| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 0569 Level of harm – Potential for minimal harm Residents Affected – Some | Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Based on interview and record review, the facility failed to provide spend down letters | |
| F 0578 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 0578 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 1) -[DIAGNOSES REDACTED]. Review of the resident’s medical record, showed the following:-An order, dated 1/1/00, for full code; -Full code noted on the face sheet; -The facility code status form, originally signed on 1/19/04 and last updated on 1/19/06, showed full code; -No further updates documented in the chart. 2. Review of Resident #208’s quarterly MDS, dated [DATE], showed the following: -admitted to the facility on [DATE]; -BIMS score of 15 out of 15, which showed no cognitive impairment; -[DIAGNOSES REDACTED]. Review of the resident’s medical record, showed the following: -An order, dated 4/29/15, for full code; -Full code noted on the face sheet; -The facility code status form, signed on 3/9/15, showed full code; -No further updates documented in the chart. 3. Review of Resident #17’s medical record, showed the following: -admission date of [DATE]; -A facility code status form, signed on 6/4/14, showed full code; -Review of the (MONTH) (YEAR) physician order [REDACTED]. -Readmission date of [DATE]; -Order, dated 9/10/17, for full code; -No further documentation showing the facility reviewed the resident’s code status since 2014. 4. Review of Resident #35’s quarterly MDS, dated [DATE], showed the following: -BIMS score of 11 out of 15, which showed moderate impairment; -[DIAGNOSES REDACTED]. Review of the POS [REDACTED]. Further review of the medical record, showed the following: -An 8 inch by 10 inch green sheet of paper in the front of the chart that read FULL CODE; -Full code noted on the face sheet. 5. During an interview on 3/9/18 at 10:45 A.M., the administrator said she expected each resident’s code status to be reviewed at least yearly but preferably with each care plan session. The face sheet, code status form and POS should all match. | |
| F 0582 Level of harm – Potential for minimal harm Residents Affected – Some | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Based on interview and record review, the facility failed to provide a Skilled Nursing |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 0582 Level of harm – Potential for minimal harm Residents Affected – Some | (continued… from page 2) -The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS- ) is issued when all covered Medicare services end for coverage reasons; -If the skilled nursing facility (SNF) believes on admission or during a resident’s stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary’s potential liability for payment for the non-covered services. The SNF’s responsibility to provide notice to the resident can be fulfilled by the use of either the SNFABN (form CMS- ) or one of the five uniform denial letters; -The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them him/herself or through other insurance they may have; -If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the beneficiary of his/her right to an expedited review of a service termination. 1. Review of Resident #9’s Skilled Nursing Facility Beneficiary Protection Notification Review, completed by facility staff on 3/8/18, showed the following: -Medicare part A skilled services episode start date 9/6/17; -Last covered day of Medicare part A service on 12/1/17; -The facility initiated the discharge from Medicare part A services when benefit days were not exhausted; -Facility staff could not provide documentation the resident received the SNFABN form CMS- or the NOMNC form. 2. Review of Resident #46’s Skilled Nursing Facility Beneficiary Protection Notification Review, completed by facility staff on 3/8/18, showed the following: -Medicare part A skilled services episode start date 1/24/18; -Last covered day of Medicare part A service on 2/15/18; -The facility initiated the discharge from Medicare part A services when benefit days were not exhausted; -Facility staff could not provide documentation the resident received the SNFABN form CMS- or the NOMNC form. 3. During an interview on 3/8/18 at approximately 1:20 P.M., the administrator said it is the responsibility of the Social Service Designee (SSD) to provide residents with all Medicare discharge forms. The SSD was terminated last week and the administrator had no way of knowing if residents received the forms. | |
| F 0604 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 0604 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 3) instrument completed by facility staff, dated 1/31/18, showed the following: -Upper and lower extremity impairment; -Incontinent of bowel and bladder; -Trunk restraint used daily; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, updated 11/14/17, showed the following: -Problem: At risk for falls related to involuntary movements and immobile related to[DIAGNOSES REDACTED]. -Goal: Free from falls and injuries; -Approach: Make sure seat belt was in place due to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of the resident’s Device Decision Guide, dated 3/26/17, showed staff determined the seat belt not to be a restraint. Review of the resident’s computer medical record, showed no further Device Decision Guide assessments after 3/26/17. Observations of the resident, showed the following: -On 3/7/18 at 7:53 A.M. and 3/8/18 at 8:16 A.M., the resident sat in a tilt-in-space wheelchair (designed for pressure relief and positioning) at a dining room table and wore a seat belt around his/her waist; -On 3/8/18 at 11:13 A.M., the resident sat in a tilt-in-space wheelchair in the dining room, in front of the television, and wore a seat belt around his/her waist; -On 3/9/18 at 8:22 A.M., the resident sat in a tilt-in-space wheelchair at the dining room table as a certified nurse aide (CNA) fed him/her breakfast and he/she wore a seat belt around his/her waist. During an interview on 3/9/18 at 10:45 A.M., the administrator said the resident’s seat belt should be assessed at each care plan. Assessments should be in the computer system. | |
| F 0606 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Based on record review and interview, the facility failed to check the Nurse Aide Registry |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 0606 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | ||
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | 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: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 – Few | (continued… from page 5) Observations of the resident on all days of the survey, from [DATE] through [DATE], showed him/her lay in bed on his her back, with a fall mat in place to the right of the bed. A tube feeding pump infused formula and water to the resident’s abdomen on a continuous basis. During an interview on [DATE] at approximately 9:00 A.M., the MDS nurse said the resident did not have a care plan. The resident should have a care plan. 3. During an interview on [DATE] at 10:45 A.M., the administrator said every resident should have a care plan that reflects their current care needs. | |
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | 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** Based on interview and record review, the facility failed to review resident’s care plans |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 – Some | (continued… from page 6) -A [DIAGNOSES REDACTED]. Review of the care plan, dated 3/19/15, showed the following: -Problem: Falls, impaired balance during transfers and ambulation; -Goal: Safely transfer self with assist of one and wheeled walker device; -Approach: Use wheeled walker for transfers. Review of the nurse’s notes, showed the following: -Fall on 11/25/17 at 5:24 P.M.; -Fall on 12/15/17 at 3:38 P.M.; -Fall on 2/22/18, no time noted. Further review of the care plan, updated on 12/15/17, showed the following: -No documentation regarding the fall on 11/25/17; -Resident fell from the bed on 12/15/17, because his/her feet tangled in the blankets. Isolated incident; -No changes to goals; -No changes to approach; -No documentation regarding the fall on 2/22/18. During an interview on 3/9/18 at 10:45 A.M., the DON said care plans should be updated after every fall with new interventions to help prevent further falls. 4. Review Resident #36’s quarterly MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Total dependence on staff for eating; -Nutrition provided by tube feeding ([DEVICE], a tube surgically inserted through the abdomen into the stomach to provide hydration, nutrition and medications). Review of the resident’s (MONTH) (YEAR) POS, showed the following: -A diet order, dated 6/28/17, for tube feeding; -An order, dated 11/03/17, for [MEDICATION NAME] 1.5 (type and strength of tube feeding formula) to be infused at 65 milliliters an hour continuously; -All oral medications to be given via [DEVICE]. Review of the resident’s care plan, provided by the facility on 3/9/18 and in use during the survey, showed the following: -Care plan last reviewed/revised on 11/14/17; -Problem: Impaired swallowing related to dysphagia; -Goal: Resident will maintain weight with feeding tube; -Approach: -Crush medications. Mix medications with pudding or apple sauce before administering; -Monitor and record intake of food; -Praise resident attempts to complete meal; -Provide supplements: Boost VHC (type of supplemental nutrition drink which provides additional calories); -Report and document when resident leaves 25% or more food uneaten; -Thicken liquids to nectar consistency before serving; -Staff failed to update the care plan’s approaches to reflect the resident’s current[DEVICE] and nutritional care needs. During an interview on 3/9/18 at 10:45 A.M., the administrator and DON said care plans should reflect the resident’s current condition and should be updated at least quarterly. | |
| 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 |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 7) quality. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 8) During observation and interview on 3/9/18 at 7:20 A.M., the resident sat in a wheelchair at a table in his/her room and wore oxygen via NC. A small plastic cup sat on the table and contained an assortment of approximately 8 pills. The resident told Nurse G he/she did not have all of his/her pills. Nurse G stood outside the room at the medication cart with his/her back to the resident. Another cup on the table held a tube of 2.5% [MEDICATION NAME] and 2.5% [MEDICATION NAME], with a refill date of 2/13/18. During an interview on 3/9/18 at 9:08 A.M., the resident said staff gave him/her medications in a cup and he/she took them on his/her own. He/she had done that for years. The [MEDICATION NAME] topical really worked and he/she always applied it to his/her arm before [MEDICAL TREATMENT] (helps filter waste, excess fluid and toxins from the blood). During an interview on 3/9/18 at 11:00 A.M., the administrator said there should be orders on the POS for oxygen administration and related care, the topical [MEDICATION NAME] and for the resident to self administer medications and apply the topical anesthetic. 2. Review of Resident #30’s quarterly MDS, dated [DATE], showed the following: -Upper and lower extremity impairment; -Incontinent of bowel and bladder; -Trunk restraint used daily; -Diagnoses included [MEDICAL CONDITION] (brain damage causing loss or impairment of motor function) and [MEDICAL CONDITION]. Review of the resident’s care plan, updated 11/14/17, showed the following: -Problem: At risk for falls related to involuntary movements and immobile related to[DIAGNOSES REDACTED].>-Goal: Free from falls and injuries; -Approach: Make sure seat belt was in place due to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of the resident’s POS, dated 3/1/18 through 3/31/18, showed no order for a seat belt. Observations of the resident, showed the following: -On 3/7/18 at 7:53 A.M. and 3/8/18 at 8:16 A.M., the resident sat in a tilt-in-space wheelchair (designed for pressure relief and positioning) at the dining room table and wore a seat belt around his/her waist; -On 3/8/18 at 11:13 A.M., the resident sat in a tilt-in-space wheelchair in the dining room, in front of the television and wore a seat belt around his/her waist; -On 3/9/18 at 8:22 A.M., the resident sat in a tilt-in-space wheelchair at the dining room table as a certified nurse aide (CNA) fed him/her breakfast. He/she wore a seat belt around his/her waist. During an interview on 3/9/18 at 11:00 A.M., the Director of Nursing (DON) said there should be an order for [REDACTED]. 3. Review of Resident #6’s annual MDS, dated [DATE], showed the following: -admitted to the facility on [DATE]; -Brief interview for mental status (BIMS), a screening tool to assess cognitive impairment, score of 9 out of 15, which showed moderate impairment; -[DIAGNOSES REDACTED].>-Dependent on staff for mobility and personal hygiene. Review of the POS [REDACTED]. Observations on 3/6/18 at 10:54 A.M., 3/7/18 at 10:48 A.M., 3/8/18 at 6:29 A.M. and 3/9/18 at 6:28 A.M., showed the resident sat in a wheelchair with a seat belt on, secured around his/her waist. During an interview on 3/9/18 at 10:45 A.M., the DON said she was not aware the resident used a seat belt. The administrator said the resident does wear a seat belt and an order should be obtained for the use of it. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 9) 4. Review of Resident #49’s annual MDS, a federally mandated assessment instrument completed by facility staff, dated 1/25/18, showed the following: -BIMS score of 14 out of 15, which showed little or no cognitive impairment; -[DIAGNOSES REDACTED]. Review of the POS [REDACTED] -An order, dated 5/4/17, to check blood sugar twice a day at 6:00 A.M. and 4:00 P.M. and administer [MEDICATION NAME] (fast acting) insulin per sliding scale (dose determined by blood sugar result); -An order, dated 5/4/17, to administer Humalog (fast acting) insulin per sliding scale twice a day at 9:00 A.M. and 5:00 P.M. Review of the Medication Administration Record [REDACTED] -[MEDICATION NAME]administered twice a day at 6:00 A.M. and 4:00 P.M.; -Humalog insulin written on the MAR indicated [REDACTED]. During an interview on 3/9/18 at 10:45 A.M., the DON, said she would not expect two fast acting insulins to be ordered for the same resident; especially around the same hour of the day. She would expect the nurse to contact the physician for clarification and not just write duplicate on the MAR; especially since the two medications are not the same. 5. Review of Resident #47’s admission MDS, dated [DATE], showed the following: -admission date of [DATE]; -No cognitive impairment; -Independent with all activities of daily living; -Pain score of 7 on a 10-point scale, with 0 being no pain and 10 being the worst possible pain; -[DIAGNOSES REDACTED]. Review of the resident’s POS, dated 3/1/18 through 3/31/18, showed the following orders, dated 1/12/18: -[MEDICATION NAME] (used to treat high blood pressure) 5 milligrams (mg), take two tables by mouth once daily; -Aspirin (used to treat pain, fever or inflammation) 81 mg, once daily; -Tamsulosin HCL (used to treat difficulty urinating) 0.4 mg, once daily; -[MEDICATION NAME] (muscle relaxer) 20 mg twice daily; -[MEDICATION NAME] (used to treat high blood pressure) 50 mg, one tablet every 12 hours; -[MEDICATION NAME] (narcotic pain reliever) 10 mg, one tablet twice daily; -[MEDICATION NAME] (used to treat inflammation) 5 mg, twice daily; -[MEDICATION NAME] (used to treat anxiety) 10mg three times daily; -Quetiapine [MEDICATION NAME] (antipsychotic medication) 100 mg at bedtime. Further review of the resident’s POS, showed no diagnoses for the administration of any of the medications. During an interview on 3/9/18 at 11:00 A.M., the DON said the resident’s POS should have diagnoses for each of the medications administered. | |
| F 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 10) restorative nursing therapy for three of 20 sampled residents (Residents #208, #48 and #32). The census was 60. 1. Review of Resident #208’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/2/18, showed the following: -Brief Interview for Mental Status (BIMS), a screening tool used to assess cognitive impairment, score of 15 out of 15, which showed no impairment; -Extensive assistance with personal care and mobility; -Supervision needed for meals; -[DIAGNOSES REDACTED]. Review of the resident’s physician order [REDACTED]. Further Review of the POS [REDACTED]. Review of the RT documentation, showed the following: -Resident received RT one time in March, (YEAR), on the 5th. -Received 20 repetitions of range of motion (ROM, the full movement potential of a joint) to both legs with use of two pound weights; -Application of protective headgear. During an interview on 3/9/18 at 8:56 AM rehabilitation manager said he/she spoke to the previous Director of Nursing (DON) about ordering protective headgear for the resident but was unsure if that DON pursued the recommendation. During an interview on 3/9/18 at 10:45 A.M. the DON said the resident did not have an order for [REDACTED]. 2. Review of Resident #48’s annual MDS, dated [DATE], showed the following: -Cognitively intact; -Functional ROM in upper extremities (shoulder, elbow, wrist, hand) impairment on one side; -[DIAGNOSES REDACTED]. -Zero days of restorative therapy, including splint/brace placement assistance, for seven of seven days assessed. Review of the resident’s medical record, showed the following: -A hand written physician’s orders [REDACTED]. -A January, (YEAR) POS: No RT order; -A February, (YEAR) POS: No RT order; -A March, (YEAR) POS: No RT order; -No documentation regarding RT on the care plan. Review of the resident’s RT record for February, (YEAR), showed the following: -an order for [REDACTED].>-Staff documented RT provided 13 out of 28 opportunities. Observations on 3/7/18 at 2:16 P. M., 3/8/18 at 1:37 P.M. and 3/9/18 at 8:22 A.M., showed a gray wrist splint lay on the over-bed table in the resident’s room. During an interview on 3/8/18 at 1:37 P.M., the resident said staff do not put his/her splint on every day. He/she usually wears it a couple of times a week. 3. Review of Resident #32’s significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Zero days of RT, including active ROM (AROM, the performance of an exercise to move a joint without any assistance or effort of another person to the muscles surrounding the joint) and passive ROM (PROM, the movement of a joint through the range of motion with no effort from the patient) and ambulation, for seven of seven days assessed. Review of the resident’s medical record, showed the following: -A physician’s orders [REDACTED]. Restorative program established for ambulation and |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 0688 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 11) bilateral lower extremity exercises; -A February, (YEAR) POS: No RT order; -A March, (YEAR) POS: No RT order; -No documentation regarding RT on the care plan. Review of the resident’s February, (YEAR), RT record, showed the following: -Exercise AROM and PROM of both lower extremities, three pound ankle weights, 20 repetitions; -Ambulation exercise within the facility 300 feet times two; -Staff failed to document the ordered frequency for the therapy to be provided; -Staff documented providing AROM, PROM and ambulation therapy on nine occasions during the month. During an interview on 3/9/18 at approximately 10:45 A.M., the Director of Nursing, said she expects staff to follow physician orders. The night nurse is responsible for ensuring orders are carried over on the POS. Restorative Therapy Aide (RTA) J is responsible for providing RT for the residents. RTA J was off on 3/8/18 and had to work as a certified nurse aide (CNA) on 3/9/18. If RTA J is not available, the resident’s nurse or CNA should provide the therapy. | |
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide enough food/fluids to maintain a resident’s health. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 12) Observation on 3/7/18 at 8:53 A.M., showed the resident sat alone at the dining room table, feeding him/herself. Observation on 3/7/18 at 1:47 P.M., showed the resident sat alone at the dining room table and a staff member assisted him/her eat. Staff did not serve him/her a shake. Observation on 3/08/18 at 8:59 A.M. and 1:22 P.M., showed the resident sat alone at the dining room table, feeding him/herself. Staff did not serve him/her a shake. During an interview on 3/9/18 at 10:45 A.M., the Director of Nursing said when a dietician makes a recommendation, he/she makes a carbon copy of the request and gives that to the charge nurse. The dietician is not allowed to write orders and it is the nurses’ responsibility to follow up with the doctor regarding the recommendation. | |
| F 0698 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Past noncompliance – remedy proposed **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 0698 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 13) medications; -Monitor lab work. If lab work is performed at [MEDICAL TREATMENT] clinic, request copies for facility medical record; -Staff failed to address the need for monitoring/assessment of the resident’s shunt site; -Staff failed to address need for ongoing communication between the facility and [MEDICAL TREATMENT] center. Review of the resident’s (MONTH) (YEAR) physician order [REDACTED]. -[DIAGNOSES REDACTED]. -An order, dated 1/30/18 for [MEDICATION NAME] ([MEDICATION NAME], blood thinner) 6 milligrams (mg) once a day; -No orders for [MEDICAL TREATMENT] treatment; -No orders for assessments or monitoring of the shunt bruit and thrill. Review of the resident’s (MONTH) (YEAR) TAR, showed no documentation of thrill assessments. Review of the resident’s (MONTH) (YEAR) nurses’ notes, showed the following: -No documentation regarding the resident’s [MEDICAL TREATMENT] treatments or assessments and monitoring of the shunt site; -On 2/16/18 at 4:00 P.M., resident observed bleeding from site of [MEDICAL TREATMENT] shunt area. The nurse applied pressure with dry dressing and noted the site continued to bleed. Staff notified the resident’s physician, who ordered the resident to be sent to the emergency room . Review of the resident’s hospital discharge record, showed the following: -Resident discharged from the hospital on [DATE]; -Chief complaint of bleeding from left upper external AV fistula; -Initial international normalized ratio (INR, a laboratory measurement of how long it takes blood to form a clot) of 4.8 (desired range is between 2.0 and 3.0), [MEDICATION NAME] held and INR drifted down, now 2.16; -Order for [MEDICATION NAME] 4 mg to be taken every day. Further review of the resident’s (MONTH) (YEAR) nurses’ notes, showed the following: -On 2/18/18 at 9:56 P.M., the resident returned from the hospital via ambulance. He/she had a large bandage over the left arm shunt site with no complaints of discomfort voiced; -No further documentation regarding the resident’s [MEDICAL TREATMENT] treatments or assessments and monitoring of the shunt site. Review of the resident’s (MONTH) (YEAR) POS, showed the following: -An order, dated 2/20/18, for [MEDICATION NAME] 6.5 mg every evening; -No orders for [MEDICAL TREATMENT] treatment; -No orders for assessments or monitoring the shunt bruit and thrill. Review of the resident’s (MONTH) (YEAR) TAR, showed no documentation of thrill assessments. Review of the (MONTH) (YEAR) nurses’ notes, showed no documentation regarding the resident’s [MEDICAL TREATMENT] treatments, assessments or monitoring of the shunt site. During an interview on 3/9/18 at 10:45 A.M., the Director of Nursing (DON) said residents who receive [MEDICAL TREATMENT] should have physician orders [REDACTED]. [MEDICAL TREATMENT] care should also be included on the resident’s care plan. | |
| F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 14) PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 15) Review of the care plan, dated 6/6/17 and in use during the survey, showed no indication why the resident needed or received the mediation. Review of the MAR, dated 2/1/18 through 2/28/18, showed the resident received [MEDICATION NAME] 0.5 mg a total of 42 times. Review of the MAR, dated 3/1/18 through 3/9/18, showed the resident received [MEDICATION NAME] 0.5 mg. a total of 11 times. 4. During an interview on 3/9/18 at 10:45 A.M., the Director of Nursing (DON) said ordered medications should have a supporting [DIAGNOSES REDACTED]. Psychiatric type medications that are ordered on a PRN basis can not be used any longer than 14 days without the physician reviewing the medication and the resident’s condition. The nurse should have spoken to the physician regarding supporting diagnoses and if the medication is appropriate to continue or discontinue. | |
| F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | 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: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 – Some | (continued… from page 16) daily; -An order, dated 9/1/17, for [MEDICATION NAME] (used to treat depression) 40 mg once daily; -An order, dated 9/1/17, for levetiracetam (used to treat [MEDICAL CONDITION]) 100mg/5 milliliters (ml), give 7.5 ml daily; -An order, dated 9/1/17, for atorvastatin (used to reduce high cholesterol) 10 mg daily; -An order, dated 9/1/17, for potassium chloride (potassium supplement) give 15 ml once daily. Observation on 3/9/18 at 8:22 A.M., showed Licensed Practical Nurse (LPN) A dispensed the pill form medications into a single plastic cup and poured the liquid medication into two separate cups. He/she placed the pills into a small plastic sleeve and crushed the medications together and poured them into a plastic drinking cup. He/she entered the resident’s room, greeted the resident and placed the crushed medications and the liquid medication onto the night stand next to the bed. He/she took the plastic cup that contained the crushed medication and entered the resident’s bathroom and poured approximately 60 ml of tap water into the cup. He/she placed a clean washcloth under the tube feeding ports. He/she used the large syringe and drew up 60 ml of the crushed mediation with the water. He/she removed placed the syringe of medication into the feeding tube port and used the syringe plunger to administer the medications to the resident. Crushed medication remained visible on the sides and bottom of the plastic cup. He/she removed the syringe and closed the tubing port. He/she removed the plunger from the syringe and reinserted the syringe into the feeding tube port. He/she poured the liquid medication one at a time into the syringe and allowed the medication to be administered by gravity. He/she flushed the tubing with 150 ml of tap water. He/she did not administer the medications separately, did not provide a water flush after each separate medication and administered the crushed medication with force via use of the syringe plunger. During an interview at that time, LPN A said she did not know that crushed medications should be administered separately. There should be no residual mediation left in cups, water can be used to rinse the cup and then administered to the resident so he/she gets the ordered medication. During an interview on 3/8/18 at 10:25 A.M., the Director of Nursing (DON) said medications given by [DEVICE] should be crushed and administered separately and each medication should be followed with a water flush. No medication residual should be left in plastic cups. 2. Review of Resident #22’s POS, dated 3/1/18 through 3/31/18 showed an order, dated 1/17/18, for [MEDICATION NAME] (inhaler used to control symptoms of [MEDICAL CONDITIONS] by relaxing the airways and keeping them open) 18 micro grams (mcg) inhale one capsule by mouth once daily. During an observation and interview on 3/8/17 at 8:07 A.M, showed LPN A did not administer the ordered inhaler treatment to Resident #22. He/she said Resident #22 can administer his/her own inhaler treatments. Further Review of the POS [REDACTED]. 3. Review of Resident #37’s POS, dated 3/1/18 through 3/31/18, showed an order, dated 11/30/17, for [MEDICATION NAME] (used to treat elevated eye pressure) 0.25 %, administer one drop into each eye daily. During an observation and interview on 3/8/18 at 7:15 A.M., Certified Medication Technician (CMT) B administered two drops of the [MEDICATION NAME] into each of the resident’s eyes. CMT B did not hold the inner canthus of either eye. During an interview on 3/8/18 at 10:25 A.M., the DON said when eye drops are administered |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 – Some | (continued… from page 17) the inner canthus should have pressure applied to prevent absorption of the medication into the residents system. All medications should be given as ordered by the physician. | |
| 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** | |
| 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, interview and record review, the facility failed to ensure the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 18) 3/2/18. Staff had been handwashing all dishes using the sanitizing sink. A part for the dishwasher had been ordered and was coming from Mexico but should arrive tomorrow. The company that serviced the machine would come out and install it as soon as it arrived. The DM took a chlorine test strip from the container and dipped it into the sanitizing sink. The strip turned a light shade of purple and did not indicate the sanitizer was at the proper level. The DM drained the sink and refilled it with water. The sanitizer dispensed automatically from a tube connected to a gallon jug of sanitizing solution, called(NAME)Laboratory, Inc. Sanitime. The DM dipped another test strip into the sink and it changed to a darker purple color. The DM said the solution should be at least 100 parts per million (PPM). The DM then matched the strip to the color coded area on the container and said it was the right shade and indicated the sanitizer was at the appropriate level to ensure the dishes were sanitized. Review of the product specification sheet for Sanitime, showed the following: -Sanitime is a quaternary ammonium chloride (QAC-type of disinfectant derived from ammonium) sanitizer; -Sanitime is an effective Environmental Protection Agency (EPA) registered sanitizer when used at 200 to 400 PPM. During an interview on 3/6/18 at 3:30 P.M., the dishwasher representative who routinely serviced the dishwasher and ordered the new part, said Sanitime sanitizer is effective at a minimum of 200 PPM. The facility should be using QAC strips, not the chlorine test strips that turned shades of purple, to check the sanitizer level in the sink. The proper test strip was plastic and only the tip turned a different color. He had supplied the facility with the plastic strips in the past, but did not know when the last time was. During an interview on 3/6/18 at 3:44 P.M., the DM said he recalled using the plastic strips, but the registered dietician told him they were not the right ones. He thought the test strips that turned purple were the correct ones. He would look to see if he still had any of the plastic ones. A few minutes later, the DM said he must have discarded the plastic strips. During an interview on 3/6/18 at 4:00 P.M., the administrator said she would send someone out to get enough paper, plastic and aluminum service-ware to use until the dishwasher was fixed. She was not aware they did not have the appropriate test strips for the sink. | |
| F 0849 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265709 |
| (X3) DATE SURVEY COMPLETED 03/09/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BELLEFONTAINE GARDENS NURSING & REHAB | STREET ADDRESS, CITY, STATE, ZIP 9500 BELLEFONTAINE ROAD | |||||||||
| 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 0849 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 19) not have a life expectancy of less than six months. Review of the facility’s Hospice Company Binder, showed the resident received hospice services. Review of the resident’s medical record, showed the following: -admission date of [DATE]; -No care plan in the electronic medical record or the hard chart; -No documentation of routine communication with the hospice company or description of services provided by hospice in the progress notes; -No documentation of routine communication with the hospice company, no coordination of care or documentation of the hospice services the resident received; -No order for hospice services on the (MONTH) (YEAR) physician order [REDACTED]. 2. Review of Resident #36’s quarterly MDS, dated [DATE], showed a life expectancy of less than six months. Review of the Hospice Company Binder, showed the resident received regular hospice services. Review of the resident’s medical record, showed the following: -admission date of [DATE]; -A care plan, last reviewed/revised on 11/14/17, showed no documentation regarding hospice services; -No documentation of routine communication with the hospice company or description of services provided by hospice in the progress notes; -No documentation of routine communication with the hospice company, no coordination of care or documentation of the hospice services the resident received; -No order for hospice services on the (MONTH) (YEAR) POS. 3. During an interview on 3/7/18 at 2:09 P.M., Licensed Practical Nurse (LPN) A, (charge nurse for Resident #5 and #36’s hall) said when hospice visits, they document in a binder. Otherwise, he/she is not sure how they communicate with the facility. He/she sees them write in the computer. 4. During an interview on 3/9/18 at 10:45 A.M., the administrator said if a resident received hospice services, it should be reflected on the care plan. Every resident should have a care plan that reflects their current care needs. The facility and the hospice company should coordinate care. This collaboration should be reflected on the care plan to show who is responsible for what. | |
