| 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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0550 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights. **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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0550 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) spat out thick, yellow, brown phlegm onto the mattress and floor. CNA Q stated the resident often spat out mucous. The CNA did not clean the phlegm off of the resident’s mattress nor off of the floor. CNA Q stripped the resident of his/her clothes and urine soaked brief. The resident lay naked, without the privacy curtains drawn, while CNA Q performed perineal care (peri-care, washing the front and back of the hips, genitals, anal area and buttocks). There was a knock on the resident’s door and CNA Q called out, come in without asking who was there. The resident lay completely bare, in open view of the doorway and the hall. The door opened, a staff member poked his/her head into the room, mumbled something to the CNA and shut the door. The resident was left uncovered during the encounter. Observation on 1/28/19 at 2:33 P.M., showed the resident in bed without clothing. His/her chest exposed. The resident’s door stood open and the privacy curtain not pulled. The resident began to pull on the privacy curtain and said, help. CNA O entered the room and pulled the curtain. During an interview at this time, CNA O said the resident had a history of [REDACTED]. During an interview on 1/30/19 at 12:06 P.M., the Director of Nursing (DON) said she would expect all staff to respect the dignity and privacy of the residents in the facility. If a housekeeping staff saw the resident in the room without clothing, she would expect them to pull the privacy curtain and close the door. The DON would had preferred the housekeeper to notify a CNA or nurse because they would be able to assist the resident with putting on clothing. If the housekeeper heard the resident say help, she would expect the housekeeper to notify nursing staff within a reasonable amount of time. 2. Review of Resident #44’s quarterly MDS, dated [DATE], showed: -[DIAGNOSES REDACTED]. -BIMS score of 5 out of 15 (indicates cognitive impairment); -No behaviors; -Incontinent of urine; -Required maximum assistance from the staff for transfers, dressing, hygiene and bathing. Observation on 1/27/19 at 7:35 A.M., showed the resident lay in bed awake. CNA G washed hands, put on gloves and told the resident he/she was going to remove his/her wet diaper. After unfastening the resident’s adult incontinence brief, CNA G turned the resident onto his/her left side and said he/she was going to remove the diaper from under him/her. CNA G provided the resident with incontinence care. After providing care, CNA G opened the door to the resident’s room, called out to an unknown staff member in the hallway to hand him/her a blue brief. After receiving the incontinence brief from the other staff member, CNA G placed the brief on the resident, dressed and transferred the resident into his/her wheelchair. 3. Review of Resident #40’s quarterly MDS, dated [DATE], showed: -[DIAGNOSES REDACTED]. -BIMS score of 3 out of 15 (indicates cognitive impairment); -No behaviors; -Incontinent of bowel and bladder; -Required total assistance from staff for transfers, dressing, eating, hygiene and bathing. Observation on 1/28/19 at 7:48 A.M., showed the resident lay in bed. CNA G washed hands, put on gloves and provided the resident with incontinence care. CNA G turned the resident onto his/her left side and told resident going to put a clean diaper on him/her. CNA G placed a clean adult incontinence brief under the resident, turned the resident onto his/her back and told the resident he/she was going to fasten the diaper. |
| 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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0550 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 2) 4. During an interview on 1/30/19 at 11:55 A.M., the DON said it would never be appropriate for staff to refer to the adult incontinence brief as a diaper, they should refer to it as a brief due to dignity issues. | |
| F 0623 Level of harm – Potential for minimal harm Residents Affected – Many | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0623 Level of harm – Potential for minimal harm Residents Affected – Many | (continued… from page 3) -Transferred to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -Transferred to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -No documentation the resident and/or the representative was provided a notice upon the emergency transfers. 6. Review of Resident #21’s medical record, showed: -Transferred to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -Transferred to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -Transferred to the hospital on [DATE]; -No documentation the resident and/or the representative was provided a notice upon the emergency transfers. 7. Review of Resident #52’s medical record, showed: -Transferred to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -Transferred to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -No documentation the resident and/or the representative received written notice upon the emergency transfers. 8. During an interview on 1/30/19 at 9:00 A.M., the Social Service Designee (SSD) said the emergency transfer notice would be issued by either the Business Office (BO) managers or the SSD, he/she had not issued any emergency transfer notices since starting at the facility in April, (YEAR). 9. During an interview on 1/30/19 at 9:10 A.M., both BO Managers A and B said they were not aware of who would be responsible for issuing an emergency transfer notice and neither of them had issued any written emergency transfer notice to any resident and/or their representative. 10. During an interview on 1/30/19 at 9:15 A.M., the Director of Nurses (DON), Assistant Director of Nurses (ADON) and Nurse C said when a resident is sent out to the hospital, they send a copy of the resident’s face sheet, physician order [REDACTED]. They had not been issuing any emergency transfer notices upon emergency transfer to the hospital with a return anticipated. | |
| F 0625 Level of harm – Potential for minimal harm Residents Affected – Many | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0625 Level of harm – Potential for minimal harm Residents Affected – Many | (continued… from page 4) -Returned to the facility from the hospital on [DATE]; -Discharge to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -Discharge to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -Discharge to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -Discharge to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -No documentation the resident and/or the representative received written notice of the facility’s bed hold policy at the time of transfers. 2. Review of Resident #28’s medical record, showed: -Discharge to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -No documentation the resident and/or the representative received written notice of the facility’s bed hold policy at the time of transfer. 3. Review of Resident #40’s medical record, showed: -discharged to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -No documentation the resident and/or the representative received written notice of the facility’s bed hold policy at the time of transfer. 4. Review of Resident #63’s medical record, showed: -discharged to the hospital on [DATE]; -No documentation the resident and/or the representative received written notice of the facility’s bed hold policy at the time of transfer. 5. Review of Resident #44’s medical record, showed: -discharged to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -discharged to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -discharged to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -discharged to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -No documentation the resident and/or the representative received written notice of the facility’s bed hold policy at the time of transfers. 6. Review of Resident #21’s medical record, showed: -discharged to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -discharged to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -discharged to the hospital on [DATE]; -No documentation the resident and/or the representative received written notice of the facility’s bed hold policy at the time of transfers. 7. Review of Resident #52’s medical record, showed: -discharged to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -discharged to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; |
| 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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0625 Level of harm – Potential for minimal harm Residents Affected – Many | (continued… from page 5) -No documentation the resident and/or the representative received written notice of the facility’s bed hold policy at the time of transfers. 8. During an interview on 1/30/19 at 9:00 A.M., the Social Service Designee (SSD) said he/she had not issued any written bed hold policy to the resident or their representative when discharged to the hospital with a return anticipated. 9. During an interview on 1/30/19 at 9:10 A.M., both Business Office Managers A and B said they were not aware of who would be responsible for issuing a written bed hold policy to a resident and or their representative when a resident is discharged to the hospital with a return anticipated, neither of them had issued any written bed hold policy to any resident and/or their representative. 10. During an interview on 1/30/19 at 9:15 A.M., the Director of Nurses (DON), Assistant Director of Nurses (ADON) and Nurse C said when a resident is sent out to the hospital, they send a copy of the resident’s face sheet, physician order [REDACTED]. They had not been issuing any written bed hold policy to the resident and or their representative upon emergency discharge to the hospital with a return anticipated. | |
| F 0640 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** | |
| F 0661 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on interview and record review, the facility staff failed to complete a |
| 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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0661 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 6) final summary of the resident’s status, a reconciliation of all pre and post discharge medications and a post-discharge plan of care. During an interview on 1/30/19 at 9:05 A.M., the Social Service Designee (SSD) said she had worked at the facility since (MONTH) (YEAR), was not aware of who would be responsible for completing a discharge summary for residents who were discharged to the community and thought it would be nursing. During an interview on 1/30/19 at 9:15 A.M., the Director of Nurses (DON), Assistant Director of Nurses (ADON) and Nurse C all said they had not been doing any discharge summary on any resident who had been discharged to the community and were unaware of the requirement. | |
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide care and assistance to perform activities of daily living for any resident who is unable. **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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 7) buttocks, removed the soiled pad from under him/her, removed gloves, covered the resident, washed hands and left the resident’s room. CNA F removed his/her gloves, washed hands and left the resident’s room. Neither CNAs E nor F cleaned the resident’s left outer genitals or buttocks to ensure all urine had been removed from the resident’s skin, nor did they dry the resident’s skin prior to leaving the room. 2. Review of Resident #18’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/7/18, showed: -[DIAGNOSES REDACTED]. -Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 (0 to 7 indicates severe cognitive impairment); -No behaviors; -Incontinent of bowel and bladder; -Required maximum assistance from staff for transfers, dressing, personal hygiene and bathing. Observation on 1/27/19 at 5:25 A.M., showed the resident lay on the bed awake. CNA F washed hands, put on gloves and provided the resident with care. CNA F removed a urine soiled adult incontinence brief, washed and dried the resident’s peri area and outer genitals, turned the resident onto his/her left side, washed the back of the resident’s thighs and then washed the rectal area. After changing his/her soiled gloves, CNA F had the resident turn onto his/her back, applied barrier cream to the peri area, covered the resident, removed his/her gloves, washed hands and left the resident’s room. CNA F did not wash the resident’s entire genital area or buttocks to ensure all urine had been removed from the resident’s skin prior to leaving the room. 3. Review of Resident #44’s quarterly MDS, dated [DATE], showed: -[DIAGNOSES REDACTED]. -BIMS score of 5 out of 15 (indicates cognitive impairment); -No behaviors; -Incontinent of urine; -Required maximum assistance from the staff for transfers, dressing, personal hygiene and bathing. Observation on 1/27/19 at 7:35 A.M., showed the resident lay in bed awake. CNA G washed hands, put on gloves, washed the resident’s peri area and genitals in a back to front motion, at least six times and then dried in the same manner. CNA G turned the resident onto his/her left side, washed and dried the back of the resident’s thighs and rectal area, applied a clean adult incontinence brief on the resident, dressed and transferred him/her into his/her wheelchair. CNA G did not wash the resident’s buttocks or hips to ensure all of the urine had been removed from the resident’s skin prior to dressing and transferring him/her into the wheelchair. 4. During an interview on 1/30/19 at 11:55 A.M., the Director of Nurses (DON) said would expect staff to wash the entire genital area and all areas of skin that may have come into contact with urine or stool, in a front to back motion, to ensure all urine and stool had been removed from the skin and to prevent skin breakdown and urinary tract infections. | |
| F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. |
| 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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 8) **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain proper placement of indwelling urinary catheters (a tube inserted into the bladder for the purpose of continual urine drainage). The facility identified two residents as having indwelling urinary catheters and of those two, problems were found with both residents (Residents #54 and #29). The census was 61. 1. Review of Resident #54’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 12/26/18, showed: -[DIAGNOSES REDACTED]. -Severe cognitive impairment with short and long term memory problems; -Gastrostomy tube ([DEVICE], a tube surgically inserted into the stomach through the abdomen for the purpose of providing liquid nutrition, hydration and medications); -Indwelling urinary catheter; -Incontinent of bowel; -Required total assistance from staff for transfers, dressing, eating, personal hygiene and bathing. Review of the resident’s electronic physician order [REDACTED]. -An order dated 9/28/18, for the use of an indwelling urinary catheter; -An order dated 9/28/18, for a #20 French (size) Foley (type of indwelling urinary catheter) catheter with a 30 cubic centimeter (cc) balloon (size of balloon on end of catheter which holds the catheter in the bladder), change as needed; -An order dated 1/3/19, to obtain an urinalysis with culture and sensitivity (UA with C&S, a urine test to identify any urinary infection and type of medication needed to clear the infection); -An order dated 1/8/19, to administer [MEDICATION NAME] (a broad spectrum antibiotic) 500-125 milligrams (mg) one tablet by [DEVICE] four times a day for 10 days for urinary tract infection. Review of the resident’s care plan, in use during the survey, showed: -Problem: Indwelling urinary catheter to promote wound healing; -Goal: Identify factors and minimize risk of urinary tract infection while promoting wound healing; -Interventions included: Catheter care every shift. Monitor catheter for proper drainage. Keep drainage bag below level of bladder. Keep bag and tubing off floor. Monitor for any signs/symptoms of a urinary tract infection. (MONTH) use dignity bag for catheter bag to keep off floor and cover bag. Review of the resident’s UA with C&S, obtained on 1/3/19 and reported on 1/8/19, showed: -Turbid yellow urine (normal is clear yellow); -White blood cells – 16 to 25 (normal is 0 to 4); -Bacteria – few (normal is none); -Culture – 50,000 to 100,000 colony forming unit (CFU) per milliliter (ml) of Extended-spectrum beta-lactamases (ESBL, a type of enzyme or chemical produced by some bacteria that cause some antibiotics not to work) producing [DIAGNOSES REDACTED] pneumonia (a bacteria normally found in the intestines). Observation on 1/28/19 at 7:13 A.M., showed the resident lay in bed with side rails up on both sides of the bed. The indwelling urinary catheter tubing draped over the top of the left side rail, down into the collection bag. Approximately 3 inches of the bottom of the collection bag lay directly on the floor without any type of privacy bag or protective covering. The collection bag contained a clear amber colored urine. |
| 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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 9) Observation on 1/29/19 at 6:57 A.M., showed the resident lay in bed. Approximately 24 inches of the indwelling urinary catheter tubing hung down over the side of the bed, looped back upward approximately 12 inches into the collection bag. The tubing contained a cloudy yellow urine without any urine in the last approximate 8 inches of the tubing where it enters the collection bag. The collection bag, without any type of protective covering or privacy bag, hung on the left side of the bed frame. Approximately 3 inches of the bottom of the collection bag lay directly on the floor. 2. Review of Resident #29’s quarterly MDS, dated [DATE], showed: -Brief interview of mental status (BIMS) score of 4 out of 15, showed the resident had severe cognitive impairment; -Extensive assistance of one person physical assist required for transfers, locomotion off unit, dressing and toilet use; -Use of an indwelling urinary catheter; -[DIAGNOSES REDACTED]. -Hospice. Review of the resident’s electronic POS, showed: -An order dated 9/28/18, for indwelling catheter care; -An order dated 11/21/18, for indwelling catheter, 20 French gauge, 30 ml balloon; -An order dated 12/26/18, for [MEDICATION NAME] (an antibiotic used to treat bacterial infections) 100 mg, 1 tab by mouth every 12 hours for ten days for urinary tract infection. Review of the resident’s care plan, in use at the time of survey, showed: -Problem (onset 3/22/18): At risk for complications due to indwelling catheter for[MEDICAL CONDITION], history of urinary tract infections; -Interventions included: Keep bag and tubing off floor. (MONTH) use leg bag as needed. Education for infection control attempted due to resident moves catheter bag around and takes out of dignity bag and sets on floor. Education effective only short periods of time due to dementia. Staff to monitor and assist as needed to prevent bag or tubing from contacting floor or being placed above level of bladder by resident. Review of the resident’s nurse’s notes from 3/13/18 through 1/29/19, showed no documentation of patient education regarding infection control or behaviors regarding his/her catheter. Observations of the resident, showed: -On 1/28/19 at 11:36 A.M., approximately 10 inches of catheter tubing filled with urine, lay on the floor under the resident’s Broda chair (medical reclining chair), not in a privacy bag. The resident attempted to push the tubing back under his/her pant leg, but it fell back onto the floor; -On 1/29/19 at 1:01 P.M., approximately 4-6 inches of catheter tubing filled with urine, lay on the floor under the resident’s Broda chair, not in a privacy bag; -On 1/29/19 at 3:49 P.M., approximately 4-6 inches of catheter tubing filled with urine, lay on the floor under the resident’s Broda chair, not in a privacy bag; -On 1/30/19 at 12:06 P.M., approximately 5 inches of catheter tubing filled with urine, lay on the floor under the resident’s Broda chair while he/she sat in the dining room awaiting lunch, not in a privacy bag. Several staff came in and out of the dining room. 3. During an interview on 1/30/19 at 11:56 A.M., the Director of Nursing (DON) said it is expected for catheter bags to be placed in privacy bags. If a catheter bag is hung on a resident’s bedside, it should be covered. Catheter tubing should never touch or drag on the floor due to infection control. Residents who move their catheter bags and/or tubing should be educated on this and the tubing should be cleansed or replaced. It is expected |
| 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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 10) that staff monitor the residents who reposition their catheter bags and tubing. | |
| F 0695 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide safe and appropriate respiratory care for a resident when needed. **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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0695 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 11) concentrator off. The oxygen tubing lay coiled on top of the concentrator without any type of bag or protective covering. The nasal prongs directly touched the concentrator. The humidifying bottle remained empty of any water. Neither the oxygen tubing nor the humidifying bottle were dated. Observation on 1/29/19 at 6:55 A.M., showed the resident lay in bed with the oxygen tubing in his/her nose and oxygen administered at 2 L a minute by nasal prongs. The humidifying bottle remained empty of any water. At 9:09 A.M., the resident had been taken out of his/her room. The oxygen concentrator had been turned off. The oxygen tubing lay coiled on top of the oxygen concentrator without any type of bag or protective covering. The humidifying bottle remained empty of water. Neither the oxygen tubing nor the humidifying bottle were dated. During an interview on 1/29/19 at 9:18 A.M., the Director of Nurses (DON) looked at the oxygen concentrator, said she would expect staff to date the tubing and humidifying bottle, keep fluid in the humidifying bottle for resident comfort and for the tubing to be placed in a plastic bag when not in use for infection control issues. The resident is on hospice and hospice takes care of orders for oxygen. | |
| 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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 12) Review of the resident’s care plan, dated (MONTH) (YEAR) and in use at the time of the survey, showed: -Problem: At risk for complications related to [MEDICAL TREATMENT] treatment; -Approach: [MEDICAL TREATMENT] on Monday, Wednesday and Friday; -Receives a diet with renal considerations. Sack lunch on [MEDICAL TREATMENT] days to maintain intake; -Pre/post treatment vital signs and weights via [MEDICAL TREATMENT] clinic staff with concerns phoned to facility’s nurse; -Keep [MEDICAL TREATMENT] clinic informed of medical changes. Review for any administration changes recommended on [MEDICAL TREATMENT] days; -Monitor bruit/thrill to left arm shunt, monitor for any signs of hemorrhage (bleed) or site infections symptoms and report to physician and [MEDICAL TREATMENT] staff, for uncontrolled bleeding, apply pressure and call initiate emergency services; -If resident is unable to reach [MEDICAL TREATMENT] appointment due to transportation issue or inclement weather, contact [MEDICAL TREATMENT] clinic for further instructions; -Avoid blood draws and blood pressures to shunt arm (left arm). Review of the resident’s January, 2019 physician order [REDACTED]. -An order, dated 11/28/18, for [MEDICAL TREATMENT] on Monday, Wednesday and Friday; -An order, dated 12/3/18, to check [MEDICAL TREATMENT] access shunt at left arm for bruit and thrill every shift. Review of the resident’s January, 2019 treatment administration record (TAR), showed the following: -Check [MEDICAL TREATMENT] access shunt at left arm for bruit and thrill every shift; -First shift showed no documentation on 1/7, 1/11, 1/26 and 1/28/19; -Second shift showed no documentation on 1/2, 1/7, 1/10, 1/11, 1/22, 1/24, 1/26 and 1/28/19; -Third shift showed no documentation on 1/2/19 through 1/28/19. Review of the resident’s January, 2019 nurse’s notes, showed the following: -On 1/17/19, resident complained of dizziness and headache. States feels [MEDICAL TREATMENT] treatment taking too much off. Contacted [MEDICAL TREATMENT] clinic to review most recent labs with no critical findings noted. vital signs 96.5 (normal 97.8 through 99.1) degrees Fahrenheit (F), heart rate 75 (normal 60 through 100), respirations 18 (normal 12 through 20), blood pressure 220/96 (normal 90/60 through 120/80). Resident reminded to change position slowly due to dizziness. As needed (PRN) given for head ache. Physician exchange phoned regarding elevated blood pressure. Awaiting call back; -New orders received for [MEDICATION NAME] (medication used to treat high blood pressure) 10 milligram (mg) now and 10 mg daily on non-[MEDICAL TREATMENT] days. Orders noted.[MEDICATION NAME] given as directed. Will continue to monitor; -On 1/25/18, received call from [MEDICAL TREATMENT] clinic with new orders to discontinue double portions, order given to dietary; -No documentation regarding the resident’s [MEDICAL TREATMENT] treatments or assessments and monitoring of the shunt site. Review of the resident’s (MONTH) 2019, vitals, showed: -On 1/17/19, temperature 97.7 degrees F; -Pulse 71; -Respirations 18; -Blood pressure 121/81; -On 1/18/19, blood pressure 136/76; -On 1/25/19, temperature 98.8 degrees F; |
| 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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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) -Pulse 80; -Respirations 16; -Blood pressure 150/60. During an interview on 1/28/19 at 11:24 A.M. and 1/29/19 at 10:49 A.M., the resident confirmed he/she goes to [MEDICAL TREATMENT] on Mondays, Wednesdays and Fridays. He/she began to get bad headaches and felt faint after he/she returned from [MEDICAL TREATMENT] in the past month. He/she reported it to staff, but he/she could not remember who. The resident said he/she refused to go back to [MEDICAL TREATMENT] until he/she saw a doctor. The facility staff does not complete an assessment before or after he/she returned from[MEDICAL TREATMENT]. Staff do not check the bruit and thrill using a stethoscope. The resident said he/she was going to [MEDICAL TREATMENT] today and tomorrow. He/she wanted to talk to the physician at the [MEDICAL TREATMENT] center to find out why he/she started to get headaches. He/she fell after he/she returned from [MEDICAL TREATMENT] about a month ago. He/she was found by staff in his/her room. He/she spoke to the social worker at the facility, but had not spoken to the physician from the facility. He/she really wanted to know why he/she was heaving headaches after [MEDICAL TREATMENT]. He/she was fine right after [MEDICAL TREATMENT] and on the way back to the facility, but once he/she returned, the headaches started. During an interview on 1/30/19 at 9:26 A.M., the resident confirmed he/she went to[MEDICAL TREATMENT] yesterday. He/she had a headache when he/she returned to the facility. He/she did not talk to the physician at the [MEDICAL TREATMENT] center. He/she was tired of the headaches. He/she refused to go to [MEDICAL TREATMENT] one day in the past month because no one did anything. The only way he/she could get the staff attention was to not go to [MEDICAL TREATMENT]. During an interview on 1/30/19 at 10:11 A.M., the social worker said the resident came from another facility which had a [MEDICAL TREATMENT] center. He/she did not like to wait to receive his/her treatment. He/she also complained of headaches and wanted to talk to the physician at the [MEDICAL TREATMENT] center. The social worker spoke to the [MEDICAL TREATMENT] center and confirmed that the physician will be available to speak to the resident today when he/she received the treatment. During an interview on 1/30/19 at 12:06 P.M., the Director of Nursing (DON) said she would expect staff to follow physician’s orders [REDACTED]. She would not expect staff to check the resident’s blood pressure, assess the site and assess for pain after every visit. The resident is asked how he/she was doing, staff chart by exception, so there was no routine. If he/she complained of something, then an assessment is completed, but it is not routinely checked. The [MEDICAL TREATMENT] center would communicate if there was a problem that needed on going monitoring. The communication between the facility and the [MEDICAL TREATMENT] center is done by phone, so there is no documentation. The DON was informed of the resident’s headaches after he/she returned from [MEDICAL TREATMENT]. The social worker had been in contact with the center. The resident believed they took too much fluid off. The DON would have to review if or how staff documented the headaches. The resident complained to the DON and she followed up and called the [MEDICAL TREATMENT] center. She was not sure when she spoke to the [MEDICAL TREATMENT] center. The DON did not believe the headaches were necessarily a reason to check vitals after [MEDICAL TREATMENT] unless the[MEDICAL TREATMENT] center wanted the facility to do something. During an interview on 1/31/19 at 4:00 P.M., the [MEDICAL TREATMENT] clinical nurse manager said he/she would expect for the facility to check the resident’s vitals, thrill and bruit, and signs of infection or change of condition. Even though the [MEDICAL TREATMENT] center checked the resident’s vitals every 30 minutes, he/she could have a |
| 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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 14) change of condition on the way back to the facility. It is important to ensure that the resident’s vital signs are checked when he/she returned to the facility. He/she spoke to the social worker this week regarding the resident’s concerns with having headaches and speaking to the physician. He/she would have expected the facility staff to monitor and assess the resident after his/her [MEDICAL TREATMENT] treatment. Typically, the [MEDICAL TREATMENT] center would have written documentation between the center and the facility; however, it had not been implemented. | |
| F 0755 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to establish a system of records |
| 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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0755 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 15) (MONTH) 2019, reviewed on 1/28/19 at 9:20 A.M., for the 400, and 500 hall liquids, showed: -64 out of 82 shifts without a count of narcotics; -Of the 18 shifts with a count of narcotics, only one nurse documented as witness to the count for 14 of the 18 shifts. 5. Review of the facility’s controlled substance shift change count check sheet, dated (MONTH) 2019, reviewed on 1/28/19 at 9:20 A.M., for the 400, and 500 hall patches, showed: -65 out of 82 shifts without a count of narcotics; -Of the 17 shifts with a count of narcotics, only one nurse documented as witness to the count for 16 of the 17 shifts. 6. Review of the facility’s controlled substance shift change count check sheet, dated (MONTH) 2019, reviewed on 1/28/19 at 9:20 A.M., for the refrigerator, showed: -57 out of 82 shifts without a count of narcotics; -Of the 25 shifts with a count of narcotics, only one nurse documented as witness to the count for 20 of the 25 shifts. 7. On 1/29/19 the DON provided the narcotic count sheets for the month of (MONTH) and said the following is all she was able to locate: -The facility’s controlled substance shift change count check sheet, dated (MONTH) (YEAR), reviewed on 1/29/19 at 1:00 P.M., for unspecified nurse’s station, showed 5 out of 93 shifts with the same nursing staff documenting for both the on and off shift narcotic count, 36 out of 93 shifts with one nurse documenting, and 24 out of 93 shifts with a narcotic count without any nursing staff documenting for on or off shift narcotic count; -The facility’s controlled substance shift change count check sheet, dated (MONTH) (YEAR), reviewed on 1/29/19 at 1:50 P.M., for unspecified nurse’s station, showed 11 out of 93 shifts with the same nursing staff documenting for both the on and off shift narcotic count, 45 out of 93 shifts with one nurse documenting, and 9 out of 93 shifts with a narcotic count without any nursing staff documenting for on or off shift narcotic count 8. During an interview on 1/29/19 at 1:40 P.M., the DON and Assistant Director of Nursing (ADON) stated: -The expectation is for nursing staff to verify the narcotic counts by counting the narcotics, recording the corresponding number and initialing for both the oncoming or off going shift on the narcotic count sheet; -The DON or ADON reviews the narcotic logs monthly; -The shift to shift narcotic count sheet is the only documentation that shows the nurses are verifying correct narcotic counts daily; -Though there are six separate narcotic shift change reports, each designated for a type of narcotic and location, the DON verified she was only able to find two narcotic shift change reports for (MONTH) (YEAR). The DON was not able to verify which location or type of narcotic the shift change reports represented. | |
| 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: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 16) facility census was 61. Review of the Medication Storage in the Facility Policy, dated November, (YEAR), showed: -Outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled or without secure closures will be immediately withdrawn from stock by the facility. They will be disposed of according to drug disposal procedures, and reordered from the pharmacy if a current order exists; -Medication and treatment carts are a property of the pharmacy, the facility is required to keep the carts clean and damage free. Review of the facility’s Labeling of Medication Containers policy, dated April, 2007, showed: -Medication labels must be legible at all times; -Any medication packaging or containers that are inadequately or improperly labeled shall be returned to the issuing pharmacy; -Labels for individual drug containers shall include all necessary information, such as: -The resident’s name; -The prescribing physician’s name; -The name, address, and telephone number of the issuing pharmacy; -The name, strength, and quantity of the drug; -The date the medication was dispensed; -Directions for use. 1. Observation on 1/28/19 at 7:00 A.M., of the nurse’s treatment cart, showed: -An opened tube of [MEDICATION NAME] gel (an antibiotic gel used for vaginal infections), unlabeled with a resident’s name; -An opened tube of Ascend (silver [MEDICATION NAME] cream, an antibiotic, works by stopping the growth of bacteria that may infect an open wound) unlabeled with a resident’s name; -Two tubes of Santyl (sterile enzymatic [MEDICATION NAME] ointment) unlabeled with a resident’s name, opened, and one tube without a cap on top; -One bottle of liquid Levetiracetam (used to treat [MEDICAL CONDITION]), expired on 1/6/19; -One bottle of [MEDICATION NAME] syrup (used to soften stools), expired on 12/2018; -One bottle of Acetic Acid (a chemical sometimes used to treat topical fungal infections), unlabeled with a resident’s name, open; -The bottom drawer had visible debris and covered in a sticky substance; -Bottles of [MEDICATION NAME], Levetiracetam and Geri [MEDICATION NAME] (used to treat coughs and congestion) had sticky substances on the sides and on the bottoms of the bottles. 2. Observation on 1/28/19 at 9:05 A.M., of the certified medical technician (CMT) medication cart for the 400-500 halls, showed: -A bottle of Vitamin B12 pills with the manufacturer expiration date rubbed off; -A bottle of [MEDICATION NAME] propionate spray (an inhaled steroid), expired 11/19/18; -A bottle of [MEDICATION NAME] Syrup (used to relive constipation), expired on 12/2018; -The bottom drawer had visible debris, was covered in a sticky substance and the bottles of oral medications were sticky with run off on the sides. 3. Observation on 1/28/19 at 11:15 A.M., of the CMT medication cart for the 100, 300 and 600 halls, showed: -A bottle of [MEDICATION NAME] syrup expired 10/2018; -A bottle of [MEDICATION NAME] syrup expired 12/2018; -A bottle of GeriCare Geri Mucil expired 8/2018; |
| 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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 17) -A bottle of [MEDICATION NAME] propionate spray, lying loose in the top drawer, without a lid; -The bottom drawer had visible debris, was covered in a sticky substance, and the bottles of oral medications were sticky with run off on the sides. 4. During an interview on 1/29/19 at 1:50 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated: -Topical ointments, creams and powders should be in a bag labeled with the resident’s name or in the box that has the pharmacy label attached; -Tubes of Santyl can be used on multiple residents if nursing staff are not applying it directly on the resident’s wound or skin. Nursing staff are directed to apply Santyl onto the bandage and not directly to the wound base; -A resident’s bottle of prescription [MEDICATION NAME] propionate should be stored with its cap on, in its box or baggy in which it was delivered from the pharmacy; -If medications are expired or no longer in use by the resident, the medication should either get returned to the pharmacy or disposed of in the appropriate manner; -Nursing staff should keep the medication cart drawers free of debris and sticky substances; -Nursing staff is expected to clean medication bottles of any spills, keeping them clean and protecting the label; -CMTs are expected to clean the medication carts every Friday. 5. Review of the manufacturer’s directions for use of Santyl Ointment, showed: -Apply Santyl ointment only to the area of the wound, from edge to edge; -Avoid application to the surrounding skin; -Apply a nickel thick layer of Santyl to the wound base; -The directions do not indicate application of the Santyl directly to the dressing. | |
| F 0770 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide timely, quality laboratory services/tests to meet the needs of residents. Based on observation, interview and record review, the facility failed to provide |
| 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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0770 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 18) after removing the strip. The open bottle of test strips sat on top of the medication cart. 3. Observation on 1/27/19 at 6:30 A.M., showed Nurse D removed a test strip from the opened BGT strip bottle and obtained a BGT on Resident #40. Nurse D did not close the cap after removing the strip. The opened bottle of test strips sat on top of the medication cart. 4. During an interview on 1/27/19 at 6:35 A.M., Nurse D said he/she had 15 residents to obtain a BGT every morning. Observation at this time, showed the opened bottle of test strips remained on top of the medication cart. 5. Observation on 1/27/19 at 6:46 A.M., at 7:00 A.M. and at 7:15 A.M., showed the opened bottle of test strips remained on top of the medication cart. 6. During an interview on 1/29/19 at 2:27 P.M., the Director of Nurses (DON) said staff should close the lid of the test strip bottle immediately after removing a test strip because leaving it open can damage the test strips and cause an inaccurate test result. | |
| F 0803 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to meet 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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0803 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 19) Review of the pureed recipes, hung above the blender in the kitchen, showed no recipe for the egg, bacon and sausage puree. 3. During an interview on 1/30/19 at 11:30 A.M., the Dietary Manager (DM) said menus should be followed for pureed recipes in order to preserve the nutritional content. Pureed food should be pudding thick so residents on pureed diets do not choke. The DM said she is the one who tastes every pureed meal served at the facility, every day of the week, for taste and texture. 4. During an interview on 1/31/19 at 12:20 P.M., Dietician K said dietary staff is expected to follow the puree recipes as approved by the dietician. If a recipe has not been provided by the dietician, then it should not be provided to the residents. It would not be acceptable to create a recipe and serve it without consulting the dietician. | |
| 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. **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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 20) soap and a tub of chlorine-based sanitizer solution. The DM took a test strip that is used to measure concentrations of quaternary ammonium compound (QAC), and dipped it into the dishwasher’s external water reservoir. She compared the strip to the guide on the packaging, which indicated a concentration level of 400 parts per million (ppm). The DM said the result was too high and the results she had been getting up until this test had been reading 100 ppm, which was what it should be. She ran the dishwasher again and used two or three more QAC test strips; all yielded the same result of 400 ppm. During an interview on [DATE] at 6:58 A.M., the DM said she was the only member of the kitchen staff who knew how to test the dishwasher’s sanitizer concentration levels. She tests the dishwasher every three days and works at the facility seven days a week. She did not have a copy of the manufacturer’s book for the dishwasher. The dishwasher does not get routine maintenance and is only serviced when needed. She could not recall the last time the dishwasher was serviced. Review of the dishwasher sanitizer logs from (MONTH) (YEAR) through (MONTH) 2019, showed levels of 100 ppm until [DATE]. From [DATE] through (MONTH) 2019, the logs showed levels of 400 ppm. The logs did not track the temperature of the dishwasher. During an interview on [DATE] at 11:30 A.M., the DM said the chlorine test strips she had been using on the dishwasher expired in (MONTH) (YEAR). She began using the QAC test strips at that time. Using the wrong test strips provided inaccurate readings of the dishwasher’s sanitizer concentration levels. It is important to have accurate readings to ensure the dishwasher is sanitizing dishes properly and the chlorine levels are not too high. | |
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide and implement an infection prevention and control program. **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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 21) Observation on 1/27/19 at 6:10 A.M., showed Nurse D applied gloves, did not clean the glucometer prior to use with any type of disinfecting agent and placed the glucometer on the used barrier from Resident #54. Nurse D placed the soiled barrier directly on top of Resident #39’s soiled bed linen. Nurse D obtained the resident’s BGT, removed the used test strip from the glucometer, removed his/her gloves and washed his/her hands. Nurse D placed the soiled barrier directly on top of the medication cart. Nurse D did not clean the glucometer machine after use with any type of disinfecting agent before moving on to the next resident. 3. Review of Resident#60’s medical record, showed a [DIAGNOSES REDACTED]. Observation on 1/27/19 at 6:13 A.M., showed Nurse D applied gloves, opened a drawer in the medication cart, got out a clean barrier and threw the soiled barrier away. He/she failed to clean the top of the medication cart, where the soiled barrier had been removed. Without cleaning the glucometer prior to use with any type of disinfecting agent, Nurse D placed the glucometer on the clean barrier. Nurse D obtained the resident’s BGT, removed his/her gloves and washed his/her hands. Nurse D did not clean the glucometer after use with any type of disinfecting agent before moving on to the next resident. 4. Review of Resident#40’s medical record, showed a [DIAGNOSES REDACTED]. Observation on 1/27/19 at 6:30 A.M., showed Nurse D applied gloves and without cleaning the glucometer prior to use with any type of disinfecting agent, Nurse D placed the glucometer on a clean barrier. Nurse D obtained the resident’s BGT, removed his/her gloves and washed his/her hands. Nurse D did not clean the glucometer machine after use with any type of disinfecting agent after use. Nurse D said he/she had approximately 15 BGTs to obtain in the morning. 5. During an interview on 1/27/19 at 7:30 A.M., Nurse D said he/she did not know the facility policy for cleaning the glucometer machine. He/she usually cleans it with a water dampened towel, but forgot to clean the machine while obtaining the BGTs. 6. During an interview on 1/29/19 at 2:27 P.M., the Director of Nursing (DON) and the Assistant Director of Nurses (ADON) both said the glucometer machine should be cleaned with a sani-wipe (germicidal disposable wipes) after each resident use. It would never be appropriate to use the same barrier on multiple residents and staff should obtain a clean barrier for each resident due to infection control. 7. Review of Resident #44’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/5/18, showed: -[DIAGNOSES REDACTED]. -Brief Interview for Mental Status (BIMS) score of 5 out of 15 (indicates cognitive impairment); -No behaviors; -Incontinent of urine; -Required maximum assistance from the staff for transfers, dressing, personal hygiene and bathing. Observation on 1/27/19 at 7:35 A.M., showed the resident lay in bed awake. Certified Nurse Assistant (CNA) G washed his/her hands, put on gloves and provided the resident with incontinence care. CNA G removed the resident’s wet with urine adult incontinence brief, washed and dried the resident’s perineal area (the surface area between the thighs, extending from the pubic bone to the tail bone) and genitals, turned the resident onto his/her left side and washed the resident’s buttocks and rectal area. Without removing his/her soiled gloves, he/she opened the resident’s door, called out for an unknown staff member to bring more supplies, took the clean supplies from the staff person, closed the door and while wearing the same soiled gloves, continued to clean the resident. Without |
| 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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 22) changing his/her soiled gloves, CNA G applied a clean adult incontinence brief and dressed the resident. During an interview on 1/30/19 at 11:55 A.M., the DON said it would never be appropriate for staff to open a closed door with soiled gloves and then without changing the gloves, continue to provide care with the same soiled gloves, due to infection control. The facility policy is to change gloves when going from dirty to clean areas. Review of the facility’s Perineal Care policy, revised (MONTH) 17, 2012, showed the policy failed to direct staff to change their gloves and sanitize their hands when going from the perineal area to the rectal area and/or before or after touching other surfaces. | |
| F 0925 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Based on observation, interview and record review, the facility failed to maintain an |
| 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: 265732 |
| (X3) DATE SURVEY COMPLETED 01/30/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTLEYS EXTENDED CARE | STREET ADDRESS, CITY, STATE, ZIP 3060 ASHBY 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 0925 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 23) facility had an issue with gnats or drain flies during his/her last routine treatment in (MONTH) (YEAR). He/she provided encouragement to the facility’s dietary staff to keep the drains clear of buildup and food debris. Keeping trash cans covered with lids when not in use will assist with pest control. During an interview on 1/30/19 at 11:30 A.M., the DM said ensuring the drains are clean and clear is not part of her dietary staff’s cleaning schedule. Dietary staff should be putting lids back on trash cans when they are not in use. | |
