (brief mental interview status) of 3, meaning he/she was severely cognitively impaired; -Stated, during the Resident Mood interview, he/she had little pleasure or interest in doing things several days, felt down, depressed or hopeless several days, had trouble falling or staying asleep or sleeping too much, and had trouble concentrating on things such as reading the newspaper or watching television; -Had no presence of behaviors during the seven day look-back period and no overall presence of behaviors; -Had no presence of wandering; -Needed only supervision, encouragement or cueing with bed mobility, walking, locomotion, and eating; -Needed extensive assistance with personal hygiene and bathing; -Used a walker for mobility assistance; -Had frequent pain; -Received antipsychotic, antidepressant and opioid medications; -Used a wander/elopement alarm daily. Record review on 1/11/19 showed the resident did not have a comprehensive Care Plan completed following his/her most recent admission MDS that included the identified care assessment areas. Record review of Supplemental Resident #29’s electronic medical record showed the resident was most recently readmitted to the facility on [DATE]. The resident’s [DIAGNOSES REDACTED]. Record review of the resident’s admission MDS, dated [DATE], showed the resident: -Was cognitively intact; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 10) -Had no hearing or vision impairment; -Did not display any indicators of mood disturbance; -Did not have the presence of any behaviors; -Needed only supervision, encouragement or cueing with transfers, walking, locomotion, and eating; -Needed limited assistance with bed mobility, dressing, toilet use and personal hygiene; -Used a wheelchair for mobility assistance. Record review on 1/11/19 of the incident reports provided showed there was no incident report for 6/13/18. During an interview on 1/15/19 at 3:30 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said they were not aware of the incident that occurred on 6/13/18 between Resident #29 and Resident #3. The night nurse did not fill out an incident report or tell the DON or the ADON about the incident, therefore there was no investigation. 2. Record review of Resident #39’s initial care plan dated 7/31/18 showed the resident: -Used a walker; -Had a [DIAGNOSES REDACTED]. Record review of the resident’s admission MDS dated [DATE] showed the following staff assessment of the resident: -Cognitively intact; -Did not have any hearing or vision impairment; -Had clear speech; -Understands others and others understand him/her; -Did not display any behaviors; -Used a walker; -The most assistance he/she required during the look-back period was: –Limited assistance of one person with moving around in his/her bed; –Limited assistance of two people with dressing; –Supervision when walking and transferring from one surface to another such as from standing to sitting on his/her bed or chair. Record review of the resident’s medical records showed there was not a comprehensive care plan for the resident. Record review of the resident’s nurses’ notes showed the resident: -Reached between a CNA’s legs three times on 8/12/18; -Was verbally inappropriate with staff on 8/12/18; -Walked by an employee and brushed him/her on his/her bottom on 8/14/18; -Told an employee he/she was going to grab their butt on 8/14/18; -Touched the stomach and breasts of an employee on 8/17/18. Record review of the resident’s nurse’s note, dated 10/8/18 showed: -The nurse went into the resident’s room about 5:00 A.M.; -The resident was standing next to his/her bed naked; -The nurse found Resident #3 laying on his/her back in the resident’s bed with his/her pants down around his/her ankles; -The nurse asked the resident what was going on and he/she said that he/she did not know; -The resident told the nurse that nothing happened between him/her and Resident #3; -Resident #3 said, What? Do you think I’m crazy? when asked if anything happened between the two residents; -Resident #3 initially refused to leave the resident’s room, but staff were able to remove Resident #3 from the resident’s room. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 11) Record review of the incident report dated 10/8/18 at 5:00 A.M. showed: -Resident #3 was found in Resident #39’s room; -Resident #3 was lying on Resident #39’s bed with his/her pants pulled down to his/her ankles; -Resident #39 was naked and standing next to Resident #3; -Resident #39 denied touching Resident #3; -Resident #3 said, What? Do you think I’m crazy? when asked if anything happened between the two residents; -Notification of the physician was left blank; -There was no documentation regarding whether the incident was reported to the Administrator; -The incident was reported to the ADON; -The incident report was signed by Licensed Practical Nurse (LPN) C. Record review of the resident’s significant change MDS dated [DATE], showed the staff assessment of the resident showed he/she was cognitively intact. During an interview on 1/11/19 at 10:05 A.M., Licensed Practical Nurse (LPN) A said: -LPN C wrote the note about the 10/8/18 incident between the resident and another resident of the opposite sex who resided on a different hall; -He/She was told that nothing happened. During an interview on 1/11/19 at 10:30 A.M., the Wound Nurse said the 10/8/18 incident was reported to the DON. During an interview on 1/11/19 at 10:52 A.M. the DON said: -Resident #3 is happily confused; -Resident #3 roams and wanders into rooms; -All that was reported to him/her regarding the incident that occurred on 10/8/18, where Resident #3 was found in Resident #39’s bed, was that the Resident #39 went to go to bed and Resident #3 was in his/her bed; -LPN C, who was the charge nurse at the time of the incident, said Resident #39 was naked and they weren’t sure what happened; -They didn’t do a full investigation, because LPN C thought Resident #3 only wandered into Resident #39’s room. During an interview on 1/11/19 10:57 A.M., the Administrator said: -He/She knew of the incident between Resident #3 and Resident #39; -He/She didn’t know exactly what happened; -He/She must not have known the full extent of the occurrence; -A full investigation should have been done and it should have been reported to him/her immediately. During an interview on 1/11/19 at 11:18 A.M., the ADON said: -The night shift charge nurse called him/her at around 5:00 A.M. and the charge nurse reported he/she went to Resident #39’s room to check his/her blood sugar that morning. When he/she walked in Resident #39 was standing by his/her bed using the urinal. He/She noticed Resident #3 in Resident #39’s bed, and asked Resident #39 what Resident #3 was doing there. Resident #39 said I don’t know. I want him/her out of my bed. When he/she asked Resident #3 what he/she was doing there, Resident #3 said he/she didn’t know. Both residents denied anything inappropriate happening. They couldn’t explain why Resident#3’s pants were down to his/her ankles; -Resident #3 is confused; -Resident #39 is not confused; -Staff immediately separated the two residents; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 12) -Resident #3 wanders down Resident #39’s hall and into residents’ rooms; -He/She asked the day shift nurse to notify the residents’ Durable Power of Attorney (DPOA)/responsible party; -Resident #3’s responsible party said he/she was not upset by it. He/She knew exactly what happened; -They notified Resident #39’s family member; -He/She reported the incident to the DON and Social Services; -He/She told the DON that Resident #3 was in Resident #39’s bed naked; -He/She didn’t remember if the physician was notified; -The ADON reviewed notes in front of this writer and said he/she did not see any documentation that showed the doctor was notified; -He/She didn’t know if anyone reported the incident to the administrator; -He/She said he/she did not make any notes about the incident; -CNA F was one of the aides present; -CNA F helped get the Resident #3 out of Resident #39’s bed; -Staff reported Resident #3 was sleepy and not happy about having to get out of bed; -Resident #39 doesn’t typically take his/her clothes off; -He/She interviewed the night shift CNA; -He/She did not talk to CNA G who was the CNA on the other hall; -He/She told the charge nurse to watch Resident #3 closely and to prevent Resident #39 from wandering down that hall; -He/She instructed Resident #39 to call if Resident #3 wandered down the hall or into his/her room; -He/She tells staff to chart on behaviors, aggression and wandering; -He/She didn’t document what his/her investigation consisted of; -Typically the DON or Social Services report to state agency; -He/She told the DON that day, 10/8/18, about the incident; -He/She was not aware of any further incidents between the two residents; -He/She had never seen Resident #39 be inappropriate with any other residents; -They don’t take statements from staff interviewed; -The nurse said there was no bruising, no redness and no semen; -They said Resident #39 was facing the bed and Resident #3 was in the bed lying in bed in a normal position; -The urinal was at the resident’s bedside on the trash can and there was urine in it; -The call light was not on; -According to the night shift CNA, he/she thought the last time he/she checked that room was around 4:00 A.M. During an interview on 1/11/19 at 2:00 P.M., CNA F said: -He/She was working on Resident #39’s hall during the incident on 10/8/18; -The charge nurse was the one who found the residents; -He/She did not see what happened; -The charge nurse told him/her that Resident #3 was in Resident #39’s bed with his/her pants down to his/her ankles and that Resident #39 was standing by the bed naked; -The charge nurse told him/her that Resident #39 said nothing happened; -Resident #39 sleeps with pull-up briefs, but takes them off at night at times; -He/She saw Resident #3 about half an hour before the incident; -Resident #3 roams around a lot at night and it is hard for staff to keep an eye on him/her; -The charge nurse told him/her to keep an eye on Resident #3 after the incident; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 13) -Resident #3 has gone into other rooms before; -Resident #3 climbs into empty beds at times. During an interview on 1/11/19 at 2:20 P.M., LPN C said: -He/She went into Resident #39’s room on 10/8/18; -Nothing was going on when he/she walked into Resident #39’s room; -It was very dark in the room and he/she did not notice Resident #3 was there until he/she sat some supplies on the bed and felt Resident #3’s leg; -Resident #3 was lying in Resident #39’s bed; -Resident #3 was on his/her back with his/her pants down to his/her ankles; -Resident #39 was standing next to the bed and was naked; -Resident #39 told him/her that he/she was trying to use his/her urinal which was on on his/her bedside table; -Resident #3 was almost asleep; -He/She did not assess Resident #3; -He/She tried to get Resident #3 to get out of Resident #39’s bed and Resident #3 was very argumentative; -He/She assisted Resident #3 in pulling his/her pants up and got him/her out of Resident #39’s room; -Resident #3 and Resident #39 said nothing happened, so he/she did not assess Resident #3; -Another staff member took Resident #3 to his/her room; -He/She thinks he/she notified both the ADON and the DON regarding the incident; -He/She completed an incident report; -He/She told the day shift nurse in report about the incident and that the family and physician still needed to be notified; -He/She asked staff to keep an eye on both residents; -He/She did not talk to any other residents about whether they had any problems with any resident(s) wandering into their rooms; -The ADON and/or DON do the investigations. During an interview on 1/11/19 at 3:00 P.M., LPN D said: -He/She was told by the night shift charge nurse (LPN C) about the incident on 10/8/18; -He/She didn’t know he/she was supposed to call the doctor; -He/She called both families; -He/She was told to pass on to staff to keep Resident #3 off of Resident #39’s hall; -They try to keep Resident #3 up toward the front of the hall; -He/She talked to the ADON and DON about what needed to be done regarding the incident and he/she was told to call the families and keep an eye on Resident #3; -He/She made sure no blood was in Resident #3’s brief; -He/She didn’t notice any bruising or redness around the inside of the resident’s thighs when Resident #3’s brief was checked; -Resident #3 said nothing happened. During an interview on 1/11/19 at 3:20 P.M., the resident said: -Another resident (Resident #3) came into his/her room one early one morning around 4:00 A.M. or 4:30 A.M. and woke him/her up; -It scared him/her when the other resident came into his/her room; -The other resident went over by his/her window. -He/She asked the other resident what he/she was doing; -He/She told the other resident he/she was in the wrong place; -He/She told the other resident that he/she thought he/she needed to leave; -The other resident got into his/her bed; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 14) -He/She then got out of his/her bed by himself/herself; -A nurse came in to check his/her blood and told the other resident he/she needed to go to his/her own room; -The nurse asked him/her if anything happened between him/her and the resident that came into his/her room and he/she told the nurse no. During a telephone interview on 1/15/19 at 5:58 P.M., CNA G said: -He/She works the night shift; -During the 10/8/18 incident he/she first saw Resident #3 at the nurses’ station; -The charge nurse asked him/her to take Resident #3 back to his/her room and ask Resident #3 what happened; -Resident #3 said nothing happened; -Currently staff try to keep an eye on Resident #3, checking on him/her four times during every eight hour shift; -He/she said if he/she were to find residents in inappropriate situations he/she would make sure the residents were safe and separate them. During an interview on 1/16/19 at 10:48 AM, the DON said: -The incident reports are filled out by the nurse and the nurse gives the incident report to him/her. -He/she did not read the nurse’s note regarding the incident. -The incident was reported to the ADON, because the ADON was on call. -He/she would not have expected the ADON to call him/her with what the ADON was told. -He/she was responsible for investigations. | |
| F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure each resident receives an accurate assessment. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 15) resident had nightly behavioral episodes (MONTH) 9 – 14, during the MDS 7-day assessment look back period: -On 6/9/18 staff documented one episode of the resident having [MEDICAL CONDITION] (a sleep disorder that is characterized by difficulty falling and/or staying asleep); -On 6/10/18 staff documented one episode of the resident having [MEDICAL CONDITION]; -On 6/11/18 staff documented three episodes of the resident having [MEDICAL CONDITION]; -On 6/12/18 staff documented three episodes of the resident having [MEDICAL CONDITION]; -On 6/13/18 staff documented four episodes of the resident having [MEDICAL CONDITION]; -On 6/14/18 staff documented four episodes of the resident having [MEDICAL CONDITION]. Record review of the resident’s Behavior Monthly Flow Sheets showed: -Forty-one behavior codes were on the list staff could choose from, which included wandering. -Episodes of wandering were not listed on the flow sheets. -Staff documented episodes from only three (anxiety, depressed/withdrawn, and [MEDICAL CONDITION]) of the forty-one behavior codes that were listed to choose from. Record review of the resident’s Nurses’ Notes, dated (MONTH) (YEAR), showed the following incidents that occurred during the MDS 7-day look back period: -On 6/13/18, at 3:32 A.M., the resident was found in another resident’s room. The resident was on the bed kissing the other resident; -On 6/13/18, at 3:37 A.M., the resident was found in the room of another resident of the opposite sex, I was just trying to get him/her up; -On 6/13/18, at 4:50 A.M., the nurse documented the resident was up three times after midnight and was assisted back to his/her room, re-orienting him/her to time and place. Record review of the resident’s most recent Admission MDS, dated [DATE], showed the resident: -Had a BIMS (brief mental interview status) of 3, meaning he/she was severely cognitively impaired; -Had no presence of behaviors during the seven day look-back period and no overall presence of behaviors; -Had no presence of wandering; -Used a wander/elopement alarm daily. Record review of the resident’s Behavior Monthly Flow Sheets showed there was no record for the month of (MONTH) (YEAR). Record review of the resident’s Nurses’ Notes, dated (MONTH) (YEAR), showed the following incidents that occurred during the MDS 7-day look back period: -On 9/9/18 at 2:59 A.M., the nurse documented he/she had redirected the resident several times that night; the resident was confused, irritable, wandering down Shady Hall (not his/her hall) going into other residents’ rooms. The resident was given pain medication and administered a topical pain cream at the beginning of the night shift, but said neither helped; -On 9/13/18 at 2:43 A.M., the nurse documented the resident had been up ambulating in the hall several times during the night. Record review of the resident’s Quarterly MDS, dated [DATE], showed the resident: -Had a BIMS of 5, meaning he/she was severely cognitively impaired; -Had no presence of wandering during the seven day look-back period; -Had no presence of behaviors; -Received antipsychotic, antidepressant and opioid medications; -Used a wander/elopement alarm daily. Record review of the resident’s (MONTH) (YEAR) Behavior Monthly Flow Sheet showed the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 16) resident had behavior episodes during the MDS look back period that included: -26 Episodes of anxiety; -28 Episodes of [MEDICAL CONDITION]. Record review of the resident’s Nurses’ Notes, dated (MONTH) (YEAR), showed the following incidents that occurred during the MDS 7-day look back period: -On 12/8/18 at 1:27 A.M., the nurse documented the resident was awake so far that shift sitting on his/her walker seat in the hallway. The resident was attempting to move another resident’s wheelchair around in the hall. The nurse was unable to redirect the resident at that time; -On 12/10/18 at 5:32 A.M., the resident was found in the bathroom in another resident’s room with his/her pants down around his/her hips. The resident was reoriented to the time and place, reminding him/her that that was not his/her room. The resident said I know, I’m just checking it out. The resident was assisted out of the bathroom and back to his/her room; -On 12/11/18 at 2:34 A.M., the resident continuously moved up and down the hallway sitting on his/her walker seat, at times walking while pushing the walker. The resident came up to the nurses’ station asking the nurse can you tell me where I can find some food? The resident was directed to dining room snack area. The nurse attempted several times to redirect the resident to time and place. The resident continued to pace around the facility with his/her walker, at times moving in and out of other residents’ rooms; -On 12/13/18 at 12:22 A.M., the resident was wheeling himself/herself up and down the hall taking things off the aide’s cart and taking things off another resident’s wheelchair. The aid asked the resident to leave the other resident’s things alone and the resident told the aide to kiss his/her ass. The nurse asked the resident to go to his/her room, so that he/she could administer pain medication and rub cream on the resident’s legs. The resident was not cooperative with the nurse and stated he/she was not going to bed. The television was turned on for the resident and the resident was offered coffee to try and make him/her comfortable. The resident said he/she did not like being bossed around; -On 12/15/18 at 5:46 A.M., the nurse documented the resident had been up several times throughout the night, drinking coffee and getting into the cart in the hallway. Record review of the resident’s quarterly MDS, dated [DATE], in progress during the facility’s annual survey, showed the resident: -Had a BIMS of 6, meaning he/she was severely cognitively impaired; -Had no overall behavioral symptoms; -Had no presence of wandering and no behaviors affecting others. During an interview on 1/11/19 at 9:30 A.M., the MDS Coordinator said when completing a resident’s MDS information is obtained from: -The resident’s record; -Through interviews and observations of the resident; -Nurses that work with the residents. During an interview on 1/15/19 at 10:00 A.M., the MDS Coordinator said he/she would be submitting MDS corrections. During an interview on 1/16/19 at 10:45 A.M., the Director of Nursing (DON) said: -The Assistant Director of Nursing (ADON) looks at the behavior sheets each month; -The sheets should be passed on to the MDS Coordinator for review during the MDS process period; -He/She expected the MDS to accurately reflect the resident’s status. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | ||
| F 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Create and put into place a plan for meeting the resident’s most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 18) 4. Record review of Resident #50’s entry tracking record showed the resident was admitted to the facility on [DATE]. Record review of the resident’s initial care plan dated 11/17/18, showed it was not signed by the staff member completing it and it was not documented that the resident’s responsible party received a copy of the initial care plan. Record review of the resident’s current profile in the electronic health record showed the resident had a designated person as his/her responsible party. 5. During an interview on 1/10/19 at 10:01 A.M., the MDS Coordinator said: -The charge nurses do baseline care plans; -He/She does not check to make sure the baseline care plans were completed; -They do not have a system in place to show if the resident and/or the resident’s responsible party was given a copy of the baseline care plan. During an interview on 1/16/19 at 10:48 AM, the DON said: -The admission nurse was responsible for developing the baseline care plan; -The MDS Coordinator was responsible for checking to ensure a baseline care plan was completed; -The nursing staff should sign and date the baseline care plan and put in the resident’s medical record; -They try to meet with family members within 24 hours and give them the baseline care plan; -He/She doesn’t know how to show if the resident or the resident’s responsible party received the baseline care plan within 48 hours. | |
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 19) showed: -The Nurse Supervisor/Charge Nurse will record in the resident’s medical record information relative to changes in the resident’s medical/mental condition or status. 1. Record review of Resident #48’s Admission Face Sheet showed that he/she admitted on[DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. -[MEDICAL CONDITION] (a progressive disease that destroys memory and other important mental functions). -Anxiety Disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Major [MEDICAL CONDITION] (a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable). Record review of the resident’s Quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility staff for care planning), dated 8/26/18 and 11/26/18 showed the resident had: -[MEDICAL CONDITION]. -Dementia Disorder. -Anxiety Disorder. -Major [MEDICAL CONDITION]. -No behaviors. Record review of resident’s physician’s orders [REDACTED]. Record review of resident’s care plans with a next review date of 1/9/19 showed: -No care plan for the use of a wander guard. -No care plan for the risk of elopement. During an interview on 1/11/19 at 11:45 A.M., the MDS Coordinator said: -He/she was not consistently doing the care plans. -He/she knows they are to be done within 24 hours of admission, quarterly, annually, and with a significant change in the resident’s condition. During an interview on 1/16/18 at 10:49 A.M., the Director of Nursing (DON) said the resident should have a care plan for the use of the wander guard and elopement risk. 2. Record review of resident #57’s closed record Admission Face Sheet showed that he/she admitted on [DATE] and discharged to the community on 11/16/18 with the following Diagnoses: [REDACTED]. -Atelectasis (partial or total collapse of a lung or a segment of a lung that was once expanded). -Debility (the quality or state of being weak, feeble, or infirm especially physical weakness). -Weakness. Record review of the resident’s Baseline Care Plan (a plan of care to meet the resident’s immediate needs developed within 48 hours of admission), dated 10/15/18, showed: -Skilled services due to weakness, [MEDICAL CONDITION], and debility. -Activities of daily living (ADL) areas as hygiene, toileting, bathing and dressing. -Safety care for transfers and balance. Record review of the resident’s Admission MDS, dated [DATE], showed the following assessment areas marked as care planned: -ADL function and Rehabilitation potential. -Pain. -Falls. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 20) -Urinary incontinence/indwelling catheter. -Pressure ulcer. -[MEDICAL CONDITION] drug use. -Dental. Record review of the resident’s medical records showed no care plans written. During an interview on 1/16/18 at 10:49 A.M., the DON said: -A comprehensive care plan should be written within 14 days after the resident’s admission. -The care plan should have a next quarterly review or target date. -The care plan is reviewed each quarter by the MDS coordinator with any new concerns added. -If an incident occurs before the next quarter the care plan should be updated immediately. -The admitting nurse writes the baseline care plan. -The MDS coordinator writes the comprehensive care plan and follows up on the care plan for updates and changes to the resident’s conditions; -The MDS coordinator is responsible for updating the care plans with necessary changes; –He/She gets information by what staff tell her; –He/She looks in the charts, looks at orders; –He/She talks to residents a lot to find any major changes. 3. Record review of Resident #28’s entry tracking form dated 4/25/18 showed the resident was admitted to the facility on [DATE]. Record review of the resident’s quarterly MDS, dated [DATE], showed the following staff assessment of the resident: -Was cognitively intact; -Required extensive assistance of at least two people with bed mobility, transferring from one surface to another, locomotion off the unit and toileting; -Required extensive assistance of one person for dressing and locomotion on the unit; -Required set up or supervision for eating and personal hygiene; -Did not walk; -Used a wheelchair; -Had a catheter; -Was incontinent of bowel; -Had impaired range of motion of both legs; -Had a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear). Observation on 1/09/19 at 7:40 A.M., showed: -The resident was asleep in his/her bed; -A catheter drainage bag was visible; -The resident’s bed was in a low position. Record review of the resident’s medical records showed there was no comprehensive care plan for the resident. During an interview on 1/10/19 at 10:01 A.M., the MDS Coordinator said the resident’s care plan was missed and it was never done. During an interview on 1/16/19 at 10:48 AM, the DON said: -Residents’ care plans should be developed within 14 days after the resident’s admission; -The MDS Coordinator was responsible for developing the comprehensive care plans. 4. Record review of Resident #39’s entry tracking form, dated 7/31/18, showed the resident admitted to the facility on [DATE]. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 21) Record review of the resident’s significant change MDS, dated [DATE], showed the following staff assessment of the resident: -Was cognitively intact; -Required limited assistance with bed mobility, dressing and toileting; -Required supervision of transferring from one surface to another, walking, eating and hygiene; -Used a walker; -Was frequently incontinent of bladder. Observation on 1/7/19 at 11:53 A.M., showed the resident was in a room with a staff member receiving a shot. Observation on 1/8/19 at 11:20 A.M., showed the resident had a splint on one of his/her fingers. Record review of the resident’s medical records showed there was no comprehensive care plan for the resident. During an interview on 1/10/19 at 10:01 A.M., the MDS Coordinator said the resident’s care plan was missed and it was never done. During an interview on 1/16/19 at 10:48 AM, the DON said: -Residents’ care plans should be developed within 14 days after the resident’s admission; -The MDS Coordinator was responsible for developing the comprehensive care plans. 5. Record review of Resident #50’s entry tracking form, dated 11/17/18, showed the resident admitted to the facility on [DATE]. Record review of the resident’s admission MDS, dated [DATE], showed the following staff assessment of the resident: -Cognitively intact; -Required extensive assistance of two or more people with bed mobility, transferring from one surface to another, locomotion off of the unit, dressing and toileting; -Required extensive assistance of one person with locomotion on the unit and hygiene; -Required set-up for eating; -Did not walk; -Used a wheelchair; -Was occasionally incontinent of bladder; -Experienced pain almost constantly; -Had a pressure ulcer; -Used oxygen. Record review of the resident’s medical records showed there was no comprehensive care plan for the resident. Record review of the resident’s discharge assessment, dated 12/28/18, showed the resident was discharged with his/her return anticipated. During an interview on 1/11/19 at 9:35 A.M., the MDS Coordinator said the resident’s care plan was missed and it was never done. During an interview on 1/16/19 at 10:48 A.M., the DON said: -Residents’ care plans should be developed within 14 days after the resident’s admission; -The MDS Coordinator was responsible for developing the comprehensive care plans. 6. Record review of Resident #14’s face sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Urinary incontinence (loss of bladder control); -Falls; and -Pressure sores (an area of damaged skin caused by staying in one position too long). Record review of the resident’s quarterly MDS, dated [DATE] showed the following: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 22) -Cognitive loss/Dementia; -Urinary incontinence; -Falls; -Pressure sores; and -The resident was unable to make decisions independently. Record review of the residents Physician order [REDACTED]. -The resident had an order for [REDACTED].>-The resident had an order for[REDACTED].>-The resident was admitted to hospice care (end of life care) with a[DIAGNOSES REDACTED]. Record review of the resident’s medical records showed there was no comprehensive care plan for the resident. During an interview on 1/11/19 at 11:45 A.M., the MDS Coordinator said: -He/She was not consistently doing the care plans; -He/She knows they are to be done within 24 hours of admission, quarterly, annually, and with a significant change in the resident’s condition. During an interview on 1/11/19 at 12:02 P.M., the DON said: -The nurse who admits the resident is responsible for the baseline care plan; -It goes to the MDS Coordinator to be dated and signed; -Quarterly care plans should be updated; -The nurses should tell him/her if there is no care plan. 7. Record review of Resident #15’s face sheet showed he/she was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the following Diagnoses:[REDACTED]. -Urinary tract infection (an infection in any part of the urinary system); -Dysphagia (a difficulty swallowing); -Muscle weakness; -Chronic pain; -Hypertension (high blood pressure); -Pacemaker (a medical device that regulates the electrical system of the heart); -[MEDICAL CONDITION] (an excess of fluids that causes swelling); -Heart block (a disease or inherited condition that causes an obstruction in the electrical system of the heart); -Peripheral Autonomic [MEDICAL CONDITION] (damage to the nerves that manage every day body functions). Record review of the resident’s Quarterly MDS, dated [DATE], showed the following staff assessment of the resident: -Was able to make every day decisions about his/her care; -Required extensive assistance for transferring from one surface to another, toileting, hygiene, using the sit to stand, transferring from bed to wheel chair; -Was able to wheel 150 feet in his/her wheel chair; -Needed supervision, encouragement or cueing during meals. Record review of the resident’s medical records showed there was no comprehensive care plan for the resident. Observation on 1/7/19 at 9:31 A.M. showed the resident: -Was wearing bilateral hearing aids and was still hard of hearing; -Was using his/her wheelchair to pedal (move) around the hallway; -Was missing his/her front teeth. During an interview on 1/7/19 at 10:15 A.M., the resident said: -He/She was missing his/her front teeth; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 23) -He/She would like dentures; -He/She just saw the dentist and the dentist told him/her that he/she is too old to get dentures. Observation on 1/9/19 at 7:38 A.M., showed Certified Nursing Assistant (CNA) A and Certified Medication Technician (CMT) A transferred the resident from his/her bed to his/her wheelchair using a sit to stand lift (a mechanical machine to move residents). During an interview on 1/9/19 at 8:38 A.M., the Wound Nurse/Registered Nurse (RN) said: -The CNA’s were instructed to keep the resident off of his/her buttock; -A moisture barrier should be applied and his/her buttock should be left opened to air. During an interview on 1/11/19 at 9:34 A.M. and 10:30 A.M., the Wound Nurse said: -The resident was prone to wounds related to moisture; -He/She gave the resident protein bars and snacks everytime he/she went in his/her room, to increase healing. -The resident had signed a waiver that he/she refused a special diet; -The resident was noncompliant and would not lay down after meals; -The resident was incontinent; -The resident was changed after every meal; -The resident refused to use a seat cushion in his/her wheelchair; -All wound related information and issues should be care planned; -The Wound Nurse could not find a care plan for (YEAR) or 2019. During an interview on 1/11/19 at 9:51 A.M., the Social Services Director (SSD) said: -The dental service was at the facility on 1/7/19; -The Dental hygienist saw the resident and verified he/she wanted to get his/her teeth fixed; -The resident was put on the list to see the dentist for treatment next month; -He/She verified there was no care plan for the resident. During an interview on 1/11/19 at 11:45 A.M., the MDS Coordinator said: -He/She was not consistently doing the care plans; -He/She knows they are to be done within 24 hours of admission, quarterly, annually, and with a significant change in the resident’s condition. During an interview on 1/11/19 at 12:02 P.M., the DON said: -The nurse who admits the resident is responsible for the baseline care plan; -It goes to the MDS Coordinator to be dated and signed; -Quarterly careplans should be updated; -The nurses should tell him/her if there was no care plan. 8. Record review of Resident #36’s face sheet showed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Neoplasm of adrenal gland and kidney (cancer); -Increased level of lactic acid (an increased level related to heart failure, severe infection or shock); -[MEDICAL CONDITION] (a type of chest pain caused by reduced blood flow to the heart); -Urinary tract infection (an infection in the urinary system); -Kidney failure (longstanding disease of the kidney); -Abdominal pain; -Brain disorder (diseases that cause your brain and nerves to deteriorate over time); -Muscle weakness; -Back pain; -Hematuria (blood in the urine); -History of [MEDICAL CONDITION] embolism (one or more arteries in the lungs are blocked by |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 24) a blood clot); -[MEDICAL CONDITION] (conditions which include diseased vessels, structural problems, and blood clots); -[MEDICAL CONDITION]-resistant Staphylococcus aureus (a group of hard to treat bacteria); -Constipation; -Diabetes (a group of diseases that result in too much sugar). Record review of the resident’s quarterly MDS, dated [DATE], showed the following staff assessment of the resident: -He/She was able to make decisions independently; -Required limited assistance with mobility, transferring, locomotion on the unit, getting dressed, toileting, and hygiene; -Required set up help for eating and drinking; -Required the use of a walker or wheelchair; -Had a catheter; -Was incontinent of bowel; -Was on scheduled and as needed pain medication; -Required non medication pain interventions; -Was almost constantly in pain. Record review of the resident’s medical record showed there was no comprehensive care plan for the resident. During an interview on 1/8/19 at 9:42 A.M., the resident said: -He/She had glasses, but needed new ones; -The Veteran’s Administration (VA) would not pay for them, because he/she owned a house and did not qualify financially; -He/She had missing teeth, would like dentures and would wear them; -The resident saw the dentist and said it would not be feasible to get dentures since he/she was on hospice; -The physicians gave him/her two to six months to live in November; -The resident went on Hospice for pain relief; -He/She had general discomfort in his/her neck, spine, and knees; -When the pain gets to a six on a zero to 10 scale he/she will ask for pain medication and it will knock it down to a four. During an interview on 1/10/19 at 9:52 A.M., the resident said: -He/She would get a shower today and liked to have catheter care done then; -He/She had a urinary tract infection when he/she came to the facility from the VA Hospital; -A course of antibiotics was given then another half course was given which cleared the UTI up; -The resident said he/she only chooses to have a dignity bag when he/she leaves the facility, because everyone knows what it is anyway. During an interview on 1/11/19 at 11:45 A.M., the MDS Coordinator said: -He/She was not consistently doing the care plans; -He/She knows they are to be done within 24 hours of admission, quarterly, annually, and with a significant change in the resident’s condition. During an interview on 01/11/19 at 12:02 P.M., the DON said: -The nurse who admits the resident is responsible for the baseline care plan; -It goes to the MDS Coordinator to be dated and signed; -Quarterly careplans should be updated; -The nurses should tell me if there is no care plan. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 25) 9. Record review of Resident #51’s face sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Generalized [MEDICAL CONDITION] (excess fluid that causes swelling); -Lyme Disease (a tick-borne illness). Record review of the resident’s quarterly MDS, dated [DATE], showed the following staff assessment of the resident: -Was not cognitively intact; -Had delusions; -Required extensive assistance for mobility, transfers, dressing, toileting, hygiene, and bathing; -Required supervision when eating; -Required a wheelchair for mobility; -Was frequently incontinent of urine and stool. Record review of the resident’s progress notes, dated 12/31/18, showed: -The resident attempted to climb out of bed several times throughout night; -The resident was assisted up to the wheelchair, watching television, rambling on mostly nonsense; -Staff were unable to redirect him/her; -A personal alarm was in place. Record review of the resident’s medical records showed there was no comprehensive care plan for the resident. During an interview on 1/11/19 at 11:45 A.M., the MDS Coordinator said: -He/She was not consistently doing the care plans; -He/She knows they are to be done within 24 hours of admission, quarterly, annually, and with a significant change in the resident’s condition. During an interview on 1/11/19 at 12:02 P.M., the DON said: -The nurse who admitted the resident was responsible for the baseline care plan; -It goes to the MDS Coordinator to be dated and signed; -Quarterly careplans should be updated; -The nurses should tell him/her if there is no care plan. During an interview on 1/15/19 at 1:25 P.M., the Charge nurse/Licensed Practical Nurse (LPN)said: -The resident was on Hospice (end of life care); -The resident had increased behaviors; -The resident was non compliant; -The staff needed to monitor the resident for safety awareness; -The resident sometimes tried to get out of bed and had a bed alarm and two side rails up; -The resident was vulgar and had been hateful; -Staff was told to redirect the resident and to remove him/her from the situation when he/she had behaviors; -The charge nurse was not able to find a care plan for this resident. Observation on 1/15/19 at 1:50 P.M., showed the resident: -Was in his/her room sitting in wheelchair; -Had a Personal alarm attached to the wheelchair; -Was able to only tell me his/her name and started to talk about his/her stuffed cats; -Had one side rail up on the bed; and -Had a bed alarm. During an interview on 1/15/19 at 2:25 P.M., Certified Medication Technician (CMT) A said: -The resident can be verbally abusive at times; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 26) -He/She is redirected when he/she has behaviors; -The resident tries to get out of bed and has a bed alarm but doesn’t try to get out of the wheelchair. Surveyor: Gray, Laura 10. Record review of Resident #3’s electronic health record showed the resident was most recently admitted to the facility on [DATE]. Record review of the resident’s most recent Admission MDS, dated [DATE], showed the resident: -Had a BIMS (brief mental interview status) of 3, meaning he/she was severely impaired cognitively; -Had no presence of behaviors during the seven day look-back period and no overall presence of behaviors; -Had no presence of wandering; -Needed only supervision, encouragement or cueing with bed mobility, walking, locomotion, and eating; -Needed extensive assistance with personal hygiene and bathing; -Used a walker for mobility assistance; -Had frequent pain; -Received antipsychotic, antidepressant and opioid medications; -Used a wander/elopement alarm daily. Record review showed the resident did not have a comprehensive care plan completed following his/her most recent admission MDS that included identified care assessment areas. Record review of the resident’s MDS tracking record showed the resident was admitted to the facility 1/7/2018 and discharged [DATE], return not anticipated, and readmitted to the facility 6/7/18. Record review of the resident’s care plan showed the last care plan review was dated 2/2/18, prior to the resident’s latest admitted . 11. Record review of Resident #6’s electronic health record showed the resident was most recently admitted to the facility on [DATE]. Record review of the resident’s most recent Admission MDS, dated [DATE], showed the resident: -Had a BIMS of 8, meaning he/she was moderately cognitively impaired; -Was tired and had trouble concentrating (12-14 days), nearly every day during the assessment period; -Had delusions; -Rejected care one to three days during the assessment period; -Needed only supervision, encouragement or cueing with walking, locomotion, dressing, eating, toilet use and personal hygiene; -Needed extensive assistance with bathing; -Used a walker and wheelchair for mobility assistance; -Was continent of bowel and bladder; -Had almost constant pain; -Used tobacco; -Received antianxiety, antibiotic, diuretic and opioid medications. Record review showed the resident did not have a comprehensive care plan completed following his/her admission MDS. 12. Record review of Supplemental Resident #29’s electronic medical record showed the resident was most recently readmitted to the facility on [DATE]. The resident’s [DIAGNOSES REDACTED]. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 27) Record review of the resident’s admission MDS, dated [DATE], showed the resident: -Was cognitively intact; -Had no hearing or vision impairment; -Did not display any indicators of mood disturbance; -Did not have the presence of any behaviors; -Needed only supervision, encouragement or cueing with transfers, walking, locomotion, and eating; -Needed limited assistance with bed mobility, dressing, toilet use and personal hygiene; -Used a wheelchair for mobility assistance; -Had an indwelling catheter; -Was continent of bowel. Record review showed the resident did not have a comprehensive care plan completed following his/her most recent admission MDS, that included the identified care assessment areas. During an interview on 1/11/19 at 9:30 A.M. the MDS Coordinator said: -The Interdisciplinary Team (IDT) meets to discuss care plans; -The team consist of Social Services, the DON, ADON, Charge Nurse, Medicare Nurse, and the main direct care giver; -The team meets to discuss cares and situations related to each resident; -He/She also talks to the physician during rounds or Quality Assurance Meetings; -He/She is responsible for making sure care plans are done; -He/She has gotten behind with care plans; -Comprehensive care plans should include the care assessments areas and be completed within seven days after the comprehensive MDS is completed. During an interview on 1/16/19 at 10:45 A.M., the DON said: -The DON, ADON, MDS Coordinator, Social Services, family members and the resident participate in care plan meetings; -He/She thought the care plan were getting done; -He/She expected each resident to have a comprehensive care plan completed. | |
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 28) 1. Record review of resident #23’s Admission Face Sheet showed he/she admitted on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. -Dementia (A general term for a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning) with behavioral disturbance. -History of falling. -Difficulty in walking. -Generalized muscle weakness. -[MEDICAL CONDITION] (A chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait). Record review of the resident’s Care Plan, dated 12/13/17, showed he/she was at risk for falls and required staff assistance to stand and transfer. Review showed staff had the following interventions in place: -Encourage him/her to use the arm-rest on his/her wheelchair when wanting to lean. -Encourage him/her to sit up-right in his/her chair. -Offer him/her to rest in bed or a recliner. -Personal alarm to be on at all times due to fall risk. -fell out of his/her wheelchair. -Striking his/her head. -Required stitches. -Monitor when he/she is leaning forward in his/her chair. -Offer him/her to rest in bed or a recliner. Record review of the resident’s Fall Incident Report, dated 5/3/18 at 11:00 P.M., showed the resident: -Had an unwitnessed fall. -Was lying on his/her left side next to the bed. -Was not wearing his/her personal alarm. -Had no noted injuries. Record review of the resident’s Nurse’s Note, dated 5/4/18 at 3:28 A.M., showed the resident: -Had an unwitnessed fall. -Was lying on his/her left side next to the bed. -Was not wearing his/her personal alarm. -Had no noted injuries. -Had personal alarm turned back on. Record review of the resident’s Fall Incident Report, dated 11/22/18 at 6:40 P.M., showed: -The resident had an unwitnessed fall. -The resident was on his/her hands and knees in front of his/her wheel chair in the dining room. -The resident had no noted injuries. Record review of the resident’s Fall Incident Report, dated 12/30/18 at 7:09 P.M., showed: -Staff pushed the resident in his/her wheelchair towards the bed. -The resident leaned his/her head down and bumped the side rail of the bed. -The resident had no injuries noted. Record review of the resident’s Nurse’s Note, dated 12/30/18 at 8:09 P.M., showed: -The resident was pushed by a staff member in his/her wheelchair towards the bed. -The resident leaned his/her head down and bumped the side rail of the bed. -The resident had no injuries noted. Record review of the resident’s Nurse’s Note, dated 12/31/18 at 9:59 A.M., showed the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 29) resident: -Had a hematoma (a localized collection of blood outside the blood vessels due to trauma including injury or surgery) with a small puncture wound noted to his/her right side of head. Record review of the resident’s Fall Incident Report, dated 1/2/19 at 7:03 P.M., showed: -The nurse heard a thump. -The resident was on the floor. -The resident had a large hematoma to his/her right forehead. Record review of the resident’s Physician order [REDACTED]. Record review of the resident’s Care Plans showed no updated interventions for falls since 12/13/17 including after the resident’s falls on 12/30/18 and 1/2/219. During an interview on 1/11/19 at 11:45 A.M., the MDS Coordinator said: -He/She was not consistently doing the care plans; -He/She knows they are to be done within 24 hours of admission, quarterly, annually, and with a significant change in the resident’s condition. During an interview on 1/16/19 at 10:49 A.M., the Director of Nursing (DON) said: -The MDS Coordinator should update the Care Plan if an incident had occurred. -The MDS Coordinator should follow-up on the Care Plans to be sure they are updated and appropriate for the resident. | |
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure services provided by the nursing facility meet professional standards of quality. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 30) -Had a [DIAGNOSES REDACTED]. -Used oxygen. Record review of the resident’s interdisciplinary progress notes dated 12/1/18 through 1/9/19 showed no documentation regarding the resident refusing to use oxygen. Record review of the resident’s (MONTH) (YEAR) TAR showed oxygen was checked as: -Left blank on 12/14/18; -Refused on 12/22/18, 12/23/18 and 12/31/18. Record review of the resident’s (MONTH) 2019 physician’s orders [REDACTED]. Record review of the resident’s oxygen saturation levels for (MONTH) 1, 2019 through (MONTH) 8, 2019 showed the resident’s oxygen saturation levels were: -Not documented on five days. -Was 94% or above on room air on three days. Record review of the resident’s (MONTH) 2019 TAR showed oxygen was checked as: -Refused 1/5/19-1/6/19. Observation on 1/7/19 at 9:49 A.M., showed the resident was in his/her room and there was no oxygen concentrator in the resident’s room. Observation on 1/8/19 at 9:45 A.M., showed the resident was in his/her room and there was no oxygen concentrator in the resident’s room. Record review of the resident’s (MONTH) 2019 TAR showed oxygen was checked as administered on 1/7/19-1/10/19. During an interview on 1/10/19 at 2:35 P.M., Licensed Practical Nurse (LPN) A said the resident refuses to wear oxygen and they don’t have a concentrator in his/her room. Observation on 1/11/19 at 7:35 A.M., showed the resident was in bed in his/her room and there was no oxygen concentrator in his/her room. During an interview on 1/11/19 at 7:35 A.M., Registered Nurse (RN) A said the resident refuses to use oxygen. During an interview on 1/11/19 at 7:40 A.M., LPN A said: -The doctor knows from doing rounds that the resident refuses to use oxygen; -The resident’s oxygen order needs to be discontinued. During an interview on 1/16/19 at 10:48 A.M., the Director of Nursing (DON) said: -Staff should follow physician’s orders [REDACTED].>-The resident refuses to use oxygen; -The nurse should call the doctor regarding the resident’s refusal to use oxygen and ask him/her what he/she wants to do; -Staff should monitor the resident’s oxygen saturation levels; -It should be documented that the resident refuses to use oxygen; -They should change the oxygen order to either an as needed order or discontinue the order. 2. Record review of Resident #6’s electronic medical record showed the resident was admitted to the facility 9/19/18. His/her [DIAGNOSES REDACTED].>-Chronic [MEDICAL CONDITION] (the permanent inability of the respiratory system to oxygenate the blood and/or remove carbon [MEDICATION NAME]); -[MEDICAL CONDITION]; -Pneumonia (an infection that inflames the air sacs in one or both lungs). Record review of the resident’s Admission MDS, dated [DATE], showed the resident: -Had a BIMS of 8, meaning he/she was moderately impaired cognitively; -Was tired and had trouble concentrating (12-14 days), nearly every day during the assessment period; -Had delusions; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 31) -Rejected care one to three days during the assessment period; -Needed only supervision, encouragement or cueing with walking, locomotion, dressing, eating, toilet use and personal hygiene; -Needed extensive assistance with bathing; -Used a walker and wheelchair for mobility assistance; -Was continent of bowel and bladder; -Had almost constant pain; -Used tobacco; -Received antianxiety, antibiotic, diuretic and opioid medications; -Received oxygen therapy. Record review of the resident’s POS dated, (MONTH) (YEAR), showed an order for [REDACTED]. Observation of the resident on 1/7/19 at 11:14 A.M., showed: -He/She was in bed watching television; -He/She was not using his/her oxygen. There was an oxygen concentrator in his/her room. Observation of the resident on 1/9/19 at 7:42 A.M., showed: -The resident was in bed asleep; -He/She was not using his/her oxygen; -His/Her oxygen concentrator was at bedside and the nasal cannula in a bag. Record review of the resident’s nurses’ notes for (MONTH) (YEAR) through (MONTH) 2019 did not show documentation of the resident refusing to use his/her oxygen continuously. During an interview on 1/9/19 at 7:43 A.M., with the resident and LPN A: -LPN A said it is often by choice whether the resident is using his/her oxygen or not; -The resident said he/she did not need his/her oxygen last night. During an interview on 1/11/19 at 9:20 A.M., CNA B said: -He/She didn’t think the resident had an order to wear his/her oxygen continuously; -He/She thought it was to be used as needed; -He/She used to work evenings and would see the resident using the oxygen more often then; -He/She was to report anything unusual to the charge nurse; -The resident not wearing the oxygen is usual; -The resident is very set in his/her ways; -If the resident does not want to wear it, he/she is going to take it off; -The resident goes out to smoke. During an interview on 1/16/19 at 10:45 A.M., the DON said: -The physician should be notified of the resident’s refusal to use the oxygen; -Staff should also check on getting a clarification for the order. 3. Record review of Resident #36’s face sheet showed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Neoplasm of adrenal gland and kidney (cancer); -Increased level of lactic acid (an increased level related to heart failure, severe infection or shock); -[MEDICAL CONDITION] (a type of chest pain caused by reduced blood flow to the heart); -Urinary tract infection (an infection in the urinary system); -Kidney failure (longstanding disease of the kidney); -Abdominal pain; -Brain disorder (diseases that cause your brain and nerves to deteriorate over time); -Muscle weakness; -Back pain; -Hematuria (blood in the urine); -History of [MEDICAL CONDITION] embolism (one or more arteries in the lungs are blocked by |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 32) a blood clot); -[MEDICAL CONDITION] (conditions which include diseased vessels, structural problems, and blood clots); -[MEDICAL CONDITION]-resistant Staphylococcus aureus (a group of hard to treat bacteria); -Constipation; and -Diabetes (a group of diseases that result in too much sugar). Record review of the resident’s quarterly MDS, dated [DATE], showed the following staff assessment of the resident: -He/She was able to make decisions independently; -Required limited assistance with mobility, transferring, locomotion on the unit, getting dressed, toileting, and hygiene; -Required set up help for eating and drinking; -Required the use of a walker or wheelchair; -Had a catheter; -Was incontinent of bowel; -Was on scheduled and as needed pain medication; -Required non medication pain interventions; -Was almost constantly in pain. During an Oberservation and interview on 1/11/19 at 1:17 P.M. showed: -The resident had a [MEDICATION NAME] (medication for heart burn or gas) pill at bedside in a medicine cup; -The resident said he/she can’t take two pills at the same time; -The resident will take one; -The staff will leave an additional one at bedside; -The staff will come back later to see if he/she took it. Record review of the (MONTH) Physician order [REDACTED]. -an order for [REDACTED].>-No order was present to leave medications at bedside. Record review of the electronic medication administration showed: -On 1/11/19 one tablet was given at 9:27 A.M.; -One tablet was given at 11:57 A.M. by Certified Medication Technician (CMT) B. During an interview on 1/11/19 at 11:30 A.M., the Charge nurse/Licensed Practical Nurse (LPN) A said it was ok to leave a medication at bedside if there was a physician order, otherwise it is not. During an interview on 1/11/19 at 12:02 P.M., the DON said medications should never be left at the resident’s bedside. | |
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate pressure ulcer care and prevent new ulcers from developing. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 33) -Urinary tract infection (an infection in any part of the urinary system); -Dysphasia (a difficulty swallowing); -Muscle weakness; -Chronic pain; -Hypertension (high blood pressure); -Pacemaker (a medical device that regulates the electrical system of the heart); -[MEDICAL CONDITION] (an excess of fluids that causes swelling); -Heart block (a disease or inherited condition that causes an obstruction in the electrical system of the heart); and -Peripheral Autonomic [MEDICAL CONDITION] (damage to the nerves that manage every day body functions). Record review of the Quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning), dated 10/11/18, showed the following staff assessment of the resident: -Was able to make every day decisions about his/her care; -Required extensive assistance for transferring from one surface to another, toileting, hygiene, using the sit to stand (a mechanical device to move residents), transferring from bed to wheel chair; -Was able to wheel 150 feet in his/her wheel chair; -Needed supervision, encouragement or cueing during meals; -Frequently incontinent of bowel and bladder. Record review of the resident’s medical records showed there was no comprehensive care plan for the resident. Record review of the resident’s Progress notes, dated 1/7/19, showed: -The Charge Nurse/Licensed Practical Nurse (LPN) A did a skin assessment which showed a 1 centimeter (cm) by 0.7 cm open area to the resident’s right buttock; -It was first observed on 1/4/19; -It was a stage 2 (Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister); -The resident’s family was notified; -The resident’s physician was notified (no orders); -The resident was positioned off the area, the area was left open to air, and [MEDICATION NAME] (a moisture barrier ointment) was applied. Observation on 1/9/19 at 7:38 A.M., with Certified Medication Technician (CMT) A and Certified Nursing Assistant (CNA) A of incontinent care showed: -The resident had a shallow open ulcer with a red pink wound bed on his/her right buttock; -CMT A applied [MEDICATION NAME] ointment to the area. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 34) -If it was a stage 2 the CMTs and CNAs should not be putting ointment on it; -He/She would call the physician and he/she will look at it when he/she comes this week. During an interview on 1/10/19 at 8:23 A.M., the Wound Physician said: -The resident had chronic wounds; -The staff knew what he/she wanted to use and they could always call him/her to get an order over the phone; -He/She was at the facility every week; -He/She was changing the residents treatment to a collagen treatment; -He/She saw the wound and it was a stage 3 (sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone); -It was due to moisture. Record review of the Physician’s Order Sheet (POS), dated 1/10/19, showed: -an order for [REDACTED].>-The treatment was to be applied daily. During an interview on 1/11/19 at 9:30 A.M., the Wound Nurse said: -The staff should have said something to him/her, as he/she was not aware of the problem; -The physician had tried several things; -The Wound Physician was at the facility every week; -The resident was noncompliant and would not lay down after meals, did not like his/her briefs changed, and refused to leave the area open to air; -The issue was related to incontinence; -He/She was changed after every meal; -The resident refused to use a seat cushion in his/her wheelchair; -The wound nurse frequently gave the resident protein snacks to increase healing; -The resident has signed a waiver and had refused a special diet, he/she eats what he/she wants to eat; -The issue should be care planned; -The nurse could not find a care plan for (YEAR) or 2019. During an interview on 1/16/19 at 12:10 P.M. the Director of Nursing (DON) said: -Staff should tell the nurse immediately if there is a new wound, so he/she can notify the Wound Physician; -The Wound Physician came to the facility every week. | |
| F 0689 Level of harm – Immediate jeopardy Residents Affected – Few | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Immediate jeopardy Residents Affected – Few | (continued… from page 35) Record review of the facility’s undated policy titled Wandering, Unsafe Resident showed: -The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. -The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. -The resident’s care plan will indicate the resident is at risk for elopement or other safety issues. -Interventions to try to maintain safety will be included in the resident’s care plan. -Nursing staff will document circumstances related to unsafe actions, including wandering by the resident. -Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. -Staff will notify the Administrator and Director of Nursing immediately, and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility. Record Review of the facility’s undated policy titled Behavior Assessment and Monitoring showed: -Problematic behavior will be identified and managed appropriately. -As a part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition (e.g., dementia, mental [MEDICAL CONDITION]), problematic behavior, or mental illness (e.g., [MEDICAL CONDITION] disorder or [MEDICAL CONDITION]). -The nursing staff will identify, document, and inform the physician about an individual’s mental status, behavior, and cognition, including: –Onset, duration and frequency of problematic behaviors or changes in behavior, cognition or mood. –Any precipitating or relevant factors (e.g., medication changes, infection, recent transfer from the hospital). -The staff will identify and discuss with the practitioner situations where non-pharmacologic approaches are indicated, and will institute such measures to the extent possible. -If a resident is being treated for [REDACTED]. -The staff will document (either in progress notes, behavior assessment forms, or other comparable approaches) the following information about specific problem behaviors: –Number and frequency of episodes, –Preceding or precipitating factor, –Interventions attempted (if psychoactive drug is used as an intervention, institute appropriate psychoactive drug monitoring), and –Outcomes associated with intervention. Record review of the facility’s policy titled Abuse and Neglect: Clinical Protocol showed: -The nurse will assess the individual and document related findings. -The nurse will report findings to the physician. -The physician and staff will identify risk factors for abuse within the facility, for example, significant numbers of residents with unmanaged problematic behavior. -Along with other staff and management, the Medical Director will help identify situations that might constitute or could be construed a neglect, for example, inappropriate management of problematic behavior -The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Immediate jeopardy Residents Affected – Few | (continued… from page 36) -The management and staff, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. Record review of the facility’s undated policy related to Monitoring Residents for Aggressive-Inappropriate Behavior showed: -All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the nursing Supervisor, the Director of Nursing Services and to the Administrator. -The facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of each incident shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator. Record review of the facility’s undated policy titled Change in Resident’s Condition or Status showed the nurse supervisor/charge nurse will notify the resident’s attending physician or on-call physician when there has been an accident or incident involving the resident. 1. Record review of the Resident #3’s MDS tracking record showed the resident was admitted to the facility 1/7/2018 and discharged [DATE], return not anticipated; and readmitted to the facility 6/7/18. Record review of the resident’s electronic health record showed the resident was most recently admitted to the facility on [DATE]. His/her [DIAGNOSES REDACTED]. -Unspecified Dementia with Behavioral Disturbance (Common behavioral disturbances can be grouped into four categories: mood disorders (e.g., depression, apathy, euphoria); sleep disorders ([MEDICAL CONDITION], hypersomnia, night-day reversal); psychotic symptoms (delusions and hallucinations); and agitation (e.g., pacing, wandering, sexual disinhibition (refers to socially or contextually inappropriate sexual behavior and is usually associated with frontal and temporal lobe pathology), aggression). -Wandering in Diseases Classified Elsewhere. -Persistent [MEDICAL CONDITION] Fibrillation (type of heart disorder marked by an irregular or rapid heartbeat). -Pain, Unspecified. -Overactive Bladder (the frequent urge to urinate and waking up at night to urinate). -Major [MEDICAL CONDITION] (a serious mood disorder that causes a persistent feeling of sadness and loss of interest) -Altered Mental Status, Unspecified (general changes in brain function, such as confusion, amnesia (memory loss), loss of alertness, disorientation (not cognizant of self, time, or place), defects in judgment or thought, unusual or strange behavior, poor regulation of emotions, and disruptions in perception). -Anxiety Disorder (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). Record review of the resident’s most recent Admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, used for care planning purposes, dated 6/14/18, showed the resident: -Had a BIMS (brief mental interview status) of 3, meaning he/she was severely cognitively impaired. -Stated, during the Resident Mood interview, he/she had little pleasure or interest in doing things several days, felt down, depressed or hopeless several days, had trouble falling or staying asleep or sleeping too much, and had trouble concentrating on things such as reading the newspaper or watching television. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Immediate jeopardy Residents Affected – Few | (continued… from page 37) -Had no presence of behaviors during the seven day look-back period and no overall presence of behaviors. -Had no presence of wandering. -Needed only supervision, encouragement or cueing with bed mobility, walking, locomotion, and eating. -Needed extensive assistance with personal hygiene and bathing. -Used a walker for mobility assistance. -Had frequent pain. -Received antipsychotic, antidepressant and opioid medications. -Used a wander/elopement alarm daily. Record review on 1/11/19 showed the resident did not have a comprehensive Care Plan completed following his/her most recent admission MDS that included identified care assessment areas. Record review of the resident’s Care Plan showed the last care plan review was completed 2/2/18, prior to the resident’s latest admitted . -Review of the resident’s care plan focus area related to his/her confusion, initiated 11/9/18, showed: –The goal was for the resident to be able to make his/her needs known, with a target date of 4/30/18, prior to the resident’s readmission to the facility and initiation of the focus area. –Certified Nurse Assistants (CNAs) should communicate with the resident’s family/caregivers regarding the resident’s capabilities and needs. –Social Services staff should discuss concerns about confusion, disease process, and nursing home placement with the resident’s family. –Nurses should monitor, document and report to the physician any changes in cognitive function, specifically changes in decision making ability, memory, recall, and general awareness, difficulty expressing self, difficulty understanding other, level of consciousness, and mental status. -Review of the resident’s focus area related to antianxiety medication, initiated 11/9/18, showed: –The goal was for the resident to show decreased episodes of signs and symptoms of anxiety through the review date. The target date was 4/30/18, prior to the initiated date. –Staff (no designation of position shown) should monitor target behavior symptoms (wandering, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. –The resident was taking antianxiety medications which were associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs. Monitor frequently for safety. -Review of the resident’s focus area related to antidepressant medication, initiated 11/9/18, showed: –The goals were for the resident to show decreased episodes of signs and symptoms of depression through the review date, and for the resident to be free from discomfort or adverse reactions related to antidepressant therapy through the review date. The target date was 4/30/18, prior to the initiated date. –Staff (no designation of position shown) was to give antidepressant medications ordered by the physician. Monitor/document side effects and effectiveness. –Monitor, document, and report to the physician as needed ongoing signs and symptoms of depression, unaltered by antidepressant medications. -Review of the resident’s focus area related to the resident receiving hypnotic and |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Immediate jeopardy Residents Affected – Few | (continued… from page 38)[MEDICAL CONDITION] medications, initiated 11/9/18, showed: –The goal was for the resident to be free of drug related complications, including movement disorder, discomfort, [MEDICAL CONDITION] (low blood pressure), gait disturbance, constipation/impaction or cognitive impairment through the review date. The target date was 4/30/18, prior to the initiated date. –Staff (no designation of position shown) was to administer medications as ordered. Monitor/document side effects and effectiveness. –Consult with pharmacist/physician to consider dosage reduction when clinically appropriate. –Discuss with family for ongoing need for use of medication. –Monitor and record occurrence of target behavior symptoms (wandering, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. –Monitor, record, and report to the physician as needed side effects and adverse reactions of psychoactive medications. –Try the following sleep encouragement techniques: Provide lighting that is conducive for sleep, maximize daily activities, and encourage socialization. Record review of the resident’s (MONTH) (YEAR) Behavior Monthly Flow Sheet showed the resident had nightly behavioral episodes (MONTH) 9 – 14, during the MDS 7-day assessment look back period: -On 6/9/18, staff documented one episode of the resident having [MEDICAL CONDITION] (inability to sleep.). -On 6/10/18, staff documented one episode of the resident having [MEDICAL CONDITION]. -On 6/11/18, staff documented three episodes of the resident having [MEDICAL CONDITION]. -On 6/12/18, staff documented three episodes of the resident having [MEDICAL CONDITION]. -On 6/13/18, staff documented four episodes of the resident having [MEDICAL CONDITION]. -On 6/14/18, staff documented four episodes of the resident having [MEDICAL CONDITION]. Record review, of the resident’s Nurses’ Notes showed the following: -On 6/13/18, at 3:32 A.M., the resident was found in another resident’s room (a resident of the opposite sex, identified as Resident #29). The resident was on the bed with Resident #29. Staff heard smacking lips. Resident #3 was kissing Resident #29. Resident #3 stated he/she had known Resident #29 for years. Resident #3 was easily redirected to his/her room. -On 6/13/18, at 3:37 A.M., the resident was found in the room of another resident of the opposite sex, he/she stated, I was just trying to get him/her up. -On 6/13/18, at 4:50 A.M., the nurse documented the resident was up three times after midnight and was assisted back to his/her room, re-orienting him/her to time and place. -On 7/1/18 at 12:30 A.M., the nurse documented the resident was up propelling himself/herself while sitting on his/her walker seat. The resident had been up for a few minutes. He/she was assisted back to his/her room. The resident stated the pain pill he/she took helped his/her discomfort a little. -On 7/7/18 at 12:24 A.M., the nurse documented the resident was up pacing in the hallways with his/her walker. -On 7/9/18 at 2:36 A.M., the nurse documented the resident was walking up and down the halls. -On 7/10/18 at 6:04 A.M., the nurse documented, the Certified Nursing Assistant (CNA) reported the resident was found in the Nurse’s Station at approximately 4:00 A.M., sitting in a chair removing his/her clothing from the waist down. The resident was re-directed to his/her room. At approximately 5:30 A.M., the resident was found in another resident’s |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Immediate jeopardy Residents Affected – Few | (continued… from page 39) room with his/her walker, starting to climb into bed with the other resident. The resident was taken to his/her room by wheelchair and shown his/her bed. At approximately 5:50 A.M., the resident was walking without his/her walker down the hall toward the exit door. The resident was given his/her walker and he/she went to the common area by the fish tank. -On 7/17/18 at 2:53 A.M., the resident was up, continuously pacing up and down the halls. -On 7/18/18 at 12:33 P.M., the nurse documented the resident was refusing to get up that day, the resident yelled at staff and told staff, if he/she had to get up, he/she was going to leave. Staff offered to bring the resident a room tray for his/her meal and the resident refused. -On 7/25/18 at 6:19 A.M., the nurse documented the resident had been up and down all night. -On 7/26/18 at 2:55 A.M., the nurse documented the resident had been in and out of bed several times; ambulates in hall and then goes back to his/her room; denied pain at that time. -On 7/27/18 at 6:07 A.M., the nurse documented the resident had been up most of the night roaming the hallways, in and out of other residents rooms. The resident was re-directed when found. Muscle rub was administered when the resident asked for something for his/her legs and feet. Resident was asleep in bed at the time the nurse was documenting. -On 8/6/18 at 3:39 A.M., the nurse documented the resident was up and continuously pacing up and down the hallways, complaining of knee pain and right hip pain. Pain medication and muscle rub was administered and follow-up noted as ineffective. -On 8/7/18 at 1:11 A.M., the nurse documented the resident was up and continuously pacing up and down the hallways with his/her walker, complaining of bilateral knee pain and right hip pain. Pain medication and muscle rub was administered and follow-up noted as ineffective. -On 8/8/18 at 11:29 P.M., the resident found Lysol Spray on the CNA’s cart and sprayed it on both of his/her legs, stating someone told him/her, that would help his/her legs quit hurting and would help the swelling. The nurse encouraged the resident not to do that again, but to let staff know and they would try to assist in other ways. The resident had been given pain medication and cream applied to his/her legs to help with restless legs, reportedly at around 10:20 P.M. -On 9/4/18 at 12:41 A.M., the resident was found across the hall from his/her room without any pants on, attempting to undercover the occupant in that room and push the occupant out of bed. When the nurse walked in and asked the resident what he/she was doing, the resident stated, the other resident was in his/her bed and he/she just wanted to lay down, because he/she was tired. The nurse informed the resident that he/she was in the wrong room, that it was not his/her bed and that his/her room was across the hall. The resident instantly apologized and turned around and began to walk out of room. The resident said he/she did not know why he/she did not have any pants on, and that he/she must have been sleep walking. The nurse assisted the resident back to his/her room, where he/she got dressed and got into his/her own bed. -On 9/9/18 at 2:59 A.M., the nurse documented he/she had re-directed the resident several times that night. The resident was confused, irritable, wandering down Shady Hall (not his/her hall) going into other resident rooms. The resident was given pain medication and administered a topical pain cream at the beginning of the night shift, but said neither helped. -On 9/13/18 at 2:43 A.M., the nurse documented the resident had been up ambulating in the hall several times during the night. Record review of the resident’s (MONTH) (YEAR) Behavior Monthly Flow Sheet showed the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Immediate jeopardy Residents Affected – Few | (continued… from page 40) resident had behavior episodes that included anxiety, [MEDICAL CONDITION], and being depressed/withdrawn; one time during the day shift (7:00 A.M. – 3:00 P.M.), 25 times during the night shift (11:00 P.M. – 7:00 A.M.), and no occurrences during the evening shift (3:00 P.M. – 11:00 P.M.) Record review of the resident’s Behavior Monthly Flow Sheets showed there was no record for the months of (MONTH) (YEAR) and (MONTH) (YEAR). Record review of the resident’s quarterly MDS, dated [DATE], showed the resident: -Had a BIMS of 5, meaning he/she was severely cognitively impaired. -Had no presence of wandering during the seven day look-back period and the assessment did not show whether there was an overall presence of behaviors. -Was independent with bed mobility, transfers, locomotion on his/her unit, -Needed only supervision, encouragement or cueing with walking, locomotion off his/her unit, dressing eating, and personal hygiene. -Needed extensive assistance with toilet use and bathing. -Used a walker for mobility assistance. -Was continent of bladder and bowel. -Had occasional pain. -Received antipsychotic, antidepressant and opioid medications. -Used a wander/elopement alarm daily. Record review, of the resident’s Nurses’ Notes showed the following: -On 10/8/18 at 5:56 A.M., the nurse assistant reported the resident made a threatening statement to his/her roommate as the roommate’s alarm was going off. The resident stated, I’m going to kill you if that alarm goes off again. The nurse assistant was assisting the roommate at that time and the personal alarm was going off. The resident was re-directed. -On 10/8/18 at 8:20 A.M., the nurse documented it was reported to him/her this morning that the resident was found in another resident’s (resident of the opposite sex, identified as Resident #39) room lying in bed without his/her pants on. The resident was assisted out of Resident #39’s room and back to his/her own bedroom. The nurse informed the resident’s responsible party of the situation and the responsible party did not wish to take any further action at that time. -On 10/8/18, the nurse noted the aide on the evening shift (time not noted) asked the resident if he/she would like to get up for dinner and the resident stated If you don’t stop waking me up, I’m going to knock you on your ass. The resident then went back to sleep and slept the rest of the shift. -On 10/9/18 at 2:46 A.M., the resident was up in the hallway and at the nurse’s station, pushing his/her walker. The resident was attempting to go down Shady Hall and was re-directed by the CNA, who was close by. The resident then proceeded into the dining room mumbling profanity, and sat on the seat of his/her walker. -On 10/9/18 at 3:32 A.M., the resident was re-directed as he/she attempted to go down Shady Hall. The nurse offered to show the resident to his/her room or to the common area in the dining room. The resident said, Okay honey, I hate this place. At the time of documentation, the resident was in the common area. -On 10/10/18 at 4:31 A.M., the nurse documented the resident was up most of the night walking on the hall where he/she resides and in the dining room area. The resident sat down for a couple of short naps, complained of pain in bilateral knees, medication was administered earlier in the shift and was effective. The resident had to be re-directed two times, with difficulty, from going down the hall where he/she did not reside. -On 10/11/18 at 1:37 A.M., the resident was found up wandering and assisted by staff to his/her room. The resident was offered a drink and to be toileted both times. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Immediate jeopardy Residents Affected – Few | (continued… from page 41) -On 10/30/18 at 2:30 A.M., the resident had been up all of the night shift thus far, pacing in the hallway, dining room, and going into other resident rooms. The nurse also noted the resident complained of pain in bilateral knees. The resident was administered pain medication and encouraged to go to bed and rest. At the time of documentation, the resident was resting in bed. -On 11/30/18 at 12:49 A.M., the nurse documented the resident was found messing with the CNA cart on the hall. The CNA attempted to re-direct the resident, and then the resident said, Well, you can shove that bottle up your ass. The cart was moved to the shower room. When the CNA passed the resident in the hall, the resident called the CNA his/her name, using profanity. -On 12/8/18 at 1:27 A.M., the nurse documented the resident was awake so far that shift, sitting on his/her walker seat in the hallway. The resident was attempting to move another resident’s wheelchair around in the hall. The nurse was unable to re-direct the resident at that time. -On 12/10/18 at 5:32 A.M., the resident was found in the bathroom in another resident’s room with his/her pants down around his/her hips. The resident was re-oriented to the time and place, reminding him/her that that was not his/her room. The resident said, I know, I’m just checking it out. The resident was assisted out of the bathroom and back to his/her room. -On 12/11/18 at 2:34 A.M., the resident continuously moved up and down the hallway sitting on his/her walker seat, at times walking while pushing the walker. The resident came up to the nurse’s station asking the nurse, can you tell me where I can find some food? The resident was directed to the dining room snack area. The nurse attempted several times to re-direct the resident to time and place. The resident continued to pace around the facility with his/her walker, at times moving in and out of other resident rooms. -On 12/13/18 at 12:22 A.M., the resident was wheeling himself/herself up and down the hall taking things off the aide’s cart and taking things off another resident’s wheelchair. The aide asked the resident to leave the other resident’s things alone and the resident told the aide to kiss his/her ass. The nurse asked the resident to go to his/her room, so that he/she could administer pain medication and rub cream on the resident’s legs. The resident was not cooperative with the nurse and stated he/she was not going to bed. The television was turned on for the resident and the resident was offered coffee to try and make him/her comfortable. The resident said he/she did not like being bossed around. -On 12/15/18 at 5:46 A.M., the nurse documented the resident had been up several times throughout the night, drinking coffee and getting into the cart in the hallway. Record review of the resident’s (MONTH) (YEAR) Behavior Monthly Flow Sheet showed the resident had behavior episodes that included anxiety, [MEDICAL CONDITION], and being depressed/withdrawn; occurring 62 times during the day shift and 77 times during the night shift. There was no documentation showing occurrences during the evening shift. Record review of the resident’s (MONTH) (YEAR) Behavior Monthly Flow Sheet showed the resident had behavior episodes that included anxiety, [MEDICAL CONDITION], and being depressed/withdrawn; occurring 60 times during the night shift. Record review of the resident’s quarterly MDS, dated [DATE], in progress during the facility’s annual survey, showed the resident: -Had a BIMS of 6, meaning he/she was severely cognitively impaired. -Had no overall behavioral symptoms. -Had no presence of wandering and no behaviors affecting others. -Was independent with walking and eating. -Needed only supervision, encouragement or cueing with bed mobility, transfers, |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Immediate jeopardy Residents Affected – Few | (continued… from page 42) locomotion, dressing, toilet use and personal hygiene. -Needed extensive assistance with bathing. -Used a walker for mobility assistance. -Was continent of bladder and bowel. -Had no presence of pain. -Received antipsychotic, antidepressant and opioid medications. Record review, of the resident’s Nurses’ Notes showed the following: -On 12/16/18 at 12:32 A.M., the nurse documented the resident continued to roll up and down the hallway while seated on his/her rolling walker. -On 12/21/18 at 5:07 A.M., the nurse documented the resident was up several times during the night. The resident was observed several times trying to go down the hall where he/she did not reside, and was re-directed back to his/her room. -On 12/24/18 at 6:10 A.M., the nurse documented the resident was found by the CNA, in another resident’s room on the hall where he/she did not reside. The resident was re-directed. The other resident started yelling at Resident #3, because the other resident thought Resident #3 had his/her walker. Record review of the resident’s (MONTH) (YEAR) Behavior Monthly Flow Sheet showed the resident had behavior episodes that included anxiety, [MEDICAL CONDITION], and being depressed/withdrawn; occurring 60 times during the night shift. Record review of the resident’s (MONTH) 2019 Behavior Monthly Flow Sheet showed the resident had behavior episodes that included anxiety, [MEDICAL CONDITION], and being depressed/withdrawn; occurring 39 times during the night shift, (MONTH) 1 -14, 2019. Observation on 1/11/19 at 11:00 A.M., showed the resident sitting on his/her walker seat rolling from the far end of the hall where he/she did not reside. The resident was headed toward 100/200/dining room hall intersection. 2. Record review of Supplemental Resident #29’s electronic medical record showed the resident was most recently readmitted to the facility on [DATE]. The resident’s [DIAGNOSES REDACTED]. Record review of the resident’s admission MDS, dated [DATE], showed the resident: -Was cognitively intact. -Had no hearing or vision impairment. -Did not display any indicators of mood disturbance. -Did not have the presence of any behaviors. -Needed only supervision, encouragement or cueing with transfers, walking, locomotion, and eating. -Needed limited assistance with bed mobility, dressing, toilet use and personal hygiene. -Used a wheelchair for mobility assistance. -Had an indwelling catheter. -Was continent of bowel. The resident did not have a comprehensive Care Plan completed following his/her most recent admission MDS. Record review of the resident’s Nurses’ Notes dated 6/13/18 at 3:34 A.M., showed a resident of the opposite sex (identified as Resident #3) went into the resident’s room, laid in bed with the resident and was kissing the resident. The resident did not appear to be in distress. When the CNA told the resident he/she was going to empty his/her Foley bag (bag to collect the urine that drains through a catheter), the resident said, I thought you were talking about this old bag as the resident was rubbing Resident #3 on his/her back. The resident was easily re-directed. During an interview on 1/11/19 at 1:14 P.M., Resident #3’s responsible party said he/she |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Immediate jeopardy Residents Affected – Few | (continued… from page 43) was not told about the incident that occurred on 6/13/18. He/she had only been told about an incident that occurred in (MONTH) (YEAR), and occurrences such as skin tears. 3. Record review of Resident #39’s initial care plan dated 7/31/18, showed the resident: -Used a walker. -Had a [DIAGNOSES REDACTED]. Record review of the resident’s order summary report dated 7/31/18, showed some of the resident’s [DIAGNOSES REDACTED]. Record review of the resident’s admission MDS dated [DATE], showed the following staff assessment of the resident: -Cognitively intact. -Did not have any hearing or vision impairment. -Had clear speech. -Understands others and others understand him/her. -Did not display any behaviors. -Used a walker. -The most assistance he/she required during the look-back period was: –Limited assistance of one person with moving around in his/her bed. –Limited assistance of two people with dressing. –Supervision when walking and transferring from one surface to another such as from standing to sitting on his/her bed or chair. Record review of the resident’s medical records showed there was not a comprehensive care plan for the resident. Record review of the resident’s nurses’ notes showed the resident: -Reached between a CNA’s legs three times on 8/12/18. -Was verbally inappropriate with staff on 8/12/18. -Walked by an employee and brushed him/her on his/her bottom on 8/14/18. -Told an employee he/she was going to grab their butt on 8/14/18. -Touched the stomach and breasts of an employee on 8/17/18. Record review of the resident’s nurse’s note dated 10/8/18 showed: -The nurse went into the resident’s room about 5:00 A.M. -The resident was standing next to his/her bed naked. -The nurse found Resident #3 laying on his/her back in the resident’s bed with his/her pants down around his/her ankles. -The nurse asked the resident what was going on and he/she said that he/she did not know. -The resident told the nurse that nothing happened between him/her and Resident #3. -Resident #3 said, What? Do you think I’m crazy? when asked if anything happened between the two residents. -Resident #3 initially refused to leave the resident’s room, but staff were able to remove Resident #3 from the resident’s room. Record review of the incident report dated 10/8/18 at 5:00 A.M. showed: -Resident #3 was found in Resident #39’s room. -Resident #3 was lying on Resident #39’s bed with his/her pants pulled down to his/her ankles. -Resident #39 was naked and standing next to Resident #3. -Resident #39 denied touching Resident #3. -Resident #3 said, What? Do you think I’m crazy? when asked if anything happened between the two residents. -Notification of the physician was left blank. -The incident was reported to the ADON. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Immediate jeopardy Residents Affected – Few | (continued… from page 44) -The incident report was signed by Licensed Practical Nurse (LPN) C. Record review of the resident’s significant change MDS dated [DATE] showed the staff assessment of the resident showed that he/she was cognitively intact. During an interview on 1/11/19 at 10:48 A.M., CNA E said: -Resident #3 is the only resident that is being monitored for wandering. -There are days when the residen | |
| F 0744 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0744 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 45) -Had a [DIAGNOSES REDACTED]. Record review on 1/11/19 of the resident’s care plan showed it did not address dementia and the resident’s psychosocial well-being. 2. Record review of Resident #20’s electronic health record showed the resident was most recently admitted to the facility on [DATE]. His/her [DIAGNOSES REDACTED]. Record review of the resident’s Admission MDS dated [DATE], showed the resident: -Had a BIMS of 7, meaning he/she was severely cognitively impaired; -Stated, during the Resident Mood interview, he/she felt down, depressed or hopeless and felt tired or had little energy; -Had no presence of behaviors; -Needed only supervision, encouragement or cueing with bed mobility, walking, locomotion, eating and personal hygiene; -Needed limited assistance with dressing; -Used a cane for mobility assistance; -Received antidepressant and antianxiety medications; and -Had a [DIAGNOSES REDACTED]. Record review on 1/11/19 of the resident’s care plan showed: -It did not address Dementia and the resident’s psychosocial well-being; -It was not personalized. During an interview on 1/11/19 at 9:30 A.M., the MDS Coordinator said: -He/She was responsible for completing the residents’ plan of care; -He/She had gotten behind. During an interview on 1/16/19 at 10:45 A.M., the Director of Nursing (DON) said: -He/She thought the care plans were getting done. -He/She expected residents with dementia to have a personalized plan of care that addressed their dementia and psychosocial well-being. | |
| F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure medication error rates are not 5 percent or greater. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 46) –Push the dose knob in until it stops, and 0 is seen in the dose window; –Hold the dose knob in and count to five slowly; –Insulin should be seen at the tip of the needle; -If you do not see insulin, repeat the priming steps, no more than four times; -If still no insulin is seen, change the needle and repeat the priming steps; -If you do not prime before each injection, you may get too much or too little insulin. Record Review of the manufacturer’s instructions for the [MEDICATION NAME] (a long[MEDICATION NAME] insulin) [MEDICATION NAME] (a brand name) Pen showed: -Always, perform the safety test (the manufacturer’s term for priming) before each injection; -Performing the safety test ensures that you get an accurate dose by: –Ensuring that the pen and needle work properly; –Removing air bubbles; –Select a dose of two units by turning the dosage selector; –Hold the pen with the needle pointing upwards; –Tap the insulin reservoir so that any air bubbles rise up toward the needle; –Press the injection button all the way in; –Check if insulin comes out of the needle tip; -Safety test may need to be performed several times before insulin is seen; -If no insulin comes out, check for air bubbles and repeat the safety test two more times to remove them; -If still no insulin comes out, the needle may be blocked, change the needle and try again. 1. Record Review of Resident #38’s Medication Administration Record [REDACTED] -Humalog three times a day (TID) before meals per a sliding scale (refers to the progressive increase in the insulin dose, based on pre-defined blood glucose ranges); –Sliding scale (SS) for a blood glucose of 244 showed give six units SQ; -[MEDICATION NAME] 20 Units in the A.M., SQ. During an observation on 1/9/19 at 7:49 A.M., of Licensed Practical Nurse (LPN) A during insulin administration showed: -He/She did not prime the Humalog pen before administering six Units SQ; -He/She did not prime the [MEDICATION NAME] pen before administering 20 Units SQ. 2. Record Review of Resident #13’s MAR, dated (MONTH) 2019, showed: -[MEDICATION NAME] five Units SQ in A.M., daily. During an observation on 1/9/19 at 8:47 A.M., of LPN A during insulin administration showed: -He/she did not prime the [MEDICATION NAME] pen before administering five Units SQ. During an interview on 1/9/19 at 8:55 A.M., LPN A said per the pharmacy that the facility uses: -They only prime an insulin pen when it is new; -They do not prime an insulin pen with each subsequence use; -He/She had been educated on the use of insulin pens during an annual in-service. During an interview on 1/16/19 at 10:49 A.M., the Director of Nursing (DON) said: -The facility’s Insulin Administration Policy should include the use of insulin pens. -He/She expected that insulin pens would be primed according to the manufacturer’s instructions. -He/She would like the medication error rate to be zero percent at all times. -He/She tries to keep the staff educated, so that medication passes are done correctly. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | ||
| F 0760 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure that residents are free from significant medication errors. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0760 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 48) insulin administration showed: -He/she did not prime the Humalog pen before administering six Units SQ. -He/she did not prime the [MEDICATION NAME] pen before administering 20 Units SQ. 2. Record Review of Resident #13’s MAR indicated [REDACTED] -Humalog SS four times a day (QID), if blood glucose level is under 199 do not give. -[MEDICATION NAME] five Units SQ in A.M., daily. During an observation on 1/9/19 at 8:47 A.M., of LPN A during insulin administration showed: -He/she held Humalog due to the resident’s blood glucose level of 188. -He/she did not prime the [MEDICATION NAME] pen before administering five Units SQ. During an interview on 1/9/19 at 8:55 A.M., LPN A said per the pharmacy that the facility uses: -They only prime an insulin pen when it is new; -They do not prime an insulin pen with each subsequence use; -He/She had been educated on the use of insulin pens during an annual in-service. During an interview on 1/16/19 at 10:49 A.M., the Director of Nursing (DON) said: -The facility’s Insulin Administration Policy should include the use of insulin pens. -He/she would expected that insulin pens would be primed according to the manufacturer’s instructions. -He/she tries to keep the staff educated so that medication passes are done correctly. | |
| F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 49) labels from the dispensing pharmacy on them. The labels were torn off; -[MEDICATION NAME] sulfate ophthalmic solution (an eye medication) 1%, an opened 5 ml bottle, with no resident’s name, date opened written on it, and did not have the original printed labels from the dispensing pharmacy on them. The labels were torn off; -[MEDICATION NAME] (a narcotic pain medication) oral solution, a 100 mg/5 ml bottle was opened without an opened date written on it; -One bottle of [MEDICATION NAME] (used for nausea and vomiting) containing 12 pills, that did not have a resident’s name on it and was in a box that also had used hair clippers, scissors, and [MEDICATION NAME] in it; -An open tube of Vaseline petroleum jelly with a physician’s orders [REDACTED]. -An opened tube of Vaseline petroleum jelly with a physician’s orders [REDACTED]. Observation on 1/7/19 at 11:15 A.M., of the medication cart for the 200 hallway showed: -[MEDICATION NAME] oral solution 100 mg/5 ml a 30 ml bottle, that had an opened date of 12/23/17 and had expired on 11/07/18; -One open tube of antifungal cream (medication to get rid of fungus), with no residents name or opened date on it and was in a drawer with resident’s food for medication administration (applesauce and crackers). During an interview on 1/7/19 at 11:30 A.M., LPN D said: -The night nurse is to check the temperature of the refrigerator every night; -The night nurse who was working was picking up shifts and may not have known it was his/her duty; -All opened medications should have a date that they were opened on them; -Expired medications should have been disposed of; -All medications should have a label on it or should be disposed of; -Medications should not be in a drawer with food, phone chargers, hair brushes, and can openers. During an interview on 1/11/19 at 12:02 P.M., the Director of Nursing (DON) said: -Medications should have a date written on them if they have been opened; -The night nurse may not have known he/she needed to check the temperature on the refrigerator; -You should never use expired medications; -Expired medications should be disposed of. -The facility has a drug buster (container with chemicals used to dispose of drugs); -Medications should have a label on them; -There is no reason medications should be in a drawer with food and a brushes. | |
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to separate damaged cans in the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 50) showed the following: – There was a build-up of food debris on the manual can opener blade; – A 105 ounce (oz.) can of diced pears and a six pound (lb.) 10 oz. can of tropical fruit cocktail in the dry storage were dented, and not separated from undented cans. Observations during the kitchen inspection on 1/8/19 between 9:42 A.M. and 12:53 P.M., showed the following: – There was a build-up of food debris on the manual can opener blade; – A one gallon (gal.) jug of soy sauce in the dry storage was marked as having been opened on 2/1 and the label stated Refrigerate After Opening; – The walk-in refrigerator and freezer floors had trash and food remains and dust build-up under the storage racks; – The dietary staff prepared foods and then moved cooked foods from the stove and placed them in steam table pans without washing hands or re-gloving between tasks. During an interview on 1/8/19 at 10:13 A.M., the Dietary Manager said dented cans are to be discarded and reported to the food vendor sales representative for refund. The Dietary Manager said the person who checks in the order should look for dents in the cans. The Dietary Manager said if other staff find dented cans they should be discarded and reported to the food vender sales representative. During an interview on 1/10/19 at 8:47 A.M., the Dietary Manager said the following: – The walk-in floors are swept on Fridays by the stock person after delivery; – The can opener blade is cleaned nightly by the night Dietary Aide; – If food needing refrigeration and had not been, it should be thrown out; – The dietary staff had been educated to wash hands and re-glove between tasks. | |
| F 0813 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Have a policy regarding use and storage of foods brought to residents by family and other visitors. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0813 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 51) – If outside food is brought in for a resident, they notify the kitchen, date and label it; – He/She was not sure where dietary staff put it; – He/She was sure there was a policy in dietary; – He/She was unsure if it was in the nursing procedures book. During an interview on 1/10/18 at 12:33 P.M., the Administrator said that the outside food policy was discussed a while ago with the dietary staff by the Dietician, but there hadn’t been an all staff in-service on it, though it should probably be added. | |
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide and implement an infection prevention and control program. Based on observation, interview and record review, the facility failed to ensure that |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 52) -The CMT’s and nurses are to wash their hands before passing medications and between each resident; -Staff are to wash hands and apply gloves if administering eye drops and/or breathing treatments; -Staff are to wash hands and apply gloves if they will be touching any other items while giving medications to a resident. During an interview on 1/11/19 at 8:30 A.M., Licensed Practical Nurse (LPN) A said: -The nurses and CMT’s are to wash their hands before passing medications; -Staff may use hand sanitizer between each resident while passing medications; -Staff should apply gloves if they know they will be touching the resident or other objects when giving a resident his/her medications; -If staff need to touch a resident or objects while giving medications, then they should wash their hands afterward and before doing the next resident’s medications. During an interview on 1/16/19 at 10:49 A.M., the Director of Nursing (DON) said: -He/she expected the CMT’s and the nurses to give resident’s their medications first before touching other objects. | |
| F 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Develop and implement policies and procedures for flu and pneumonia vaccinations. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/5/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265780 |
| (X3) DATE SURVEY COMPLETED 01/17/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ADRIAN MANOR HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 402 WEST FIRST STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 53) -The wound nurse was responsible for making sure vaccines were done; -He/She expected the resident to have been up to date with his/her vaccines. | |
